Episodes
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We’re back! Let’s Talk about CBT has been on hiatus for a little while but now it is back with a brand-new host Helen Macdonald, the Senior Clinical Advisor for the BABCP.
Each episode Helen will be talking to experts in the different fields of CBT and also to those who have experienced CBT, what it was like for them and how it helped.
This episode Helen is talking to one of the BABCP’s Experts by Experience, Paul Edwards. Paul experienced PTSD after working for many years in the police. He talks to Helen about the first time he went for CBT and what you can expect when you first see a CBT therapist. The conversation covers various topics, including anxiety, depression, phobias, living with a long-term health condition, and the role of measures and outcomes in therapy. In this conversation, Helen MacDonald and Paul discuss the importance of seeking help for mental health struggles and the role of CBT in managing anxiety and other conditions. They also talk about the importance of finding an accredited and registered therapy and how you can find one.
If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on X or email us at [email protected].
Useful links:
For more on CBT the BABCP website is www.babcp.com
Accredited therapists can be found at www.cbtregisteruk.com
Credits:
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Transcript:
Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the senior clinical advisor for the British Association for Behavioural and Cognitive Psychotherapies. I'm really delighted today to be joined by Paul Edwards, who is going to talk to us about his experience of CBT.
And Paul, I would like to start by asking you to introduce yourself and tell us a bit about you.
Paul: Helen, thank you. I guess the first thing it probably is important to tell the listeners is how we met and why I'm talking to you now. So, we originally met about four years ago when you were at the other side of a desk at a university doing an assessment on accreditation of a CBT course, and I was sitting there as somebody who uses his own lived experience, to talk to the students, about what it's like from this side of the fence or this side of the desk or this side of the couch, I suppose, And then from that I was asked if I'd like to apply for a role that was being advertised by the BABCP, as advising as a lived experience person.
And I guess my background is, is a little bit that I actually was diagnosed with PTSD back in 2009 now, as a result of work that I undertook as a police officer and unfortunately, still suffered until 2016 when I had to retire and had to reach out. to another, another psychologist because I'd already had dealings with psychologists, but, they were no longer available to me. And I actually found what was called at the time, the IAPT service, which was the Improving Access to Psychological Therapies. And after about 18 months treatment, I said, can I give something back and can I volunteer? And my life just changed. So, we met. Yeah, four years ago, probably now.
Helen: thank you so much, Paul. And we're really grateful to you for sharing those experiences. And you said about having PTSD, Post Traumatic Stress Disorder, and how it ultimately led to you having to retire. And then you found someone who could help. Would you like to just tell us a bit about what someone might not know about being on the receiving end of CBT?
Paul: I feel that actual CBT is like a physiotherapy for the brain. And it's about if you go to the doctors and they diagnose you with a calf strain, they'll send you to the physio and they'll give you a series of exercises to do in between your sessions with your physio to hopefully make your calf better.
And CBT is very much, for me, like that, in as much that you have your sessions with your therapist, but it's your hard work in between those sessions to utilize the tools and exercises that you've been given, to make you better. And then when you go back to your next session, you discuss that and you see, over time that you're honing those tools to actually sometimes realising that you're not using those tools at all, but you are, you're using them on a daily basis, but they become so ingrained in changing the way you think positively and also taking out the negativity about how you can improve. And, and yeah, it works sometimes, and it doesn't work sometimes and it's bloody hard work and it is shattering, but it works for me.
Helen: Thank you, Paul. And I think it's really important when you say it's hard work, the way you described it there sounds like the therapist was like the coach telling you how to or working with you to. look at how you were thinking and what you were doing and agreeing things that you could change and practice that were going to lead to a better quality of life. At the same time though, you're thinking about things that are really difficult.
Paul: Yeah.
Helen: And when you say it was shattering and it was really difficult, was it worth it?
Paul: Oh God. Yeah, absolutely. I remember way back in about 2018, it would be, that there was, there was a fantastic person who helped me when I was coming up for retirement. And we talked about what I was going to do when I, when I left the police and I was, you know, I said, you know, well, I don't know, but maybe I've always fancied being a TV extra and, That was it. And I saw her about 18 months later, and she said, God, Paul, you look so much better. You're not grey anymore. You know, what have you done about this? And it was like, she said I was a different person. Do I still struggle? Yes. Have I got a different outlook on life? Yes. Do I still have to take care of myself? Yes. But, I've got a great life now. I'm living the dream is my, is my phrase. It is such a better place to be where I am now.
Helen: I'm really pleased to hear that, Paul. So, the hard work that you put into changing things for the better has really paid off and that doesn't mean that everything's perfect or that you're just doing positive thinking in the face of difficulty, you've got a different approach to handling those difficulties and you've got a better quality of life.
Paul: Yeah, absolutely. And don't get me wrong, I had some great psychologists before 2016, but I concentrated on other things and we dealt with other traumas and dealt with it in other ways and using other, other ways of working. I became subjected to probably re traumatising myself because of the horrendous things I'd seen and heard. So, it was about just changing my thought processes and, and my psychologist said, Well, you know, we don't want to re traumatise you, let's look at something different. Let's look at a different part and see if we can change that. And, and that was, very difficult, but it meant that I had to look into myself again and be honest with myself and start thinking about my honesty and what I was going to tell my psychologist because I wanted to protect that psychologist because I didn't want them to hear and talk about the things that I'd had to witness because I didn't think it was fair, but I then understood that I needed to and that my psychologist would be taken care of. Which was, which was lovely. So, I became able to be honest with myself, which therefore I can be honest with my therapist.
Helen: Thank you, Paul. And what I'm hearing there is that one of your instincts, if you like, in that situation was to protect the therapist from hearing difficult stuff. And actually the therapist themselves have their own opportunity to talk about what's difficult for them. So, the person who's coming for therapy can speak freely, although I'm saying that it's quite difficult to do. And certainly Post Traumatic Stress Disorder isn't the only thing that people go for CBT about, there are a number of different anxiety difficulties, depression, and also a wider range of things, including how to live well with a long term health condition and your experience could perhaps really help in terms of somebody going for their first session, not knowing what to expect.
As a CBT therapist, I have never had somebody lie down on a couch. So, tell us a little bit about what you think people should know if they are thinking of going for CBT or if they think that somebody they care about might benefit from CBT. What's it like going for that first appointment?
Paul: Bloody difficult. It's very difficult because by the very nature of the illnesses that we have that we want to go and speak to a psychologist, often we're either losing confidence or we're, we're anxious about going. So I have a phrase now and it's called smiley eyes and it, and it was developed because the very first time that I walked up to the, the place that I had my CBT in 2016, the receptionist opened the door and had these most amazing engaging smiley eyes and it, it drew me in.
And I thought, wow. And then when I walked through the door and saw the psychologist again, it was like having a chat. It was, I feel that for me, I know now, I know now. And I've spoken to a number of psychologists who say it's not just having a chat. It is to me. And that is the gift of a very good psychologist, that they are giving you all these wonderful things.
But it's got to be a collaboration. It's got to be like having a chat. We don't want to be lectured, often. I didn't want to have homework because I hated homework at school. So, it was a matter of going in and, and talking with my psychologist about how it worked for me as an individual, and that was the one thing that with the three psychologists that I saw, they all treated me as an individual, which I think is very, very important, because what works for one person doesn't work for another.
Helen: So it's really important that you trust the person and you make a connection. A good therapist will make you feel at ease, make you feel as safe as you can to talk about difficult stuff. And it's important that you do get on with each other because you're working closely together. You use the word collaboration and it's definitely got to be about working together. Although you said earlier, you're not sure about the word expert, you're the expert on what's happening to you, even though the therapist will have some expertise in what might help, the kind of things to do and so there was something very important about that initial warmth and greeting from the service as well as the therapist.
Paul: Oh, absolutely. And you know, as I said earlier, I'm honoured to speak at some universities to students who are learning how to be therapists. And the one thing I always say to them is think about if somebody tells you their innermost thoughts, they might never have told anybody and they might have only just realised it and accepted it themselves. So think about if you were sitting, thinking about, should I put in this thesis to my lecturer? I'm not sure about it. And how nervous you feel. Think about that person on the other side of the, you know, your therapy room or your zoom call or your telephone call, thinking about that. What they're going to be feeling. So to get through the door, we've probably been through where we've got to admit it to ourselves. We then got to admit it to somebody else. Sometimes we've then got to book the appointment. We then got to get in the car to get the appointment or turn on the computer. And then we've got to actually physically get there and walk through.
And then when we're asked the question, we're going to tell you. We've been through a lot of steps every single time that we go for therapy. It's not just the first time, it's every time because things develop. So, you know, it's, it's fantastic to have the ability to want to tell someone that. So when I say it's fantastic to have the ability, I mean, in the therapist, having the ability to, to make it that you want to tell them that because you trust them.
Helen: So that first appointment, it might take quite a bit of determination to turn up in spite of probably feeling nervous and not completely knowing what to expect, but a good therapist will really make the effort to connect with you and then gently try to find out what the main things are that you have come for help with and give you space to work out how you want to say what you want to say so that you both got , a shared understanding of what's going on.So your therapist really does know, or has a good sense of what might help.
So, when you think about that very first session and what your expectations were and what you know now about having CBT, what would you say are the main things that are different?
Paul: Oh, well, I don't actually remember my first session because I was so poorly. I found out afterwards there was three of us in the room because the psychologist had a student in there, but I was, I, I didn't know, but I still remember those smiley eyes and I remember the smiley eyes of the receptionist. And I remember the smiley eyes of my therapist. And I knew I was in the right place. I felt that this person cared for me and was interested and, you know, please don't think that the, the psychologist before I didn't feel that, you know, they were fantastic, but I was in a different place.
I didn't accept it myself. I had different boundaries. I wanted to stay in the police. I, you know, I thought, well, if I, you know, if I admit this, I'm not going to have my, my job and I can't do my job. So a hundred percent of me was giving to my job. And unfortunately, that meant that the rest of my life couldn't cope, but my job and my professionalism never waned because I made sure of that, but it meant that I hadn't got the room in my head and the space in my head for family and friends.
And it was at the point that I realized that. It wasn't going to be helpful for the rest of my life that I had to say, you know what, I'm going to have to, something's going to have to give now. And unfortunately, that was, you know, my career, but up until that point, I'm proud to say that I worked at the highest level and I gave a hundred percent.
Now I realised that I have to have a life work balance rather than a work life balance, because I put life first. And I say that to everybody have a life work balance. It doesn't mean you can't have a good work ethic. It doesn't mean you can't work hard. It's just what's important in that. So what's the difference between the first session then and the first session now?
Well, I didn't remember the first session. Now, I know that that psychologist was there to help me and there to test me and to look at my weaknesses. Look at my issues, but also look at my strengths and make me realize I'd got some because I didn't realise I had.
Helen: That's really important, Paul, and thank you for sharing what that was like. I really appreciate that you've been so open and up front with me about those experiences.
Paul: So let's turn this round to you then Helen as a therapist And you talked about lots of conditions, and things that people could have help with seeing a CBT therapist because obviously I have PTSD and I have the associated anxiety and depression and I still deal with that. What are the other things that people can have help with that they, some that they do have heard, have heard of, but other things that they might not know can be helped by CBT?
Helen: Well, that's a really good question. And I would say that CBT is particularly good at helping people with anxiety and depression. So different kinds of anxiety, many people will have heard, for example, of Obsessive-Compulsive Disorder, OCD, or Generalized Anxiety Disorder where people worry a lot, and it's very ordinary to worry, but when it gets out of hand, other things like phobias, for example, where the anxiety is much more than you'd expect for the amount of danger people sometimes worry too much about getting ill or being ill, so they might have an illness anxiety. Those are very common anxiety difficulties that people have. CBT, I mean, you've already mentioned this, but CBT is also very good for depression. Whether that's a relatively short term episode of really low mood, or whether it's more severe and ongoing, then perhaps the less well known things that CBT is good for. For example, helping people live well if they have a psychotic disorder, maybe hearing voices, for example, or having beliefs that are quite extreme and unusual, and want to have help with that. It's also very good for living with a long term health condition where there isn't anything medical that can cure the condition, but for example, living well with something like diabetes or long term pain.
Paul: interestingly, you spoke about phobias then, Is the work that a good therapist doing just in the, the consulting room or just over, the, this telephone or, or do you do other things? I'm thinking of somebody I knew who had a phobia of, particular escalators and heights, and they were told to go out and do that. You know, try and go on an escalator and, they managed to get up to the top floor of Selfridges in Birmingham because that's where the shoes were and that helped. But would you just, you know, would you just talk about these things, or do you go out and about or do you encourage people to, to do these with you and without?
Helen: Again, that's, that's a really good point, Paul, and the psychotherapy answer is it depends. So let's think about some examples. So sometimes you will be mostly in the therapist's office or, and as you've mentioned, sometimes on the phone or it can be on a video call. but sometimes it's really, really useful to go out and do something together.
And when you said about somebody who's afraid of being on an escalator, sometimes it really helps to find a way of doing that step by step and doing it together. So, whether that's together with someone else that you trust or with the therapist, you might start off by finding what's the easiest escalator that we've got locally that we can use and let's do that together. And let me walk up the stairs and wait for you and you do it on your own, but I'll be there waiting. Then you do it on your own and come back down and meet me. Then go and do it with a friend and then do it on your own. So, there's a process of doing this step by step. So you are facing the fear, you are challenging how difficult it is to do this when you're anxious. But you find a place where you can take the anxiety with you successfully, so we don't drop you in the deep end. We don't suddenly say, right, you're going all the way to the fifth floor now. We start one step at a time, but we do know that you want to get to the shoes or whatever your own personal goal and motivation is there's got to be a good reason to do it gives you something to aim towards, but also when you've done it, there's a real sense of achievement. And if I'm honest as a therapist, it's delightful for me as well as for the person I'm working with when we do achieve that.
Sometimes it isn't necessarily that we're facing a phobia, but it might be that we're testing out something. Maybe, I believe that it's really harmful for me to leave something untidy or only check something once. We might do an experiment and test out what it's like to change what we're doing at the moment and see what happens. And again, it's about agreeing it together. It's not my job to tell somebody what to go and do. It's my job to work with somebody to make sure that they've got the tools they need to take their anxiety with them. And sometimes that anxiety will get less, it'll get more manageable. Sometimes it goes away altogether, but that's not something I would promise.
What I would do is work my very hardest to make the anxiety so that the person can manage it successfully and live their life to the full, even if they do still have some.
Paul: And, and for me, I think one of the things that I remember is that my, you know, my mental health manifested itself in physical symptoms as well. So it was like when I was thinking about things, I was feeling sick, I was feeling tearful. and that's, that's to be expected at times, isn't it? And, and even when you're facing your fears or you’re talking through what you're experiencing. It's, it's, it's a normal thing. And, and even when I had pure CBT, it can be exhausting.
And I said to my therapist, please. Tell people that, you know, your therapy doesn't end in the session. And it's okay to say to people, well, go and have a little walk around, make sure you can get somebody to pick you up or make sure you can get home or make sure you've got a bit of a safe space for half an hour afterwards and you haven't got to, you know, maybe pick the kids up or whatever, because that that's important time for you as well.
Helen: That's a really important message. Yes, I agree with you there, Paul, is making sure that you're okay, give yourself a bit of space and processing time and trying to make it so that you don't have to dash straight off to pick up the kids or go back to work immediately, trying to arrange it so that you've got a little bit of breathing space to just make sure you're okay, maybe make a note of important things that you want to think about later, but not immediately dashing off to do something that requires all your concentration. And I agree with you, it is tiring. You said at the beginning it's just having a chat and now you've talked about all the things that you actually do in a session. It's a tiring chat and tiring to talk about how it feels, tiring to think about different ways of doing things, tiring to challenge some of the assumptions that we make about things. Yes it is having a chat, but really can be quite tiring.
Paul: And I think that the one thing that you said in there as well, you know, you talk about what would you recommend. Take a pen and paper. Because often you cannot remember. everything you put it in there. So, make notes if you need to. Your therapist will be making notes, so why can't you? And also, you know, I think about some of the tasks I was given in between my sessions, rather than calling it my homework, my tasks I was given in between sessions to, I suffered particularly with, staying awake at night thinking about conversations I was going to have with the person I was going to see the next day and it manifested itself I would actually make up the conversations with every single possible answer that I could have- and guess what- 99 times out of 100 I never even saw the person let alone had the conversation. So it was about even if I'm thinking in the middle of the night, you know, what I'm going to do, just write it down, get rid of it, you know, and I guess that's, you know, coming back again, Helen to put in the, the ball in your court and saying, well, what, what techniques are there for people?
Helen: Well, one of the things that you're saying there about keeping a note and writing things down can be very useful, partly to make sure that we don't forget things, but also so that it isn't going round and round in your head. The, and because it's very individual, there may be a combination of things like step by step facing something that makes you anxious, step by step changing what you're doing to improve your mood. So perhaps testing out what it's like to do something that you perhaps think you're not going to enjoy, but to see whether it actually gives you some sense of satisfaction or gives you some positive feedback, testing out whether a different way of doing something works better. So there's a combination of understanding what's going on, testing out different ways of doing things, making plans to balance what things you're doing. Sometimes there may be things about resting better. So you said about getting a better night's sleep and a lot of people will feel that they could manage everything a bit better if they slept better. So that can be important.
Testing out different ways of approaching things, asking is that reasonable to say that to myself? Sometimes people are thinking quite harsh things about themselves or thinking that they can't change things. But with that approach of, well, let's see, if we test something out different and see if that works.
So there's a combination of different things that the therapist might do but it should always be very much the, you're a team, you're working together, your therapist is right there alongside you. Even when you've agreed you're going to do something between sessions, it's that the therapist has agreed this with you. You've thought about what might happen if you do this and how you're going to handle it. And as you've said, sometimes it's a surprise that it goes much better than we thought it was going to. So, so we're testing our predictions and sometimes it's a surprise. It's almost like being a scientist. You're doing experiments, you're testing things out, you're seeing what happens if you do this. And the therapist will have some ideas about the kind of things that will work. but you're the one doing, doing the actual doing of it.
Paul: And little things like, you know, I, I remember, I was taught a lovely technique and it's called the 5, 4, 3, 2, 1, technique about when you're anxious. And it's about, I guess it's about grounding yourself in the here and now and not, trying to worry about what you're anxious about so you try and get back into what is there now. Can you just explain that?
I mean, I know I know I'm really fortunate. I practice it so much. I probably call it the 2-1 So could you just explain how what that is in a more eloquent way than myself?
Helen: I think you explained that really well, Paul, but what we're talking about is doing things that help you manage anxiety when it's starting to get in the way and bringing yourself back to in the here and now. And for example, it might be, can I describe things that I can see around me? Can I see five things that are green? Can I feel my feet on the floor? Tell whether it's windy and all of those things will help to make me aware of being in the here and now and that the anxiety is a feeling, but I don't have to be carried away by it.
Paul: And there's another lovely one that, I, you know, when people are worrying about things and, it's basically about putting something in a box and only giving yourself a certain time during the day to worry about those things when you open the box and often when you've got that time to yourself.
So give yourself a specific time where you, you know, are not worrying about the kids or in going to sport or doing whatever. So you've got yourself half an hour and that's your worry time in essence. And, you know, I use it on my phone and it's like, well, what am I worrying about? I'll put that in my worry box and then I'll only allow myself to look at that between seven and half past tonight. And by the time I've got there, I'll be done. I'm not worrying about the five things. I might be worrying slightly about one of them, but that's more manageable. And then I can deal with that. So what's the thought behind? I guess I've explained it, but what, what's the psychological thought behind that? And, and who would have devised that?
I mean, who are these people who have devised CBT in the past? Because we haven't even explored that yet.
Helen: Well, so firstly, the, the worry box idea, Paul, is it's a really clever psychological technique is that we can tell ourselves that we're going to worry about this properly later. Right now, we're busy doing something else, but we've made an appointment with ourselves where we can worry properly about it.
And like you've said, if we reassure ourselves that actually, we are, we're going to deal with what's going on through our mind. It reassures our mind and allows it not to run away with us. And then when we do come to it, we can check, well, how much of a problem is this really? And if it's not really much of a problem, it's easier to let it go.
And if it really is a problem, we've made space to actually think about, well, what can I do about it then? so that technique and so many of the other techniques that are part of Cognitive and Behavioural psychotherapies have been developed in two directions, I suppose. In one direction, it's about working with real people and seeing what happens to them, and checking what works, and then looking at lots of other people and seeing whether those sorts of things work. So, we would call that practice based evidence. So, it's from doing the actual work of working with people. From the other direction, then, there is more laboratory kind of science about understanding as much as we can about how people behave and why we do what we do, and then if that is the case, then this particular technique ought to work. Let's ask people if they're willing to test it out and see whether it works, and if it works, we can include that in our toolkit. Either way, CBT is developed from trying to work out what it is that works and doing that.
So, so that's why we think that evidence is important, why it's important to be scientific about it as far as we can, even though it's also really, really important that we're working with human beings here. We're working with people and never losing sight of. That connection and collaboration and working together. So although we don't often use the word art and science, it is very much that combination
Paul: And I guess that's where the measures and outcomes, you know, come into the science part and the evidence base. So, so for me, it's about just a question of if I wanted to read up on the history of CBT, which actually I have done a little. Who are the people who have probably started it and made the most influence in the last 50 years, because BABCP is 50 years old now, so I guess we're going back before that to the start of CBT maybe, but who's been influential in that last 50 years as well?
Helen: Well, there are so many really incredible researchers and therapists, it's very hard to name just a few. One of the most influential though would be Professor Aaron T. Beck, who was one of the first people to really look into the way that people think has a big impact on how they feel. And so challenging, testing out whether those thoughts make sense and experimenting with doing things differently, very much influenced by his work and, and he's very, very well known in our field, from, The Behavioural side, there've been some laboratory experiments with animals a hundred years ago.
And I must admit nowadays, I'm not sure that we would regard it as very ethical. Understanding from people-there was somebody called BF Skinner, who very much helped us to understand that we do things because we get a reward from them and we stop doing things because we don't or because they feel, they make us feel worse. But that's a long time ago now. And more recently in the field, we have many researchers all over the world, a combination of people in the States, in the UK, but also in the wider global network. There's some incredible work being done in Japan, in India, you name it. There's some incredible work going on in CBT and it all adds to how can we help people better with their mental health?
Paul: and I think that for me as the patient and, and being part of the BABCP family, as I like to, to think I'm part of now, I've been very honoured to meet some very learned people who are members of the BABCP. And it, it astounds me that, you know, when I talk to them, although it shouldn't, they're just the most amazing people and I'm very lucky that I've got a couple of signed books as well from people that I take around, when I do my TV extra work. And one of them is a fascinating book by Helen Macdonald, believe it or not on long term conditions that, that I thoroughly recommend people, read, and another one and another area that I don't think we've touched on that. I was honoured to speak with is, a guy called, Professor Glenn Waller, who writes about eating disorders. So eating disorders. It's one of those things that people maybe don't think about when they think of CBT, but certainly Glenn Waller has been very informative in that.
And how, how do you feel about the work in that area? And, and how important that may be. I know we'll probably go on in a bit about how people can access, CBT and, you know, and NHS and private, but I think for me is the certain things that maybe we need to bring into the CBT family in NHS services and eating disorders for me would be one is, you know, what are your thoughts about those areas and other areas that you'd like to see brought into more primary care?
Helen: Again, thank you for bringing that up, Paul. And very much so eating disorders are important. and CBT has a really good evidence base there and eating disorders is a really good example of where somebody working in CBT in combination with a team of other professionals, can be particularly helpful. So perhaps working with occupational therapists, social workers, doctors, for example. And you mentioned our book about persistent pain, which is another example of working together with a team. So we wrote that book together with a doctor and with a physiotherapist.
Paul: Yeah, yeah.
Helen: And so sometimes depending on what the difficulties are, working together as a team of professionals is the best way forward.
There are other areas which I haven't mentioned for example people with personality issues which again can be seen as quite severe but there is help available and at the moment there is more training available for people to be able to become therapists to help with those issues. And whether it's in primary care in the NHS or in secondary care or in hospital services, there are CBT therapists more available than they used to be and this is developing all the time. And I did notice just then, Paul, that you said about, whether you access CBT on the NHS and, and you received CBT through the NHS, but there are other ways of accessing CBT.
Paul: That was going to be my very next question is how do we as patients feel, happy that the therapist we are seeing is professionally trained, has got a, a good background and for want of a phrase that I'm going to pinch off, do what it says on the tin. But do what it says on the tin because I, I am aware that CBT therapists aren't protected by title. So unfortunately, there are people who, could advertise as CBT therapist when they haven't had specific training or they don't have continual development. So, The NHS, if you're accessing through the NHS, through NHS Talking Therapies or anything, they will be accredited.
So, you know, you can do that online, you can do it via your GP. More so for the protection of the public and the making sure that the public are happy. What have the BABCP done to ensure that the psychotherapists that they have within them do what they say it does on the tin.
Helen: yes, that's a number of very important points you're making there, Paul. And first point, do check that your therapist is qualified. You mentioned accredited. So a CBT psychotherapist will, or should be, Accredited which means that they can be on the CBT Register UK and Ireland. That's a register which is recognised by the Professional Standards Authority, which is the nearest you can get to being on a register like doctors and nurses.
But at the moment, anyone can actually call themselves a psychotherapist. So it's important to check our register at BABCP. We have CBT therapists, but we have other people who use Cognitive and Behavioural therapies. Some of those people are called Wellbeing Practitioners that are probably most well known in England.
We also have people who are called Evidence Based Parent Trainers who work with the parents of children and on that register, everybody has met the qualifications, the professional development, they're having supervision, and they have to show that they work in a professional and ethical way and that covers the whole of Ireland, Scotland, Wales and England.
So do check that your therapist is on that Register and feel free to ask your therapist any other questions about specialist areas. For example, if they have qualifications to work particularly with children, particularly with eating disorders, or particularly from, with people from different backgrounds.
Do feel free to ask and a good therapist will always be happy to answer those questions and provide you with any evidence that you need to feel comfortable you're working with the right person.
Paul: that's the key, isn't it? Because if it's your hard-earned money, you want to make sure that you've got the right person. And for me, I would say if they're not prepared to answer the question, look on that register and find somebody who will, because there's many fantastic therapists out there.
Helen: And what we'll do is make sure that all of those links, any information about us that we've spoken in this episode will be linked to on our show page.
Paul, we're just about out of time. So, what would you say are the absolute key messages that you want our listeners to take away from this episode? What the most important messages,
Paul: If you're struggling, don't wait. If you're struggling, please don't wait. Don't wait until you think that you're at the end of your tether for want of a better phrase, you know, nip it in the bud if you can at the start, but even if you are further down the line, please just reach out. And like you say, Helen, there's, there's various ways you can reach out. You can reach out via the NHS. You can reach out privately. I think we could probably talk for another hour or two about a CBT from my perspective and, and how much it's, it has meant to me. But also what I will say is I wish I'd have known now what, or should I say I wish I knew then what I knew now about being able to, to, to open myself up, more than, you know, telling someone and protecting them as well, because there was stuff that I had to re-enter therapy in 2021.
And it took me till then to tell my therapist something because I was like disgusted with myself for having seen and heard it so much. But actually, it was really important in my continual development, but yeah, don't wait, just, just, you know, reach out and understand that you will have to work hard yourself, but it is worth it at the end.
If you want to run a marathon. You're not going to run a marathon by just doing the training sessions when you see your PT once a week. And you are going to get cramp, and you are going to get muscle sores, and you are going to get hard work in between. But when you complete that marathon, or even a half marathon, or even 5k, or even 100 meters, it's really worth it.
Helen: Paul, thank you so much for joining us today. We're really grateful for you speaking with me and it's wonderful to hear all your experiences and for you to share that, to encourage people to seek help if they need it and what might work. Thank you.
Paul: Pleasure. Thanks Helen.
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The British Association for Behavioural and Cognitive Psychotherapies, the lead organisation for cognitive behavioural therapy (CBT) in the UK and Ireland, is 50 years old this year. In this episode Dr Lucy Maddox explores how CBT has changed over the last 50 years. Lucy speaks to founding members Isaac Marks, Howard Lomas and Ivy Blackburn, previous President David Clark, outgoing President Andrew Beck and incoming President Saiqa Naz about changes through the years and possible future directions for CBT.
Podcast episode produced by Dr Lucy Maddox for BABCP
Transcript
Dr Lucy Maddox: Hello, my name is Dr Lucy Maddox and this is Let’s Talk about CBT, the podcast brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP. This episode is a bit unusual, it’s the 50th anniversary of the British Association for Behavioural and Cognitive Psychotherapies this year. And I thought this would be a nice opportunity to explore some of the history of cognitive behavioural therapy, especially the last 50 years.
Some of the roots of CBT can actually be traced way back. Epictetus, an ancient Greek Stoic philosopher wrote that man is disturbed not by things, but by the views he takes of them. This is pretty close to one of the main ideas of cognitive behavioural therapy, that it’s the meaning that we give to events, rather than the events themselves which is important. But actually, cognitive behavioural therapy started off without the C. To find out more, I made a few phone calls.
Isaac Marks: Hello, Isaac Marks here.
Dr Lucy Maddox: Isaac Marks was one of the founding members of BABCP and a key figure in the development of behavioural therapy in Britain. I asked him if he could remember what CBT was like 50 years ago.
Isaac Marks: Originally it was just BT and a few years later the cognitive was added. At the time, the main psychotherapy was dynamic psychotherapy, sort of Freudian and Jungian. But just a handful of us in Groote Schuur Hospital psychiatric department, that’s in Cape Town, developed an interest in brief psychotherapy. And I was advised if I was really interested in it and I was thinking of taking it up as a sub profession, that I should come to the Maudsley in London.
Dr Lucy Maddox: Isaac and his wife moved to London from South Africa and Isaac studied psychiatry at the Maudsley Hospital in Camberwell.
What was it about CBT that had interested you so much?
Isaac Marks: Because it was a brief psychotherapy, much briefer than the analytic psychodynamic psychotherapy. We were short of therapists and there wasn’t that much money to pay for extended therapy, just a few sessions. Six or eight sessions something like that could achieve all what one needed to. They had quite a lot of article studies.
Dr Lucy Maddox: And I guess that’s still true today, that those are some of the real standout features of it, aren’t they? That it is a briefer intervention than some other longer-term therapies and that it’s got a really high quality evidence base.
Isaac Marks: I think that’s probably true, yes.
Howard Lomas: There was a group that met at the Middlesex Hospital every month. And that was set up by the likes of Vic Meyer, Isaac Marks, Derek Jayhugh.
Dr Lucy Maddox: That’s Howard Lomas, another founding member of BABCP remembering how the organisation got set up 50 years ago from lots of different interest groups coming together.
Howard Lomas: These various groups that got together and said, “Why don’t we have a national organisation?” So that was formed back in 1972.
Dr Lucy Maddox: Howard’s professional background was different to Isaac’s psychiatry training, but he found behaviour therapy just as useful.
Howard Lomas: I’d originally trained well in social work, but I was a childcare officer with Lancashire County Council.
Dr Lucy Maddox: And how were you using CBT or behaviour therapy in your practice?
Howard Lomas: Well, as a general approach to everything, thinking of everything in terms of learning theory. How do we learn to do what we do and maintain it with children? Things like non-attendance at school and other problems, behavioural problems with children and then later problems with adults.
But I suppose when I moved to Bury in 1973, I was very much involved in resettlement of people with learning disability from the huge hospitals that we had up here in the north. We’d three hospitals within sight of each other, each with more than 2,000 patients.
Dr Lucy Maddox: Wow.
Howard Lomas: They’re all closed now long since, but yeah, the start of that whole closure programme of trying to get people out into the community. You learn normal behaviour by being in a normal environment, which people in institutions clearly aren’t and weren’t. So it’s trying to create that ordinary valued environment for people. And simply doing that would teach them ordinary behaviours, valued behaviours. It was evidence-based, it was also very effective.
It looked at behaviour for what it was rather than what might be inferred. I suppose I saw psychology as more of a science (laughs). I’m still in touch with some of the people that are resettled from way back. People who had been completely written off as there’s no way they could ever live in their own home are now thriving, absolutely.
Dr Lucy Maddox: Now, Howard’s and Isaac’s memories of CBT 50 years ago highlight that an important route of CBT is behavioural learning theory. This includes ideas of classical conditioning, where in a famous experiment which you’ve probably heard of, Pavlov, taught his dogs to salivate in response to the bell that he rang for their dinner rather than the dinner itself. And operant conditioning, where animals and humans learn to do more or less of a behaviour based on the consequences which happen in response to that behaviour.
Howard Lomas: Half a dozen of us sitting with Skinner, chatting for three hours. So that was quite influential (laughs).
Dr Lucy Maddox: Skinner was another of the early behaviourists, and Howard has memories of being lectured by Skinner at Keele University. The formation of BABCP was important for therapists at the time because behavioural therapy back then was quite a niche field.
Howard Lomas: It was publicly very unpopular indeed. Behaviour therapy was known very much as behaviour modification, which has got an involuntary feel about it, even the name that it was being thrust upon people. And even at that time, aversion therapy was being used for trying to change homosexuality in people, aversion therapy then. Which is quite topical now with the whole debate on conversion therapy.
Dr Lucy Maddox: Absolutely. We’ve signed up to the memorandum of understanding against conversion therapy.
Howard Lomas: The aversive is horrible. And there was a big scandal at I think it was Napsbury Hospital about their clinical programme, which was allegedly based on behaviour modification, more aversive techniques. So there was a big scandal and that led to a major government inquiry, and they asked for anyone to offer, submit evidence on the whole question of behaviour modification, which BABP did. And that then formed the basis of our guidelines for good practice.
Dr Lucy Maddox: Just a note, if you’re listening to this as a cognitive behavioural therapist, please do read the memorandum of understanding against conversion therapy online at www.babcp.com. It makes it clear why we’re opposed to conversion therapy in any form. I’ll put the link in the show notes, too. Like Isaac, Howard remembered that shift from behaviour therapy to cognitive behavioural therapy.
Howard Lomas: Well, I was always against adding the C. I was always taught that behaviour has three components to it: motor behaviour, cognitive behaviour, and affective behaviour. So behaviour included cognitive, so why did you have to have it as a separate thing? Although in those early days I used to get told off if I spoke about thoughts and feelings.
Dr Lucy Maddox: Did you?
Howard Lomas: Yeah, because you can’t see them. You can’t measure them.
Dr Lucy Maddox: Yeah, interesting, although there’s still a lot of measurement, isn’t there? But maybe it’s like you say what we think we can measure has maybe changed.
Howard Lomas: That’s right, yeah. Yeah, I think the measurement and the evidence is so important.
Ivy Blackburn: We actually changed the name when we started it was called the British Association for Behaviour Psychotherapy. So at one of the conferences we passed a motion and added the C.
Dr Lucy Maddox: That’s Ivy Blackburn, another founding member of BABCP.
Ivy Blackburn: At that point well, I was a qualified clinical psychologist. I’d just finished my PhD, I trained in Edinburgh. And I was working in a research set up, an MRC unit called the Brain Metabolism Unit.
Dr Lucy Maddox: And so, CBT at that time was quite a new thing?
Ivy Blackburn: Very, very new. I actually had just discovered Beck as it was, while I was going the research for my PhD, which was in depression. And I used to correspond with him and he used to send me his early papers and things like that.
Dr Lucy Maddox: Ivy’s talking there about Aaron Beck, also sometimes known as Tim Beck. Also sometimes called the father of CBT.
Ivy Blackburn: With Aaron Beck I always signed I M Blackburn. And the story he used to tell at conferences was he always thought I M Blackburn was an old Scottish man. (Laughs) So once he came to Edinburgh, he was on a sabbatical, and we were sitting at I think it was a case conference. He was sitting next to my boss, who was somebody called Dr Ashcroft, and I was sitting next to him.
He turned to Ashcroft and said, “Could you show where I M Blackburn is?” Dr Ashcroft said, “You’re sitting next to her.” Yeah. So that’s how it all started, you know, we were a small group in those days, very small group.
Dr Lucy Maddox: Do you remember what you were excited about by CBT at that time?
Ivy Blackburn: I thought the research that Beck was doing about the factors in depression, about the role of thoughts I thought that was very interesting. The unit where I was working one of their things was working with treatment resistant depression. And they used to go through, the research was a series of drugs. You start with Drug A. If Drug A doesn’t work, you go to B, to C to D.
By the time they’d got to E and had nothing else to do I said, “I’ll take them.” And that’s how I started. I just thought it was very meaningful to me. They loved it, people talked to them and they could talk about what mattered to them, and they actually got better. Not long after that we decided to do the famous first ever trial in cognitive therapy for depression. That was published in 1981.
Oxford started at the same time, they also had started, John Tisdale and his group, a treatment trial. So ours came out in 1981 and theirs came out in 1984, I think. So we were actually the two centres, Edinburgh and Oxford. But cognitive therapy has developed so much. There’s all sorts of offshoots, I don’t know very much about. But another big person who did his PhD with me, big one at the moment who’s still active I think is Paul Gilbert. He was one of my PhD students.
Dr Lucy Maddox: Was he? Wow, yes. Because of course he founded compassionate mind therapy, yeah.
Ivy Blackburn: That’s it.
Dr Lucy Maddox: If you want to hear more about compassion focused therapy, you can check out the earlier podcast with Paul Gilbert. And in fact, if you’re interested in any of the different flavours of CBT which are now around, series one is a really good place to start. We go through lots of different types of CBT there and we hear from therapists and also people who’ve had those different types of CBT. Am I right in thinking as well you were a chair of BABCP?
Ivy Blackburn: That I was a what?
Dr Lucy Maddox: A chair? Like a president of the organisation, is that right?
Ivy Blackburn: Yes, I was. I was president, yes.
Dr Lucy Maddox: Yes, and were you the first woman president?
Ivy Blackburn: Yes. And I am of mixed race, so that was a bit of first as well. I went to Newcastle from Edinburgh in 1993. I think it was 1993.
Dr Lucy Maddox: And what was your experience like of being president?
Ivy Blackburn: As I say, we were so small in those days, you know, we had these little cosy conferences. We met in Newcastle every month. I was very, very well supported by Paul Salkovskis so he sort of guided me through. It was easy and of course some of those people are still there.
Dr Lucy Maddox: Yeah, you’re the big names.
Ivy Blackburn: (Laughs) We are, we are the oldies. Have I enjoyed it? Yes. Yes, I have enjoyed this work very, very much, yeah.
Dr Lucy Maddox: What have you enjoyed about it?
Ivy Blackburn: My work was very diversified because I was obviously also an academic so I did research, I did teaching, I organised a course. But I always carried on with my clinical work and I think that’s what I enjoyed the most, clinical work. This is what’s rewarding, isn’t it?
Dr Lucy Maddox: For sure. Yeah, absolutely.
David Clark: It was an exciting time. And people talked about it as a cognitive revolution. And I think it was a revolution.
Dr Lucy Maddox: That’s David Clark. He’s based at the Oxford Centre for Cognitive therapy, which Ivy was talking about. We also met David in the very first episode of this podcast. He joined the BABCP in the late 70s, when the dominant approach was still behaviour therapy. But as we heard from Ivy Blackburn, there was a crosspollination of ideas from the United States, where Aaron Beck was working on cognitive therapy for depression.
The idea that the way we perceive the world and our future can affect how we feel about it is now rather taken for granted. But at the time it was quite a radical idea.
David Clark: We suddenly started looking at a whole range of different potential therapy manoeuvres. There are thousands of ways you can change people’s beliefs and it was really exciting.
Dr Lucy Maddox: The interlock between beliefs, behaviours, memory and attention was really the basis of cognitive behavioural therapy as we now know it, with the model of thoughts, feelings, behaviours and bodily sensations, which is a fundamental part of most explanations of CBT today. Another root which CBT grew out of was rational emotive behaviour therapy, which Albert Ellis pioneered in the 50s and which also included thoughts, behaviours and emotions in its way of thinking about problems.
In the late 80s and 90s, CBT as we now know it, grew out of all of these roots, behaviourism, rational emotive behaviour therapy, and influenced by the work of Aaron Beck and the bringing together of all of these different ideas. Through the 80s and 90s, lots of disorder specific psychological models were created, to try to tackle specific problems. For example, models for panic disorder, obsessive compulsive disorder, posttraumatic stress disorder, and other problems were developed and really changed the treatment for those difficulties.
David Clark: And then, of course people start spotting ah, yeah, but some of the maintenance processes that had been invoked in a disorder specific model are also applying in other disorders. safety behaviour which Paul Salkovskis of course really pioneered is a good example of that. And also changes in attention, ways in which memory processes can go wrong. And so, you start moving into this way of thinking which is a bit more transdiagnostic.
Dr Lucy Maddox: Yeah, lovely, so actually it’s kind of gone from a very transdiagnostic one treatment fits all at the very start to then getting much more specific and nuanced. To then zooming out again to a bit more of a broader picture again.
David Clark: Yeah. And I think this is the sort of healthy dialectic that you experience when a field is moving forward.
Dr Lucy Maddox: And I suppose that’s one thing that I feel like CBT I mean, other therapies too perhaps, but CBT in particular it feels like it really is a learning therapy, where it’s very good at creating an evidence base. And then holding that evidence base up to the light and saying, “Hang on, what could we be doing better here?” And it does feel like it’s continually evolving perhaps because of how well evidenced it is.
David Clark: I think that’s right. I think it’s always had a very close link to the evidence base. But I think other therapies are going in a similar way, and I think this is really all to the good.
Dr Lucy Maddox: What do you think of the? Because the sort of family of CBTs if you like, I think of them as a family, there different therapies that have developed I guess a little bit more recently which still draw on cognitive and behavioural principles. But maybe sort of run with a different strand of it each time. So I suppose I’m thinking about APT and DBT and compassion focused therapies. How do you see those fitting?
David Clark: I’m just an empiricist, so I think what I think of them depends on what the outcome data is (laughs) with the particular conditions that they’re involved with. But when you get an approach which seems to be doing well and maybe improving on something else, then one always has to look at it. One of my friends, close friends through much of my career was Tim Beck who sadly died last year.
But he was a very jokey person in many ways. But one of the points that he would sometimes make when someone said to him, “Well, what’s cognitive therapy?” He would say, “Well, anything that works.” And of course, it was a joke in a sense, but it was also serious because he was always watching for what other people did in other therapy approaches to see if they’d got something which cracks open beliefs in a way that he hadn’t seen before.
And if so, it miraculously got incorporated into cognitive therapy. It’s really important that we as therapists always keep our eyes open to these things. One of the big developments more recently in the field has been to think well, how can we bring these advances to the public so that really large numbers of people benefit?
Dr Lucy Maddox: Yeah, and of course improving access to psychological therapies has been a massive part of that.
David Clark: Yes. It’s been a great honour to work with so many wonderful people who put in such hard effort to lobby for that. And then, to create the services and crucially, to make them work so effectively that successive governments across the whole political spectrum have cherished and expanded the programme.
At the moment it is the only aspect of our mental health services where outcomes are recorded on everyone and are published. In my worst nightmares I would not have dreamt that we’d still have almost every other area of mental health provision in the dark ages in terms of public transparency. And also in terms of learning.
Dr Lucy Maddox: As David said there, a national improving access to psychological therapies programme in England doesn’t only include CBT. But it has been instrumental in increasing access to CBT as well as other evidence-based therapies within England. It’s also been responsible for creating a whole generation of low intensity therapists, who deliver CBT as part of a stepped care model.
Where briefer interventions, often in the form of guided self-help, are offered for less severe presenting problems. Now we move a little later in the history of CBT. I got in touch with the outgoing president of BABCP, Andrew Beck, and asked him how he first came across CBT. He told me about his first experience of the BABCP conference as a trainee clinical psychologist back in 1997.
Andrew Beck: I managed to get a free ticket to it by DJing at the social party afterwards.
Dr Lucy Maddox: Did you?
Andrew Beck: Yeah, I did, I DJed at that and got a load of Rod Holland’s photographs from past conferences and made a sort of slideshow of them, which we showed, while I was DJing and it was great. But I really felt like I’d come home because there was such a wide variety of people there. It was people from all different professional backgrounds, all coming together and talking about the real practical aspects of working in mental health.
Yeah, it was a real eye opener for me. Being around people who you feel share the same concerns, the same interests, who want things to be better in the same kind of way that you do is great. You feel like you’re part of a community then, don’t you? And being part of that community sustains you in what you’re doing in a really nice way.
Dr Lucy Maddox: What was it about CBT that you liked?
Andrew Beck: It was pragmatic, and I think there was something about it that was very much about being in the room with someone and helping them to get past the things that were stopping them getting on in life. And it was that really present focused aspect of it that appealed to me. That I felt like as a cognitive behaviour therapist, you were going to help someone find something to take home with them and do differently to improve things. And I think that was what really clicked for me, to be honest, Lucy.
I came in 25 years ago, at a point where CBT had begun to be thought about as a therapy in a very coherent way. A lot of the models that we use now and are familiar with, were all really well established. And it was easy to imagine that it had always been like that. But of course, talking to some of the people who were around in those formative years, it’s been really interesting to hear that history of how the therapy has developed.
And I’m told that there was a raging argument about whether these ideas about behaviour therapy and those ideas about cognitions could be brought together in one therapeutic organisation. And how that might look. Because they were quite distinct camps at times, really, with quite different ideas about what therapy ought to be like. And whether these very disparate ideas could sit well together in one organisation and what that organisation ought to be called.
But of course, by 25 years ago attending conference, what we now think about as second wave CBT felt very formed, actually. And what’s happened in the 25 years since is the third wave therapies have developed their evidence base, developed their theoretical foundations and have really grown in popularity. And there’s a whole group now of therapies that are considered to be part of the family of cognitive behaviour therapies but are the kind of next wave.
Dr Lucy Maddox: So Andrew talks there about first wave CBT, which was really just behavioural therapy. Second wave CBT, where the thoughts got added. And third wave CBT, which is the larger family of therapies we now think of. As I said before, if you want more information on the different sorts of CBT, check out the podcast in series one. As we heard from Howard earlier, not everything about the past history of CBT is rosy by any means. Is there anything that you’re glad that we’ve left behind in terms of how CBT has changed in the last 50 years?
Andrew Beck: Yeah, I am, actually. There’s a few things I think are real problems in the history of our therapy. And probably the one that stands out the most is the role of behaviour therapy predominantly in conversion therapy for people that are LGBT identities. And if you look back at conference proceedings from BABCP conferences 30, 40 years ago this was something that was seen as unproblematic.
That there was an idea that people who were unhappy with their sexual identity could have their sexual identity changed through behaviour therapy. And looking back now that was appalling and actually for many people at the time it would have been seen as appalling, too. So it’s not just one of those things that with the benefit of hindsight doesn’t look great, actually it didn’t look great at the time, I think for a lot of people.
And if you were a gay member of our organisation and came to conference and saw that as part of the conference proceedings, that would have been a really alienating process, really. And I think the other thing is because CBT has often been aligned with diagnostic frameworks over the course of CBT’s history, really see now and understood now as being quite unhelpful.
And the one that most stands out for me, I think is borderline personality disorder, which is a way of describing people who generally experienced extraordinarily abusive and invalidating environments growing up, who have developed all sorts of strategies to manage those difficult environments. But who have been understood by services as having a problematic or disordered personality. And I think broadly speaking, the world of mental health is moving away from that as a diagnostic category.
Dr Lucy Maddox: Andrew is the outgoing president of BABCP, and he’s just about to hand over to Saiqa Naz, which is the last person I spoke to. Her perspective on CBT comes from her training as first a low intensity therapist, then a high intensity therapist and now as a trainee clinical psychologist.
Saiqa Naz: I really enjoyed my training, there was a core group of us. We had a routine, we’d go to Costa and have a coffee beforehand. So for me, I remember that (laughs), the social aspect of it. I think that really makes a difference to a training experience, just having that network of support around you. We’re actually celebrating our 10 years of friendship this year. So I’ve been in CBT for 10 years now this year, so it’s nice to be part of BABCP and hopefully be part of its future as well.
And I’m mindful I’m probably a bit different to the other presidents in terms I might be a bit younger, or not a professor. But hopefully bring something different to the organisation. Yeah, I think when I trained as a low intensity CBT it was in the early days of the IAPT programme. So just really interesting to see something so huge being rolled out nationally. And how it was being developed locally, so I trained in Sheffield and we were based in GP surgeries.
And I really liked that model, working a little bit more closely with other healthcare professionals, GPs. I’ve still held onto the skills that I learnt as a low intensity CBT practitioner, when I trained as a CBT therapist. So it lent itself really well to training as a CBT therapist. And again, I think both are valuable in their own right.
The step care model is really important if you’re thinking about long waiting lists and people having access to treatment sooner rather than later. So I think in that sense, the low intensity CBT role has really revolutionised mental health and how services are delivered today.
Dr Lucy Maddox: David and Andrew both had similar respect for the low intensity role and how it’s changed access to CBT.
David Clark: We now have people with a wide range of backgrounds, non-medical backgrounds, who are delivering evidence-based therapies and are considered on an equal basis and are considered to be real experts. So that sort of democratisation of mental health provision has been obviously an incredibly good thing.
Andrew Beck: We’re really lucky in BABCP in that we’ve got a bunch of great low intensity members who are involved on board level, at committees. And I think that’s going to be a big part of who we are as an organisation.
Dr Lucy Maddox: Saiqa and Andrew were also two of the authors of the IAPT positive practice guide for working with Black, Asian and minority ethnic service users, which is available at www.babcp.com and also in the show notes. Saiqa had some ideas about what would help this to be rolled out more fully.
Saiqa Naz: I think there’s quite a few things that will help. So people like Andrew and myself can take a step back and that’s having representation in those senior leadership roles, decision making roles. What we see is that IAPT has opened the doors for people from underrepresented groups, so working class backgrounds, BAME backgrounds, men, people with disabilities.
But what we need to see is those people in more senior leadership roles. And personally I would like to see ringfenced funding now, to help the implementation of the guide. Otherwise, I think the system will keep relying on goodwill and it could be a bit exhausting.
Dr Lucy Maddox: What about the future of CBT? We don’t know how it will change in the next 50 years. But everyone I interviewed had some ideas.
Saiqa Naz: I think for me looking forward I want us to learn more about our CBT heritage. We were just talking about it at the beginning, thinking about who are we inheriting the knowledge from? Where has it come from? Because it will help us to connect with CBT and also think about what’s the legacy of CBT long after we’re gone what we’re leaving behind for the next generation.
And also, how are we going to support the development in a way we are privileged here with the amount of resources that we do get in mental health and the level of training. But how can we pass it on to more lower middle income countries? Taking CBT to communities I think is really important because sometimes I think an organisation can become too insular and just be focused on the inward and on itself. But having that one foot in, one foot out is really helpful.
Dr Lucy Maddox: Andrew agreed that involving people with lived experience of having had CBT is really important when we think about the future development of the therapy and how it might evolve over the next 50 years.
Andrew Beck: It enables us to think a little bit more about barriers to engaging in therapy, what we need to do differently to bring people in, what we need to do once people are in therapy. And it’s been a really lovely development, I think in CBT to think more about that. We really don’t know, we’re very much at the edges of thinking about how our therapies might develop over the next 25 and 50 years.
So it’s a really exciting time. We need to keep pushing and refining our ideas to improve. But the other one for me is about access and outcomes for diverse populations. CBT needs adaptation and therapists need to be able to take into account cultural contexts in order to do that because the large datasets that we’ve got show that for many communities their outcomes are not as good.
Now, part of that I think is because those communities experience particular social and economic hardship and marginalisation, and therapy can’t fix that. But part of it is because therapists just need to get better at thinking about difference in the way we work. So I think that’s going to be an exciting project over the coming years. And we’re just at the start of that, really.
Ivy Blackburn: I think it will be still there with a lot of development, side developments, as we see at the moment, like compassionate and all sorts. Different branches. But I don’t see it disappearing to be replaced, developing as it should be. The beginning was very, very quick developing from depression it quickly went to anxiety. And then, Paul and David went into panic disorder, all this. One after the other, different methods.
David Clark: I just hope that the speed of progress in the next 50 years is at least as fast as we’ve had in the last 50. And we get to a situation where helping people learn how to deal with setbacks in their life and deal with mental health problems becomes much more routine in society. I assume we’re going to have much more digital. I’m sure AI is going to help with a number of things.
But I’m also sure that the absolutely basic qualities that are in therapy about having someone who really cares what’s going on with you, being warm and empathic and really wanting to understand the world from your perspective will remain dominant and really important.
Isaac Marks: Well, I imagine that new methods will continue to be developed from time to time by people in different countries. And as far as I can see, it’s the sort of approach that I think is likely to continue for the foreseeable future.
Dr Lucy Maddox: I hope that’s given you a bit of a flavour of how CBT has grown and developed, especially in the last 50 years from its behavioural roots to the diverse and flourishing therapy that it is today. Do check out the other episodes of the podcast to hear from people who have actually had the therapy to hear in their own words what it’s been like for different problems and with different types of CBT. Meanwhile from me, that’s goodbye. Take good care and enjoy your summer wherever you are.
END OF AUDIO
Shownotes
Photo by Ryan Gagnon from Unsplash
Music by Gabriel Stebbing
Produced for BABCP by Lucy Maddox
For more on BABCP check out www.babcp.com
The Memorandum of Understanding Against Conversion Therapy can be found online here: https://babcp.com/Therapists/BAME-Positive-Practice-Guide
The IAPT Positive Practice Guide for BAME Service Users can be found here: https://babcp.com/Therapists/Memorandum-Against-Conversion-Therapy
For more on different types of CBT check out series 1.
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In this bonus episode of Let's Talk About CBT, hear Dr Lucy Maddox interview Dr Tom Ward and Angie about SlowMo: digitally supported face-to-face CBT for paranoia combined with a mobile app for use in daily life.
Podcast episode produced by Dr Lucy Maddox for BABCP
Transcript
Dr Lucy Maddox: Hello and welcome to Let’s Talk about CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not, and how it can be useful. In this episode, I’ll be finding out about an exciting new blended therapy, SlowMo, for people who are experiencing paranoia.
This digitally supported therapy has been developed over 10 years with a team of people including designers from the Royal College of Art in London, a team of people who have experienced paranoia. And a team of clinical researchers, including Professor Philippa Garety, Dr Amy Hardy and Dr Tom Ward.
The design of this intervention really prioritised the experience of people using the therapy in what’s called a design led approach. To understand more I video called Tom Ward, research clinical psychologist based in Kings College London, and I had a phone call with Angie, who’s experienced using the therapy. Here’s Angie’s story.
Angie: I mean, I’ve had psychosis for many years. About 20 years ago I was really poorly, I was in and out of hospital. Going back about 20 years ago they kept giving me different diagnoses and I expect everybody else had the same thing. Anyway, then I met a psychiatrist and I was with him for over 20 years until he retired. And he really helped me a lot, I was actually diagnosed with schizophrenia.
Part of me was really scared and another part of me was sort of relieved that I knew that I was dealing with. I get voices, sometimes I see or feel things that aren’t really there. But part of my diagnosis is I also get very depressed. And when I get very depressed, that’s when the voices are at their worst because I haven’t got the strength to sort of fight them off, if you like.
If I’m having a good day, then I can use the skills I’ve learnt in the past to not listen to the voices and to have a reasonably good day. If I’m having a bad day and it’s a duvet day, then that’s when I really suffer with the voices. Unless you can actually accept that you have this issue, and you actually accept that you need the help, it doesn’t matter what they do to help you, you’re just not going to take it on board.
Dr Lucy Maddox: Angie wanted some help, specifically with paranoid thoughts she was experiencing about people looking at her or laughing at her. She found out about the SlowMo trial and applied to be a part of it. And ended up being one of the very first people to try the therapy. Tom led on the delivery of therapy in the trial.
Dr Tom Ward: I’ve worked and have worked for the last couple of years trying to develop and test digital interventions for people experiencing psychosis. So I’ve been involved in developing interventions that help people who are experiencing distressing voices. And been involved in work in a therapy called avatar therapy and more recently I’ve been working with colleagues to develop an intervention designed to help people who are experiencing fear of harm from others, which we would sometimes refer to as paranoia.
Dr Lucy Maddox: In case listeners wonder what avatar therapy is could you just briefly say what that is?
Dr Tom Ward: So in avatar therapy, digital technology is used with the person to create a representation of the distressing voice that they hear. So we work with the person to create an avatar which has an image which matches the image the person has of their distressing voice. And which comes to sound like the voice that they hear. And we use this avatar direct in dialogue.
Very much with the rationale that many people who are experiencing distressing voices have relationships with their voice where they feel disempowered and lacking power and control. And we try to use the work with avatars and the dialogue with avatars to provide an opportunity for the person to reclaim power and control. And so we’re very much working directly with the experience in quite a potentially powerful way for people.
Dr Lucy Maddox: Could you tell me about the current project you’re working on, so SlowMo?
Dr Tom Ward: Yeah, so the first thing to say is that SlowMo stands for slow down for a moment. And so, it’s a therapy which is a targeted therapy for people who are experiencing paranoia. And it’s based in the idea that’s been popularised by Daniel Kahneman and other people that human thinking can be sort of thought about in terms of two different types of thinking. There’s fast thinking where we approach situations and we go with our first impression.
We go with our intuition and gut feeling and we don’t take time to think it through. And slow thinking is more around taking a step back from situations and weighing things up and considering different ways of looking at situations. So one of the things to say is that fast thinking is part of human nature, we all do it and in many different times in our lives.
But what we know from research into the experiences of people with psychosis is that people who worry about harm from other people, people who have significant paranoia can often be very likely to engage in this fast thinking. And find it difficult to feel safe in situations and to slow down and consider what else might be going on in the situation.
So the therapy is designed to help people build an awareness of this fast thinking which is a part of human nature but can be particularly difficult if we’re feeling unsafe. And it’s designed to support people to be able to slow down and feel safer in their lives. And managing situations so they can really engage and enjoy their lives in a way that perhaps in the past has been difficult.
Dr Lucy Maddox: Fast thinking I guess that’s something like you were saying that we all can get into a bit.
Dr Tom Ward: The first message that we try to get across within the therapy is that fast thinking is part of human nature, it’s natural. And there are times when thinking fast is actually very helpful for people, sometimes we need to react to situations, and we need to recognise where we are unsafe and there’s danger.
But in the context of when people are feeling unsafe throughout so much of their life, and in situations where perhaps the danger isn’t quite as much as the fear suggests it is, fast thinking can leave people feeling unsafe in situations where it might start to be a barrier to people living their lives.
And slow thinking is something that we’re all capable of, but all human beings find it difficult and people experiencing psychosis and worrying can find this difficult as well. But we’re really trying to find ways to support people to do that, to feel safe in their lives.
Dr Lucy Maddox: And how does the therapy work? What does it look like?
Dr Tom Ward: We would describe it as a blended digital therapy. And it’s important to explain what that means. The blending aspect of this is that we try to take the best of face-to-face therapy and the building of a relationship with someone. But we try to improve the therapy through using, through blending digital technology into what we do.
So the therapy involves eight face-to-face sessions, but each of these sessions is supported by an easy to use website effectively, an interactive website. So within a session, you’d be talking to the person or the person would be talking with the therapist but also interacting with a touchscreen laptop. And this provides information, it provides interactive ways that the person can build a picture of their own worries about other people or situations.
And really visualise what’s happening in a way that in psychological therapy we talk about a formulation. A formulation, an understanding of somebody’s difficulties. But the digital technology in SlowMo is trying to really bring the person into that process of understanding what’s going on and making it very engaging and interactive and visual and memorable for the person.
In order to try to support the person to make changes in their daily life, there’s also a mobile app that comes alongside the therapy, which is very much aimed at taking what the person has learnt in the therapy and applying it into their daily life.
Dr Lucy Maddox: Here’s Angie on what she remembers this digitally supported therapy being like.
Angie: You could choose pretty much where you wanted to do the therapy, you could have it at home, or you could have it in a café or somewhere else where you felt comfortable. So I did it in a café, a local café, with a lady called Alison. And what it consists of the clinician, Alison, she had a laptop. My heart sank originally because I thought oh no, I’m no good on computers. And I explained to her that I wasn’t very good on a computer.
And she was so lovely, so patient, she said, “I can do most of it for you.” So that was fine. What the therapy was it did what it says on the tin, really. It taught you to slow your mind down, and to break things up into little pieces, like for instance I used to be terrified of getting on the bus because I thought people were talking about me and laughing at me.
Dr Lucy Maddox: That’s a horrible feeling.
Angie: Yeah, yeah. And this sort of therapy taught me to break it up. To say myself, “Well, hang on a minute, these people aren’t looking at you. They’re talking to their friends, they’re on their phone.” Just take it easy. And it’s a very simple idea but it works because although you know in your heart of hearts that that is the way to do it, when you’re actually in the situation, you forget. You just panic and to learn these skills was really good.
Dr Lucy Maddox: I asked Tom to describe what the digital component of the treatment looks like.
Dr Tom Ward: The website allows a person to build a picture of their worries. And these are using thought bubbles effectively, but really engaging well presented thought bubbles. And the idea of these is that they’re personalised and tailored for the person. So within a session, the person will be describing their worries but also creating these worry bubbles on the website. And the idea of fast thinking and slow thinking is represented by the way in which these bubbles spin.
So when we’re talking about building an awareness of fast thinking, the person is actually able to control how fast their worry bubbles are spinning. And when we’re talking about maybe ways of slowing down the person can see visually how the worry is slowing down. So they build a picture of their worries and also importantly are building a kind of access to safer or more positive thoughts.
And these are visualised as again bubbles the person creates, which can be made into different colours, depending on the person’s preference and can be linked into the worries and can be used on the mobile app outside of sessions. As somebody who’s worked in more traditional face-to-face CBT therapy, having these in the session and the person in control and interacting is a really significant thing to have in the session, really enhances the experience.
Dr Lucy Maddox: I like the idea of the different colours and the different movement. Can you make the bubbles bigger and smaller as well?
Dr Tom Ward: Absolutely. As you would have in a more traditional CBT session, at the beginning of a session, the person’s asked about how their week has gone, how much of the worry has been on your mind, how distressing has it been. And ratings are done on the touchscreen app, so the person is able to rate and see the change in the bubble. So if it’s been a week where it’s been a little bit less distressing, the person changes the slider and there’s that visual change as well that the person can see.
And also, through the course of the therapy, we talk about different ways to slow down. And people develop their own strategies for slowing down in the situations that they’re struggling with. And the idea of the mobile app is that these strategies that the person might be able to think of in the session. They can be very difficult to think about when you’re actually in a situation where you’re worried if you’re on a bus or on a tube.
So the idea is that these tips, these colourful tips can be brought into the mobile app. And the person can be just one or two touches away from something which they’ve created themselves and they know can help them in that situation.
Dr Lucy Maddox: Angie used the app when she was out and about.
Angie: They gave you a phone with an app on it. You put in all your fears, like getting on the bus or being in a crowd, and then you put in what they called your support bubbles. They came up on screen in little bubbles and it had what you used to cope with these voices and delusions. And you could look on your phone, and it would come up.
Like for instance if I was in a crowd and I wanted to get away, you’d go onto your phone. And it would say things like just remember no one’s looking. Just slow down. And you could use this phone on the bus because nobody knew you weren’t just using a normal smartphone.
Dr Lucy Maddox: Yeah, absolutely. That sounds really, really useful to have it on you all the time.
Angie: It was very useful, very useful. And yeah, nobody looks at anybody now, everybody’s got a phone, so nobody thinks that you’re doing anything different.
Dr Lucy Maddox: It’s so true, it’s more unusual not to have a phone actually now, isn’t it?
Angie: (Laughs) It is. Yeah.
Dr Lucy Maddox: Tom thought those blended approach meant that there was more chance that people could carry on learning from therapy into their day-to-day life.
Dr Tom Ward: Having worked with people for many years, my experience is that really important things can be discussed during a therapy session and really meaningful understanding can emerge. And yet, that can actually be difficult to remember or to use when you need it, when the person needs it, which is in the flow of their life. So that’s really what the digital technology is allowing us to try to do here in SlowMo.
Dr Lucy Maddox: And were the sessions weekly and how long were they for?
Dr Tom Ward: It involved eight sessions conducted weekly. On average they’d range between 60 and 75 minutes across the trial. Given that it’s not simply talking one to one, face-to-face talking for 50, 60 minutes. Given that there’s interaction with the website, where people are listening to the experiences of other people with similar experiences it struck me that actually people were able to engage for slightly longer than we might expect within a more traditional approach.
And also, the other thing that we were very keen to do is where the person was willing, we wanted to take the therapy out into situations where the person was most worried. So this meant taking the phone out with the person to try their slowing down strategies in situations they were fearing.
Dr Lucy Maddox: Yeah, that’s really interesting what you said about people being able to tolerate slightly longer makes me think about sometimes how having difficult conversations can be easier if you’re not having to look at each other all the time. So like if you’re driving or something, sometimes you can have a more in depth conversation. And I was just wondering if you thought that tolerance of slightly longer was to do with the conversation being triangulated through something else as well or whether it was for another reason?
Dr Tom Ward: I absolutely agree with that. I think prior to having delivered the therapy I had some worries or reflections about what would it be like to not have a one-to-one discussion where you’re going back and forth in that way? Because that’s what I’d known, and I wondered whether it might be clunky in some way to have the structure of the website and the material and how that would work in the process of a session.
I wondered how that was going to go. And how it went is exactly how you’ve described it. That the fact that the attention was triangulated, and the person could click and listen to people who had experiences that they may connect with or they might not connect with. And that could be used as a springboard back into a discussion around how the person’s situation was similar or different.
That really did seem to facilitate a really therapeutic process, which to me had some significant benefits over the classic mode of delivery of cognitive interventions. It naturally lent itself towards collaboration because the person was actually controlling the touchscreen and clicking on things. And true collaboration in that way was facilitated. One of the sessions towards the end talks about how our past experiences of relationships can affect how we worry about things in the here and now.
And that can bring up some of the experiences of the people that we’ve worked with involve experiences of trauma and bullying and discrimination are very painful experiences, which can be really painful and difficult to discuss in sessions. And the fact that they were able to hear the experiences of other people and choose the extent to which they wanted to discuss their own experiences. It felt to me that the power was very much with the person in the session and the triangulation really helped in that respect.
Dr Lucy Maddox: And eight sessions is kind of not that long actually, I was thinking. What happens in those sessions? Is there quite a similar content that they tend to follow? Or is it a bit flexible?
Dr Tom Ward: So partly the answer to that question is that it’s targeted and structured. And the evidence from the trial was that therapy was delivered very much as planned. And there are issues within psychological interventions, particularly in the context of psychosis where there’s so much complexity to the situation that it can be hard to retain the clear focus across longer periods of work.
Very much what we were able to do here is provide an engaging way for somebody to really understand and make changes in one very specific area which proved helpful. Having said that, what we’ve also found and we might talk about the findings in a bit more detail. We’ve found that the improvements that we saw in the trial were not limited to the people’s experience of paranoia.
But we actually saw more general improvements in wellbeing, quality of life and the person’s self concept and positive sense of themselves. And that showed that as well as targeting fast and slow thinking, we were able to work with this flexibility to be able to bring in other aspects that might have been relevant for the person. And we know within the context of psychosis how the person sees themselves and self esteem can be so critical. So we were able to target other areas as well within our main focus also.
Angie: I’ve suffered with psychosis for many years and I found this probably one of the most helpful tools that I’ve been offered.
Dr Lucy Maddox: What do you think made the difference? What do you think made it more helpful?
Angie: Probably I was in the right frame of mind. I think it’s important that you accept that you do need some help. So I think that made a difference. Also, it was such a simple idea that you could grasp. And they’d show you little pictures of things. For instance there was a picture of a man with a wallet in his hand, and he was running.
And you had to say what you thought was happening, just to show how your thoughts can be different. I said that it looked like he might have pinched it and was running away. And she said, “Yes, that’s one option.” Or she said that he could have found it and was chasing after the person that had lost it. So it was just a way of learning how to think, to rethink it.
Dr Lucy Maddox: So like opening up just the possibility of there being other explanations for something?
Angie: Exactly. Yes, exactly.
Dr Lucy Maddox: Sometimes people can experience worried or paranoid thoughts about the internet. And I was curious to know how that fed into the design of the app. Here’s Tom.
Dr Tom Ward: It was something that we were considering at the beginning of the trial as something that was potentially something that people might worry about. And one of the ways in which the phone was set up is such that it was possible to use it without connecting it to the internet. So it was possible to have the phone just as a sort of a standalone resource that wouldn’t be connected to the internet and wouldn’t be synchronised with the session. Given that people might potentially have concerns about information that they were adding to a phone being transferred across.
But in effect in the trial, actually people didn’t commonly express those concerns and liked the fact that what they were doing with the phone was actually linked into the session, and it was automatically bringing that into the session. So the concerns around the technology and the surveillance were actually not as significant across the trial as perhaps one might think at the beginning. It was quite interesting to see how naturally people were engaging with the technology in the session.
Dr Lucy Maddox: That’s really interesting and I bet it took so much thinking through at the start to think through all of these potential problems.
Dr Tom Ward: Absolutely, and part of the blending of therapy so that you have face-to-face therapy which is augmented by digital therapies you have an opportunity to develop a therapeutic relationship. To develop trust, which is so crucial when we’re working with anybody but particularly people who’ve experienced worries about other people and paranoia. So in a sense that relationship is facilitating the person engaging with technology, because there is an element of trust, hopefully in the person that they’re seeing.
Dr Lucy Maddox: Sounds like it was a nice experience for you as a therapist as well.
Dr Tom Ward: Absolutely. It’s a nice experience to feel that it’s a really clear and collaborative thing that we’re doing with the person. And it’s thought and designed in a way to make it engaging and easy to use and enjoyable. Yeah, that was a real pleasure to be delivering a therapy that people were engaging with in that way. I sometimes feel you sometimes hear people talk about discussions about whether people are, the idea of socialising people to a psychological model.
Or you even hear sometimes people say, “Perhaps somebody is not psychologically minded.” And you still hear that. And it always really surprises me because it implies somehow that we have the great therapies already and the issue is really the person is not really getting it or able to get it.
Whereas the reality is that we need to develop and provide psychological interventions that meet the needs of a diverse range of people. And actually, in a room face-to-face talking for 50 minutes can be really helpful for lots of people, but it’s not for everybody. And so, I felt really privileged that in collaboration with others like Dr Amy Hardy who really led on this, that we were able to deliver something that really seemed to meet the needs of a really diverse range of people. And so that felt really good to do that.
Dr Lucy Maddox: I was just thinking the only time it would be less accessible I guess is if someone doesn’t have so much access to the internet or to digital technologies. Is that a kind of barrier that’s come up at all or have you mostly found that people tend to have access?
Dr Tom Ward: This is a really important question because it’s about the extent to which some of the people that we work with may be excluded digitally. As you say, maybe don’t have access to wifi, don’t have access to smartphones. Within the trial, we are looking to develop an intervention that works for everybody, regardless of their prior experience or confidence with technology.
We had quite a few people in the trial that would come having not had any access to smartphones, using digital technology or laptops. And one of the interesting things that we’re looking at is just that actually this is an intervention that was engaging for people regardless of their other experiences of digital technology.
But what we actually did within the therapy is that we provided the phone, the app that was loaded onto a smartphone. So that it meant that people could use that and take that away and could have access to that. And it didn’t need to be connected to wifi at all during the week, it was something that the person could take away, and engage with and use.
And when they came back into the session, it would be synchronised with the website so that anything that they’d added they might have noticed the worry or created a helpful positive thought. It would all be synchronised so that it was held within the website. So no learning was lost, it was facilitating in that way.
Dr Lucy Maddox: I asked Angie what had changed for her in her life since SlowMo.
Angie: Before I couldn’t always get on the bus, that was a tricky one. I didn’t like going into crowds, I’d stay home quite a bit. Then I did the SlowMo and the SlowMo made a real difference because it taught me how to think in a positive way and not in a negative way. And it meant that I could actually sit on a bus and not have to get off at a stop because I was feeling conscious of people looking at me. I could go out and meet friends. It really made a difference.
Dr Lucy Maddox: That’s so good. A trial of the effects of SlowMo has recently been published. So what did you find?
Dr Tom Ward: So what we found is that this was an intervention that was designed to help people who were experiencing worries about harm from others or experiencing paranoia. And what we found was that people who received the therapy did show reduced levels of worries about harm from others or paranoia at our follow up periods. So it was effective in what it was designed to do.
One of the other things that we were trying to do here is that it’s designed as a targeted intervention. So we wanted to know is it effective in helping people reduce paranoia? And if it is, does it work in the way in which it’s been designed to work? And that means does it help people to slow down their fast thinking? And is that part of what helps them reduce paranoia?
And so what we found is that people that had the intervention were showing significant reductions in paranoia at the follow ups, compared to people who had standardised treatment as usual. And we also found that it did work in the way that we’d anticipated, it seemed to work by allowing people to slow down their thinking and worry less. So that was really, really encouraging evidence of the effectiveness of the intervention.
And as I’ve mentioned before, the significant changes were not limited to the paranoia measures that we had. We also found really important changes in areas such as quality of life, wellbeing and positive beliefs about the self, really. These are outcomes that are really valued by service users. If you think about what people want from psychological interventions and therapies, people would often say, “I want my life to be better. I want to be enjoying myself. I want to be able to go out and work.”
So we were really, really happy to see that not only was SlowMo effective in reducing paranoia in the way that we expected it to. We were also seeing broader improvements in those important areas as well, so that was really good to see.
Dr Lucy Maddox: That’s fantastic. And really great that it’s actually effective in reducing paranoia as well as reducing those other outcomes to do with quality of life and how people feel. That’s really exciting.
Dr Tom Ward: Absolutely. Other things that we were interested in that I’d mentioned before. We wanted to see the extent to which we were successful in designing an intervention that was engaging and accessible and liked by people. And so we’re really encouraged by the evidence that we’ve got that this was something that people engaged with.
Actually, delivering psychological therapy in the context of people who experience paranoia and may have difficulties building trusting relationships it can be challenging. And drop out from therapy is something that is a significant issue in our field. And so, from the perspective of someone who was responsible for the therapy across the trial, I was so happy to see that we managed to have 80% of the people in the trial who were allocated to receive the therapy completed all of the planned sessions.
And in the context of the field that we work in, this was something that we’re really happy with and speaks to an intervention that people engaged with. And we’re going to be looking at also measures of enjoyment that we’ve also collected. And they’re also showing signs that people found this an enjoyable and engaging experience. So excited about those areas of the outcomes as well as the main outcomes on paranoia and other areas.
Dr Lucy Maddox: That’s great, great results. And really promising, I guess, for using this approach in the future for other sorts of interventions as well, using this design led approach.
Dr Tom Ward: Some of the things that we do take from what we’ve learnt is that yeah, this approach to human centred design and this engagement with thinking about making our interventions more appealing to people. This is really something that people are beginning to think about, but we need to take very seriously. Yeah, we need to start to make interventions look and feel the way people want them to.
And that’s something important. And the other thing is about the blending of digital therapy with face-to-face therapy. I think some people understandably worry when they hear about digital therapy. And they worry that maybe we’ll lose something important. That most psychologists and clinicians will think about therapeutic relationship and how central that is.
And I think people worry sometimes that digital technology might end up lead us away from that important truth. But what we’re trying to do with the blending of digital technology is to take what we do well in face-to-face therapy and just make it better. And make it more effective, make it more engaging and make it work for people in their lives, because that’s where the important change should be occurring.
Dr Lucy Maddox: I asked Angie if there was anything else she wanted to say about the therapy.
Angie: I’d just like to say that if you’re offered a therapy, then it’s worth having a go. If you feel that you’re in the right place in your head, and you’re offered some sort of therapy, it’s a good idea to embrace it and use all the help that you can. Because like me, many years ago I used to think I could cope with it and the voices would go away, and I’d be okay.
But if you don’t take up opportunities when you feel like it, then you’ll miss out and people are there to help you. And you’ve got to try and understand that. And also, with the SlowMo, you’ve got the beauty of the technology with the laptop, but you’ve still got the clinician working with you. So you’ve still got a person that you can talk to. So that’s my advice to try. I know it’s not always easy but try and take up things that you’re offered and don’t be frightened to ask, if there’s anything.
Dr Lucy Maddox: Yeah, that’s really, really helpful advice. And actually, you asked, didn’t you? And then you got on the trial, so that was really good.
Angie: That’s right, I had to keep on. But as I say, I got there, and it worked.
Dr Lucy Maddox: Yeah, it’s great, good for you.
Angie: Thank you.
Dr Lucy Maddox: Thank you to both my experts, Angie and Tom Ward. If you’d like more information on the SlowMo therapy, have a look at the show notes where you can find the website link. There’s a link in there as well to Angie talking on the One Show about the therapy. For more on CBT in general, and for our register of accredited therapists, check out www.babcp.com. And have a listen to our other podcast episodes for more on different types of CBT and the problems that it can help with. I hope you’ve enjoyed this bonus episode. I hope things are going well for you.
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Show Notes
Websites
For more about the research check out: http://slowmotherapy.co.ukAngie talks about SlowMo on The One Show: https://youtu.be/lCI7LKFbyrw
For more on BABCP visit www.babcp.com
Articles
These academic journal articles below are all produced by the SlowMo team to investigate the therapy.Ward, T., Hardy, A., Holm, R., et al. (2022) SlowMo therapy, a new digital blended therapy for fear of harm from others: An account of therapy personalisation within a targeted intervention. Psychology And Psychotherapy: Theory, Research And Practice. DOI : 10.1111/papt.12377
Garety P, Ward T, Emsley R, et al. (2021) Effects of SlowMo, a Blended Digital Therapy Targeting Reasoning, on Paranoia Among People With Psychosis: A Randomized Clinical Trial. JAMA Psychiatry. 2021 Jul 1;78(7):714-725. doi: 10.1001/jamapsychiatry.2021.0326. PMID: 33825827; PMCID: PMC8027943.
Hardy A, Wojdecka A, West J, et al. (2018) How Inclusive, User-Centered Design Research Can Improve Psychological Therapies for Psychosis: Development of SlowMo. JMIR Ment Health ;5(4):e11222 doi: 10.2196/11222
Garety, P.A., Ward, T., Freeman, D. et al. (2017) SlowMo, a digital therapy targeting reasoning in paranoia, versus treatment as usual in the treatment of people who fear harm from others: study protocol for a randomised controlled trial. Trials 18, 510 . https://doi.org/10.1186/s13063-017-2242-7
Books
Overcoming Paranoid and Suspicious Thoughts by Freeman, Freeman & Garety
https://overcoming.co.uk/600/Overcoming-Paranoid-And-Suspicious-Thoughts---FreemanFreemanGarety -
Children don't come with a manual, and parenting can be hard. What is evidence-based parenting training and how can it help? Dr Lucy Maddox interviews Sue Howson and Jane, about their experiences of delivering and receiving this intervention for parents of primary school aged children.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Sue and Jane both recommended this book:
The Incredible Years (R): Trouble Shooting Guide for Parents of Children Aged 3-8 Years
By Carolyn Webster-Stratton (Author)
Sue also recommended this book:
Helping the Noncompliant Child Family-Based Treatment for Oppositional Behaviour Robert J. McMahon, Rex L.Forehand 2nd Edition Paperback (01 Sep 2005) ISBN 978-1593852412
Websiteshttp://www.incredibleyears.com/
https://theministryofparenting.com/
https://www.nurturingmindsconsultancy.co.uk/
For more on CBT the BABCP website is www.babcp.com
Accredited therapists can be found at www.cbtregisteruk.com
Courses
The courses where Sue works are available here, and there are similar courses around the country:
https://www.reading.ac.uk/charliewaller/cwi-iapt.aspx
Photo by Markus Spiske on Unsplash
This episode was edited by Eliza Lomas
Transcript
Lucy: Hello and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not and how it can be useful.
This episode is the last in the current series so we’ll be having a break for a bit, apart from a cheeky bonus episode, which is planned for a few months’ time so look out for that.
Today, I’m finding out about evidence-based parenting training. This is a type of intervention for the parents of primary school aged children. It draws on similar principles to cognitive behavioural therapy about links between thoughts, feelings, behaviours and bodily sensations and ideas from social learning theory. It also draws some ideas from child development such as attachment theory and parenting styles.
To understand more about all of this, I met with Sue Howson, parenting practitioner who works in child mental health services and Jane, a parent who has experienced the training herself.
Jane: My name is Jane and I’ve got a little boy called Jack who is seven and he’s in Year 3.
Lucy: And you’ve experienced evidence-based parenting training, is that right?
Jane: Yeah, I have. It’s something called the Incredible Years. And there was a really nice lady called Sue and my school put us in touch to form a group to kind of help me manage Jack a little bit more at home.
Lucy: So, your journey into it was that the school let you know about it?
Jane: Yeah. Basically, I was having a few issues with Jack at home and I think it was kind of impacting on school as well. So, I was working with the special needs coordinator and she, obviously, had me, Jack and my family in mind as someone who might benefit from working a little bit with Sue.
I was a bit nervous at first, you know, like professionals coming in, getting involved. But she was really nice and it was really beneficial.
Lucy: Is it okay to ask what sort of difficulties you were having at home, sort of what was going on?
Jane: Yeah, I can tell you now because it’s all changed, it’s much better.
Lucy: Oh good, that’s great to hear.
Jane: I mean, Jack’s a lovely boy. He’s my eldest and he’s really nice and just a bit of a joy – he is now. But I think one of the main things that I was struggling with, with him, was kind of difficulties with falling asleep. In the evenings, he would always want me to fall asleep either next to him or in his bed and that was kind of impacting on our evening, mine and my husband’s quite a lot. And it was taking up a lot of time and I think evenings are quite hard because you’re so tired and you just want to go to bed.
So, that was one of the issues. And the no sleep was impacting on all aspects of our family life, really. I would just be really tired all the time and quite short, and end up shouting at Jack when I just wanted him to go to sleep and he wouldn’t. And shouting wasn’t ideal and doesn’t help but I’d just get frustrated, really and I think quite a lot of us were quite unhappy.
Lucy: That sounds super hard.
Jane: Yeah. I mean, he is seven but he’d kind of throw a massive wobbly if he didn’t get what he wanted, like, I don’t know, like an extra biscuit or chocolate finger or something from the cupboard, he would just kind of lose it. And that was really hard to deal with, particularly when you’re tired. I know you shouldn’t but you always kind of end up giving in a little bit, don’t you, because you just want the easy life. And you know that you shouldn’t but…
Sue: It’s really hard when you’re being shouted at or when you’re exhausted like that.
Jane: And I’d also feel like the path of least resistance, like sometimes it just easier to give in, even though I knew that I shouldn’t. So, I guess those are the main issues, really, kind of thinking about his behaviour.
And there were a few concerns from school in terms of his behaviour. Obviously, he was tired at school and maybe not doing as much as he could be schoolwork-wise. It was kind of impacting everything, really. So, that’s where Sue came in.
Sue: My name’s Sue Howson and I am a parenting practitioner and I’ve worked in CAMHS for many years, background in social work. I’ve been working with children and families for years and years and years. But I also have a role of teaching practitioners at the University of Reading.
Lucy: And do you teach practitioners about evidence-based parenting training?
Sue: Yeah, absolutely. So, I have trainees coming from various different parts of the country to Reading University where we teach two really strong evidence-based parenting interventions where the practitioners become super equipped to go out into the community and offer the support that the parents need.
Lucy: Fantastic. And this is all extremely topical because BABCP have recently launched the evidence-based parent training accreditation pathway.
Sue: Yes, which means that the parent training pathway is now on par with the CBT pathway, which is hugely exciting for all those people out there that are actually during parent training and offering parenting interventions. It’s a really great way to get those skills and practices recognised. So yes, I’m really excited by that too.
Lucy: Could you say a little bit about what evidence-based parent training is?
Sue: It is a practice that is based in social learning theory and really focuses on the attachment relationships and building the relationships between parent and child and building on parental self-confidence and self-efficacy and trying to equip the parent and skill up the parent to notice particular behaviours in a child and them then feeling confident in applying a particular technique or a particular method in the moment which will make a difference to – fingers crossed – to the outcome of that little interaction between parent and child.
Lucy: When we’re talking about social learning theory, by that do you mean the way that we all learn from what we see around us?
Sue: Yeah. It’s learned from our environment and the things we see around us.
Lucy: So, it’s kind of providing parents and carers with a different model of how to do things.
Sue: Yes. So, perhaps in their upbringing, they were brought up with one particular style of parenting and parent training offers, perhaps, a selection of different ideas on how they may choose to interact with their child that’s different from the way that they were brought up.
Lucy: Which is very interesting, actually, isn’t it? Because, you know, it’s not something that’s taught in school, is it, parenting? So, it’s very much something that people do quite intuitively or in the way that they’ve been brought up or that their friends are doing it. So, there’s a lot of social influence involved, actually, isn’t there?
Sue: A huge amount of social influence. And quite often, in homes, both parents don’t do it the same way. So, just because you do it one way, your partner might do it in a different way and you may never have even discussed that until you reach a point where you’re having challenges with your child.
So, you may end up having to think about things and being much more consistent. Especially with children with ADHD and autistic spectrum difficulties, the consistency element is really, really important.
Lucy: I asked Jane what she’d expected from evidence-based parenting training.
Jane: Oh, I was a bit nervous and apprehensive to begin with because, you know, it’s bit embarrassing, isn’t it? You’re the one with the naughty kid that doesn’t do what they’re meant to.
Sue kind of made me feel super relaxed from the start. She’s really approachable and just like normal, like not too expert, not using all these words that I didn’t understand. And she was quite relaxed so that kind of made me feel quite relaxed and let me feel comfortable to ask questions, even though they might have been silly or they might seem obvious.
So, that was really nice in the beginning. I liked how she said things about the group rules, like intense confidentiality and respect and that made me feel like it was okay to share, really.
Lucy: That sounds really important.
Jane: Yeah. And I think one of the biggest things, obviously, apart from the actual strategies she gave me, was being able to meet other parents in a similar situation who had a child like mine. And we kind of set up a WhatsApp group after, which is really nice. Now Sue’s worked her magic, that kind of keeps us going. Like if you’re having a bad day, you can still speak to someone who knows.
Lucy: I asked Sue to talk us through what evidence-based parenting training involves and she said there are two methods. The first is the group process, which Jane did. This is usually two hours a week minimum for 12 to 14 weeks on the Incredible Years programme together with parents who are experiencing similar difficulties.
Sue: The other offer would be an individual based programme, which we tend to offer for parents who find it hard to access the group. Or maybe they’ve tried a group before and it hasn’t necessarily worked. Or a parent that doesn’t feel quite ready or confident enough to go into a group so we would offer those parents a sort of one-to-one. Building a very similar model but the child is involved in those.
So, the group one is just for parents but the individual programme, the child comes along to those sessions as well.
Lucy: That’s great. And it’s lovely that it can be so flexible so it can be group or individual. That sounds really important.
Sue: Both have been able to go remote now. That’s been quite a spectacular shift and I think that It’s gone down quite well for parents because it means they don’t have to organise childcare in order to be able to attend groups and things. You know, practitioners have been able to offer them in the evenings, perhaps when kids are in bed or at school, when parents aren’t working. So yeah, it’s gone down really well.
Lucy: That’s fantastic. Yeah, that sounds really helpful. I was really curious about the sort of key skills and techniques that you teach in the evidence-based parent training. What are some of the topmost important skills do you think that get taught?
Sue: The first quarter of the programme, I would suggest, is focused on building that relationship. And that’s largely done through child-led play, spending time together.
Jane: One of the things that we were asked to do was to set aside 15 minutes dedicated time each day to play with him. And I loved it and I felt like I learned loads about him in terms of some of the things he could do with play that I didn’t even know about because I was probably too busy doing the washing up, previously. Rather than me just getting frustrated and shouting. It really kind of built our relationship.
Lucy: That sounds really fun, actually, yeah.
Jane: Yeah, yeah, it’s nice to be a big kid rather than just be adult all the time.
Lucy: Back to Sue.
Sue: There’s a particular way of playing and it’s not just what you do, it’s the way that you do it. We particularly look at noticing what a child’s doing well.
If you’ve got a child who is inattentive, for example, it might be very helpful for the parent to notice when that child is paying attention and focusing. Quickly jump in with praise to encourage that child to do it again. So, that’s the bit of social learning that we’re building on there. So, the child is paying attention, the parent notices the child is paying attention. The parent says, well done to child, so child is more likely to pay attention in that way again.
Jane: Another thing that I learned was like the attention rule. So, it’s kind of drummed into us so what they always say is whichever behaviour you pay most attention to you will see more of and kind of flipping that on its head. So, thinking about what attention I was giving to Jack, whether it was positive or negative and trying to focus on the positives, really, which kind of gave me a little bit of perspective.
I just felt as though he was really difficult all the time, whereas, actually, if took a step back and focused, I realised that he wasn’t and there were lots of really good things that he was doing that I didn’t always necessarily notice.
Sue: We also look at the ways of praising a child or rewarding a child. Quite often – and I’ve definitely been guilty of it myself – is putting a tag on a praise statement, for example. So, we might say, “Ooh, well done for tidying your bedroom. Why can’t you do that all of the time?” And that’s the tag. The tag there is, “Why can’t you do that all the time?” So, we’ve given with one had the praise, “Well done for tidying your bedroom.” But quite often as parents, we will take away the praise by adding that, “I wish you could do that all the time,” or, “Why can’t you be more like your brother?” Or we’ll add a something that actually negates the praise.
So, parents, by week five, six are really becoming conscious of the language that they use and how impactful that can be. And this really works well with the group of kids that I’ve talked about already because they’re quite selective with their listening, perhaps or they don’t really hear it all. So, it’s very powerful for kids to make sure that they’re genuinely hearing praise.
What else do we do? We then go on beyond praise and start thinking about our ability to remove that attention. So, we think about how we ignore a child. And quite often, parents will tell me, “Oh yeah, yeah, yeah, I ignore my children. I can ignore my children for five hours.”
We’re not talking about not being with a child or the child being occupied very happily doing something else. We’re actually talking about an active removal of a parental attention, which is then when the child complies again, then the parent comes back and uses their attention in a particular way to reinforce the positive behaviour.
Lucy: When would a parent do that kind of taking the attention away? Would that be in response to something in particular?
Sue: Yeah, ignoring a particular behaviour. And we suggest that those are the behaviours that are annoying type behaviours. So, we’re talking about whingeing and whining and grumbling and answering back and nagging, you know, “Mummy, can I have a biscuit? Can I have a biscuit? Can I have a biscuit?” The parent has said no and that potentially could escalate between parent and child, where the child says, “You are the worst parent in the world. I hate you. It’s not fair.” But the parent needs to be ignoring that the whole way through.
Kids are brilliant at this, absolutely brilliant, really clever at trying to get parental attention. So, they will up their behaviour. So, they may be saying, “Yeah, you’re the worst parent in the world. I don’t love you anymore. It’s not fair. Lucy down the road, she’s allowed to do this, that and the other.” Quite often, parents will snap at that point, therefore, no longer ignoring the negative behaviour that the child is presenting.
So, the skill is for the parent to be able to keep a lid on it until the child has run out of energy in their negative behaviour. And when the child comes back down, that’s when we want parents to reengage with the child and respond in a positive way to the quiet, calm, polite behaviour that you hope your child is now exhibiting.
Jane: Sue helped me, teaching me strategies to calm down, things like breathing techniques and stuff, obviously, for me and for him so that when he was on the verge of losing it, he could count to 10 or take some deep breaths. It wasn’t like I was just shutting the door and leaving him to lose his mind. And that really helps.
I understand ignore sounds awful but I think it’s about, it’s like what you do and how you do it, rather than ignoring and leaving him to it. Because that’s not very nice.
Sue: The idea of an ignore is only for the duration of the negative behaviour. So, if you think about the whingeing and whining for the biscuit, how long can a child continue to ask you for that biscuit? Five, 10 minutes, tops. You’re not leaving them in a room, you’re not walking out on them, you have just got to develop this sort of Teflon coating where you hear what they’re saying but you choose not to respond to it.
But it’s the parent’s removal of attention that’s key.
So, if a parent is actually leaving the room, then they’re not actively ignoring, they are doing something else. But an active ignore, which is what we’re talking about, the parent has to be very present because the moment the child has come back down that sort of angry curve, they come back down the other side. So, what you try to do if you wait for them to deescalate and then move on and get them involved in another task.
Lucy: I’m just thinking it’s sometimes really difficult to do, isn’t it, just as you describe that kind of…
Sue: Yeah.
Lucy: …snap. Just as things are escalating, particularly in a public situation. Or I guess if you feel that you’re worried that the child’s upset as well, it’s hard, isn’t it?
Sue: Desperately hard, especially if you understand why your child is worried or you understand why your child is fearful, you know, if you’ve got an anxious child, for example. So, parents have to be able to work out which is a behaviour that they want to encourage or which is a behaviour that they want to see less of. And we spend a lot of time thinking about those things.
Parents will say they’re very good at ignoring children but they quite often forget to reengage at the other end. So, the active ignore is a big step.
Lucy: I wanted to know from Jane how it felt to remove a tension in more difficult settings like in public.
Jane: Because I had – well, script is the wrong word – but like a thing to follow, it kind of built my confidence in being able to do it. I think once he kind of learned where the boundaries were at home, it kind of like resolved itself a little bit when we were out in public because he knew from the beginning that it wasn’t going to wash and he was just going to get ignored.
And flipping it on its head in terms of the negative tension, the positive tension, it just kind of got a bit easier because I felt a bit more confident and then I had the skills to cope.
Lucy: Another important aspect which Sue talked about is how we think about the language that we use when we talk to children.
Sue: Quite often, we use a lot of negative commands, “Be careful.” It’s sort of an empty command, what does it actually mean? Whereas autistic spectrum children who probably need very, very clear communication, if they’re playing on a climbing frame, for example, “Be careful,” could be replaced with, “Hang onto the bars,” or, “Use both feet on the climbing frame,” really clear for children to know exactly what they should be doing.
And it’s amazing when you tune in to that and you start listening to your friends and your relatives and things, you do realise that in everyday English, we use a huge number of negative commands for children. You listen to teachers in schools and they’re saying, “Don’t wriggle, don’t poke him next to you, don’t do this, don’t do that.” But what we should be saying is, “Please do, please do this, please do that,” because children quite often only hear the last word that comes out of our mouth. So, if we said, “Don’t run,” the only word they hear is run.
Lucy: Absolutely. And it’s also quite negative, isn’t it, if someone’s constantly telling you stuff not to do. I don’t know, it feels different in tone, doesn’t it to telling you stuff that they would like you to do.
Sue: And when you set them off, in the same CBT-type model, you set them off with homework and home practice and things to do, when they come back the following week, they often say, “Well, the atmosphere in my house completely changed because we were focusing on positives, not negatives.” And again, it begins to shift what you notice as well.
Jane: It’s kind of a bit of a bugbear of mine and now I’ve realised it. Like, quite often, a lot of my friends and even my in-laws or my parents will say, “Oh, you’ve done really well, good boy, good boy.” And for me, it was like thinking about what that even was. Sue really helped me see the importance of being specific around the praise that you’re using. So, that kind of then links it to their behaviour rather than just being, “Oh yeah, that was really good.”
So, specific praise for me was really important. I saw a really big impact on Jack’s behaviour when I was able to use really specific praise with him to, kind of, you know, highlight the good stuff that he’d been doing, like putting his plate in the dishwasher or calming down after an ignore, you know. Like when he was able to use his breathing strategies and then come back and then when we started to play, I’ve said, “Well done for calming down,” or that kind of stuff. So, the specific praise, brilliant.
I think also, thinking about some of the phrases and the language that I use with him. So, if he’s really wanting something like, I don’t know, wanting loads of ice cream or something but he won’t eat his dinner, a little phrase like, “When you’ve eaten your dinner, then you can have your ice cream,” the when-then thing worked really well for me and made me think about the kind of words I was using and the impact that was having. Because, obviously, what I was doing before wasn’t helping.
And I guess the other big thing for me that helped was the use of rewards. So, it helped me think about a specific target for Jack in terms of how we could get him to stay in his own bed. We used like Batman stickers when he was able to do it.
Lucy: That sounds nice.
Jane: And then when he did it consistently for like five nights, we then went ten pin bowling, which was lovely.
Sue: Oh great.
Jane: Yeah. Everything just became a lot more positive, really.
Lucy: That sounds really powerful.
Jane: It was, actually, yeah.
Lucy: Often, parents find that things like time out just aren’t necessary once praise and play and positive attention are in place.
Sue: Absolutely, absolutely. And I don’t know whether you’ve noticed that while I’ve been talking to you, I keep doing this, I keep forming a sort of pyramid with my hands. And the fundamentals of the parent training is really about building that broad base at the bottom, which includes play and attending to a child and listening and problem solving. These are all the building blocks of a really strong relationship. And we’ve got praise in there and we’ve got rewards in there.
And then as you move up the pyramid, you’ve got to start thinking about the other sort of techniques. We’ve got the children stuff at the bottom, you know, all the stuff that you can do with your children to build the relationship. And then you start thinking about the techniques that parents can apply to kind of modify behaviour. So, that’s when we start talking about ignoring or the language that we use, thinking about command statements and starting to put in boundaries.
And then as you get to the tippy top of the pyramid, you’re thinking about time out and the use of consequences.
But fingers crossed and a lot of periods experience this when they’re going through our programme, they start by saying, “I just want to hear about time out. I just want to hear about how to do it better.” We say, “Hey! No, no, no, we’re going to start at the bottom. We’re going to build that relationship.”
And by the time we get to the point where we want to tell them about time out, they actually find that they don’t need to use time out as much as they did at the beginning because they have so many other effective strategies on managing behaviour and noticing different behaviours before we get to the top, before we get to the point where we may need to put in a consequence or a time out.
Lucy: And the very, very end bit of that pyramid that you were describing, the time out is probably something that people kind of are really familiar with, actually, because it’s around because of programmes like Supernanny.
Sue: Yeah, you’re right and people love it on Supernanny, because she spends a lot of time talking about “naughty steps,” doesn’t she?
Lucy: There’s a lot of naughty steps in Supernanny. Is it the same in evidence-based parenting training or is it a bit different?
Sue: It’s similar but it does hang onto that idea of differential attention. So, you can’t just put a child on a naughty step or a naughty spot – and we wouldn’t necessarily use that phrase – we would encourage a parent to be removing their attention on purpose for a period of time. And that time is linked to age, which is very much similar to the Supernanny model.
But one of the things that we would absolutely advocate is making sure that when the child has completed their moment of exclusion, the child comes back into the family activity in a calm state and they’re not expected to say sorry. They’re just expected to come back calm and quiet and you just move on with your activity.
A lot of parents don’t necessarily like hearing the bit about not saying sorry. One of the ways I try to describe it is if you’ve ever had an argument yourself, you don’t immediately calm down. You’re not always receptive to apologising or hearing somebody else’s view. So, by asking a child to apologise in that moment, you either get a, “Ugh, sorry!” which doesn’t mean anything anyway or you will get a reignition of the fire, of the flames of the heat of that moment.
So, it’s actually better to choose your moment to have that discussion, have that teaching element of your parental relationship when the child is calm or by modelling calm yourself or reminding them of what they do well, going back down that pyramid and through play. And the child will enjoy the attention they’re getting so much when they’re being played with in a particular and positive way versus the attention they get when they are simmering and smouldering. So, that’s the rationale.
Lucy: It also sounds less shaming because there’s something tricky, isn’t there, about when any of us have been told off, that rush of shame that you get to begin with. I guess your kind of avoiding like really going over that by getting a child to go over things and say sorry.
Sue: Yes, when they’ve thrown something at their brother and that’s why you’ve removed them from that scenario for a few minutes, they know that they shouldn’t have thrown that thing at their brother or they shouldn’t have kicked you or they shouldn’t have sworn at you.
So, that’s the sort of step on from the ignore and ignore is in the moment hoping that the child can deescalate, wind themselves back in. But if you feel like they have gone beyond that, so there are some behaviours that we completely see as being completely unacceptable and those are the sort of violent behaviours, then that’s when we would put them into the total removal of parental attention, the sort of time out type space.
And so, we do spend quite a bit of time thinking about parents’ thoughts and their physical emotion. So, we think about how cross they are when they’re ignoring or how wound up they are when they’re trying to do time out and we think about how they choose to behave, how they choose to respond to their child as a result of those thoughts and those feelings. So, we try to incorporate those three elements as best we can.
Lucy: I was curious to know whether Jane used any of the techniques from the top of the pyramid like time out with her son.
Jane: I don’t really feel as though we had to use it so much, I think mainly because of Jack’s age, he’s a bit bigger now. The ignore and the praise and the play and the positive attention and also building the relationship had the biggest impact.
And like Sue talked quite a lot about your pyramid being upside down beforehand or properly ignoring, you know, with any like real idea of how to do it or what I was doing. Or maybe trying to put him on the step and then he wouldn’t and then it just all goes wrong.
So, I was probably doing a lot of that at the beginning whilst trying to get through my day and not spending enough time with him and not doing the bottom stuff, which I think, obviously, is what for me has made the biggest difference.
Lucy: But you were doing the best you could, weren’t you, at the time?
Jane: Yeah.
Lucy: Super hard.
Jane: I feel like they don’t come with a manual, do they? But that’s why the group kind of helped really. It gave me a bit of perspective like to stand back and think about things that are kind of happening on a day-to-day and what was going on for both of us, really. And also like a checklist in my head about what to do and when and that was amazing in terms of my confidence, really.
Lucy: I asked Sue what changes she saw from the start of the programme to the end.
Sue: Yes, most parents want to come in and they really, really want to hear about these big time out, big guns approaches, potentially as a little bit of resistance to the idea of building a relationship. “Oh come on, come on, come on, let’s move on. I just want to hear about the big stuff. Why are we wasting our time on this little stuff? I just want to hear about the big stuff.”
But by week three or four, they really do begin to see shifts in the way their children are responding to them and the tone in the house about noticing the positives rather than just looking at the negatives. So, we really see shift early on.
And like I say, by the end, fingers crossed, you would hope that parents are not needing… you know, they feel quite proud when we get to the sort of time out stage of the programme and they go, “Yeah, I get this but I don’t need it,” you know.
So, we do see big, big, big shifts through parents. And one of the things I love and one of the reasons I just keep going with this is because I see that confidence building in parents. And we have parents coming back and saying, “Yeah, we only talked about getting my child to bed but I now realise that if I just apply the same ideas and the same principles, I can use that with, ooh, getting him into school or encouraging him to do his homework.”
So, there are all sorts. We are building skills which you then hope can be sort of expanded out and used in all sorts of settings.
Lucy: And it’s called evidence-based parent training. What is the evidence base like for it?
Sue: The evidence base for both of the programmes that I’ve mentioned so helping the non-compliant child and in particular the Incredible Years, I mean, Incredible Years has had 25 years of research and has been developed over, I think it’s now delivered in 32 countries in 32 different languages to all sorts of different communities.
And it isn’t prescriptive. Parents come along and you work with parents’ individual goals. So, each individual in that group will be working towards their own goal in that group but they’ll have the support of the leaders plus their colleagues in that group who will help them reach that goal. So, it’s sort of tailor made, if you like, to fit individuals who are going through similar things but individuals within a group. Or in the individual programme it’s even more tailor made by definition, I suppose.
But yes, the shifts are huge and it doesn’t necessarily happen in two or three weeks. I think sometimes, parent training has been thought to be done to somebody. But you definitely have to have this sort of collaborative relationship, there’s no other word for it, but this joint working in order to reach the parents’ goals. So, I think that’s really important to get the outcomes that you want.
If I was just telling somebody to do this, you know, “Go home tonight and do this,” that wouldn’t necessarily have the impact of exploring how it’s going to work in your house. And thinking about the parent, well, they know their children the best, don’t they? So, you work with whatever the parent is bringing to you and thinking about how these principles will apply in that instance.
Lucy: And what do you like about your role delivering evidence-based parenting training?
Sue: I like the fact that parents become much more confident in their parenting skill. I love the fact that they come in a little bit like sort of timid mice and go out like roaring lions with the confidence that they’ve got by the end.
I think it changes the way they relate to their children, I think it changes the way they relate to each other as parents and I think it just changes atmospheres in households, which I think is really magical.
Lucy: I asked Jane if there was anything she didn’t like about the sessions and she had no bad things to say. So, I asked her what she enjoyed about it.
Jane: Learning about how to play properly, I think. With Jack, I’m not being like too directive. Like before I was like, “Jack, do this, do this, build your tower, build your train track like that, that’s wrong, dah, dah, dah,” and I didn’t realise how negative I was being.
So yeah, I guess the most enjoyable bit for me was having that dedicated time to spend with Jack playing and watching him play and kind of getting to know him a bit more. Playing and building our relationship really was my favourite.
Lucy: And what sort of difference has it made?
Jane: I just think everyone’s a lot happier at home, which is great. I’m not shouting as much. Jack’s a lot happier because he’s not being shouted at. And the whole house is just a lot calmer and a lot happier and everyone is a lot more positive towards each other and it just makes the atmosphere a lot nicer. There’s a lot less whingeing and moaning and whining from all of us and nagging. (Laughs)
And yeah, I feel like, because Jack’s now able to sleep in his own bed properly without me, it’s really had a positive impact on mine and my husband’s relationship because we actually get an evening together to watch Strictly Come Dancing or, I don’t know, something that’s not to do with the kids. So, that’s really helped.
And I think also because Jack’s now sleeping better and things are happier at home, school is better as well, he’s not so tired. So, he’s able to focus a bit more and get on with his schoolwork a bit more. So, that’s the kind of feedback I’ve had from school, which is nice.
Lucy: It sounds like a really good result.
Jane: Oh yeah, I loved it, yeah, I loved it. It changed my life, anyway. I’d recommend it to anyone.
And no matter how hard a problem seems, there will be someone else out there that’s got a problem like you. You’re not on your own and it’s okay to struggle. Pretty life changing, really.
Lucy: If you’re listening and you want to know more about how to access this sort of support, you can explore your local services online and check out Incredible Years groups in particular. You can also ask your GP who may refer you to Child and Adolescent Mental Health Services.
If you’ve got a child with a diagnosis with ADHD and you want this sort of support, you can ask, “Where can I access parent-based intervention?”
Thank you so much to both of my experts, Sue Howson and Jane. If you’d like more information on evidence-based parenting training, have a look at the show notes. And for any parents juggling home school and work at the moment, my thoughts are with you and I really hope you’re doing okay.
For more on CBT in general and for a register of accredited therapists, check out BABCP.comand have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with. There are quite a few episodes to do with children, including Shirley Reynolds on values-based activities in the pandemic and Maria Loades on helping children with loneliness during Covid-19.
That’s all for now, take care.
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In this episode Dr Lucy Maddox speaks to Sharon and Dr Anne Garland, about CBT for depression. Hear how Sharon describes it, and how both group and individual therapy helped.Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Books
Overcoming Depression by Paul Gilbert
Podcast Episodes
CBT for Perfectionism
Compassion Focussed Therapy
Websites
www.babcp.com
www.cbtregisteruk.com
Image by Kevin Mueller on Unsplash
Transcript
Lucy: Hello and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not and how it can be useful.
In this episode we’re thinking about CBT for depression. I spoke with Dr Anne Garland who spent 25 years working with people who experience depression and Sharon, who has experienced it herself.
Both Anne and Sharon come from a nursing background. Anne now works at the Oxford Cognitive Therapy Centre as a consultant psychotherapist, but she used to work in Nottingham, which is where Sharon had CBT for depression. Here’s Sharon.
How would you describe what depression is like?
Sharon: When I was going to school, when I was a little girl, an infant, we would have to go over the fields because I lived in the country, and go down. I could hear the bell of the junior school but couldn’t find it because of the fog. I walked round and round, I was five, walked round and round and round in those fields trying to get to the bell where I knew I would be safe and being terrified on my own. And that’s how it feels actually. Darkness, cold, very frightening.
Lucy: I asked Anne how depression gets diagnosed and she described a range of symptoms.
Anne: In its acute phase it’s characterised by what would be considered a range of symptoms. So, tiredness, lethargy, lack of motivation, poor concentration, difficulty remembering. Some of the most debilitating symptoms are often disturbed sleep and absence of any sense of enjoyment or pleasure in life and that can be very distressing to people. People can be really plagued with suicidal thoughts and feelings of hopelessness that life is pointless.
I think one of the most devastating things about depression as an illness is it robs people of their ability to do everyday things. So for example, getting up, getting dressed, getting washed, deciding what you want to wear can all be really impaired by the symptoms of depression. I try and help people to understand that the symptoms are real, they’re not imagined. Often people will tell me that they imagine these things or that they aren’t real and that it’s all in their mind.
Their symptoms are real, they exist in the body and do exert a really detrimental effect on just your ability to do what most of us take for granted on a day-to-day basis.
Lucy: And so it’s a lot more than sadness isn’t it?
Anne: Absolutely. It can be very profound feelings of sadness but often that’s amplified by feelings of extreme guilt, of shame, anger and anxiety is another common feature of depression.
Also, when people are very profoundly depressed they can actually just feel numb and feel nothing and that in itself can be very distressing because things that might normally move you to feel a real sense of connection. Say for example your children or your grandchildren, you may have no feelings whatsoever, and that in itself can be very alarming to people.
Lucy: The way that depression and its treatment are thought about can vary depending on who you speak to. Just like with other sorts of mental health problems. More biological viewpoints prioritise thinking about brain changes that can occur with depression while more social perspectives prioritise thinking about the context that people are part of.
Anne: As CBT tends to take a more pragmatic view of thinking about a connection between events in our environment, our reactions to those in terms of biology, thoughts, feelings and behaviour and how all of those things interact and that’s a very pragmatic way of thinking about things really. And I guess traditionally in CBT there’s the idea of making what is referred to as a psycho biosocial intervention. What that essentially means is that you can use medication plus psychological therapies – particularly CBT in this instance – and interventions that may influence your environment.
If you do those things altogether then you’re more likely to get a better outcome, which is really what our service in Nottingham is predicated on that idea. That if you think about all of those aspects in a practical, pragmatic way, then that may maximise your chances of seeing an improvement in depression.
And I think one of the challenges in depression, if you look at the research literature, is once you’ve had one episode of depression, you have a 25% chance of another. Once you’ve had two, a 50% chance. And once you’ve had three, a 95% chance of another episode. So the concept of recurrence becomes really important.
A lot of the work we do with people who have more persistent treatment resistant depression is really trying to help the person develop strategies for managing the illness on a long term basis. So it’s very much about trying to manage your mood and how you structure your day and your life and activities and that type of thing. I can be a very complex illness to work with.
Lucy: For Sharon, her first experience of depression was 20 years ago when depression suddenly had a huge effect on her and her life.
Sharon: And at the time the word they used was ‘decompensated’. Like a little hamster in a wheel and I just couldn’t keep going anymore and everything fell apart. I ended up being admitted to a psychiatric hospital for a few weeks.
Lucy: Ten years later, Sharon had another episode.
Sharon: I just couldn’t manage everything, working full-time, single parent, no family support and it just all imploded, I just couldn’t manage, I became really depressed again.
Lucy: This time she saw a psychiatrist who suggested she try CBT alongside medication. Although reluctant, she went ahead with it. At the time the therapy offered had little effect on her.
Sharon: I can’t describe it, it juts was an academic exercise to me.
Lucy: However, a few years later he doctor encouraged her to try CBT again.
Sharon: Because I like to please, not upset anyone, I went along to it. And it was a group CBT and it was compassion-focused, compassionate-based CBT and it was over about 20-24 weeks, something like that. We met every week, this small group.
Lucy: This time it was different, things started making sense for her.
Sharon: We went through that limbic system, the old brain, the new brain, the threat, soothing, drive, and all this explanation which for me, was a very good fit. Because suddenly, it was like a revelation, “So it’s not just me being weak then.” Even though people had told me, I didn’t really believe it.
So this information was important for me and from that we started to develop the discussions of, “Why do I think the way that I do?” Which was what the early CBT had done but somehow this meant more. It actually touched me.
And being in that small group and hearing other people talking and the two therapists that were there guiding, compassionate responses and, “What would we say to this person?” enabled me to see actually far more clearly the relevance of what they were doing.
Lucy: That sounds super helpful.
Sharon: You could offer a compassionate response and you could see the effect it was having and when they said to me I found it very hard to take, I couldn’t accept anybody being kind or compassionate.
Lucy: Sharon had a combination of group compassion-focused CBT which you can also hear more about in the episode on compassion-focused therapy, as well as individual CBT for depression. I asked Anne to talk us through how individual CBT for depression works.
Anne: Well, CBT for depression has two aspects to it really. The first aspect is the idea of symptom relief and really the purpose of that aspect of the treatment is really to try and help people re-engage with activities.
Say for example you feel too tired to get up out of bed, get washed and dressed and make your breakfast in the 30 minutes you normally would have done that, you might try and break that down into smaller tasks. So you might get out of bed and have a cup of tea. You then might get your breakfast and have another break and then you might get dressed.
So this idea that if you make an allowance for your energy levels, your concentration and try and approach tasks by breaking them down into manageable chunks, that will start to get you active again. So that’s really the first step of symptom relief.
The second aspect of symptom relief in depression is really trying to look at the role thoughts might play in the context of depressed mood. And what the research tells us in the cognitive science of depression is once mood becomes depressed, thinking becomes more negative in content. It also becomes more concrete and more over general, so it’s hard for us to be specific in our recall.
And another important factor, a thing that occurs once mood becomes depressed is our memory more readily recalls past unpleasant painful memories and actively screens out positive or neutral memories. The reason why this is important is that our ability to solve problems is really based on being able to retrieve information from the past about how we did that.
But once mood becomes depressed, you’re trying to do an everyday thing like say, I don’t know, mend a broken sink pipe, and you’re trying to do that, but because your mood is depressed and your concentration isn’t great, it’s harder to do. But also, all that’s coming back to you is all the times things have gone wrong, not the times when they’ve gone well. There’s a tendency when mood is depressed for thinking to be very all or nothing. Or you might predict that if you try something it won’t work and therefore you don’t do it. So it’s really about trying to work at that level as well.
The second part to CBT is really what I would call a more psychological component which is really trying to look at some of what the theory might refer to as psychological vulnerability. So trying to look at some of our beliefs that might underpin our depressive episodes or might make it difficult for us to make progress.
Lucy: Looking at the underlying beliefs was something Sharon remembers as being important for her.
Sharon: So the group was great and from that I then moved into a yearlong one-to-one CBT. And that went into, right back to early life experiences, what sort of things have actually helped to develop you, it’s not your fault, these things happened to you, you were too young, you had no control. And a lot of forgiveness, which I’ve never been able to forgive myself even though I now accept I never did anything wrong. And I wouldn’t have been able to do that before.
But the outcomes from that yearlong – it’s longer than a year because I became very unwell – but when we got to the end of it, we’d worked through looking at the rules that I live my life with and deconstructing them. Where have they come from? Do they stand up to scrutiny? What might be better rules to live with? All with this compassionate focus.
And at the end of it, I’ve still got it now, I’ve got it with me now actually, it’s like a little credit card size piece of card, laminated cardboard with the rules on it, my new rules in case I need a little sort of quick fix of reminder of it. But they’re there, so it’s there all the time.
Lucy: Would you be able to give an example of one?
Sharon: I mean the major one, I was a perfectionist. I had to do everything right. And that’s because I used to get punished, I had a very traumatic, abusive childhood and was punished quite a lot, quite severely. And so I had to get everything right and it had to be right the first time and if I didn’t, I’d get really stressed and worried about it.
In order to replace that now is, I like to do things to a high standard, but it’s okay when they don’t go to plan. Good enough is okay. So things just have to be good enough.
Lucy: That’s great, it sounds a really nice modification because it’s not like you’re giving up on liking to do things to a high standard but you’re just being a bit kinder to yourself with that.
Sharon: Yes, that’s right and to say good enough is okay, yeah.
And the other thing, I’m very obedient, still. If somebody tells me to do something, I’m very likely to do it because I fear consequences. And so that was one that guided, was a very strong guiding thing. And then the other one, so once you’ve got that, it’s okay to be myself, I can let my own needs and feelings be known. I get along with others, but I don’t have to do what they say.
Lucy: Lovely.
Sharon: So they’re just a couple of examples for the way it changed from my rigid control of myself to get through life safely. It was all about safety with me, and security, being safe. To actually thinking, you don’t need to do that, it’s not necessary. You can relax and enjoy yourself and there are no consequences of any significance, to me personally.
Lucy: Some of Sharon’s unhelpful rules for living came from difficult early experiences, although sometimes it’s less clear where these rules come from. You don’t have to know to be able to use CBT.
It’s super helpful to have those examples because I think it can feel so abstract can’t it, when somebody is referred to therapy and they’re not really sure what it’s like. I just think it really helps to hear the exact experiences that somebody else has had.
Sharon: Lots of things actually. You don’t realise, I found, you don’t actually realise you’re living by these rules. It sounds ridiculous (laughs), I didn’t realise until it was discussed in detail with me, gently probing and not going any further than I wanted to. But each time a bit further until actually it was out there. I kind of realised, that’s how I was thinking because it’s so tightly hidden.
Lucy: I asked Anne if someone was a fly on the wall watching a session, what would they see going on?
Anne: I guess they would see really, in terms of starting at the very beginning, trying to help the person to consider the links between events in their environment and then biological symptoms, thoughts, feelings and behaviour.
Just to give you a very simple example of that, say you’ve been depressed for six months and your sleep is affected, it’s taken you until 3:00 in the morning to get to sleep and the alarm has gone off at 7:00, so you’ve woken up in bed. That would be your event in your environment. You feel exhausted and your head is like cotton wool. That would be biological symptoms. And importantly there, most of us when we’re deprived of sleep might feel that way but that becomes intensified in depression.
You might have thoughts like, I can’t be bothered to get up, I feel really tired. You might notice that your mood is really low and so you might lay longer in bed. But also then you might have overslept, so you might then start to have critical thoughts like, you’re really useless, you can’t even get out of bed on time, you’re going to let people down at work, you’re going to be in trouble. You might then start feeling anxious and perhaps a bit guilty.
So you’d really be trying to help people to see that sort of connection.
The aim of antidepressants, if people use them, is really to try and help them to influence some of the biological symptoms of depression and lift mood slightly. So some people do recognise in taking an antidepressant that their mood lifts slightly, some of the symptoms are a bit better. They can do a bit more and therefore their thoughts are not necessarily as negative in content or they’re not as harsh with themselves.
What we’re trying to do in CBT is add to the effects of that by tackling behaviour and thoughts. Usually one of the first homework assignments is to complete an activity schedule. An activity schedule is a diary with every day of the week broken down into hourly slots and what we ask the person to do is keep a record of what they’re doing on an hour-by-hour basis.
We ask them to rate two things there. One is mastery, which is how well you engaged with the activity given how you were feeling. And given how you were feeling is really important because an important part of that initial rationale is making an allowance for the symptoms of depression which are real.
And then the second rating is how much you enjoyed it. So it’s really important to check out if the person feels able to do that.
On the basis on that you’d look for patterns and quite often what you’d see is a pattern between inactivity and low mood and that’s often a marker for rumination.
Also you’d be trying to look for if there had been any activities that are giving the person any sense of pleasure and when you do the ratings, you rate it on a scale of nought to 10. So nought is low and 10 is the high end. And really anything over a four is quite good when your mood is depressed, so that’s what we’d be looking for.
Then we might try and look at activities that the person used to do and enjoy but they’ve given up. Or activities that the person is avoiding and try and think about how we can re-engage with some of those.
Lucy: Here’s Sharon on how her life has changed through doing activities that make her feel good.
Sharon: I had a big fear of meeting up with people, so I wouldn’t go to anything social. I’ve been on my own since the relationship ended 20 years ago and I just won’t take the chance, I won’t risk it again. And all of these things I’ve relaxed now – not that I’m going out with anybody – but I am actually more willing. I meet people for coffee now and I’ll join up with a dog walk and things with other people. Whereas before I’d always make an excuse at the last minute and not go. And I stopped doing that.
Anne: Another important factor in these early stages is really just trying to think also about the effects of not eating and not having a good sleep routine because those two things can really amplify biological symptoms.
Trying to get people to eat regularly and again, with the sleep, trying to re-establish a sleep routine. Thinking about things like caffeine consumption and perhaps not drinking any caffeine after lunch. So very practical things to start with and then trying to begin to schedule pleasurable activities. And also, as I said before, breaking tasks down into manageable chunks.
Lucy: It sounds like breaking stuff down, making it really small and manageable and scaling things back is really important. What other sorts of things might somebody see if they were observing a CBT session?
Anne: I guess they would see us working together. It’s very much what’s referred to as a collaborative endeavour. The person receiving treatment, they bring their expertise and knowledge in how depression affects them on a day-to-day basis. And I bring my expertise and knowledge in terms of how to help people begin to tackle their depression.
We’d also be writing lots of things down. Working towards goals as well, goal setting is a very important part of CBT. So the beginning of treatment you’d be thinking about what problems the person wanted to tackle and what would be the goals that would indicate you’d started to work on those problems.
So it’s very much a participative activity, is CBT. So the person really needs to make an active commitment to try and work within the model. Now obviously depressive symptoms in themselves can make that a challenge because lack of motivation is a key symptom of depression.
So again, in the early stages you might see the therapist working very hard to help the person to engage with treatment.
Lucy: Negative automatic thoughts are those which occur to us automatically. So we don’t have control over thinking that way. And they tend to frame the experiences that we’re having in a way that makes us feel bad about ourselves, or what we’re doing, or about the world around us. They can have a really big impact on our mood and sometimes we don’t even notice that they’re happening.
For people who experience depression, automatic negative thoughts such as ‘I can’t cope’, can often be problematic and persistent.
How might CBT help people to manage those thoughts?
Anne: Well, there’s a variety of methods that can be used. The first one is really just trying to help the person to recognise when they occur, so what are the triggers to them. And also how do they make them feel and what is the impact of that.
And then you can try what’s called modifying or challenging automatic thoughts. So you can apply a series of questions to a thought, what is the evidence for the thought? What is the evidence against the thought? What is the alternative perspective?
And this is a really useful strategy when you’re working with depression because people with depression apply rules to themselves that they wouldn’t apply to other people. So very typically I might ask the person, “Can you tell me the name of somebody whose opinion you respect?” And then I would say, “If you heard your friend Jane say that she was lazy, what would you say to her?” And then I might reverse that and say, “If Jane were here, what would Jane say to you?”
What you’re trying to do is bring flexibility to the thought processes because in depression thinking processes are very rigid, they’re very all or nothing, so they don’t see the shades of grey and they’re very over general.
You then also try to help them to think about what is the impact of thinking this way, or what can you do next? How can you test this out? Which is where the idea of behavioural experiments come from.
Lucy: Behavioural experiments are planned activities to test the validity of a belief. They’re an information gathering exercise, so we test how accurate an individual belief is.
For Sharon re-joining her group helped her test some of her beliefs about what the group members thought about her having left.
Sharon: The group was a challenge because I don’t like being in a group with people. It’s an effort to keep smiling. But I learnt there that I didn’t need to. So I’d be stressed before I went there for quite a number of them and actually I just stopped going, just after halfway through because I just couldn’t cope with it. It was just too intense, it was too much.
And so Catherine phoned me and persuaded me back and I said, “I can’t go in there, I can’t go in there,” and I walked out. I can’t go back in that room when I’ve walked out. And it was just gentle nudging and when I went in they were just, “Oh, hello,” nobody made a comment at all and I was astonished because I thought somebody was going to say, “Oh, back are you?” Not at all, and that was another illustration of my disordered thinking.
So that was a tiring six months, but at the end of it I felt quite upbeat that I’d achieved something.
The individual sessions for the year, they were always extremely positive. But I always came out of there feeling that it was a job well done, I’d achieved something. I never felt, “Ugh, I’m not coming back,” not once. It was excellent from start to finish.
Lucy: I wanted to know from Sharon how she coped with negative thoughts and if she uses the techniques which Anne mentions.
Sharon: I still use all those CBT techniques of the alternative way of looking… What’s another reason that this could be…? Is that really the way this is when you’re feeling down? Deconstruct it. What actually is it that’s a concern here? And are you actually…? Are you thinking about this clearly or could something else be happening? So I still use all of those techniques every day.
Lucy: Do you? It’s really hard isn’t it when you’re having a worry or a thought about how things are in your own head that’s distressing. It feels real doesn’t it? We all feel that our reality is real. How do you manage to capture those thoughts and to sort of use those techniques?
Sharon: I write it down. Things, when they start to swirl around my head and then I know from experience when I’m feeling well, this is just going to look nothing like the original issue unless you get it out of your head. And so I write it down and then I think, what’s actually… I deconstruct it and then put it back together again.
Lucy: And when you’re coming out of it, did you notice yourself coming out of it? Did you notice things changing or was it after it’s gone that you kind of look back and see it differently?
Sharon: Coming out of it, in some ways it’s a bit scary actually because you get used to being in that gloom and that dark. And it requires effort to re-engage and make contact with people and all the rest of it.
It was a year ago that I finished; I’ve been well since then, yeah. So I felt smiley, I’ve had a few, we all have in the last year haven’t we, had a lot of low… Even thinking like that, thinking it’s not me not trying hard enough, I’m thinking why wouldn’t I feel like this? Everybody is feeling like this. So I consider that, when I think like that, I give myself a little mental pat on the shoulder for thinking, “Excellent thinking Sharon.”
Lucy: I asked Anne what the evidence base was like for CBT for depression.
Anne: Well, there’s a very strong evidence base that goes right back to the 70s and 80s really. Essentially, if you summarise, if you look at NICE guidance, what the research tells us is that CBT used alone is as effective as an antidepressant on its own. The two things in combination produce the best outcome. Particularly for people who have moderate to severe depression.
For people who have more mild depression, you might actually just start with CBT and that can be highly effective.
Lucy: The current NICE guidelines recommend CBT for depression and also a range of other treatments. I’ve put a link in the show notes for those guidelines.
Anne: If you look at the evidence base for people with more persistent treatment resistant depression, there is evidence from two studies that I was involved in. One back in the 90s with Jan Scott and Eugene Paykel who were both professors of psychiatry who have now retired. And a more recent one that Richard Morris, Professor of Psychiatry in Nottingham and I conducted where we looked at using CBT in combination with pharmacology for people with more, either chronic depression or persistent treatment resistance. And there is a lot of evidence that it’s very effective in helping people manage the disorder rather than trying to get rid of it completely.
Lucy: That’s really helpful for people to know isn’t it? I suppose not everything might totally resolve and it might be more a case of living with it effectively.
Anne: Exactly, yeah.
Lucy: Are there things you think people should know before they come for CBT?
Anne: I think particularly just picking up on that last point as well, thinking about the impact of childhood trauma can have in terms of depressed mood. When we think about trauma we’re thinking about that in a broad context of it might be sexual and physical abuse, but much more commonly, it’s actual emotional abuse and neglect, childhood neglect, particularly in terms of how that impacts on what psychology would refer to as attachments. Our ability to make and maintain reciprocally beneficial relationships with other people.
And there’s increasing amount of evidence to show that where attachments are disrupted, then that can have a profound effect in terms of adult depression. And I think that’s where a lot of the research is focusing now in terms of thinking about how you might develop more focused interventions in CBT terms.
I think the other thing is that CBT is a very practical therapy. So there’s an idea that you participate, you will be asked to complete, what we refer to as ‘homework’, which isn’t a phrase many people like. So you’d be asked to work on your problems in between sessions.
Initially it’s very here and now focused. So it’s really trying to think about what your problems are on a day-to-day basis in terms of how the depression affects you. And then later in therapy if necessary, we might go back to some childhood events. But generally speaking you only go backwards to the degree to which it tells you how that influences what goes on in the here and now.
It’s also about doing, it’s not just about talking.
Lucy: For Sharon, although she doesn’t feel depression has disappeared completely from her life, she’s found a way to cope and see her thoughts for what they are, thoughts, rather than acting on them. I wanted to know what she would say to anybody thinking of trying CBT for depression.
Sharon: Go for it! Definitely! I think the thing is to be prepared; you’ve got to put some effort into it to get something out of it.
Lucy: The experience that Sharon had of trying therapy more than once and finding it a better fit at a later date can happen to anyone, either because the therapist is a better fit, the type of approach works more or sometimes because the therapist has had more experience in a particular model of therapy.
It’s always okay to raise it with a therapist if you feel like things aren’t working for you. It’s also important to be able to check out what training or experience the therapist has had with treating the problem that you’re going to see them for. One way to check this out is by seeing if they’re accredited with BABCP.
Sharon: As I say, it was a revelation. In fact one of the biggest things was listening to people talking. You think, gosh, that’s how I think!
Lucy: If you’d like more information on CBT for depression, have a look at the show notes. For more on CBT in general and for a register of accredited therapists, check out BABCP.com.
Have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with.
There’s one with Paul Gilbert, who Anne mentions and also Chris Winson, who speak about compassion-focused therapy for depression. And there’s loads more on other common problems that CBT can help with including anxiety.
Thank you to both of my experts, Sharon and Dr Anne Garland.
Thank you for listening and I hope you’re keeping well in these odd times we’re all living through. Until next time, take care.
END OF AUDIO
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Anxiety is one of the most common mental health problems, but there's a good evidence-base for CBT as a helpful intervention. In this podcast, Dr Lucy Maddox speaks with Dr Blake Stobie and Claire Read, about what CBT for anxiety is like, and how anxious thoughts can be like the circle line.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Websites
BABCP
https://www.babcp.com
Accredited register of CBT therapists
https://www.cbtregisteruk.com
Anxiety UK
https://www.anxietyuk.org.uk
NICE guidelines on anxiety
https://www.nice.org.uk/guidance/qs53
Apps
Claire recommended the Thought Diary Pro app as being helpful to use in conjunction with therapy to complete thought records.
https://www.good-thinking.uk/resources/thought-diary-pro/
Books
Claire recommended this workbook on Overcoming Low Self Esteem by Melanie Fennell https://www.amazon.co.uk/Overcoming-Low-Self-Esteem-Self-help-Course/dp/1845292375/ref=sr_1_2?dchild=1&keywords=self+esteem+workbook+melanie+fennell&qid=1605884391&s=books&sr=1-2
And this book by Helen Kennerley on Overcoming Anxiety is part of the same series
https://www.amazon.co.uk/Overcoming-Anxiety-Books-Prescription-Title/dp/1849018782/ref=sr_1_1?dchild=1&keywords=overcoming+anxiety&qid=1605884437&s=books&sr=1-1
Credits
Image used is by Robert Tudor from Unsplash
Podcast episode produced and edited by Lucy Maddox for BABCP
Transcript
Lucy: Hello and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not and how it can be useful.
In this episode we’re thinking about CBT for depression. I spoke with Dr Anne Garland who spent 25 years working with people who experience depression and Sharon, who has experienced it herself.
Both Anne and Sharon come from a nursing background. Anne now works at the Oxford Cognitive Therapy Centre as a consultant psychotherapist, but she used to work in Nottingham, which is where Sharon had CBT for depression. Here’s Sharon.
How would you describe what depression is like?
Sharon: When I was going to school, when I was a little girl, an infant, we would have to go over the fields because I lived in the country, and go down. I could hear the bell of the junior school but couldn’t find it because of the fog. I walked round and round, I was five, walked round and round and round in those fields trying to get to the bell where I knew I would be safe and being terrified on my own. And that’s how it feels actually. Darkness, cold, very frightening.
Lucy: I asked Anne how depression gets diagnosed and she described a range of symptoms.
Anne: In its acute phase it’s characterised by what would be considered a range of symptoms. So, tiredness, lethargy, lack of motivation, poor concentration, difficulty remembering. Some of the most debilitating symptoms are often disturbed sleep and absence of any sense of enjoyment or pleasure in life and that can be very distressing to people. People can be really plagued with suicidal thoughts and feelings of hopelessness that life is pointless.
I think one of the most devastating things about depression as an illness is it robs people of their ability to do everyday things. So for example, getting up, getting dressed, getting washed, deciding what you want to wear can all be really impaired by the symptoms of depression. I try and help people to understand that the symptoms are real, they’re not imagined. Often people will tell me that they imagine these things or that they aren’t real and that it’s all in their mind.
Their symptoms are real, they exist in the body and do exert a really detrimental effect on just your ability to do what most of us take for granted on a day-to-day basis.
Lucy: And so it’s a lot more than sadness isn’t it?
Anne: Absolutely. It can be very profound feelings of sadness but often that’s amplified by feelings of extreme guilt, of shame, anger and anxiety is another common feature of depression.
Also, when people are very profoundly depressed they can actually just feel numb and feel nothing and that in itself can be very distressing because things that might normally move you to feel a real sense of connection. Say for example your children or your grandchildren, you may have no feelings whatsoever, and that in itself can be very alarming to people.
Lucy: The way that depression and its treatment are thought about can vary depending on who you speak to. Just like with other sorts of mental health problems. More biological viewpoints prioritise thinking about brain changes that can occur with depression while more social perspectives prioritise thinking about the context that people are part of.
Anne: As CBT tends to take a more pragmatic view of thinking about a connection between events in our environment, our reactions to those in terms of biology, thoughts, feelings and behaviour and how all of those things interact and that’s a very pragmatic way of thinking about things really. And I guess traditionally in CBT there’s the idea of making what is referred to as a psycho biosocial intervention. What that essentially means is that you can use medication plus psychological therapies – particularly CBT in this instance – and interventions that may influence your environment.
If you do those things altogether then you’re more likely to get a better outcome, which is really what our service in Nottingham is predicated on that idea. That if you think about all of those aspects in a practical, pragmatic way, then that may maximise your chances of seeing an improvement in depression.
And I think one of the challenges in depression, if you look at the research literature, is once you’ve had one episode of depression, you have a 25% chance of another. Once you’ve had two, a 50% chance. And once you’ve had three, a 95% chance of another episode. So the concept of recurrence becomes really important.
A lot of the work we do with people who have more persistent treatment resistant depression is really trying to help the person develop strategies for managing the illness on a long term basis. So it’s very much about trying to manage your mood and how you structure your day and your life and activities and that type of thing. I can be a very complex illness to work with.
Lucy: For Sharon, her first experience of depression was 20 years ago when depression suddenly had a huge effect on her and her life.
Sharon: And at the time the word they used was ‘decompensated’. Like a little hamster in a wheel and I just couldn’t keep going anymore and everything fell apart. I ended up being admitted to a psychiatric hospital for a few weeks.
Lucy: Ten years later, Sharon had another episode.
Sharon: I just couldn’t manage everything, working full-time, single parent, no family support and it just all imploded, I just couldn’t manage, I became really depressed again.
Lucy: This time she saw a psychiatrist who suggested she try CBT alongside medication. Although reluctant, she went ahead with it. At the time the therapy offered had little effect on her.
Sharon: I can’t describe it, it juts was an academic exercise to me.
Lucy: However, a few years later he doctor encouraged her to try CBT again.
Sharon: Because I like to please, not upset anyone, I went along to it. And it was a group CBT and it was compassion-focused, compassionate-based CBT and it was over about 20-24 weeks, something like that. We met every week, this small group.
Lucy: This time it was different, things started making sense for her.
Sharon: We went through that limbic system, the old brain, the new brain, the threat, soothing, drive, and all this explanation which for me, was a very good fit. Because suddenly, it was like a revelation, “So it’s not just me being weak then.” Even though people had told me, I didn’t really believe it.
So this information was important for me and from that we started to develop the discussions of, “Why do I think the way that I do?” Which was what the early CBT had done but somehow this meant more. It actually touched me.
And being in that small group and hearing other people talking and the two therapists that were there guiding, compassionate responses and, “What would we say to this person?” enabled me to see actually far more clearly the relevance of what they were doing.
Lucy: That sounds super helpful.
Sharon: You could offer a compassionate response and you could see the effect it was having and when they said to me I found it very hard to take, I couldn’t accept anybody being kind or compassionate.
Lucy: Sharon had a combination of group compassion-focused CBT which you can also hear more about in the episode on compassion-focused therapy, as well as individual CBT for depression. I asked Anne to talk us through how individual CBT for depression works.
Anne: Well, CBT for depression has two aspects to it really. The first aspect is the idea of symptom relief and really the purpose of that aspect of the treatment is really to try and help people re-engage with activities.
Say for example you feel too tired to get up out of bed, get washed and dressed and make your breakfast in the 30 minutes you normally would have done that, you might try and break that down into smaller tasks. So you might get out of bed and have a cup of tea. You then might get your breakfast and have another break and then you might get dressed.
So this idea that if you make an allowance for your energy levels, your concentration and try and approach tasks by breaking them down into manageable chunks, that will start to get you active again. So that’s really the first step of symptom relief.
The second aspect of symptom relief in depression is really trying to look at the role thoughts might play in the context of depressed mood. And what the research tells us in the cognitive science of depression is once mood becomes depressed, thinking becomes more negative in content. It also becomes more concrete and more over general, so it’s hard for us to be specific in our recall.
And another important factor, a thing that occurs once mood becomes depressed is our memory more readily recalls past unpleasant painful memories and actively screens out positive or neutral memories. The reason why this is important is that our ability to solve problems is really based on being able to retrieve information from the past about how we did that.
But once mood becomes depressed, you’re trying to do an everyday thing like say, I don’t know, mend a broken sink pipe, and you’re trying to do that, but because your mood is depressed and your concentration isn’t great, it’s harder to do. But also, all that’s coming back to you is all the times things have gone wrong, not the times when they’ve gone well. There’s a tendency when mood is depressed for thinking to be very all or nothing. Or you might predict that if you try something it won’t work and therefore you don’t do it. So it’s really about trying to work at that level as well.
The second part to CBT is really what I would call a more psychological component which is really trying to look at some of what the theory might refer to as psychological vulnerability. So trying to look at some of our beliefs that might underpin our depressive episodes or might make it difficult for us to make progress.
Lucy: Looking at the underlying beliefs was something Sharon remembers as being important for her.
Sharon: So the group was great and from that I then moved into a yearlong one-to-one CBT. And that went into, right back to early life experiences, what sort of things have actually helped to develop you, it’s not your fault, these things happened to you, you were too young, you had no control. And a lot of forgiveness, which I’ve never been able to forgive myself even though I now accept I never did anything wrong. And I wouldn’t have been able to do that before.
But the outcomes from that yearlong – it’s longer than a year because I became very unwell – but when we got to the end of it, we’d worked through looking at the rules that I live my life with and deconstructing them. Where have they come from? Do they stand up to scrutiny? What might be better rules to live with? All with this compassionate focus.
And at the end of it, I’ve still got it now, I’ve got it with me now actually, it’s like a little credit card size piece of card, laminated cardboard with the rules on it, my new rules in case I need a little sort of quick fix of reminder of it. But they’re there, so it’s there all the time.
Lucy: Would you be able to give an example of one?
Sharon: I mean the major one, I was a perfectionist. I had to do everything right. And that’s because I used to get punished, I had a very traumatic, abusive childhood and was punished quite a lot, quite severely. And so I had to get everything right and it had to be right the first time and if I didn’t, I’d get really stressed and worried about it.
In order to replace that now is, I like to do things to a high standard, but it’s okay when they don’t go to plan. Good enough is okay. So things just have to be good enough.
Lucy: That’s great, it sounds a really nice modification because it’s not like you’re giving up on liking to do things to a high standard but you’re just being a bit kinder to yourself with that.
Sharon: Yes, that’s right and to say good enough is okay, yeah.
And the other thing, I’m very obedient, still. If somebody tells me to do something, I’m very likely to do it because I fear consequences. And so that was one that guided, was a very strong guiding thing. And then the other one, so once you’ve got that, it’s okay to be myself, I can let my own needs and feelings be known. I get along with others, but I don’t have to do what they say.
Lucy: Lovely.
Sharon: So they’re just a couple of examples for the way it changed from my rigid control of myself to get through life safely. It was all about safety with me, and security, being safe. To actually thinking, you don’t need to do that, it’s not necessary. You can relax and enjoy yourself and there are no consequences of any significance, to me personally.
Lucy: Some of Sharon’s unhelpful rules for living came from difficult early experiences, although sometimes it’s less clear where these rules come from. You don’t have to know to be able to use CBT.
It’s super helpful to have those examples because I think it can feel so abstract can’t it, when somebody is referred to therapy and they’re not really sure what it’s like. I just think it really helps to hear the exact experiences that somebody else has had.
Sharon: Lots of things actually. You don’t realise, I found, you don’t actually realise you’re living by these rules. It sounds ridiculous (laughs), I didn’t realise until it was discussed in detail with me, gently probing and not going any further than I wanted to. But each time a bit further until actually it was out there. I kind of realised, that’s how I was thinking because it’s so tightly hidden.
Lucy: I asked Anne if someone was a fly on the wall watching a session, what would they see going on?
Anne: I guess they would see really, in terms of starting at the very beginning, trying to help the person to consider the links between events in their environment and then biological symptoms, thoughts, feelings and behaviour.
Just to give you a very simple example of that, say you’ve been depressed for six months and your sleep is affected, it’s taken you until 3:00 in the morning to get to sleep and the alarm has gone off at 7:00, so you’ve woken up in bed. That would be your event in your environment. You feel exhausted and your head is like cotton wool. That would be biological symptoms. And importantly there, most of us when we’re deprived of sleep might feel that way but that becomes intensified in depression.
You might have thoughts like, I can’t be bothered to get up, I feel really tired. You might notice that your mood is really low and so you might lay longer in bed. But also then you might have overslept, so you might then start to have critical thoughts like, you’re really useless, you can’t even get out of bed on time, you’re going to let people down at work, you’re going to be in trouble. You might then start feeling anxious and perhaps a bit guilty.
So you’d really be trying to help people to see that sort of connection.
The aim of antidepressants, if people use them, is really to try and help them to influence some of the biological symptoms of depression and lift mood slightly. So some people do recognise in taking an antidepressant that their mood lifts slightly, some of the symptoms are a bit better. They can do a bit more and therefore their thoughts are not necessarily as negative in content or they’re not as harsh with themselves.
What we’re trying to do in CBT is add to the effects of that by tackling behaviour and thoughts. Usually one of the first homework assignments is to complete an activity schedule. An activity schedule is a diary with every day of the week broken down into hourly slots and what we ask the person to do is keep a record of what they’re doing on an hour-by-hour basis.
We ask them to rate two things there. One is mastery, which is how well you engaged with the activity given how you were feeling. And given how you were feeling is really important because an important part of that initial rationale is making an allowance for the symptoms of depression which are real.
And then the second rating is how much you enjoyed it. So it’s really important to check out if the person feels able to do that.
On the basis on that you’d look for patterns and quite often what you’d see is a pattern between inactivity and low mood and that’s often a marker for rumination.
Also you’d be trying to look for if there had been any activities that are giving the person any sense of pleasure and when you do the ratings, you rate it on a scale of nought to 10. So nought is low and 10 is the high end. And really anything over a four is quite good when your mood is depressed, so that’s what we’d be looking for.
Then we might try and look at activities that the person used to do and enjoy but they’ve given up. Or activities that the person is avoiding and try and think about how we can re-engage with some of those.
Lucy: Here’s Sharon on how her life has changed through doing activities that make her feel good.
Sharon: I had a big fear of meeting up with people, so I wouldn’t go to anything social. I’ve been on my own since the relationship ended 20 years ago and I just won’t take the chance, I won’t risk it again. And all of these things I’ve relaxed now – not that I’m going out with anybody – but I am actually more willing. I meet people for coffee now and I’ll join up with a dog walk and things with other people. Whereas before I’d always make an excuse at the last minute and not go. And I stopped doing that.
Anne: Another important factor in these early stages is really just trying to think also about the effects of not eating and not having a good sleep routine because those two things can really amplify biological symptoms.
Trying to get people to eat regularly and again, with the sleep, trying to re-establish a sleep routine. Thinking about things like caffeine consumption and perhaps not drinking any caffeine after lunch. So very practical things to start with and then trying to begin to schedule pleasurable activities. And also, as I said before, breaking tasks down into manageable chunks.
Lucy: It sounds like breaking stuff down, making it really small and manageable and scaling things back is really important. What other sorts of things might somebody see if they were observing a CBT session?
Anne: I guess they would see us working together. It’s very much what’s referred to as a collaborative endeavour. The person receiving treatment, they bring their expertise and knowledge in how depression affects them on a day-to-day basis. And I bring my expertise and knowledge in terms of how to help people begin to tackle their depression.
We’d also be writing lots of things down. Working towards goals as well, goal setting is a very important part of CBT. So the beginning of treatment you’d be thinking about what problems the person wanted to tackle and what would be the goals that would indicate you’d started to work on those problems.
So it’s very much a participative activity, is CBT. So the person really needs to make an active commitment to try and work within the model. Now obviously depressive symptoms in themselves can make that a challenge because lack of motivation is a key symptom of depression.
So again, in the early stages you might see the therapist working very hard to help the person to engage with treatment.
Lucy: Negative automatic thoughts are those which occur to us automatically. So we don’t have control over thinking that way. And they tend to frame the experiences that we’re having in a way that makes us feel bad about ourselves, or what we’re doing, or about the world around us. They can have a really big impact on our mood and sometimes we don’t even notice that they’re happening.
For people who experience depression, automatic negative thoughts such as ‘I can’t cope’, can often be problematic and persistent.
How might CBT help people to manage those thoughts?
Anne: Well, there’s a variety of methods that can be used. The first one is really just trying to help the person to recognise when they occur, so what are the triggers to them. And also how do they make them feel and what is the impact of that.
And then you can try what’s called modifying or challenging automatic thoughts. So you can apply a series of questions to a thought, what is the evidence for the thought? What is the evidence against the thought? What is the alternative perspective?
And this is a really useful strategy when you’re working with depression because people with depression apply rules to themselves that they wouldn’t apply to other people. So very typically I might ask the person, “Can you tell me the name of somebody whose opinion you respect?” And then I would say, “If you heard your friend Jane say that she was lazy, what would you say to her?” And then I might reverse that and say, “If Jane were here, what would Jane say to you?”
What you’re trying to do is bring flexibility to the thought processes because in depression thinking processes are very rigid, they’re very all or nothing, so they don’t see the shades of grey and they’re very over general.
You then also try to help them to think about what is the impact of thinking this way, or what can you do next? How can you test this out? Which is where the idea of behavioural experiments come from.
Lucy: Behavioural experiments are planned activities to test the validity of a belief. They’re an information gathering exercise, so we test how accurate an individual belief is.
For Sharon re-joining her group helped her test some of her beliefs about what the group members thought about her having left.
Sharon: The group was a challenge because I don’t like being in a group with people. It’s an effort to keep smiling. But I learnt there that I didn’t need to. So I’d be stressed before I went there for quite a number of them and actually I just stopped going, just after halfway through because I just couldn’t cope with it. It was just too intense, it was too much.
And so Catherine phoned me and persuaded me back and I said, “I can’t go in there, I can’t go in there,” and I walked out. I can’t go back in that room when I’ve walked out. And it was just gentle nudging and when I went in they were just, “Oh, hello,” nobody made a comment at all and I was astonished because I thought somebody was going to say, “Oh, back are you?” Not at all, and that was another illustration of my disordered thinking.
So that was a tiring six months, but at the end of it I felt quite upbeat that I’d achieved something.
The individual sessions for the year, they were always extremely positive. But I always came out of there feeling that it was a job well done, I’d achieved something. I never felt, “Ugh, I’m not coming back,” not once. It was excellent from start to finish.
Lucy: I wanted to know from Sharon how she coped with negative thoughts and if she uses the techniques which Anne mentions.
Sharon: I still use all those CBT techniques of the alternative way of looking… What’s another reason that this could be…? Is that really the way this is when you’re feeling down? Deconstruct it. What actually is it that’s a concern here? And are you actually…? Are you thinking about this clearly or could something else be happening? So I still use all of those techniques every day.
Lucy: Do you? It’s really hard isn’t it when you’re having a worry or a thought about how things are in your own head that’s distressing. It feels real doesn’t it? We all feel that our reality is real. How do you manage to capture those thoughts and to sort of use those techniques?
Sharon: I write it down. Things, when they start to swirl around my head and then I know from experience when I’m feeling well, this is just going to look nothing like the original issue unless you get it out of your head. And so I write it down and then I think, what’s actually… I deconstruct it and then put it back together again.
Lucy: And when you’re coming out of it, did you notice yourself coming out of it? Did you notice things changing or was it after it’s gone that you kind of look back and see it differently?
Sharon: Coming out of it, in some ways it’s a bit scary actually because you get used to being in that gloom and that dark. And it requires effort to re-engage and make contact with people and all the rest of it.
It was a year ago that I finished; I’ve been well since then, yeah. So I felt smiley, I’ve had a few, we all have in the last year haven’t we, had a lot of low… Even thinking like that, thinking it’s not me not trying hard enough, I’m thinking why wouldn’t I feel like this? Everybody is feeling like this. So I consider that, when I think like that, I give myself a little mental pat on the shoulder for thinking, “Excellent thinking Sharon.”
Lucy: I asked Anne what the evidence base was like for CBT for depression.
Anne: Well, there’s a very strong evidence base that goes right back to the 70s and 80s really. Essentially, if you summarise, if you look at NICE guidance, what the research tells us is that CBT used alone is as effective as an antidepressant on its own. The two things in combination produce the best outcome. Particularly for people who have moderate to severe depression.
For people who have more mild depression, you might actually just start with CBT and that can be highly effective.
Lucy: The current NICE guidelines recommend CBT for depression and also a range of other treatments. I’ve put a link in the show notes for those guidelines.
Anne: If you look at the evidence base for people with more persistent treatment resistant depression, there is evidence from two studies that I was involved in. One back in the 90s with Jan Scott and Eugene Paykel who were both professors of psychiatry who have now retired. And a more recent one that Richard Morris, Professor of Psychiatry in Nottingham and I conducted where we looked at using CBT in combination with pharmacology for people with more, either chronic depression or persistent treatment resistance. And there is a lot of evidence that it’s very effective in helping people manage the disorder rather than trying to get rid of it completely.
Lucy: That’s really helpful for people to know isn’t it? I suppose not everything might totally resolve and it might be more a case of living with it effectively.
Anne: Exactly, yeah.
Lucy: Are there things you think people should know before they come for CBT?
Anne: I think particularly just picking up on that last point as well, thinking about the impact of childhood trauma can have in terms of depressed mood. When we think about trauma we’re thinking about that in a broad context of it might be sexual and physical abuse, but much more commonly, it’s actual emotional abuse and neglect, childhood neglect, particularly in terms of how that impacts on what psychology would refer to as attachments. Our ability to make and maintain reciprocally beneficial relationships with other people.
And there’s increasing amount of evidence to show that where attachments are disrupted, then that can have a profound effect in terms of adult depression. And I think that’s where a lot of the research is focusing now in terms of thinking about how you might develop more focused interventions in CBT terms.
I think the other thing is that CBT is a very practical therapy. So there’s an idea that you participate, you will be asked to complete, what we refer to as ‘homework’, which isn’t a phrase many people like. So you’d be asked to work on your problems in between sessions.
Initially it’s very here and now focused. So it’s really trying to think about what your problems are on a day-to-day basis in terms of how the depression affects you. And then later in therapy if necessary, we might go back to some childhood events. But generally speaking you only go backwards to the degree to which it tells you how that influences what goes on in the here and now.
It’s also about doing, it’s not just about talking.
Lucy: For Sharon, although she doesn’t feel depression has disappeared completely from her life, she’s found a way to cope and see her thoughts for what they are, thoughts, rather than acting on them. I wanted to know what she would say to anybody thinking of trying CBT for depression.
Sharon: Go for it! Definitely! I think the thing is to be prepared; you’ve got to put some effort into it to get something out of it.
Lucy: The experience that Sharon had of trying therapy more than once and finding it a better fit at a later date can happen to anyone, either because the therapist is a better fit, the type of approach works more or sometimes because the therapist has had more experience in a particular model of therapy.
It’s always okay to raise it with a therapist if you feel like things aren’t working for you. It’s also important to be able to check out what training or experience the therapist has had with treating the problem that you’re going to see them for. One way to check this out is by seeing if they’re accredited with BABCP.
Sharon: As I say, it was a revelation. In fact one of the biggest things was listening to people talking. You think, gosh, that’s how I think!
Lucy: If you’d like more information on CBT for depression, have a look at the show notes. For more on CBT in general and for a register of accredited therapists, check out BABCP.com.
Have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with.
There’s one with Paul Gilbert, who Anne mentions and also Chris Winson, who speak about compassion-focused therapy for depression. And there’s loads more on other common problems that CBT can help with including anxiety.
Thank you to both of my experts, Sharon and Dr Anne Garland.
Thank you for listening and I hope you’re keeping well in these odd times we’re all living through. Until next time, take care.
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We tend to think about therapy as something that is helpful for individuals, but what about when you want to address problems which affect you and a partner or spouse? In this episode, Dr Lucy Maddox speaks to Dan Kolubinski about cognitive behavioural couples therapy, and hears from Liz and Richard about what the experience was like for them.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Dan recommended the book Fighting For Your Marriage by Markman, Stanley & Blumberg
https://www.amazon.co.uk/Fighting-Your-Marriage-Best-seller-Preventing-dp-0470485914/dp/0470485914/ref=dp_ob_title_bk
Some journal articles on couples therapy are available free online here:
https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/information/let-s-talk-about-cbt-podcast
The podcast survey is here and takes 5 minutes: https://www.surveymonkey.co.uk/r/podcastLTACBT
The BABCP website is at www.babcp.com
And the CBT Register of accredited CBT therapists is at https://www.cbtregisteruk.com
Photo by Nick Fewings on Unsplash
Transcript
Lucy: Hello, and welcome to Let’s Talk About CBT. It’s great to have you listening.
When we think about therapy, we often think of one-to-one conversations between one person and their therapist. But what about when the problems that we’re going for help with are related to how we’re getting on with a partner or a spouse? Cognitive behavioural couples therapy helps with these sorts of difficulties. To understand more about it I spoke to a married couple, Richard and Liz, and Dan Kolubinski, their therapist.
Richard and Liz did this therapy privately, but couples therapy is also available on the NHS to help with some specific difficulties. We hear more about that from Dan later on. For now though let’s hear what Richard and Liz thought of their couples therapy in this interview which I recorded with them remotely.
Richard: My name’s Richard. I’m 37 years old and I’ve been married to Liz for just over seven years now. I’m a postie at the moment, and kind of lived in Essex most of my life.
Liz: It’s like a dating programme.
Richard: It is, isn’t it? Yeah, a little bit. (laughs)
Liz: So I’m Liz and I make cakes for a living, and write about mental health. So that’s us.
Lucy: That’s great. So thanks so much for agreeing to speak with me about your experience of couples therapy, and specifically cognitive behavioural couples therapy. Would you mind telling me how you came across it and what made you think you might want to try it?
Liz: Yeah. So I think it’s something that we’ve spoken about in the past. And we’ve both had therapy separately, and I think we’ve both had various different types of therapy. So Richard has had CBT before, I think we’ve both done psycho-dynamic counselling.
So when we decided we were going to do it, we realised that for us it was more beneficial to almost do a crash course, as it were, together. So to do a whole weekend, rather than a little bit once a week. And that was how we discovered Dan, and were able to book in with him.
Richard: Yeah, I think we both understand the value or had both experienced and understood the value of therapy individually. So it was kind of an easy step for us then to decide there could be a lot of value in doing this together.
Lucy: That makes total sense. So you already had a bit of an understanding of what it might be like, or what it’s like on an individual level?
Liz: Yeah, definitely. And actually very early on in our marriage we had some couples counselling, which I don’t think was actually as successful, and it was after that that we had separate counselling. And I think it was after we were both able to get ourselves into better positions, as it were, that that’s when we were able to come back together and experience some therapy together.
Lucy: That’s really interesting. Do you think that helped you access the conversations together in a different way?
Richard: Yes, I think it did. I think we both had an experience of therapy, of CBT and of other therapies, and the structure they would take or how they engaged you and enabled you to talk safely, and the prompts that might be used.
When we did it together, it did make the conversations a bit freer, a bit more open. And I think we both felt it was a safe environment, which when we first had it I don’t think we did feel. And that made a big difference I think.
Liz: Yeah. And I think as with any relationship, until you’ve got a level of happiness with yourself, it’s very difficult to have a relationship with somebody else that involves vulnerability or trust.
And I don’t think we had that the first time we tried having counselling together. I think we were almost so reliant on our relationship to form who we were, that the first time around we put too much pressure on ourselves, on the relationship, and also on the counselling, and we expected some magic wand. Whereas now we’ve realised it actually does take a bit of work.
Richard: Yeah.
Liz: But obviously the pay-off is huge, so that’s brilliant.
Lucy: That’s so nice. Sometimes you see adverts for couples counselling, or couples conversations, when people are thinking of getting married. Was that something that was around for you?
Liz: (Laughs) Yeah, slightly ironically we started it and it was meant to be three sessions long, or four sessions long, and I think before the second or third session we had such a big argument that we never went back.
So yeah, again it’s something that I think in hindsight there were warning bells that both of us were probably having our own inner struggles, as it were. And that we weren’t really able to reap the benefits of that pre-marriage counselling. But I would definitely recommend it to any friends who were getting married.
Richard: Yeah, absolutely.
Liz: I’d definitely recommend it, even if it’s just to get the conversation started.
Lucy: Yeah, it’s interesting. So there are some conversations it feels like almost we don't quite have permission to have without somebody prompting it or some kind of structure around it.
Liz: Yeah, definitely. And I think it takes a certain amount of emotional maturity to have conversations like that, or the difficult conversations, and not to take something personally or get defensive. And I think that that’s something as a society we don’t necessarily encourage people to have those conversations, or to be able to freely explore things without there being some element of self-worth dependent on it.
Lucy: Liz and Richard went for therapy after experiencing a bit of a rocky patch in their relationship.
What was it like going for the weekend?
Richard: I think it was really beneficial. It’s certainly something that – hopefully we’ll never be in that similar circumstance again – but in a situation where we thought it was beneficial, doing it over… was it three nights?
Liz: Yeah, three nights.
Richard: Was really valuable, because it kept you in that space. So there were no distractions from, I don’t know, going to work, having to get back, get to the session.
Then inevitably when you finish the session you get home and normal life kicks in straightaway. So whether it’s cooking dinner or having to get ready for the next day, that’s unavoidable. But in this situation we were really able to take ourselves away from normality and the routine, and really focus on it. And I think it had a great impact doing it that way.
Liz: Definitely. And also I think that having – because the sessions each day I think ran from 10:00 till 1:00, and then 2:00 till 4:00. So having those extended sessions meant you could really get down to what was happening and really attack that. As opposed to when it’s say weekly, hour long sessions, having to almost get past the initial boundaries that you might have set up and break those down, and get into a place of being able to talk freely.
Lucy: And were there other people there as well? Were there other couples there or was it just you?
Liz: It was just us.
Richard: Yeah.
Lucy: And what was it like before you went? Was it frightening to think about going?
Richard: I suppose for me it was a sense of that nervous excitement. So I didn’t quite know what was going to happen. I knew what I wanted from it. And it was the kind of knowledge that this was going to be good for us, at least for me.
Liz: Definitely. And I think one of the first things, on our first evening there, we had the initial introduction session together. And Dan did say it was quite unusual to be dealing with a couple who were in such a good place. And that was quite nice actually, and we definitely subscribe to the idea that therapy isn’t just for when something goes wrong; it’s actually really useful to keep things right, as it were.
And I think it was funny because the things we thought we were going to end up talking about over the weekend, actually it all came down largely to communication, which I think is often the case with couples. And learning how to communicate with each other.
Lucy: Before we hear more about Richard’s and Liz’s experience, here’s Dan to give the bigger picture on this type of therapy.
Dan: My name is Dr Dan Kolubinski, and I am the clinical director of Reconnect UK, which is a CBCT based intensive retreat programme.
Lucy: And what’s your professional background?
Dan: My master’s degree is in counselling psychology, and a PhD in psychology as well. And I’ve been a CBT therapist for about 15 years now.
Lucy: Cognitive behavioural couples therapy might be something that people haven’t heard of before. Could you explain what it is?
Dan: Well, as in CBT, in cognitive behavioural therapy, there are these two different aspects; there are cognitions and there are behaviours. The ideas are that if you change those two things you might change how a person feels. And with the couples aspect of it, it’s built on the same principles, but trying to treat a relationship rather than an identified client. It’s not just about one person, it’s about how the two of them as a unit are.
So the primary focus is on the behaviour side of things. The idea is that if I can change what the couple are doing, that will change the way that they think about each other which will change the fundamental feelings of the relationship.
And so that breaks down into a couple of different components. There’s on the one hand, ‘do nice things’; trying to bring up some of those caring behaviours. That if I know what my partner likes and how they feel cared for, we have to guide the couple sometimes to actually doing those things.
And the other thing is around skill building. So we’ll have things particularly around communication; really breaking it down to some of the fundamentals of how we talk to one another to make sure the message that’s sent is the message that’s received.
Lucy: Could you give some examples of the sorts of changes in the way that people talk to each other that you might encourage?
Dan: There are a couple of one-liners that I like to use in the work that I do. And one of the big ones I think that comes up in communication is that it’s very important to listen in order to understand, rather than listen in order to respond.
So most of the time when couples get into a conversation, even the positive ones but especially the negative ones, rather than hearing what the other person is saying, what we have a tendency to do is already think about what we’re going to say next. And so I’m not engaging with what my partner is saying, I’m already finding holes in their argument, I’m already stating my next case in my head.
And so we really have to stop that process so that people can slow things down and really make sure that what’s coming across is what was meant to come across. So that idea of I need to button my lip, I need to put my world view on the shelf and I need to listen to what’s being said, in order to understand it.
Lucy: That sounds super useful for all sorts of relationships actually.
Dan: Absolutely, yeah. These are generalisable principles, I think. It’s when we’re dealing with a couple, that’s really the emphasis, but the same sorts of principles can be used for other family members, can be used for co-workers, can be used for neighbours. It’s all about just two people interacting with each other.
Lucy: And so if a couple came to a therapist for cognitive behavioural couples therapy, what could they expect?
Dan: They can expect somebody who’s there to try and understand their own point of view, but isn’t going to take their side. So the role of the therapist really is to try and guide those conversations, and shift away from accusations and misunderstandings.
And to act almost as a bit of a mediator sometimes, in the very beginning. Eventually, like any good CBT therapist, our job is to try and make ourselves obsolete as quickly as possible. So it is about trying to skill them up to have those conversations. But in the beginning we can be there to try and translate; make sure that the message that's sent is the message that’s received.
One thing that I meant to say, and I got a bit side-tracked, was one of the key principles is if I do something different then my partner might do something different. Usually what we’re doing is we’re waiting for our partner to do something different before I do something different.
And there are some interesting things with that. Number one is I have to take the lead; if I put 55% to 60% of the responsibility for my relationship on my shoulders, and just expect 40% to 45% from my partner, then if both people are doing that then they probably stand a good chance. So I’m not doing a tit for tat, trying to keep score; I’m actually taking a little bit more of the initiative, willingly. And then if I do that, chances are I’m going to inspire that good in my partner and they’ll do that as well.
But the other thing that comes up I think in a lot of sessions is that people have a tendency to do something that seems like a good idea at the time, but can be really destructive to a relationship, and that is we have a tendency to follow the golden rule. Now what I mean by that is that the golden rule, treat other people the way you want to be treated – and it sounds good, and generally I’m very supportive of it – but it actually ends up being really bad relationship advice. It becomes so much more important to treat the other person the way that they want to be treated.
So if I’m doing all of the nice things for my partner that I would want her to do for me, they’re not going to land well. And I’m not going to get the credit for them, because I’m not speaking in her language, I’m speaking in mine.
Lucy: So are the first few sessions trying to get that shared understanding with a couple, of what the problems are?
Dan: Typically. The first few sessions are usually assessment-based. So an assessment would take a little bit longer in CBCT than it would with CBT. Because typically – and again, this is something that couples can expect – the first session would usually be with the couple themselves. Coming in, getting a sense of the history, where they are now, current state of play, what might bring them to therapy. And getting their story; what brought them up to this particular point. We go right back to the very beginning.
And I think there it’s necessary not just to hear what the couple is saying, but also how the couple are saying it. There’s a fair amount of information in how people tell their own story. And then we can see if there still is some love there between the two of them; if they’re warm and fuzzy. It’s amazing when you ask a couple how did they meet, they both look at each other and they smile. That can be really quite telling, compared to those that just stare off into the distance as if they wished that day didn’t happen.
But then we get into conversations with them as individuals. So there will be a couple of sessions where it is about tell me your story, tell me your side of things. We need to be able to understand both of them. And so that’s a part of the assessment as well.
And then the final assessment session would be bringing it together. So as CBT therapists, we’ll draw this out in what we call a formulation, which is just this diagram that links our thoughts, our emotions and our behaviours, and our view of the world, to one another, to each other.
Because I can see my partner’s behaviour, what I can’t see is what’s underneath that. What are their thoughts? How are they feeling in these moments when they do what they do that drives me crazy, and then how do I react, and then how does my reaction then impact my partner? So we’ll go through a session looking at that system, and the habits that have been formed.
And then from there we’ll get into the communication side of things. I usually do. Starting off with the talking element of trying to understand each other. And at the same time, usually for homework between sessions, we would also expect a fair amount more of the positive behaviour, the caring behaviour. So that they’re actually do something differently; hitting the ground running and trying to demonstrate that they care about one another, which they typically aren’t doing by default.
Lucy: Are there any other concrete examples from therapy of things you encourage people to do differently, that have caused a change in thinking?
Dan: Yeah, I think generally speaking, there’s a common thing that I see with a lot of couples. When we get into the formulation diagram – and so as I said, it has this connection between what we’re thinking, what we’re feeling and what we’re doing. And it’s informed by this higher idea of how we see the world.
And if I’m looking at my partner’s behaviour for example – and I’m doing that through my lens, I’m doing that through the way that I see the world – well that’s just going to be crazy town. It’s not going to make any sense to me whatsoever; “I don’t know why you’re being so unreasonable. Can’t you see that?”
And then we start to slow things down and start to highlight the other person’s framework. And if I’m really open to that, that you see the world from a certain point of view, where we agree, we don’t have problems. The problems come from where we might be on a different page. And we’ve done that because we’ve had different experiences.
And when couples start to really slow it down and listen to where those connections are being made, or how those experiences have shaped why they might see things the way that they might see things, it is amazing how the walls start to come down.
Lucy: I bet that’s really rewarding.
Dan: Absolutely, absolutely. But frustrating in equal measure, because it’s also one of those things that might be blatantly obvious to the therapist, but it’s not obvious to the couple.
Lucy: Back to Richard and Liz. I wanted to know what practical techniques they’d learned that they could use day-to-day?
Richard: Yeah, so I think one of the early ones we did at the weekend was just about active listening. And like Liz says, a lot of it was about communication. And so we did some exercises talking about aspects of our relationship, and ensuring each of us was being listened to properly. And so we did an element of one person would talk about how they were feeling and the other person would almost paraphrase, and repeat it back to them to try and ensure that they had taken in what they were saying and understood it.
And the understanding bit was key, because initially there’s that aspect of right, I need to remember this and say back to her, so to your other half. But if you do that, and I’ll admit I did that initially, you get caught out so quickly because all you’re trying to do is to remember it to repeat, instead of actually taking it in. And so that was a really valuable exercise that we’ve tried to continue using day-to-day as much as we can.
Liz: Yeah. And I think one thing that really stuck with me was we did an exercise about what’s the best case scenario to come out of this, how does that look, what will happen if that doesn’t happen? And so actually exploring possible consequences. And I found that really helpful. Because I think so often you can get caught up in the moment and being concerned with who’s in the right, who’s in the wrong, who hasn’t washed up, whatever. And actually lose sight of what it means and what could that niggle lead to, and is it important in the run of things?
Yeah, it was very helpful to be able to step out and be given written exercises to help us step out of the now and consider what the future looks like together, and what we can do to make that happen.
Lucy: How nice to be asked what the best case scenario is as well.
Liz: Yes.
Lucy: I don’t know about you, but I so often spend time worrying about the worst case scenario, so yeah.
Liz: For me it always sticks in my mind now, that if something happens, I think is bringing this up, is fussing over this going to get me closer to that best case scenario? If it’s not, then can you let it go? And that’s quite helpful. Like I say, I do that all the time, I let so much stuff go now. (Laughs)
Lucy: It’s super hard though this stuff though, isn’t it? It’s really hard.
Liz: It is. And I think especially at the moment, I think that’s the thing. The idea of being able to step out of things is very helpful at the moment because emotions are running high, and so it can be difficult sometimes to know if what you are feeling is actually a direct consequence of something that has happened with your partner, or just made up of general stress about everything.
Richard: The current situation.
Liz: Yes, absolutely.
Lucy: Are there other things that you think people should know, if they’re thinking of embarking on cognitive behavioural couples therapy?
Liz: I’d say that it’s definitely an investment. Because it’s not the cheapest thing to do, especially if you’re doing a weekend of it. But the pay-off has been incredible. And this is why we were so eager to speak to you, because we do still get so much from it.
So for example one thing we’d spoken about at the weekend was the idea of having time to check in with each other each week. And talk about how things are going and what our hopes are for the week ahead, and also hold each other accountable for things if we need to.
And so now once a week we have what we call an MM, our Marriage Meeting. And every week we come to the meeting with two things that we’re grateful for, or that we’ve really appreciated that the other one has done in the week. And I love a spreadsheet, so we have a little form that we fill out that basically at the beginning says we will always come to these meetings positive and ready to engage.
And that has been really lovely, and that’s something that I think has kind of become part of our week now, hasn’t it?
Richard: It has. Very much so, yeah.
Liz: It’s really lovely. And I mean I’d say physically things are much better as well. So obviously things… It seeps into other aspects of a relationship; when certain aspects are good other aspects are good.
Richard: Sometimes it may only be 20 minutes or something like that. So it’s not something that will last for hours, but it’s just a really good way to check in with each other.
Liz: Yeah. And initially we made sure we kind of sat down at a desk or on the sofas opposite each other. And now we have got to the stage, when the weather’s been nice, we might sit outside in the sun with a G&T and have it. Or we’ve had a couple where one of us is sat in the bath and the other one is sat there chatting. So we are now integrating it into our everyday life, but it’s a specific thing we make sure we do.
Lucy: It’s interesting though the idea of the meeting, because it’s such an important area of our lives, and yet we don’t always put the same amount of effort into it that we might a job or other aspects of our life.
Liz: Yeah, it’s funny you say about the job, because one thing that really struck me from that weekend, was when we spoke about relationships and roles in a relationship, and we said how essentially we have roles to play. So initially we audition for that role when we’re getting to know each other. And then it’s like okay, I’ve interviewed you for this job, you can be the role of my boyfriend or fiancé or husband, and we need to show up in those roles. And we need to give consideration to what we’ve agreed to be together in each other’s lives.
And that I think was something that really hit home for me as well. And I think the meetings help us do that in a sense; we both show up to work each week.
Richard: We do indeed.
Liz: And it just resets that I think.
Lucy: As I mentioned earlier, Richard and Liz did their therapy sessions over the course of one intensive weekend, and it was a private arrangement rather than an NHS service.
Dan explained to me what other sorts of options are available.
Dan: There are these two different streams I guess that would be useful to see what might be accessible via the NHS. I should say that within the NHS, the real criteria there is mainly around depression; I think some services will offer it for substance misuse as well. So it would be good to know what might be available and what the criteria would be in order to be able to access that.
And so as a useful treatment for depression, usually you would have one, and then sometimes two people, who would meet the criteria for a mood disorder. And in couples therapy, the relationship and the depression can relate to each other; they can build on each other. And so by treating the relationship you can have a significant impact on depression.
In private practice, which is where I think most couple therapists reside, there it would be accessing online directories, looking at Google, typing in things like CBCT, cognitive behavioural couples therapy, or just behavioural couple therapy.
I should add that there are those therapists who actually don’t look at the thoughts as much, it’s more just the behaviours. And that is the fundamental core; it’s about doing things differently. So behavioural couple therapy would usually be something people would have on a website, if that’s what they’re offering.
Lucy: Obviously it must be different for every couple, but roughly how long would a treatment take?
Dan: It would be similar to a lot of individual CBT. It can be for some really low level; we want to prepare things, we don’t want to have the cracks form later, a little bit prevention. That can just be a few sessions; five, six or so of the actual treatment, once you get out of the assessment stage. That would be about three or four really, if they’re just doing prevention stuff.
But typically a course of therapy would be about 10, 12, maybe upwards of about 15 sessions. Sometimes more, it could be upwards of 20, depending on how entrenched these old habits are.
Lucy: And is that something you do get; people coming early on in a relationship to try to head-off bad habits?
Dan: Absolutely. That’s something that certain religious organisations have been doing for quite a while. The Catholic church has always expected couples to go through a marriage preparation course. And there are fewer people who are seeking that religious intervention now, so they come to us. We have the same principles, and a lot of the same material.
And so we see the divorce rate is 42%; that’s a pretty staggering number when you think about all of the unhappy married couples, it’s about a coin toss about whether or not any couple is going to make it and be happy. But there are things that we can do in order to make sure that we’re in the right 50%.
Lucy: And what got you into doing this sort of therapy?
Dan: I’ve always been fascinated by relationships. I was first inspired by Albert Ellis, as a first year psych student, and I knew this was the area I was going to work in. But then as I was going through my studies, I just became really fascinated with relationships.
I’m one of the very fortunate ones, my parents are still together after 40 years – coming up on 50 years actually, very soon. And I just always appreciated their relationship, the way they interact with each other, the way they talk.
And in conversations I’ve had with clients over the years, I do recognise that very rarely is there the one person who’s fully to blame. It’s usually a system thing. And I think what the world needs more of is just slowing things down and trying to listen to understand, rather than listening to respond.
And so it’s a very different type of work than if you’re working with depression or anxiety, that’s very much around distress and trying to reduce distress. There’s distress in relationships, but it’s the system that’s the problem rather than there being an issue with mood or anxiety.
Lucy: Do you ever feel sort of caught in the middle as the therapist?
Dan: Sometimes. It’s really odd when a couple has been particularly conflictual, and been fighting a fair amount, and they want to feel heard. And they’re already under the impression that they’re the reasonable one, and if you can just fix my partner then we’ll be okay. Very rarely is that ever the case. But you do get dragged into that a little bit.
That’s rare. Most couples, they come to see a couples therapist because they recognise that there’s a problem with how they’re interacting rather than, “Just try and fix my partner.” But it does happen.
Lucy: It sounds like hard work, actually.
Dan: It’s very much a game of mindfulness, I think, for a couples therapist. You always have to be on the ball and always in the moment. Especially with those couples who can trigger each other really quickly, and get caught in that vicious cycle of arguing, and they think they’re the right one and their partner’s the wrong one. And just blinking; you think you’re having a productive conversation and it can just set off.
So we have to be far more active than we would do when treating individual clients, to make sure we’re interrupting that pattern, because it’s happening live. If I’m treating an individual, I might generate a panic attack, but one doesn’t generally spontaneously happen in a session, but in couples therapy, the fights do.
Lucy: Do you think it has made you more able to listen in that kind of slowed down way that you talked about?
Dan: Well, there are skills there to try and understand some of the fundamental premise that someone might be saying. And I think I recognise that just about every topic under the sun tends to be a lot more complicated than what some people tend to think.
There are very few simple answers in this world, and I think that idea of being that mediator, from seeing a couple to diplomacy between nations, are all just aspects of the same spectrum. It’s just people feeling unheard and misunderstood, and sometimes closing their ears to the other side.
Lucy: Couples therapy is in the NICE guidelines, which draw on different research studies to understand what the most effective therapies are for different sorts of problems. I asked Dan what the evidence base for this type of therapy is.
Dan: It’s a bit of a tricky question to answer, for a couple of reasons. The short answer is, pretty good; not absolutely fantastic, there’s no guarantee I think for any couple. But it is better than nothing, and it is one of those very few evidence-based treatments that we have. There is a lot of couple work out there that doesn't have the evidence base, that behavioural couples therapy would do.
And a lot of the time it really does depend on the couple. Again, one of the shocking statistics is that the average couple could very well wait around six years of having problems before they seek help. And as a result of that, it does linger and become and become a bit more complicated.
And it’s the same thing with the relationship, and so those who are able to see the cracks beginning to form, they tend to fare a little bit better than the couple who have canyons that have come into their ways of communicating. But I think with an open mind, with an understanding, and with a willingness to be able to hear – which is usually the biggest obstacle – then a couple can do well with some good tools and the right direction.
Lucy: One really tricky thing about evaluating the effectiveness of cognitive behavioural couples therapy is that unlike individual CBT, the aim isn’t always to make the relationship better. Pre and post scores on a relationship satisfaction measure aren’t always the best indicators.
Sometimes couples use therapy to determine whether ending the relationship is the best option for them, which could still be a good outcome even if the scores don’t improve.
I asked Richard and Liz what else had stayed with them since doing the therapy.
Richard: For me I suppose it’s more the approach. So if people were interested in doing it, then the environment that you’re going into is one of the safest that you’ll have to talk about the really difficult stuff. So there’s no reason not to be as open as you can. And don’t hold back, because there’s no point, you won’t benefit from it. So I would just thoroughly recommend being as open and honest as you can, and you really will reap the benefits from it.
I think it’s almost like that green light to be able to say maybe the things that you haven’t said before, or the things that you’ve been scared of saying. Because it might be that those things in the past have been a catalyst for an argument or some difficulties. Whereas in this space you’ve got someone who, if it does go that way, can bring it back, and also is there to help balance the conversations.
And so once you’ve done it once in that environment, and realised the benefits, then just keep doing it, because it’s very, very powerful.
Lucy: It sounds helpful for stepping out of patterns that we can all get into.
Liz: Yeah. And I think also it was having someone there who is trained, and they have this incredible toolbox of things that they can give to you.
And the range of things that we spoke about, I think there were some things that I think we didn’t realise we would speak about, which actually in hindsight, of course they were going to come up. And we dealt with things across the spectrum of a relationship, didn’t we?
Richard: Yeah, we did. Yeah.
Liz: And we were given tools not only to help us communicate there, at the time, but then also afterwards. And that has been really helpful for us as well. So we haven’t just been left to get on with it, and hope that everything works out okay.
I think we’ve tried sometimes in the past to deal with things by Googling them and looking for articles. And you end up with all of these things that are suggestions as to how you can improve your relationship. But actually having a professional who takes the time to sit down to work out what’s best for the two of you is invaluable.
Richard: I think it was almost like – and not to sound too cheesy – but we went there wanting to know how to dance, like how to do a Viennese waltz, and Dan was able to pull us back and say well, let’s just make sure you can hold hands properly, first.
Liz: Yes. Yeah, exactly that. I still want to learn to Viennese waltz but…
Richard: Yeah.
Lucy: What was the hardest thing, do you think, about it?
Liz: There were elements where we were talking about physical things in our relationship, that you have the schoolgirl kind of – you get embarrassed talking about things like that.
But much like Rich said earlier, when he said just be honest about something, and when it doesn’t go wrong you’ll realise it’s a safe place to keep being honest. And I think that’s the thing. As soon as you start talking about something, and you realise the world hasn’t stopped turning, it’s then like that switch – again, as Rich said – that switch goes on and you actually realise this is okay, and this is normal.
Richard: Yeah.
Lucy: And what do you think the best thing has been to come out of it?
Richard: It’s hard to answer that, because I just think it’s the way we are. So the developments in our relationship, the way we communicate. The closeness, like Liz says, physically and mentally, is better than it has been, I think. So okay those butterflies may have gone, but like Liz says, it has been replaced by just a stronger bond.
Liz: A different type of butterflies.
Richard: A different type of butterflies.
Liz: Yeah, maybe.
Richard: Do you know what I think is important; it encourages you to want to continue to do that. So you don't go there have a session or a number of sessions, and once you’re done, that’s it, you’re fixed. It doesn’t work like that. But it encourages you to develop yourselves and keep going with, like Liz says, with the tools you’ve been given.
Lucy: But brave to be able to do that as well, because it’s challenging too.
Liz: Yeah, absolutely. Because the path most trodden is the one you go back to, isn’t it? But yeah, just recognising I think those old behaviours is a victory in itself.
Lucy: I asked Liz, Richard and Dan for their final thoughts for couples who are thinking about having this type of therapy.
Liz: If anyone’s even thinking about it, take the leap, because the one thing you’ll wish is that you’d done it sooner. And the good thing is if you’re going to invest one day in it, you might as well invest sooner rather than later, because then you’ll have longer with the benefits of it. And it’s worth it.
Dan: I’d definitely encourage it. And there is an element of don’t wait; don’t wait until it’s too late. There are those couples that I have seen where, in the session, five sessions in, one partner might say to another, “Look, had you offered to do this five months ago I would have been there, but I’ve lost it, and the fire’s out now.” And so this is a time limited situation sometimes. People do end up getting to a point where they’ve passed the point of no return and they just shut down.
So a relationship, it’s a little bit like a fire. The flames tend to go out pretty quickly – the passion, the heat – and we have that in the first six months to two years, and then that starts to go. And that’s the case for any relationship. But you would expect the embers to be glowing, you would expect some sort of heat to still be generated from what’s left, from those coals.
But there is a time when that starts to extinguish. Sometimes it’s as dramatic as a bucket of water being poured over it, sometimes it’s just time, and it burns itself out. And so the sooner tends to be the better. And that would be the main advice.
Lucy: And just one last question, how do you know when to stop?
Dan: (Laughs) That’s a great question. As I say, I think my job is to make myself obsolete as quickly as possible.
And in your typical therapy, there’s a difference between treating relationship distress and treating substance misuse. With substance misuse there’s very manualised – today is session two, therefore we’re going to talk about this; this is session five, so therefore we’re going to talk about… They’re very rigid and strict in what they do, and it’s a very dedicated programme.
For relationship distress, generally for the population where substances aren’t involved, it’s a little bit more open, shall we say. We deal with what’s going on at the time. And I have a loose structure in my head, where I want to deal with things like caring, communication, and conflict management. Those are the three things that I want to make sure the couple has. So they have a lot of positive going in, they have little negative coming out, and they’re able to use the tools to understand each other better. When they can do those three things then we start to wrap up.
And it would be very similar to how do you know you’re done with depression. People feel a little bit more confident moving forward and don’t really need you as much; we can phase things out a bit. They’re managing their own conflicts.
Most problems won’t go away; about two thirds of all conflict are what they refer to as unsolvable problems. When you pick a partner you pick a set of problems – that’s kind of how relationships work. But they can manage them better; they’re not sparking each other off. They’re not becoming emotive conversations, they’re becoming much more productive conversations around understanding and meaning. And then I’m not really required any more.
Lucy: Thank you to all of my guests, Richard, Liz and Dan. If you’d like more information on CBT for couples, have a look at the show notes.
For more on CBT in general and for our register of accredited therapists, check out BABCP.com. And have a listen to our other podcast episodes for more on different types of CBT, and the problems it can help with like clinical perfectionism and body dysmorphic disorder.
That’s all for now. Thanks for listening and take good care.
END OF AUDIO
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What is digital CBT? How does therapy work over the internet? Can it ever be as good as face-to-face? Dr Lucy Maddox hears from Dr Graham Thew and Fiona McLauchlan-Hyde about an internet-based CBT programme for PTSD. Fiona shares her experience of how this therapist-supported programme helped her through traumatic grief, and also has some helpful advice for people trying to comfort those who are bereaved.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
BABCP website is at www.babcp.com
CBT Register of accredited CBT therapists is at https://www.cbtregisteruk.com
BPS Top tips for psychological sessions delivered by video call for adult patients
https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Top%20tips%20for%20psychological%20sessions%20by%20video%20%28adult%20patients%29.pdf
Resource from OCD-UK on getting the most out of online CBT
https://www.babcp.com/files/Therapists/Oxford-OCD-Making-the-Most-Out-of-Remote-Therapy-for-Patients-by-OCDUK.pdf
Graham’s recent paper in the Cognitive Behavioural Therapist can be found on the podcast journal article page
https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/information/let-s-talk-about-cbt-podcast
Information from Cruse about traumatic grief
https://www.cruse.org.uk/get-help/traumatic-bereavement/traumatic-loss
The Good Grief Trust
https://www.thegoodgrieftrust.org
Image is by Cassie Boca on Unsplash
Transcript
Lucy: Before we get started, I want to remind you about the survey which I released at the beginning of August. I really would like to know more about who is listening to these podcasts and what you would like. The link to the survey is in the show notes and it takes about five minutes to complete. If you have time to fill it in I would be really grateful.
Hello, and welcome to Let’s Talk About CBT, with me, Dr Lucy Maddox. This podcast is all about CBT, what it is, what it’s not, and how it can be useful.
Today I am exploring digital CBT. I speak to a therapist who has been researching internet based CBT programmes that are supported by a therapist, and I speak to someone who has experienced this first hand.
The particular programme that we talk about is for PTSD, which we’ve heard about before in a previous episode. In this case PTSD was related to an experience of traumatic grief.
Fiona: I think I started last September and I finished just before lockdown, actually.
Lucy: Gosh, so in a way good timing.
Fiona: Yeah, it was great timing to finish just before lockdown. It put me in a good place I think, to be able to deal with what was going on, rather than if it had been six months earlier it would have been a very different experience I think.
Lucy: It took Fiona, who is based in Oxfordshire, a long time to find this type of therapy.
Fiona: It all started six and a half years ago, when my husband died of cancer.
Lucy: I’m so sorry.
Fiona: He was diagnosed in the June, and he died in the December, and it was really horrific. He was 49, I was 42 at the time. And so it was heartbreaking and I couldn’t cope. I couldn’t cope afterwards. We had a little girl, she was seven when he died. And my world was turned upside down.
And I got help at first. But then, as with all things, life goes on around you and everyone thinks you’re fine. And I was still putting my lipstick on, so therefore everyone thought I was okay. And I felt I was getting worse and worse, and no one would believe me.
And it wasn’t until I threw all of my toys out of the pram; after having therapy through my local GP – so this was last year, last summer – sitting in my car afterwards for about an hour just sobbing, because no one believed me that I was feeling as bad as I was.
And I asked to be put in touch with TalkingSpace. And they put me forward for a trial with Oxfordshire Mental Health, and it changed my life. It absolutely changed my life. Because I was drowning and no one believed me, it was awful.
Lucy: It sounds like such a dark time.
Fiona: It was a really dark time. And everyone just kept saying come on, you know, it’s been so many years. And I was functioning, but I think it was last year… So I suffered from panic attacks; I suffered from panic attacks from before my husband died, and they got worse. They’d gone away for years and then they came back when he was diagnosed.
And last summer, around this time last year, I had such a severe panic attack, I was driving my daughter and she had to call an ambulance. And that was when I decided that come what may I needed help.
But it was still quite some time after that. I still had to go through about six weeks of people going, “Come on, you’re fine. Take a pill.” And I didn’t want to take a pill. So yeah, I was lucky, eventually.
Lucy: It sounds like you had to be really tenacious to get access to the therapy?
Fiona: It was a real, real battle. And as much as I really liked my GP, and my GP was the person who was there when my husband was dying. So he knew what happened and how horrific it was. But in the end his last thing was, “No more therapy. You’re lonely. You need to go out and find yourself another man.” And that was when it just – that was when I sat in my car for an hour and a half and cried.
Because it wasn’t that, I knew it wasn’t that. I knew there was something really wrong, and that I really, really needed help. And TalkingSpace came in, and I had a huge amount of telephone conversations and meetings in person, just for them to try and work out which way to send me.
Lucy: Fiona was diagnosed with post traumatic stress disorder. Fiona’s experience of losing her husband was deeply traumatic; not only the death but the lead up to it.
Fiona: I mean obviously it didn’t just happen to me; a lot of us were affected by it. But it was a particularly brutal and nasty way to die.
And you see the other thing is I did most of the nursing when my husband was sick. I don’t know how it happened like that, but it just did. So all of a sudden I became a nurse, which is not on my CV.
Lucy: Super, super hard. Yeah.
Fiona: And for us, Paul’s death was so horrific. He had a lot of failed operations, there was a lot of emergency surgery, there was an awful lot of blood everywhere. There were ambulances called in the middle of the night. He didn’t just have cancer and pass away, he suffered every day for those however many months it was.
And all of those things that we did automatically; like he had a feeding tube, because he had oesophageal cancer. So with me setting up the feeding tube every night, and flushing all of the feeding tubes out in the morning. And all of those things that you do automatically, because you’re trying to keep your loved one alive, they hit you later.
So his death, apart from – it sounds terrible to say this – apart from his death being the trauma, his illness was a trauma too. Because I did everything I could, but I couldn’t make him better. And this is part of my therapy, just my guilt at not being able to save him.
Lucy: The therapy that Fiona was referred to was a trial based at the Oxford Centre for Anxiety, Disorders and Trauma.
Graham: My name is Graham Thew. I am a clinical psychologist. And I do a job that’s split between research and clinical work.
So my research work I do at the University of Oxford, at the Oxford Centre for Anxiety, Disorders and Trauma. And my clinical work I do at two different services that are part of the IAPT programme, the Improving Access to Psychological Therapies programme. So that’s the Healthy Minds service in Buckinghamshire and the TalkingSpace Plus service in Oxfordshire. And both my research work and my clinical work all focus on digital treatment and digital therapies.
Lucy: Graham wasn’t Fiona’s therapist, but he’s involved in the trial that she took part in. I asked him about what digital therapy is.
And when you say digital CBT, what do you mean?
Graham: Yeah, that’s a great question, because I think terms like digital CBT can actually cover a range of different things.
So as we’ve just mentioned, we might be referring to webcam sessions; so video conference sessions that would perhaps cover the same content as a face-to-face therapy session. So you would still be able to see your therapist on webcam, and you both agree to meet at a specific time.
But digital CBT and other online treatments can be broader and look a little bit different to that as well. So for example there are some forms of CBT that still take place online with a therapist at a specific time, but instead of seeing them and talking to them via webcam, you’d actually be typing; you and the therapist would be typing to each other live, in real time.
Lucy: Like a kind of Messenger chat?
Graham: Exactly, like a sort of instant messaging chat.
And then another different category altogether is more of a sort of internet-based CBT programme. So that would be where there’s a website or a programme that has a lot of the therapy content written, perhaps in the form of little treatment modules. So written texts, videos, that sort of thing. And you would therefore work through those in your own time, and perhaps have some support from the therapist every so often; maybe in the form of messaging or a phone call or something.
So it can be a bit confusing because terms like digital CBT can mean different things.
Lucy: Is your research looking at all of those types of digital CBT?
Graham: The work that I’ve done has mostly focused on the last category that I talked about; the forms where treatment is partly written down and put into an internet programme in a series of modules, but that there’s support from a therapist. In the programmes that I’ve worked with most closely, the therapist would communicate with you by telephone, by messaging, and also occasionally via webcam as well.
Lucy: Fiona met her therapist at the start of treatment, but from then on she worked through online modules and she also had regular contact with weekly phone calls and messaging in between sessions.
Fiona: There were phone calls with the therapist, they were quite lengthy, but all of the way through it she would send me text messages, saying, “Don’t forget to take a tea break.” There was a lot of talk about tea. (Laughs) Or, “It’s a beautiful sunny day Fiona, can you get outside for a bit?” Just little nudges, little reminders to take time.
I found it much easier to have a telephone call with her. I think it did help that I’d met her once, so I knew what she looked like. But there was a complete and utter trust and we got on, and I really, really liked her. And I liked the fact that she understood me straightaway. And it didn’t bother me that it wasn't face-to-face.
And there was something that was really quite comforting about still being in my own home, and with my own surroundings, and with things that comforted me. And if I’d finished the modules, or I’d finished a conversation, and I was feeling low, then I was instantly able to do something.
I mean we had this one thing where I had this one particular piece of music that we actually played at my husband’s funeral, but it’s a northern soul track. And if I was feeling really low, I was told to put that on really loudly, which I did. I probably annoyed the neighbours, but anyway, it worked.
It just felt like someone had your back; that someone was just there who understood and was helping you along. It was sort of invisible support and it was fantastic.
Lucy: The content of the modules that Fiona was working through were developed to be as close to the content of the face-to-face therapy as possible. Graham explained.
Graham: I’m lucky to work with some very clever and creative people, who have been able to adapt certain treatment elements that we would do face-to-face, to think about how they could work online.
So the PTSD programme, again is really trying to faithfully replicate the same elements that would be done in face-to-face CBT treatment for PTSD. So the modules focus on a range of different topics. I guess beginning with some sort of information and explanation about what PTSD is, and why some of the difficulties that people might be experiencing are understandable, given what has happened.
And then the modules go on to help people start to think about the idea of reclaiming their life; trying to get back elements of their life that might have got a bit stuck, or have dropped off in terms of what they’ve been doing since the trauma.
And then as people progress through therapy, they would go on to actually working on the memory of the trauma itself. The idea being really trying to process what’s happened, so that it can be put away in the past where it belongs, so that it doesn’t keep popping back up and causing those difficult re-experiencing type difficulties.
Lucy: I asked Fiona what sorts of things she remembers from the modules.
Fiona: There was a lot about working on your triggers, which was great for me, although it was really hard to work out what the triggers were. So for instance one of my triggers was dark, rainy nights, because I associated that with driving back from the hospital. And wet leaves sent me into a… But then you don’t think, “How can wet leaves possibly make me feel this terrible?” But it’s true, it did.
And there are certain smells; the smell of copper coins reminded me of the smell of blood. Because my husband died of oesophageal cancer there was an awful lot of vomiting of blood. So things like that, that are in the back of your mind; you work on them to bring them forward and deal with them. It’s hard. It’s really hard. But when things start to make sense, you start to feel better. Or that’s how it worked for me anyway.
Lucy: You said about being able to identify the triggers. What did you then do with that knowledge?
Fiona: If I just take you to an example of what happened for me, is that I was driving home from work; I picked my car up and I was doing my journey home, from getting off the bus from work. And it was a dark, rainy, winter’s night, and I started to feel like I was going to have a panic attack. And I was on the dual carriageway, and there was not a lot I could do. And that’s when we worked out that dark, wet, November nights, were a real trigger for me.
So what my therapist did was uploaded an image of a dark, wet street with wet leaves everywhere. And I then had to go and look at the image, concentrate on the image, until I could cope with it.
And the first time I looked at it, I fell apart. It was awful, it was the most awful feeling.
And then I’d keep going back to it. It was about taking yourself… You are no longer in that situation which I was in six and a half years ago. My daughter’s at home, I’m doing this tomorrow, Paul’s no longer suffering. So yeah, it was about the here and now, and not being in the past anymore. Not believing it was those same nights when my husband was dying.
Lucy: So some things that you could say to yourself that would remind you that you were safe now.
Fiona: Yes. A lot about being safe, and a lot of thinking that my husband was no longer suffering. That I was safe, my daughter was safe, he wasn’t in pain.
Lucy: That sounds really important, yeah.
Fiona: I found it worked incredibly well for me, because I could keep going back to it. Or if I wanted time to think about something, I could stop, go and make a cup of tea, and let things in gradually, to try and work out why I was feeling the way I was.
So it was like 24/7 therapy, seven days a week. The modules were released for you, so you could never race ahead. My therapist released a module when she thought I was ready for that module.
There was a lot of work before we worked on the death of a loved one, which I was dreading. But it just meant that if it was 2:00 on a Sunday afternoon and I was feeling really, really low, I could go back in and go through something that I thought might help.
Lucy: And the module that you were dreading, the death of a loved one, what was that like when you got to it?
Fiona: It wasn’t as tough as I was expecting, but that’s kind of always the way, isn’t it? The death of a loved one all made sense. And I think it was the right time that I did it, because I’d already started to feel better. So that’s what was brilliant about it; it was all done at exactly the right time.
So there weren’t any of them that weren’t tough. I mean the toughest one of all was when I had to write my story. So you physically write your story, about what happened to you. And I had no trouble remembering the events and in which order they happened, but when you actually see it written in front of you, and you write it yourself; for me that was the breaking point, that was when things started to turn around. Because that’s when I realised that I had been through something utterly horrific. And I was allowed to feel the way that I was, because anybody would do in that situation.
So it’s almost like when I read my story, as hideous as it was, and as upsetting as it was, and I cried a lot when I wrote it. That was the point where I let myself off the hook a bit, for want of a better expression.
Lucy: Yeah, so you could kind of witness what had happened to you almost.
Fiona: Yes. Yeah, it’s exactly that.
Lucy: The programme for PTSD that Fiona did, and another similar one for social anxiety, have shown promising results. I asked Graham to explain the evidence base for this sort of therapy.
Graham: Yeah, we have done a few studies so far, starting with some initial pilot studies, to test the programmes. And also some randomised control trials; so comparing them to other forms of treatment. And what’s been really, really pleasing to see so far, is that the results that we’ve been getting are really encouraging. Really showing that people can make great improvements using this format of treatment, and actually can really overcome their difficulties.
So we’re very excited about the potential for our programmes, and for this format of treatment in general. Because I think it really can change people’s lives and make a real difference, in the same way that face-to-face therapies can.
One other thing to add perhaps is that another possible advantage of programmes that have some of the treatment content written down, is that they can be translated into other languages and shared around the world a little bit more easily.
So some of my work has been working with some teams in other countries to try and see how these treatments perform in a different culture to where they were originally developed. And I think the format there can be quite helpful in terms of translating and sending it to other countries and cultures who would like to use it, and feel that it could be helpful for them.
Lucy: Yeah, absolutely. And even different people in this country, who don’t have English as a first language. That sounds really helpful, yeah.
Graham: Yeah, absolutely.
Lucy: In general, although some people sometimes worry about whether digital CBT will be as good as face-to-face, Graham thinks that the evidence is promising overall.
Graham: So it’s quite an interesting one. I think there’s a sense amongst many people, both members of the public, and therapists and researchers, that digital CBT and online treatments are quite a new development. But actually when you look at the literature, it’s really quite extensive; these kinds of things have been being researched for over 20 years. There’s now over 300 randomised control studies looking at the effectiveness of different internet-based programmes.
So there’s actually a lot more evidence out there than people realise. There are a few things I guess that we can conclude from the evidence so far. Obviously it’s a very rapidly growing area, and lots of people are doing more studies all of the time. But generally it seems that online treatments, when they’re compared – they’re most usually compared to people on a waiting list, or a group that aren’t receiving any treatment at the moment. And so generally those studies will find that actually an online treatment is much better in terms of your clinical outcomes, compared to waiting or doing nothing.
Treatments that have support from a therapist generally do a little bit better than ones that are unguided; that don’t have that therapist support.
Studies have generally done follow-up, usually up to one year, or the longest I think I’ve seen is up to five years after treatment. Those studies all generally seem to find that the gains that people have made during the treatment have been maintained over that time. So that’s really encouraging.
Lucy: One limit to the evidence base is that there are not as many studies comparing digital to face-to-face treatment.
Graham: Generally what those studies have found is where the digital treatments have support from a therapist and have been compared to a face-to-face treatment, the outcomes are similar. It’s really exciting I think to know that actually the outcomes might be similar; it could be just as helpful for you doing your treatment online as it is face-to-face.
There is need for more studies doing that direct comparison, because they’re not quite as common as other forms of research in this area. Some of those review studies have suggested that maybe there are some studies within that that perhaps aren’t the highest quality at the moment. So I think there is need to do more work on that.
Lucy: And is digital CBT better for any particular people, or any particular problems?
Graham: I don’t think we have the evidence yet to know that. But I think there are a number of potential advantages that people might experience doing their treatment digitally. I tend to see it as being that we’re not necessarily looking for digital treatments to be replacing face-to-face work. It might be a really helpful option for people.
They are quite flexible for people, so people can do them maybe in the evenings, at weekends maybe, if they’re working, or they can fit it around other commitments that they have. I guess it avoids the cost and the time that they might need to take off work or travelling to an appointment.
And as I mentioned before, the idea of going at your own pace and maybe going back and re-reading, or re-looking at something from earlier in treatment, that you wanted to kind of refresh on.
Lucy: Fiona sometimes used her commute on a coach to London to work through the modules.
Fiona: It helped me doing that, because if I started to feel panicky or anxious, I’d then concentrate on my surroundings.
Lucy: And how have things changed since having had the therapy? Apart from there being a global pandemic and everyone going into lockdown.
Fiona: Well, for a start I wouldn’t have been able to deal with the global pandemic and going into lockdown, I don’t think. My mother did mention that to me the other day, how proud she was of me, because I was dealing with it. So that was a good thing.
I’m calmer. I’m not going to say that my panics have… I haven’t had a panic attack since. I’ve nearly had them, but I can get out of them easily – well, easier. I’m calmer, I’m more relaxed. I’ve got a sense of wellbeing, apart from the global pandemic. I’m just happier.
I’m not saying it’s all completely gone away, because I miss my husband, but it’s not crushing anymore. And I can think of him and smile, whereas before all I saw was the illness and the pain. And it still flashes into my head, but it was flashing into my head all the time before, and it’s not doing that now. And I think I’m better equipped to deal with things now than I was before.
Lucy: That sounds really different, yeah.
Fiona and Graham had some advice to share for anyone thinking about having digital CBT.
Graham: I definitely recommend asking what sort of studies or research had been done on that particular internet programme. Because as we’ve said they do vary a lot, and so I guess it would be good to know that what’s being considered has been tested and shown to be helpful for people.
Then I guess the other questions; one would be what format is the treatment? Because I think even though it might be called digital CBT or something, that might still vary a lot. So is it going to be done over webcam sessions, or typing, or a written programme online?
And then I guess a last question to think about, or to recommend people ask, would be about what support there is from the therapist. So particularly what format that support would come in and how often they would get to speak or interact with their therapist in some way. Is it messaging once a week, or is it phone calls? Because I think it’s important to get a sense of that.
Lucy: Graham has also been part of writing some guidelines, to help people know what to ask when they’re offered digital provision of therapies. I’ve linked to this document in the show notes.
Graham: So I guess at the moment, in the context of the coronavirus, it might be the case that some people are a bit worried about seeking help, because of concerns about having to go and see someone, or meet them face-to-face. But I would encourage people not to put off trying to make contact and reach out to people.
Most services at the moment are offering a lot of digital and telephone options, so it really wouldn’t necessarily be the case of having to go and see someone in person.
And obviously this is a tough time for all of us, placing many strains on our mental health. So I would encourage people to reach out if they’re struggling and need some extra support.
Lucy: Graham also had a thought for people who might worry about the relationship that can be built with digital CBT and whether it can be as good.
Graham: Actually there have already now been a few studies looking at the idea of a therapeutic relationship online. What those studies have found is that actually the people who have been going through an online, digital treatment, do report a similar level of connection to their therapist as people who are doing their treatment face-to-face.
One idea I have about that, and that might be interesting to explore a little bit more in some studies, is I guess in online treatments you have the ability to send your therapist a message at any time. And obviously it’s not possible for them to get back to you instantly all of the time. But I think for many people that can give quite a powerful sense of their therapist being there for them. That might go some way to really strengthening that connection.
Which perhaps is slightly different in face-to-face. Where you would perhaps have an hour together with your therapist, and then it wouldn’t be common that you would be speaking to them or contacting them too much until your next session.
Lucy: It’s really nice to hear about the difference between the two types of therapy. It’s making me think it would be nice if people had the choice sometimes, between the different types, because they do feel maybe slightly different.
Graham: Yeah, definitely. I think it would be nice to move towards a place where we have these options easily available and that then people could be able to make a choice about what they think is going to work best for them.
I don’t think we’re quite there yet, because a lot of these programmes are still in the earlier stages of development. There is obviously also quite a lot of work to train therapists in how to use them and to actually get them embedded within clinical services. But certainly that work is happening, so hopefully we are moving in that direction.
Fiona: I would say do it. Even if you’ve got reservations, absolutely do it. You’ve still got someone there who’s got your back and wants to help you get better. So I certainly wouldn’t shy away from it just because it’s a different format. It didn’t seem any different to me, and it really did change my life.
But the fact that it was always there if I needed it was invaluable, absolutely invaluable. Because to be able to message your therapist at – it didn’t matter what time. If I was awake at 1:00 in the morning, I mean she wasn’t going to answer, but it didn’t matter. I could still send that message because the next day she’d respond. And I’d got it out of my head and I wasn’t dwelling on it, because I’d sent that question out there.
So just try. Even if it takes you out of your comfort zone, even more than you’re already out of, because you’re having therapy. I feel really lucky that I got that type of therapy, I really do.
Lucy: Do you have any advice for people who maybe are trying to comfort loved ones who are grieving? Do you have any advice for them?
Fiona: I think the awful thing about grief, everyone thinks – unless it’s happened to them – the number of people who said to me, “Come on, pull yourself together.” I mean it was absolutely astounding. A lot of people who didn’t, but also their lives go on. And so at the beginning when someone dies you have an awful lot of support, and then it disappears.
Don’t tell them to get over it, (laughs) don’t tell them to pull themselves together. I think the thing is to listen; to listen and to be sympathetic. Just to not try and make it right. I think that’s what I found, is a lot of people just didn’t want me to be in pain anymore. So they tried to jolly me up or push it away.
And I think it’s really hard if you haven’t been through it to be really, truly, truly sympathetic. But I think the best thing to do is listen and comfort, and not try to make it better. Because the only thing that’s going to make it better is for your loved one not to be dead, and that can’t happen. So you just need gentle support, I would say.
What’s so great about the therapy is I can say it was terrible, it was awful. But then in just a matter of fact way. My heart doesn’t hurt any more. I know that sounds like a real Disney thing to say, but it’s true. And it took ages to get there, to get the help, but I got it. And I’m just really grateful I got it. Yeah, I feel really lucky about that. Thank goodness. (Laughs)
Lucy: That’s all from me. Massive thanks to both Graham and Fiona for sharing their experience and knowledge.
Both digital therapy and traumatic grief are very relevant at the moment, as the effects of the pandemic continue to impact. And I’ve put information in the show notes if you’d like to know any more about either of those things.
Take good care and please do fill out that survey if you get a moment, I’d love to hear from you.
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Podcast episode produced by Dr Lucy Maddox for BABCP
Photo by Emily Morter on Unsplash
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What does existing research tell us about the possible impact of the pandemic on children and young people's mental health? Dr Lucy Maddox speaks with Dr Maria Loades about Maria and colleagues' recent rapid review of the literature on isolation and mental health, and what CBT principles suggest can be helpful to head off problems, in particular with loneliness during the pandemic.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Maria recommended lots of helpful resources on loneliness and social isolation which we've listed here:
Books
Together: Loneliness, Health And What Happens when we find Connection – Vivek Murthy https://www.amazon.co.uk/Together-Loneliness-Health-Happens-Connection/dp/1788162773
Overcoming social anxiety and shyness https://www.amazon.co.uk/Overcoming-Social-Anxiety-Shyness-Gillian/dp/1849010005
Overcoming your children’s social anxiety and shyness https://www.amazon.co.uk/dp/1845290879/ref=cm_sw_em_r_mt_dp_U_6p13EbZ0ER2XD
Websites
Mind - https://www.mind.org.uk/information-support/tips-for-everyday-living/loneliness/about-loneliness/
How to cope with loneliness during coronavirus – https://www.verywellmind.com/how-to-cope-with-loneliness-during-coronavirus-4799661
TEDx talk by Will Wright ‘Loneliness is literally killing us’ - https://www.youtube.com/watch?v=ruh6rN5UrME&feature=youtu.be
Loneliness and isolation in teenagers – a parent’s guide https://www.bupa.co.uk/newsroom/ourviews/2019/05/teenager-loneliness
As always if you want more information on BABCP check out www.babcp.com
If you want to find a CBT accredited therapist check the register of BABCP accredited therapists https://www.cbtregisteruk.com/
Articles
The rapid review we talked about is here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267797/
Podcast
That podcast episode with Shirley Reynolds on teenagers doing more of what matters to them is here: https://letstalkaboutcbt.libsyn.com/helping-teenagers-do-more-of-what-matters-to-them
Transcript
Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. In this episode brought to you by the British Association for Behavioural and Cognitive Psychotherapies, we think about the possible effects of quarantine on children and young people’s mental health. I’ll let my guest for today introduce herself.
Maria: My name is Dr Maria Loades and I’m a clinical psychologist and I work at the University of Bath as a lecturer on the doctorate and clinical psychology programme.
Lucy: Maria and her colleagues have been especially interested in the effects of the pandemic on children and young people. She co-authored a rapid review of evidence to try to understand what this effect is likely to be.
Maria: What we wanted to do was to look at two things. One is the studies that have been done that have looked at social isolation in a pandemic context in children and young people and how that’s impacted on their mental health. Secondly, we were also interested in thinking, okay, if these measures mean that young people experience this increase in loneliness, what do we know about how loneliness might be related to mental health for children and young people.
Lucy: So obviously there’s not loads of pandemics to study, but you’re trying to work out from what’s been done before, how does loneliness impact on mental health problems for children and young people? You turned the review around really quickly didn’t you, because normally it takes months to do something like this.
Maria: Yes, we really felt like it was particularly important to pull this together as quickly as we could to inform policy and practice going forward.
Lucy: And what did you find?
Maria: As we expected, there isn’t much known about the impact of pandemics specifically. There was just one study that looked at mental health in children and young people in a pandemic context and it did find that there was significantly increased rates of mental health problems for those who had experienced disease containment measures like quarantine or social isolation. And the study focused on trauma symptoms and they found really much higher rates of trauma symptoms amongst those young people who had experienced those disease containment measures. But that is only one study.
More broadly though, there were over 60 studies that looked at loneliness and mental health. And we found that there is good evidence that loneliness increases the chances of developing mental health problems, both anxiety and depression, up to nine years later.
So there’s not only a loneliness and depression and anxiety linked when we measured them at the same point in time, but there’s good evidence that being lonely now will mean an increase in risk of mental health problems at a later date.
Lucy: Maria thought one study was particularly interesting. It looked at duration of loneliness compared to intensity of loneliness.
Maria: Now what we mean by that is how long the loneliness is going on for, as compared to how strong the loneliness is. And what this study found, and it was a big study, is that actually the longer we’re lonely for, the more closely linked that is with mental health problems than how strong the loneliness is.
Lucy: What are some things that might be helpful to head off these problems?
Maria: We know that loneliness is that feeling we get when our social connections are not what we would want them to be. In the current context, of course, socially connecting in the normal ways, like at school or at college, for young people, is curtailed. But we can still connect in other ways.
Lucy: Maria emphasised how important connecting for play dates over video calls can be, as well as meeting up for play now lockdown is easing, and using more old school ways of communicating as well, like sending friends cards or letters.
Maria: The other thing we can do is more broadly to think about how we promote activities amongst young people that support wellbeing in every which way we can. As well as making sure we’re providing a listening ear for young people and being open to hearing what they might be worried about or what they might be feeling sad about and problem solving that where we can. Actually giving them permission, this is a really unusual circumstance and it’s okay and it’s normal for it not to feel very good.
Lucy: Some things that we know promote wellbeing include regular exercise, good quality sleep, healthy eating and time spent on activities that young people enjoy and feel proud of.
Maria: As one goes for a walk you see rainbows in the windows and my little one looks and points and knows that those rainbows mean that there are other children out there. And I think that’s incredibly helpful in terms of feeling a sense of community, connectedness, which also helps to overcome that loneliness.
Lucy: So although there may be an increased risk of mental health problems as a result of the pandemic, there’s also lots and lots that we can do that would be protective.
Maria: Definitely. I think it’s really important too that we make a distinction between young people who might be feeling lonely now and during this context, but who were pretty well socially connected beforehand. And of course, other young people who might have been lonely beforehand and this has maybe made things worse, or that their loneliness is ongoing at this stage.
For those young people who have maybe been feeling lonely for a much longer time, we might need to do something more individualised and more specific in terms of helping them to think about how they can make social connections going forward, as we resume life to some degree.
Lucy: I asked Maria whether she thought that as we are able to see people more, there might also be some anxiety around socialising.
Maria: You know, the reality is, we haven’t been practicing socialising nearly as much as we’d normally do. So we might well feel rusty and we might well even be worried about connecting socially with each other again. Add into that, of course we’ve had a lot of messages in recent weeks about the risk of interacting with each other because of the risk of infection. And so I think anxiety about getting physically close to each other and interacting with each other is going to be really natural in weeks going forward.
And I think again, the CBT principles can really help us to deal with those social anxieties too. So the first principle that I think is really important to remember is: The first step to tackling fear is facing it.
Lucy: CBT principles suggest breaking down a scary situation into steps and gradually building the confidence to face the fear by conquering one step at a time. So starting with a text message to a friend and working up to meeting face-to-face, for example.
Another tip to help with social anxiety is trying not to focus on how we’re coming across to someone but to focus on what someone is saying rather than getting caught up in thoughts about what they think about us. Thinking about thoughts, just as thoughts rather than facts is one thing that can help with this too, both for children and adults.
Maria: There’s certain developmental reasons why children and young people may be struggling particularly and those are about the key importance of play and of social interaction to development at those ages. But actually this is something that everybody is experiencing.
I do think the majority of children and young people, and adults more generally, will have a few wobbles, but will manage and will bounce back as we go forward. But for some, I think it will be a little more difficult and they’ll need to maybe engage in a bit of self-help using some of these CBT principles or indeed actually to go on and get some more professional help.
Lucy: Maria’s review has implications for school policy.
Maria: What we’re really encouraging, both schools but also policymakers to support is that as schools return and resume their normal activities, that they focus on allowing children and young people to reconnect rather than emphasising catching up academically. We know, again, from lots of studies and reviews that have been done that having mental health problems gets in the way of academic attainment.
We’ve got a strong rationale really for arguing, okay, let’s make sure now that we try and overcome loneliness rather than prioritising catching up with school work in the short-term because actually in the longer term that’s going to be beneficial to school work as well as to wellbeing more generally.
Lucy: I was curious to know if Maria thought any children and young people might actually have benefitted from lockdown. I see children and young people in my clinical practice and I’ve seen a real mixed bag of responses.
Maria: I do think that there are some young people who have actually found lockdown to be a real relief, particularly young people who struggled more with school and who struggled more with social interactions. Again, they’re young people who might struggle particularly with the return to school as things get restarted again.
Lucy: Another group Maria highlighted were children and young people with particular transition points at this time.
Maria: People who, for example, had exams cancelled. Whilst in the short-term that might be a real relief not to have to study and not to have to face GCSEs or A-Levels for instance, I think again, going forward, then there’s worries for those young people about what did that mean for them and how do they pick up from where they left off.
Lucy: Super hard isn’t it, because there’s such a range of experiences that will be going on in people’s homes as well. I suppose one thing that has been really on my mind is children and young people who are from backgrounds where they will be disadvantaged by being at home, or perhaps even in danger for one reason or another.
Maria: I think that’s a real problem and I do a lot of work with colleagues in South Africa, for whom lots of what we’ve been talking about as helpful strategies just don’t apply. Most children and young people don’t have access to the internet and can’t continue to keep in touch by virtual play dates, for instance. So what do you do for those kind of populations who are disadvantaged in terms of being able to remain in digital contact with one another. It’s really tricky.
I think we should all be concerned about those young people for whom home isn’t a safe place. And that’s a small minority of children, but a really big concern.
Schools often have a function of being able to do that check-in and that noticing of when children aren’t doing okay and to pick up on that and we haven’t had the ability to do that. So I think the needs of those children are going to be really important to thoroughly meet as we resume education contact and so forth.
Lucy: Maria’s overall message was one of realistic optimism.
Maria: I think parents are understandably fearful about what this is going to mean for the wellbeing of their children going forward and, what’s that phrase? Realistic optimism. I do think the vast majority are going to bounce back and a few wobbles, a bit of encouragement, a bit of a push sometimes, but they’ll manage it. And the few who get a little more stuck, we do have things that we can offer to help.
Lucy: That’s all for now. I hope you enjoyed this episode and found it useful. If you’d like to listen to more on children and young people, there’s another episode with Shirley Reynolds, talking about how to help young people do more of what matters to them at this time. There’s also loads in the back catalogue about different types of CBT and different problems it can help with. For example, compassion focused therapy or CBT for hoarding disorder.
As ever, if you have ideas for new topics, feel free to get in touch with me at lucy.maddox@BABCP.com. Take care for now.
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How does doing more of what matters help teenagers with low mood and depression? And what can we all learn from this, particularly at the moment? Prof Shirley Reynolds speaks to Dr Lucy Maddox.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
If you want to know more the following resources might be helpful.
Books
Shirley has written two books about depression in teenagers, one for teens and one for parents:
For parents: Teenage Depression: CBT Guide for Parents https://www.amazon.co.uk/Teenage-Depression-CBT-Guide-Parents/dp/147211454X
For adolescents: Am I Depressed and What Can I Do About It? https://www.amazon.co.uk/Am-Depressed-What-Can-About/dp/1472114531/ref=pd_lpo_14_t_0/260-4076808-4951665?_encoding=UTF8&pd_rd_i=1472114531&pd_rd_r=bd1ea151-b4d3-40bc-99bc-583aa3824613&pd_rd_w=xtKq9&pd_rd_wg=CFBxI&pf_rd_p=7b8e3b03-1439-4489-abd4-4a138cf4eca6&pf_rd_r=MFANFKSAD9RE92R6XS65&psc=1&refRID=MFANFKSAD9RE92R6XS65
Websites
BABCP website www.babcp.com
Register of BABCP accredited therapists https://www.cbtregisteruk.com/
These resources about child and adolescent mental health might also be useful
Young Minds https://youngminds.org.uk/
MindEd https://www.minded.org.uk/
Association for Child and Adolescent Mental Health https://www.acamh.org/
Other resources
Shirley is running a course with Future Learn from 1st week in June about adolescent depression – aimed to help parents and professionals understand and help young people who struggle with low mood: https://www.mooc-list.com/course/understanding-depression-and-low-mood-young-people-futurelearn
Have you seen the BABCP animation about what CBT is? Only 1 minute long and available here: https://www.youtube.com/watch?v=ZRijYOJp5e0
Photo by Daria Tumanova on Unsplash
Podcast episode produced by Dr Lucy Maddox for BABCP
Transcript
Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. This podcast is all about CBT, what it is, what it’s not and how it can be useful. Today I’m speaking to Professor Shirley Reynolds from the University of Reading about how doing more of what matters can help teenagers boost their mood, and how this might be particularly helpful for all of us to remember at the current time.
Shirley: The thing I’m really mostly interested in is understanding more about adolescent depression in order to help us really develop better treatments and better ways of preventing young people from developing depression. So that we can really try and divert them away from a path that can lead into a lifetime of problems with low mood.
Lucy: Fantastic. And at this time in particular when we’re all shutting doors a bit because of the pandemic and teenagers are shutting doors as well, what can your research tell us that might be helpful at this time in particular do you think?
Shirley: I think there are some general points and some more specific points. I think the general point is that one of the things we know, not just from our own research but from many people’s research is that when you’re a teenager, most teenagers are going to be incredibly attached to and reliant on having relationships with their friends, their peers.
The family becomes a bit less important, it’s not unimportant, but the importance of it becomes a little bit less and that’s replaced by a really, really strong focus on needing to be part of a social group. Being accepted by other people, contributing to things with your friends, being part of something bigger than yourself.
And so what that tells us then is that a period like now when young people simply cannot have those relationships in the normal ways, that this is a potential point of really massive stress for them and distress for them. And we need to try and support them; to maintain any relationships they already have, in whatever way is possible.
And what most parents are currently struggling with, but I think getting a handle on, is that currently that is going to be on a computer.
It’s not just young people, we all need these things. This is a lifelong thing for most people, but it’s a particular importance at that critical development period when we’re teenagers.
Lucy: So making sure that we’re supporting the young people in our lives to maintain contact with their friends in whatever way is possible.
Shirley: In whatever way is possible, absolutely. And accepting and understanding that it’s frustrating and difficult and anxiety provoking and that that’s true for everybody, parents, children, and everybody else.
There’s a degree to which we have to kind of let our normal expectations just be shifted around a bit and learn to live with that and be okay with that.
Lucy: Actually, just you talking about teenagers in particular made me think about that tension that can happen sometimes between teenagers really wanting to be independent and maybe family really wanting to comfort teenagers during this time. And sometimes that can be a really tricky balance to walk, can’t it, if you’re a parent who wants to offer comfort and your teenager is saying, “No, leave me alone.” Is there anything, from your point of view, that you would say about that?
Shirley: I think that’s absolutely right because the other task of being an adolescent or a teenager or growing up is to learn to be independent and to learn to do things on your own. And at the moment everybody is forced to spend 24/7 with their families and that exploration and getting out there and taking a bit of a risk and learning about yourself in the world is something, it’s very hard for teenagers to do at the moment. So they are going to need time to be separate and to be on their own.
And it is fine for them to tell you to back off and it’s inevitable that people will feel a little bit pushed away and maybe left out or maybe tempers will be frayed and there’ll be a bit more irritability. But again, I think that’s one of those inevitable challenges that there’s no right answer for this.
So I think that tension between needing support and also needing to be separate is really a massive struggle, especially for people who live in very small houses, don’t have outside space. So sharing bedrooms. I think trying to find a space for young people to call their own, for at least some of the time is going to be really important, if that’s at all possible.
Lucy: Yeah, really helpful. And helpful to remember that in the midst of trying to homeschool and all the rest of it as well actually, that to be somebody’s teacher and mum and seeing them all the time is not possible.
And some of the research that you’ve done that I found really interesting has been about valued actions. I wondered if you could say a little bit more about what valued actions are?
Shirley: Yeah, so this comes from the research we’ve done with teenagers with depression and low mood. What we see when somebody has depression or beginning to become depressed is that as we feel a little bit worse, what we tend to do – this is in normal life – is to take ourselves out of our normal social activities. So young people who have got problems with depression very often, nearly always, spend more time on their own than they would have previously.
And as they do that, as they take themselves further out, they get less reward from life. So fewer of the things that would have just happened in their normal daily life, a smile from somebody or a shared joke or something that you notice outside of the house that just made you feel good about yourself, those things just are less available to you. They happen less because you take yourself out of what’s happening in life.
As you withdraw what we see is you get less reward from life, or less of what we would call the ‘feel good factor’. And when you get less of the ‘feel good factor’, that makes you feel worse. And as you feel worse, you withdraw a little bit more and you get less reward and then you get less of the ‘feel good factor’.
So you find that young people with depression and adults with depression get themselves into this very hard to escape from cycle, this vicious cycle.
Lucy: Shirley’s research looks at ways of trying to break the cycle of low mood and doing less.
Shirley: So, we want to break the cycle and the way we turn it around when we’re working with young people is we help them to do more of what matters. More of what matters are things that are important to them and we help them decide what matters to them by talking to them about their values.
Lucy: Values are guiding principles in life, the things that show us the direction we want to go in. To work out what matters sometimes takes some real reflection on what it is that’s important to us.
Shirley: Now, they’re really big questions, why am I here? What am I doing? What is the point of it all? They’re massive questions, but they’re brilliant questions and lots of teenagers are sort of playing around with them anyway. So if we can tap into that need to work out why I’m here and what I’m doing and what my values are, it becomes a really exciting, interesting conversation.
Lucy: Shirley told me about three main areas that she tends to ask young people to think about. Values to do with themselves, like health or fun, values to do with things that matter, like education or politics and values to do with people that matter, like family and friends.
Shirley: And then the idea is that once we’ve helped them think about what their values are, which we can do in a very structured way, we then help them to do a little bit more of what matters. These are the valued activities.
So tiny little, small, easy to do activities that help them get a little bit more of that ‘feel good factor’.
Lucy: By increasing time spent on things that matter, that vicious cycle Shirley talked about before can be reversed.
Shirley: And as that reward comes back, we start to reverse the cycle. They feel a little bit less bad, so they’re able to do a little bit more and that makes them feel a little bit better. Then they can do a little bit more and so on.
So we’re taking the cycle we had that was dragging them down and we’re turning it into a cycle that can help them build their life back up again.
Lucy: Shirley encourages young people to think of a wide range of things that they can to help them move towards their values. Key is to make each step as easy as possible so young people feel a sense of achieving what they want, not failing. Also key is that the things really do matter to the young person.
Shirley: Most kids are doing a whole load of stuff that other people make them do. Their lives are much more circumscribed than adults’ lives. They’re told what to do by other people. There are hundreds of things they can’t get out of. So you can be really busy doing loads of stuff, but if it doesn’t really matter, you don’t get that ‘feel good factor’.
We find even 11 year olds and 12 year olds can begin to tell you about things that really matter to them. And these don’t have to be sophisticated or complicated or smart. The importance of the value is not in its cleverness, we just care that it kind of lights you up a bit.
Lucy: Because what matters to each young person is specific to them, how the treatment looks is very individualised.
Shirley: Everybody is following a similar recipe, but what they’ll be doing and how they’ll be doing it and how we’ll help them to do it will be completely different for every young person. The way we get them into the this, we get them to keep diaries really. And that is to help us see, and for them to see what they’re currently doing and what it usually shows us is that there’s almost no reward in their daily life. And so it helps us also find times in their days and their weeks when we can pack a bit of reward in, or we can swap one activity to another.
So when we do it for ourselves and we write down our activities and then we write down our values, and we try and map across, we’ll nearly all find a huge gap between what we value and how we’re spending our time. We’re just saying, “Where’s the flex here in your life to put in more of what matters?”
Lucy: Shirley’s research has found that people are less likely to drop out of therapy when the treatment focuses on what matters to them in this way. It also helps young people move on from feeling stuck in the here and now.
Shirley: We don’t talk about the future in an explicit way, but when you talk to a 15 year old about what their values are, they’re nearly always going to connect with the future and where they want to go and what they see themselves as. And it allows them to kind of use a bit of, yeah, just a little bit of imagination about, “Oh, I don’t know…”
And if they’ve never thought about what they want or what their values are, they go, “Oh, I don’t know.” It’s actually quite an interesting question, even if it’s something you’ve never thought about.
I mean the other part of what we do is we try and get other people in the young person’s life to help them with those rewards because young people don’t have as much autonomy or as much money. They don’t have as many resources. They sometimes need practical help to get things done. Or they need encouragement, giving lifts or arranging things at home that are a little bit different to give a young person a bit more space.
Or thinking about rewards that might be shared, like deciding on somebody’s favourite meal and then going out and doing the shopping together and then cooking together. That can be quite nice because it’s a kind of value about wanting to get on with my family but it might also be learning a skill.
Lucy: I asked Shirley how we can use these same principles at the moment, even though young people, and adults too, are going to be unable to do all the things that they value at the moment.
Shirley: I don’t think there are any fundamental differences. I just think we’re looking at a different range and a different kind of repertoire that we can use.
Lucy: What Shirley said earlier about teenagers being so, so busy, but actually their time is all stuffed with things that other people want them to do made me wonder whether there’s a slight perspective shift that’s helpful for young people and for adults. From thinking about how much stuff we’re all doing to really thinking about how much of that stuff matters to us.
Shirley: And I think if we thought more a little bit about well, what are the rewards I’m going to get from this, what am I going to take away from this that’s going to make me feel good, we might make different choices about how we’re going to spend our time. For me it’s all about the search for more positive experiences. It’s not about getting rid of bad experiences because we’re all going to have bad experiences, that’s just part and parcel of life. But if we’re filling a lot of our time with positive rewarding experiences, there is, by default, less of the time to have more negative experiences.
Lucy: There’s maybe something here for all of us. At the moment when our usual schedules are for lots of us upside down, maybe it’s a chance to pay attention in a different way, to helping young people in our lives to be doing stuff that matters to them. And also to be thinking about this for ourselves.
Shirley: Learning to savour things, paying attention to those positive things that sometimes we perhaps just let them go and they’ve gone before we’ve kind of properly enjoyed them. There’s a sort of opportunity to just notice a little bit more deliberately some of the more positive aspects. And that could be something like our first cup of tea in the morning.
Lucy: Always the best one.
Shirley: Exactly! Or the cat purring on your lap or I don’t know, silly things, tiny things and they’re different, some of them are shared, but many of them are very personal. It doesn’t matter what they are, it’s just capturing them somehow.
I like my phone for that reason, I do a lot of photographs of things that make me feel good because then I kind of feel I’m carrying them in my pocket. I think it’s always about finding the thing that fits your preferences and your personal style. But I do think some sort of recording of what is happening in your life, especially when we’re living through a weird time like this, is likely to be useful.
So that could be through writing. It could be through photos. It could be through just what you email your friends. But I think some way of kind of recording what you’re doing, where you’re at in your life and spending a bit of time just thinking about that becomes a very helpful habit to have. Because it can stop you falling down into those vicious cycles that when we don’t notice we’re falling into them, it can be much harder to climb back out later.
I would just say, I think everyone needs to give themselves a bit of a break, and their kids. And we just all need to just, what’s that expression… Be kind.
Lucy: Wise words there I think, being kind to ourselves and each other goes a long way.
I hope you enjoyed that episode and can think about how both you and any young people in your lives can do more of what matters. It’s challenging at this time but there are still lots of possibilities.
I’ve put some resources that Shirley recommended in the show notes and if you want to hear more about values in particular, check out the episode on acceptance and commitment therapy. We speak about values in that as well.
That’s all for now, take care.
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We're all living through uncertain times at the moment. What does research from CBT tell us about what tends to help people tolerate uncertainty? Dr Lucy Maddox interviews Professor Mark Freeston about what might help.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
For more on BABCP our website is www.babcp.com
For Mark's research survey follow this link:
https://www.ncl.ac.uk/who-we-are/coronavirus/research/uncertainty/
A preprint of Mark's research paper on coronavirus and uncertainty is available here:
https://www.researchgate.net/publication/340653312_Towards_a_model_of_uncertainty_distress_in_the_context_of_Coronavirus_Covid-19
If you feel like you're struggling here are some resources:
https://www.nhs.uk/oneyou/every-mind-matters/
https://www.samaritans.org/
https://www.nhs.uk/conditions/stress-anxiety-depression/mental-health-helplines/
https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-services/how-to-access-mental-health-services/
The register of BABCP accredited CBT therapists is here:
https://www.cbtregisteruk.com/
Photo by Katie Mourn on Unsplash
Episode edited and produced by Lucy Maddox
Music by Gabriel Stebbing
Transcript
Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. This podcast is brought to you by the British Association for Behavioural and Cognitive Psychotherapies, BABCP. It’s all about CBT, what it is, what it’s not and how it can be useful.
Today in another post-pandemic special episode I’m speaking remotely to Professor Mark Freeston from Newcastle University. Mark’s research is about how intolerance of uncertainty relates to anxiety and he spoke to me about how findings from this research can be relevant at this current, very uncertain time.
Mark was clear that feelings of anxiety and distress in response to the current pandemic are totally normal.
Mark: Anxiety problems that we see in mental health services have an element that is recognised to be excessive about them. But what we’re looking at at the moment, which is anxiety and distress in response to the coronavirus pandemic doesn’t necessarily have this excessive element about it. So it’s not a disorder, it’s just a lot of very anxious and distressed people.
Lucy: How is your research particularly relevant at the moment?
Mark: Since the early 90s, we’ve been looking at a thing called ‘intolerance of uncertainty’. This is particularly timely given the high level of uncertainty that’s going on. Some people find not knowing, the unknownness of things as particularly difficult to manage.
Lucy: It’s quite an existential problem almost, isn’t it? It’s quite a human problem that we all might have at different moments.
Mark: The evolutionary theory, so some very clever evolutionary psychologists and they say that everyone is probably born to be intolerant of uncertainty, but to greater or lesser degrees we become more able to tolerate uncertainty. So it’s not like a personality trait that is sort of stuck at the same level all your life. When different things happen your ability to tolerate the unknownness of things is likely to change, not necessarily on a day-to-day basis, but you may have periods of greater tolerance or intolerance of uncertainty.
Lucy: Is it that intolerance of uncertainty which leads us to feel very anxious?
Mark: Eventually, yes. The way we’ve been looking at it in our current research and we’ve been working on this for over a year, because we’ve been thinking about before the pandemic came along, we’d been thinking about caregivers of people with dementia or people living with chronic and fluctuating illnesses. And so we were thinking about a lot of different types of contexts where there’s both scary things happening and a lot of uncertainty going on at the same time.
If you are intolerant of uncertainty and there is real uncertainty around, you are going to probably perceive the situation as being more uncertain than it is. So you start off not liking uncertainty, then when things are uncertain, not only do you not like it, but you see the situation as even more uncertain. And you probably also look at the things that might happen, particularly the bad things that might happen as more likely. It’s that combination we think, that makes people anxious.
Lucy: And then at the moment, do the same things apply, might some of us feel more anxious in response to what’s going on with the pandemic than others?
Mark: Yes, and obviously people who have got more at stake, so people who are at greater risk, also about financial things. It’s at multiple levels that there’s lots of uncertainty going on and some people find this more difficult than others.
Lucy: Mark told me about some research which suggests that over the last 30 years we’ve all been finding uncertainty harder to tolerate.
Mark: What we found is that intolerance of uncertainty scores have been going up since the 1990s.
Lucy: Oh really?
Mark: Yeah, so essentially year on year. One of my colleagues in Canada, Nick Carlton did a very nice study where they looked at all the published North American studies of similar types, examples, and then they looked at the extent to which people had mobile phones or high speed broadband.
And so if you think from the early 90s through until the mid-2015s, then there’s been a massive increase in our degree of connectedness, the access of information. And so one of the ideas is that the more information that we have available, the less certain we are about things.
Lucy: This research suggests that sometimes too much information can be unhelpful, can make us more uncertain.
Mark categorised information about Coronavirus into three types. Information that we need to know, like the current rules that we’re all expected to follow. Information that might be interesting to know, like answers to responsible questions that are being asked about what’s happening. And then less helpful information which is unreliable or even malicious.
Even the responsible questions might sometimes be problematic because they’re often unanswerable, so they might just generate more uncertainty.
Mark: There’s a lot of people working on the assumption that the answer is out there if only I can find it. From the point of view I’ve been working from, we can’t information our way out of this, out of feeling uncertain.
Lucy: We will likely all have had other times in our lives when things have felt uncertain and when it’s felt difficult to tolerate this.
Mark: I was reflecting on my own life and I’ve emigrated three times in my life, okay? From the UK to New Zealand, from New Zealand to Quebec and Quebec back to the UK. And so obviously they tend to be very uncertain times because you don’t quite know what to expect.
So things like emigration or becoming a parent for the first time or moving in with a partner for the first time. So it’s not just bad things, but these are just things where you don’t know what it’s going to be like because you haven’t done it before.
Everyone has had experience of big changes, sometimes they’re chosen sometimes they’re imposed. And there’s only so much you can find out, the rest you have to wait and see and that’s an uncomfortable state to be in. But the belief that drives people to try and get more and more information is that the answer is there, but it probably isn’t. It would be nice to say that the information is there, but it’s not.
Lucy: What do you know about, from your research, into intolerance of uncertainty that might help people at this time?
Mark: I think there’s two main things to do at this time. I think one thing is people really thinking about their use of information and where they’re getting it from and is that being helpful or not. Those are the things you want to manage the intake.
But there might be other types of information that might be worth finding out, that might put a bit more balance back into things. Are the birds still singing? What are some of the things that people are doing to help each other out?
Rather than stories about all the things we don’t know, there’s plenty of stories about people who are actually getting on and doing things, groups of people getting organised. So being a bit more selective in what news you go looking for.
Lucy: I really like that. The birds are still singing in Bristol, happily! (Laughs)
Mark: They’re still singing here in Whitley Bay as well and as usual, as for every year, we’ve got a particularly noisy group of sparrows that have taken up residence and I’m pretty sure the starlings will be under the eaves and they’ll be making noise for the next few months. That bit hasn’t changed.
Lucy: So managing information could be about restricting input of stuff that’s not so helpful, but also looking for information that balances the picture out a bit, it’s really nice.
Mark: Yeah, certainly. And I guess that looking for information, that balances things out a bit leads onto the next point, which is the thing about intolerance of uncertainty is that we need the presence of safety rather than just the absence of threat. So if we don’t have the presence of safety, that’s when we feel uncomfortable and that’s when intolerance of uncertainty kicks in.
So it’s not just that there’s no possibility of bad things happening, it’s about the presence of signs that things are okay in very small ways. Hence are the birds still singing? That’s an example.
We know how disrupting the pandemic has been at all sorts of levels, but it’s very easy to focus on the big disruptions, right? So people cannot go out, they cannot socialise, they cannot go to school, but there’s probably lots of little disruptions that people don’t even notice as much. Small routines of everyday life.
Lucy: One of the everyday routines that Mark has made sure to keep the same is his morning cup of coffee and a new small thing he’s noticed is that he started to eat Marmite again, which he hasn’t had since he was a boy.
Mark: So I guess it was one of the signals of safety that would go back a long way. It’s these small routines that can help us feel safer, even when there’s a lot of uncertainty.
Lucy: That’s really nice because that’s something we have some control over actually isn’t it?
Mark: Yes.
Lucy: Whether we can keep some of those small routines in place.
Mark: Many, many, many people have been taken, if you like, out of their comfort zone. What are the different things that help us feel settled and safe? And then that means that if we can get those, our perception of uncertainty will go down, our perception of danger will go down a bit and we’ll be a little less distressed and anxious.
Lucy: So two things there which might help at this time based on the research that Mark has done. Number one, thinking about which information we seek out and how often. And number two, thinking about how we signal to ourselves that we’re safe. Perhaps in quite small, but still significant ways.
Mark: There’s other types of information that says the world is still as we know it and that’s sort of the link between feeling safe and information management. That’s where the two come together.
Lucy: Although we’re all experiencing uncertainty at the moment, Mark acknowledged that some people may be finding things extra hard if they have personal experiences in their past which resonate with what’s happening at the moment in some way.
Mark: There’ll be things happening, whether it’s due to isolation, whether it’s medical threat, whether it’s seeing one part of your life being disrupted. This is going to, I guess wake up or trigger things that you might not have thought about for a long time.
So I think it’s being able to recognise that it isn’t just what’s going on outside in the world, it’s what’s going on inside your own mind as there’s a degree of match between some of the things that you’re being exposed to, that we’re all being exposed to, and things that we’ve lived through in the past.
Lucy: If you feel like that’s the case for you at the moment, do please try to reach out and seek help, whether from friends and family or from professional sources of support.
I’ve put some links in the show notes to some different resources and also to the BABCP register of accredited CBT therapists. Also in the show notes is a link to the survey that Mark has been sharing and a recent journal article that he’s written.
If you liked this episode, there are loads more you can listen to at the Let’s Talk about CBT website, or wherever you get your podcast from. There’s a short episode featuring Jo Daniels about anxiety in relation to coronavirus and a new episode about CBT bipolar disorder too.
If you have ideas for other episodes, feel free to get in touch at [email protected].
Meanwhile, stay safe and stay well. We spoke in this episode about how the birds are still singing, so I thought I’d leave you with a little bit of birdsong recorded just outside of Bristol after the theme tune plays us out.
END OF AUDIO
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Note: This episode was recorded before government guidance on restricting travel due to coronavirus.
We all experience ups and downs in mood, but what happens when the highs are so high and the lows are so low that it really interferes with your life? In this episode we hear from Cate Catmore and Professor Steven Jones about CBT for bipolar disorder.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
For more resources check out these links below.
Books
Coping with bipolar disorder by Steve Jones, Peter Haywood and Dominic Lam
https://www.amazon.co.uk/Coping-Bipolar-Disorder-CBT-Informed-Depression-ebook/dp/B07ZWQ877T/ref=sr_1_1?dchild=1&keywords=coping+with+bipolar+disorder&qid=1585237730&s=digital-text&sr=1-1
Overcoming Mood Swings by Jan Scott
https://www.amazon.co.uk/dp/B003GUBILQ/ref=dp-kindle-redirect?_encoding=UTF8&btkr=1
Online resources
NICE guidelines on bipolar are summarised here
https://www.nice.org.uk/guidance/cg185
Cate spoke about mindfulness. You can hear more about mindfulness-based cognitive therapies here
https://letstalkaboutcbt.libsyn.com/lets-talk-about-cbt-mindfulness-based-therapies
This BPS report is called Understanding Bipolar Disorder
https://shop.bps.org.uk/understanding-bipolar-disorder.html
Recovery toolkit for friends and relatives of someone with bipolar disorder based on research at Lancaster University
https://reacttoolkit.uk/
Guardian article on CBT for bipolar disorder by Lucy from a few years ago
https://www.theguardian.com/science/sifting-the-evidence/2016/feb/08/nice-critique-a-call-for-more-research-not-an-excuse-for-less-treatment-psychotherapy-cbt
If you’d like to read more academic journal articles this range of papers about bipolar disorder has been made free until 30th April 2020 from the BABCP journals
https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/bipolar-articles-from-bcp-and-tcbt
The photo is by Claire Satera on Unsplash
This episode was produced by Lucy Maddox.
Transcript
Lucy: Hello and welcome to let's talk about CBT, with me, Dr Lucy Maddox. This podcast brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP is all about CBT. What it is, what it's not and how it can be useful. As an aside, if you listen regularly to this podcast and like it, please do consider rating and reviewing it, it helps other people to find it.
And if you have ideas for other episodes that you'd like to listen to, just let me know at [email protected]. Right then, I thought I'd start this episode with a quote from Kaye Redfield Jamison, who's a clinical psychologist and writer. She writes, "When you're high it's tremendous, the ideas and feelings are fast and frequent like shooting stars, and you follow them until you find better and brighter ones.
But somewhere, this changes. The fast ideas are far too fast and there are far too many. You are irritable, angry, frightened, uncontrollable and enmeshed totally in the blackest caves of the mind." That was about Kaye's experience of bipolar disorder which is the diagnosis that this episode concentrates on.
For this podcast, I went to Lancaster and met Cate, who's experienced the highs and lows of bipolar disorder and what CBT can do to help. And Steve, whose research team works on a CBT-based intervention for bipolar disorder.
Cate: I'm Cate Catmore, I'm 64, and I live with my husband, got two children, two sons and two granddaughters. I did CBT a while ago and then I had a course of recovery-based CBT recently.
Steve: Hi, I'm Steve Jones, I'm co-director of the Spectrum Centre for mental health research at Lancaster University. The focus of our work is on trying to learn more about the psychological and social factors underpinning bipolar disorder and related conditions. And to use that information and learning to develop new interventions that are developed with the service user in mind. We've been in existence for about 11 or 12 years, and we've always had people with lived experience of bipolar disorder as colleagues as well as collaborators.
Lucy: Cate had her recovery-based CBT as part of a research study at Lancaster University, delivered by one of Steve's colleagues. It's not the first time Cate had CBT for bipolar disorder, but she felt she was more able to access it this time round.
Cate: In the very first place I had CBT when I was hospitalised about 10 years ago. I hadn't kept up with it, and I'd just let it slide, really. And then, I heard about recovery-based CBT through a bipolar support group at Lancaster University.
Lucy: I asked Cate about her experience of having bipolar disorder.
Cate: I didn't have too many manic episodes, but I have to say that was how it was diagnosed, and I must admit I did enjoy the manic phase.
Lucy: What did it feel like?
Cate: It felt free and exciting and I wanted to do everything that I could, and I felt that everything that I did I was doing very well. The main thing that I remember or being very enthusiastic at work and doing a lot more than I was called on to do. I was lucky that I didn't spend all that much, but I did give a lot of money away to charity.
But the best thing (laughs) and it sounds so self-important, but we went out a lot then, probably instigated by me. Me and my husband went out a lot. I used to say, "Oh got to get to this party early, because nobody will enjoy themselves if I don't get there."
Lucy: What a lovely feeling, though.
Cate: It was a lovely feeling, and sometimes I think I wish I could be a bit more like that. And I don't really get the highs anymore, I get the lows, but not the highs. And I know that they're dangerous and they're not healthy, but when you experience them, they are quite nice (laughs).
Lucy: Yeah, it sounds nice.
Cate: Mine wasn't destructive, I have to say, so I was lucky that I just had the nice inside feelings. I didn't gamble like some people do, and I didn't go out and buy a car or anything like that, just made me feel really good and bigger than I was.
Lucy: Yeah, that's a really nice way of describing. Bigger. Yeah. And what's the other end of the experience? So, the lower bit like?
Cate: Well, the lower bit was very low. Part of the manic bit eventually made things quite stressful because I was jumping from one thing to another. And so, work did become stressful and then home life became stressful because I was trying to do so much at home. And then, I got an eating disorder, and they both seemed to feed one another. So, losing weight so much made me more manic, I think.
And then, the more manic I was, the less I ate because I was doing so much, didn't have any appetite. So, it was that, really that led to me to be admitted to hospital. And then, I wasn't really high anymore after that. Then, the low bit started, which lasted a long time. So, I was in hospital quite a long time.
I think I left a lot of myself behind in that hospital. I don't really think I've ever been quite the same person that I was before. Even though I was assured I was, I think it does have a big effect. Yeah.
Lucy: Steve described the definition of bipolar disorder to me.
Steve: I guess bipolar disorder is typically defined in terms of experience of substantial variation in mood. So, most people with bipolar disorder will have experience of both periods of mania where mood is extremely elevated, people can feel very euphoric. They can have lots of energy, but often that can be mixed together with other things, which make it more complicated like feeling very irritable or frustrated.
And then, periods of depression, which are not unlike periods of depression, feeling rather hopeless and very down, and finding it really hard to get going and engage in normal life. And historically, bipolar has been seen as those two things, really. And what tends to be missed out is that often people are experiencing quite a lot of challenges in between those sorts of episodes, where they're not really experiencing mania and they're not really experiencing depression, but there's often quite a lot of mood variation going on.
And people are also working quite hard to make sense of the variety of experiences that they have. So, quite a lot of our work is targeting that middle period, which seems to be actually pretty crucial for people to then develop a platform for getting on with their lives.
Cate: Mood swings but extreme ones. Yeah, and they can last a varying length of time as well. So, people can be manic just for a short length of time, mine was relatively short, I suppose, two months. But then, I've found that the other side of it is quite dark, the depression can be quite dark. So, I think it's just like an exaggerated way of how a lot of people are, that just manage it normally in their day-to-day life.
I sometimes think that people are a bit wary of mood swings and think that something that they say that's wrong might cause a sudden up or a sudden down. And it isn't like that, at all. It's not so erratic as that.
Lucy: So, what does CBT for bipolar disorder involve?
Steve: An important part of any successful intervention with people with experience of bipolar and a core aspect of the recovery-focused approach is really working with the person initially, to get a shared understanding of their experiences that have brought them to the intervention.
Which isn't just a symptom history, because obviously with things like variable mood, the point, the continuum between something that's a problem and something that's normal experience and parsing those things out is one of the challenges people live with. So, people will often be able to for instance identify experiences where mood elevation has been in some ways amazingly good for them.
It allowed them to get a promotion or complete a task they otherwise might not have been able to complete. But then, there are also occasions when that's tipped over into something that's had a profound effect on their lives. And it's not hard to imagine how trying to pull all that together and make sense of it. Which bits do you want, which bits don't you want, which bits are you, which bits are some part of bipolar isn't something people find readily easily resolved without a bit of time and reflection, I think. So, getting that story clear and in a shared way can be a really useful platform for them working out, okay, so what do you want to change? And what do you want to have more of?
Lucy: So, anyone listening, who's thinking that they might want to try CBT for bipolar they could expect to have that kind of shared understanding at the start about what's happened for them and what they would like to work on?
Steve: We're not going to assume that it's about mood or it's about something else. We're going to work with you to find out what is the thing that's causing you difficulty and how shall we address that together.
Lucy: Cate told me a bit about what her most recent experience of CBT had been like.
Cate: Well, it was a talking therapy. We talked about issues that bothered me, and basically about ways to cope with those, identifying what they were, and what triggered them. And different ways of coming to terms with them and coping with them.
Lucy: If you were describing it to somebody who hadn't had it before, what would they see happening in the room? What was going on?
Cate: Well, two people talking together, basically in a chatting way, some writing going on to remind you what had been discussed with the therapist, and then to work on that during the week. I found it very helpful, I found it perhaps a bit stressful at first. And it did bring some things to the surface that were quite emotional, so sometimes there was a bit of crying going on.
But that was usually resolved during the course of the session, and then given ways to work on that. And why those feelings caused upset as well. The sessions lasted about an hour, sometimes a little bit over, not usually less. And it was a course of 12 weeks. And during that 12 weeks, I kept a diary of what we talked about. And then, kept a diary during the week, to keep a record of what had happened. And then, a memo to myself to talk to Lizzie about what had come up during the week.
Lucy: That's great, sounds really organised.
Cate: It was, yeah.
Lucy: And do you still use some of the techniques now?
Cate: I do, I was looking back at the diary that I'd made and yeah, I have kept it on board. It's not a therapy you do 12 weeks of therapy and that's it, it's finished, all your problems are gone, you get on with your life and it's all finished. You're cured sort of thing. It's something it's an ongoing process.
Lucy: Because recovery-focused CBT for bipolar disorder is focused on helping with whatever goals the person brings, it can include different CBT techniques, which help with different problems.
Steve: So, we use tools that we know from CBT for bipolar, CBT for anxiety, psychological approaches to substance use to bring together a package for that individual. So, the manual for recovery-focused therapy is quite a long document, because it encompasses all these possibilities. And it reflects what we were talking about, about quite individualised routes through therapy.
Lucy: What's your favourite kind of strategies to use from it? What sort of things do you use?
Cate: I use distraction, and something comforting that I find soothing, like sewing or seeing a friend or phoning my sister, but reading is a big thing as well. Sometimes even cleaning the cooker, something a bit mindless, really, just a distraction. But also, to remember that the feelings that I have aren't special to me. That not only people with bipolar or depression get feelings like that, that everybody does, the population does. And not to get too hung up on it, and I also use mindfulness as well, which is a big thing, yeah.
Lucy: Mindfulness is something that the episode on mindfulness-based cognitive therapy has loads more information about if you're interested. This is how Cate came to find mindfulness.
Cate: I did an online course in it which was great. It was to bring yourself back into the moment all the time, because so much time is spent thinking about the past, which I do and ruminating on things, which are big. That's gone, and if you're wasting your time now, now is all that you've got. And people miss so much in the moment. There was a lot of different ways to keep mindful.
A lot of it was just sitting and concentrating on breathing for two minutes. But also, when you're out walking, to look at the trees, to feel the ground underneath your feet, really ground yourself, literally to feel yourself walking. And I do notice things more while I'm out, and it makes it a pleasure. Exercise is often recommended for people, but you can go out for a walk and you can keep your head down and worry about things and just be walking.
You're in the fresh air and you're doing some exercise, but you're not really noticing what's going on around you, which is the soothing bit. Listening, mindful listening is a big thing as well. I tend to let my thoughts run away with me. So, when somebody's speaking I'm thinking about the next thing that I'm going to say rather than really listening to them. And that's been a big thing for me, to actually listen to somebody else properly.
Lucy: That's really interesting, have you noticed it makes a difference to the conversations you have?
Cate: Yeah, it has, I feel more involved with the person and what they're saying. And I think it probably makes me feel kinder towards the person, as well. Yeah.
Lucy: I've been reading some stuff about being kind to yourself recently, as well. Do you think that comes into it, too?
Cate: It does, yeah. I definitely think being kinder to yourself, not making too much of things, not thinking about all the bad things about yourself. But concentrate on the good things that you can do and the good things that you can do now and in the future. And not think about the bad things that you've already done, which are gone. You can't do anything about it now, it's finished.
Lucy: Cate talked about distraction, self-soothing and mindfulness strategies there. Other strategies that might be used in CBT for bipolar disorder might include trying out different behaviours to see what difference they make to mood. And sometimes gradually doing things that feel quite hard to do but that make someone feel better. There might also be ways of thinking that are getting someone stuck and Steve talked about some of these.
Steve: When people come in low mood, they may have a lot of negative thoughts and beliefs and tapping into those and looking at ways of finding alternative ways of thinking could be really useful. When somebody's mood is going up, you can also look at the patterns of thinking that are going on there. And work with the person to examine those in relation to how useful are they, how risky are they?
What elements of those do they feel that they want to retain? And how can some aspects that may be problematic be adjusted? I think one of the things that people will often struggle somewhat with is recalibrating. So, if somebody is at quite a low ebb when they come into therapy, and they've got an awareness of what they were previously able to do, which was often functioning at a higher level for anyone.
People will often come with a view that they either need to be there or nowhere. They either need to be right on top of where they were performing at their peak, or there's no point. And so, actually even fairly simple behavioural experiments, testing out, doing things that aren't meeting that criterion but are reasonable things to be doing. And the impact that that can have on subtle shifts in mood can be really useful on unsticking people.
Lucy: Cate told me a bit more about some of her experiences before and how she feels now.
Cate: I think I'm more on an even keel with some downs now. Yeah, and I try and think that everybody has that. And everybody finds a different way of managing it.
Lucy: I know you were saying you felt like you'd left a lot behind, but actually it sounds like you have gained a lot of different skills and strategies actually through your experiences as well.
Cate: Yeah, I think I have, and leaving work was a big thing, because I felt left work under a bit of a cloud, really, because it meant going into hospital.
Lucy: What were you working as?
Cate: I was a gynae nurse, and I worked on the gynae ward and in a bit of gynae oncology and in the outpatients as well. So, I did like my job and I had a lot of good friends, but I felt that I'd left under a bad situation, really. And I never did go back to work after, which used to worry me, because I didn't go back to work. Well, I stopped work when I was 51. So, it used to worry me, not working worried me for a long time. But then when all my friends started retiring, it felt a bit better (laughs).
Lucy: I asked Steve about that sense of loss that Cate had described earlier. Something Cate said really stuck with me, actually, just about how she really enjoyed some of the highs and actually not having those felt like quite a loss. How do you manage that in the therapy?
Steve: I think for a start, you deal with that by taking it seriously. So, I think a lot of people will have had the experience maybe with some other clinicians that they may have come into over the years of being slightly patronised in their valuing of these highs. That it's just you're not well, so that's just you not being well. You need to have something which makes you not go there.
I think working with the person to get a thorough understanding of actually okay, what does go on in those? Are there versions of that are dangerous to you and risky to you? And are there versions of that that are less so? And at what point do these things tip over? Can allow people to actually experience a range of mood states that are part of human experience.
So, on the one hand, yes being sleep deprived for three weeks while you do lots of things is probably for most people likely to lead them into challenging situations. But small amounts of changes in routine to accomplish a certain task, followed by a planned way of decompressing afterwards can actually work quite well for some people. So, that's why it's not a short therapy in a sense.
It's taking the time to be able to unpack those things for people, so that you're working together to see what you can take from that valued element of experience and what needs to be adjusted.
Lucy: Steve was really clear that someone shouldn't have to go to multiple services if they experience multiple problems. That CBT for bipolar disorder could flex to help people with not only ups and downs in mood, but also anxiety, substance misuse or other more functional goals. I was curious about how Steve measured change. Must be quite a challenge for measuring how effective therapies are, when there are quite a lot of different goals that each person might come with.
Steve: Yes, that's a very good point. And I think there's quite a debate about what's a good measure of an outcome. So, our position on that is that most people actually come for help because of subjective problems, their perception that they're experiencing something that's difficult. So, in the past, a subjective outcome has almost been regarded as not a proper outcome.
Whereas I think if it's done properly, they are absolutely important outcomes, because if people are happy with how they are functioning and where they're at, relative to where they want to be, in a sense they're doing what they need to do. And my view is as clinical psychologists, that's our job is to support people to get where they want to be.
Lucy: Cate now works in a range of volunteer roles.
Cate: With the voluntary work, I'm confident when I go out and do that.
Lucy: What's that? What sort of voluntary work are you doing?
Cate: Well, I'll go and read individually with the children at the local primary school. So, I did the five- and six-year-olds last year, but I was quite pleased really, because they said, "You're really confident with the children, and you know a lot about phonics. So, will you read with the little ones?" So, I've got four- and five-year-olds now. They're really sweet (laughs).
Lucy: Lovely.
Cate: Yeah, I think you're really giving something, because learning to read is so basic to everything else. And then, the other voluntary work that I do is through church. And it's street pastors, you'll have street pastors in Bristol but you'll never have seen them.
Lucy: No, I don't know them.
Cate: So, it's run through all the churches in Preston. And it was started in Birmingham as a response to gun crime. The police asked could churches be around and about and talking to people. And gun crime did go down, and it spread out from there, from gun crime the people the street pastors were meeting homeless people. And then, helping people who were on a night out, who couldn't help themselves, they'd drunk too much. So, yeah, we try and get homeless people to go to services.
Lucy: I also asked Steve about the evidence base for CBT for bipolar disorder. He mentions NICE guidelines here, which are from the National Institute of Clinical Excellence. I've put a link in the show notes if you're curious.
Steve: So, the evidence is pretty good for the impact of CBT on mood and relapse. So, the NICE guidance for bipolar disorder in 2014 recommends that everyone living with bipolar has access to the opportunity to engage with psychological therapy based on their systematic review of the evidence.
The evidence on enhancing personal recovery is not as large, partly because it's an evolving field and it's more in the last eight years, I think, there's been a lot of interest in that. But certainly, as I mentioned with our recovery-focused trial, we've got evidence for that being beneficial. And it does seem as though there are a range of ways you can improve those sorts of outcomes.
Lucy: Cate described therapy as being like a river.
Cate: I've seen it described as a river, and the therapy is on one side, but one day you've got to swim across that river and get to the other side.
Lucy: I've not heard that before, I like that. Yes.
Cate: Yeah, it's quite nice, I did think at one time when I was still having therapy and thinking about getting to the other side, what if I get swept away? Which is a bit of a risk, but you've got to keep the image set in your mind that it will be calm waters that you swim across.
Lucy: I think there's something in that, though, isn't there? That fear of what are you stepping into? And is it going to be worse not better?
Cate: Yeah, I don’t think any therapy is a one size fits all. And I think you have to be in the right place to engage with it, as well.
Lucy: Steve thinks views on CBT for bipolar disorder have come a long way.
Steve: I remember when we were first doing one of the very early trials of CBT for bipolar. There was a lot of resistance to it from clinical colleagues in the sense that their argument was when people are manic, you can't work with them. When they're profoundly depressed, you can't work with them. And if they're not in either, what problem is left? It's a very simplistic view of people's experience, but that's where we were maybe in the mid 90s.
Now, there are a range of studies going on internationally in bipolar and I think there's a gradually increasing recognition that the psychological dimension to experiencing bipolar isn't a nice to have. But is a crucial aspect of both improving outcomes for people with bipolar, but also helping them with the human task of making sense of what's actually gone on.
Lucy: Cate was encouraging about trying CBT for bipolar disorder if you're considering it.
Cate: I'd definitely give it a go. I think perhaps the name cognitive behavioural therapy sounds a bit off putting. But it's a way of getting to understand your feelings, getting to understand different phases of bipolar and how to cope with them. They're actually quite simple, and it's good to have some help.
Lucy: I asked Steve why he likes working in talking therapies for bipolar disorder.
Steve: Bipolar if you like is pretty rare in terms of being a condition where some of the cardinal symptoms actually can confer an advantage. And I also find it personally fascinating working with people who are living alongside these experiences. I think actually living with the turbulence that bipolar can generate is pretty challenging.
And frankly, I admire the way a lot of people actually fold that into their lives and get on with a really engaged life. And if we can do something to support them in that, I think that's a worthwhile thing to do.
Lucy: That's all for today. Thanks so much listening. There are links in the show notes to more resources, and if you liked this episode, there are lots more you can listen to. Series one went through different types of CBT and series two is working through different types of problem that CBT can help with, including recent episodes on self-harm and perfectionism.
If you're thinking about having CBT and you want to find a BABCP accredited therapist, check out www.babcp.com and look for CBT register.
Thanks so much, lovely chatting with you.
Cate: Is that it?
Lucy: That's it.
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This is an understandably stressful time and it's normal to feel worried. What can we learn from CBT for health anxiety that might help us with feelings of anxiety during the pandemic? In this short bonus episode, Dr Lucy Maddox interviews Dr Jo Daniels from Bath University, about things we know are likely to help.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Read an article by Dr Jo Daniels on how to stop anxiety about coronavirus spiralling out of control here: https://theconversation.com/coronavirus-how-to-stop-the-anxiety-spiralling-out-of-control-133166
Another article about panic here: https://thepsychologist.bps.org.uk/truth-about-panic
And this about how it's normal to feel worried: https://www.ft.com/content/d6c65a50-6395-11ea-abcc-910c5b38d9ed
BBC piece on protecting your mental health at this time:
https://www.bbc.co.uk/news/health-51873799
BABCP: www.babcp.com
Photo by Kelly Sikkema on Unsplash
Transcript
Lucy: Hi, I’m Dr Lucy Maddox and this is Let’s Talk About CBT. This is a podcast brought to you by the British Association for Behavioral and Cognitive Psychotherapies.
This is a bit of an unusual episode. I’ve come to Bath University to interview Dr Jo Daniels who has experience in researching health anxiety in relation to medical conditions. There’s obviously a great deal of worry around at the moment, understandably, in relation to coronavirus.
I’ve come to ask Jo about how we can look after our psychological wellbeing as well as our physical health. The information that Jo talks about is based on cognitive behavioural therapy principles for anxiety. Obviously there’s no evidence base for this in relation to coronavirus in particular, but really health anxiety in relation to any physical illness has some very similar features, so we hope that this advice can be helpful.
Jo: My name is Jo Daniels and I’m a senior lecturer in clinical psychology and also a clinical psychologist working in health.
Lucy: Could you say a bit about the work that you’ve done that’s relevant to our reactions to the coronavirus pandemic?
Jo: The research that I’ve done so far is focused on health anxiety and distress in medical conditions. I do some work in the emergency department and think about why people keep coming back in and it’s usually to do with anxiety rather than pain. I’ve also worked in health anxiety in complex conditions such as Addison’s disease, chronic fatigue syndrome, also stroke, looking at how important anxiety is in both emotion and physical experience.
Lucy: Fab. I mean it’s really understandable that people are feeling worried at this time because there’s loads of stuff around about Covid-19 and about what we should be doing about it. What advice would you have about how we can avoid spiralling out into panic about what’s happening?
Jo: I think the first thing to say, which feels quite important, is it’s very, very normal to have a fear response, to feel anxious because this is a threat really and that’s the way that our brains are interpreting it, as a threat. Important to just accept that we’re all a little bit worried at the moment and we’re really in it together.
In terms of the things that we can do help ourselves, it’s a digital age, so a lot of people are accessing various sources of media and information at the moment. Thinking about where the notifications are essential, thinking about the sources of information that we access, where some of the new stories are designed to be alarmist.
Keeping perspective is really, really important and we can do that in a number of ways. So keeping in touch, especially if we’re moving into having to be at home, we need to be in touch with people to keep perspective and also to keep ourselves happy.
Also trying to stay calm. It’s really important that we go about our normal daily business as much as we can. Things are going to change over the next few months, but normality is really important. So ensuring that we do the same things that we normally do and don’t adapt too much because sometimes when we do that, we start to do things that are actually counterproductive.
Lucy: So like a balance between following the advice that’s out there, the sensible advice on reputable websites, but doing as much as we can to keep our routine and keep in touch digitally with people that we care about?
Jo: Exactly. It’s really important to be vigilant, but not hyper vigilant. If you look for trouble, that’s what you’ll find.
Lucy: What does hyper vigilance mean, just in case people don’t know that?
Jo: That’s when we’re really paying extra attention to things. You see that a lot in health anxiety and at the moment I think a lot of us may be doing that, looking for signs of coronavirus.
The interesting thing is, is that actually if we become quite anxious; we will product physical symptoms in our body that may mimic it. So things like chest pain, you can get a bit of chest pain or dizziness, nausea, feeling a bit hot, all of those physical sensations can be anxiety or they can be something like coronavirus, which is another reason why it’s important to stay calm. As obvious as it sounds, to keep breathing.
Lucy: I find that really interesting because if I get anxious or worried, I normally feel like I get quite short of breath. Is that quite a common symptom that you would say?
Jo: Yes, definitely. We see hyperventilating – even if it’s at moderate level you might not even notice – in anxiety. Some shallow breathing and again, that sends signals to the brain that there is a threat and it does trigger off, it can trigger off a ‘fight or flight’ response, or an anxiety response. And there is a lot that we can do to help ourselves at this time, but panicking and anxiety is not helpful.
Lucy: Could you say a bit more about ‘fight or flight’ response, I expect people would have heard about that, but just a bit more detail?
Jo: So fear is a very normal response and that fear response is ultimately designed to keep you safe, it’s a survival mechanism. We can receive incoming information that triggers off a ‘fight or flight’ response that actually isn’t a real threat to us. It’s designed to deal with threats such as seeing a scary lion chasing us in the African plain, but actually we still get an anxiety response, a ‘fight or flight’ response when we send a text message to the wrong person, for example.
What happens then is we have a lot of hormones released around our body and people might be familiar with breaking into a sweat or hyperventilating a little bit or palpitations. Many, many symptoms are essentially designed so that we can fight really hard or run really fast just to keep us safe.
Lucy: But not very helpful to run away from a mobile phone when we send a wrong text message.
Jo: No, not really, that’s where it doesn’t work very well, ‘fight or flight’ response because we haven’t evolved, if you like, to be able to distinguish between what’s a real threat and what’s being perceived as something like a social threat where a ‘fight or flight’ response actually can be quite unhelpful and actually stressful.
Lucy: It’s tricky with this isn’t it, because it is a real threat and at the same time there’s a quite a lot of panic around which might be unhelpful.
Jo: Yes, exactly and that again brings on further symptoms associated with anxiety. So it’s really important to, as much as we can, give our bodies and our brains the message that actually there is a threat, but we can deal with it in a pragmatic way.
Lucy: If someone has an existing mental health problem, any advice about how to stop that being exacerbated?
Jo: I think it’s a difficult time for people who have got anxiety already because they’re already going to be quite sensitive to anything else that can be perceived as a threat.
The same applies really, so trying to maintain distance from the difficulty, just following the sensible precautions, making sure that you’re in contact with the people who care about you, both friends and family, but also GP as well, if things are escalating a little bit and it becomes unmanageable or you become preoccupied. It’s really important to put into place strategies that you know that work.
Lucy: So still that balance between making sure you’re accessing information about what to do, but not over checking, either symptoms in yourself or over checking websites that might be showing quite scary stories.
Jo: That’s right. We know that panic breeds panic. So if we see other people panic buying, then we’re more inclined to do that as well. So just trying to, again, take a step back when we feel ourselves becoming anxious and trying to retain that perspective.
Lucy: One of the things that’s so tricky about this is that there’s a lot of uncertainty around about what’s going to happen and what we’re going to be advised.
Jo: We are mostly intolerant of uncertainty and that in itself can be problematic in the sense that this will perpetuate anxiety, that’ll keep anxiety going. Rather than the actual illness itself, or the fear of the illness, it’s the uncertainty of, “Will I catch it? Will I be able to manage it? Will I be badly affected?”
Lucy: And actually it can get us checking online news a lot more can’t it, to see what are we being advised on a moment-to-moment basis.
Jo: That’s right and that’s the problem sometimes with anxiety. Even mild anxiety, because some of us who may not be usually prone to anxiety, will feel a little bit anxious at this time, for understandable reasons. But some of those strategies we use are counterproductive. I don’t know of any good examples of where people have Googled their symptoms and come off feeling better.
So check that checking behaviour, it can make us feel better momentarily, but really serves to increase our anxiety and of course then we get stuck in a loop feeling like because that anxiety was reduced for a moment by checking, that we keep doing it. But of course, it really serves to increase our anxiety.
Lucy: What are some things that we can do that would be more helpful than checking online?
Jo: One of the things we can do, given that we are experiencing mild levels of ‘fight or flight’ response, that fear response, is to try and get rid of some of that adrenaline. Exercise is really important, not only does it get rid of that adrenaline, it also allows us to keep perspective and keep fit at the same time.
But also just making sure that we keep in touch, check reliable sources and just follow the guidance. There are a lot of busy people who have got a lot of knowledge in this area who are giving very sound advice. So just keep up to date with what the precautions are.
Lucy: And how do we know that these things are helpful?
Jo: Thankfully we know a lot about anxiety, so for many, many years there’s been lots of research, lots of empirical data-based studies which have supported the development of models of anxiety. And anxiety is the same applied in different settings.
Whilst anxiety in mathematical conditions may not present the same, it’s very, very similar. Those principles which are underpinned by cognitive behavioural approach we’ve seen work in other situations where people experience anxiety, and in that sense there’s no difference here. People tend to do the same kinds of things when they’re anxious and we know that the same kinds of things will help.
Lucy: So to sum up, follow the advice on the government websites. Try to look after yourselves and other people by managing some of the anxiety response that’s going on as well.
Jo: That’s right.
Lucy: Have you got anything that you would like to add at all?
Jo: I think what feels essential is that where we can, we respond to this in a compassionate and community focused way. We’re going to be in this together as a community, so it’s really important that we look out for our neighbours, those who are vulnerable to us and express some understanding towards those who do feel anxious, who are finding it difficult.
Lucy: I hope you found that as helpful as I did. And if by the time this podcast is out we have moved into a phase where we’re having to stay at home a bit more, I hope you can remember those tips of trying to keep a routine as much as possible, following advice, but also trying not to get too preoccupied. Jo described this as having some kind of normality within an abnormal situation.
If you’re stuck at home and you want to listen to some more podcasts, there’s plenty of episodes of Let’s Talk About CBT to keep you company.
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Imagine being asked to give up the most effective strategy you have for coping with stressful situations... this is often what it can feel like to people trying to give up self-harm.
In this episode, Dr Lucy Maddox talks to Jane, who first used self-harm when she was 14, and Dr Lucy Taylor, who works with young people to try to overcome self-harm.
This episode contains discussion about self-harm and reference to suicide.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Books
Cutting Down by Lucy Taylor, Mima Simic, & Ulrike Schmidt
https://www.amazon.co.uk/Cutting-Down-workbook-treating-self-harm/dp/0415624533
Websites
www.cbtregister.uk for a list of BABCP accredited therapists
https://youngminds.org.uk/ for resources for parents and children about self harm
https://www.minded.org.uk/ for resources on child and adolescent mental health and development
www.babcp.com for more CBT resources
You can also listen to our podcast on Dialectical Behavioural Therapy, or DBT, for more on a different approach to self harming.
Transcript
Lucy: Hi, and welcome to let's talk about CBT, with me, Dr Lucy Maddox. This podcast, brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP, is all about CBT. What it is, what it's not, and how it can be useful. Today, we're focusing on CBT for self-harm.
We obviously talk a lot about self-harm and we also mention suicide, so please look after yourselves and if you know that's something that's especially hard for you to listen to, then maybe just skip this one.
Jane: I think self-harm is something that is a way to control your feelings. It was a way for me to feel something and know why I was feeling it, and know that I was doing it, and know that I could understand it.
Lucy: That was Jane, who we're going to hear more from in a bit. For this episode, I also went to speak to Dr Lucy Taylor, a clinical psychologist, who has worked for 20 years in the NHS, mostly with children and young people. And who now works in private practice in Surrey.
Lucy T: My main interests are self-harm and cognitive behavioural therapy and how to engage young people that might be struggling a little bit to come to therapy.
Lucy: Could you say a little bit about what self-harm is?
Lucy T: Yeah, I think generally, the way we think about self-harm is on a dimension, and when we look at the literature and we look at the studies on self-harm, we talk about causing deliberate harm to your body. And that might be through cutting yourself or burning yourself or taking an overdose. But when we're talking about the dimension, it might mean also maybe drinking a little bit too much alcohol or not eating nutritionally rich food or restricting your diet.
So, it can mean lots of different things, but when we're talking about it within the clinic, it's a deliberate act of hurting yourself. And sometimes that can mean you want to die, and often that isn't because you want to die, but it is a way of coping.
Lucy: So, it sounds like a bit of a spectrum of experience, actually.
Lucy T: Yes. And I think when people come to the clinic, it's starting to cause problems. So, it might be that we all occasionally do things that actually aren't great for us, but it doesn't necessarily cause a problem in our everyday lives.
When it's becoming more it's affecting functioning or it's starting to affect relationships, or work or jobs or school, or when people are concerned about others, that's usually when they come to the clinic.
Lucy: For Jane, self-harm was first around for her when she was a teenager. But she didn't actually get help until her early 20s.
Jane: My name is Jane, I self-harmed from the age of 14.
People spoke about it openly.
Lucy: Like in your class, you mean?
Jane: Just in general, but it was still very looked down upon. I remember being in school, and I had these colourful bits of material over my arms, because I had cut myself. And because they weren't uniform, the teacher made me stand up in front of the class and take them off.
Lucy: That's so grim.
Jane: Yeah, (laughs) I don't think she knew, I don't think that's intent. But that's another thing, had it been talked about the way it is now, that would have probably been the first thing that came to her head, maybe it's that. It doesn't mean that it is, maybe I'm just being defiant and want to wear my rainbow armbands, but I don't think she was aware.
But then, even then, there was no conversation with a counsellor, they told my mum, that was it, but my mum already knew.
Lucy: It's disappointing, though, isn't it? I don’t know, it makes me feel sad to think of you as a young girl, not getting help at that point.
Jane: Yeah, but it was just something that I think a lot of kids of did, and a lot of people that I knew did it for different reasons, in different ways.
Lucy: I spoke to Lucy Taylor about the prevalence of self-harm in young people.
Lucy T: I think recent statistics suggest that at least one in 10 young people self-harm at some point. And I suspect it's probably more than that, but that's what we know about.
Lucy: That's an awful lot, actually, isn't it?
Lucy T: Yeah, it is, and I think it's a growing problem. And I think part of the problem is that when you talk to somebody, self-harm is often a very effective way in the short-term of managing a very difficult feeling. It can feel like the emotions which can feel very muddled up and complicated and overwhelming, that actually using the physical act of hurting yourself can reduce that in the short-term.
I think through CBT and through exploration, what people find is that actually, there are more longer-term difficulties that get associated with it, and it's not helping them to move forwards in their life and to manage those emotions. So, part of the initial stages would be figuring out what the pros and cons might be of self-harm.
Lucy: I guess they might be different in the long-term and in the short-term.
Lucy T: Absolutely, yes. And also, different situations might have different triggers, might have different functions for the young person. It's really getting them to be very good at taking a step back and recognising what they're doing, rather than just launching straight into it. So, giving them a little bit of a choice point.
Often, people aren't brilliant or don't have great skills in managing difficult emotions. So, part of CBT would be to help introduce and offer them skills and strategies to test out, to deal with emotions in a maybe less harmful way.
Lucy: For Jane, it was a bit later on in her early 20s that she found herself suddenly struggling again.
Jane: I didn't really see any big issues within myself until I was about 20 and I started having panic attacks. I had just moved to London from Scotland, and my gran had passed away, and I think a lot just happened that I didn't necessarily deal with. But it took about a year for them to realise that it was anything anxiety-based.
I was given medication for an ear infection, because I told them I was dizzy. I was put on heart monitors. I was given an MRI.
And then, eventually, I did my research, and went to the doctor and said, "Look, I don't feel like I'm having panic attacks, because I can breathe, but from what I've read, that might be what's happening to me." So, they put me in the local CBT programme.
I was eventually diagnosed with panic disorder, which is that you live in a panic attack, it never ends, you wake up and you panic because you're panicking. But you don't know that you're panicking, and you just go like that from day to day to day. And it is exhausting.
Lucy: That's a really long wait to be living in a panic attack. That's a beautiful description of it.
And so, it was anxiety that had brought you to the CBT pathway. But then, you were talking about self-harm in that therapy as well, is that right?
Jane: Absolutely. I think everybody has different kinds of panic attacks, but mine were all-consuming, all the time.
And I think self-harm is something that is a way to control your feelings. And so, it's very, very easy to slip into, I had stopped for years. And then, when that all happened, I just slipped right back into it. Because it was a way for me to feel something and know why I was feeling it, and know that I was doing it, and know that I could understand it.
I think the good thing about CBT is they let you come to your own conclusions. They're more trying to get you to understand your feelings and find a way to break a cycle. And to disassociate the feelings of panic and anxiety and sadness and depression and self-harm and all those things… Especially with self-harm, you do relate it to feeling good, no part of it is good, but at the time it makes you feel good, which is awful, but when you're desperate…
Lucy: Really understandable though as well. There's a reason for doing it, isn't there?
Jane: Absolutely.
Lucy: Lucy agreed the reasons for self-harm are very individualised.
Lucy T: There's numerous different reasons why people might self-harm. What people have said in the past is sometimes it's a way of managing difficult emotions. Sometimes it's a result of having had quite a difficult traumatic time in the past. Sometimes it might be about feeling nothing, feeling numb and wanting to feel something.
And I think it's really important to understand and help the young person to think through why they might be self-harming.
So, part of the initial stages of CBT would be thinking with maybe some education around why other people self-harm. Normalising self-harm, not that it's acceptable and a great way of coping, but actually there's a lot of people out there who are self-harming.
Lucy: And what sort of thing happens in the clinic? What does cognitive behavioural therapy for self-harm look like?
Lucy T: Well, generally, I would be very interested first of all in whether the young person, as I mostly work with young people, whether the person is wanting to come or feeling that they are being slightly pushed into coming through a caring adult often.
So, at first, it would be just getting a sense of why the person feels that they're here. Getting to know them, hopefully creating an atmosphere that's safe and confidential.
And then, thinking with them about what they might want to be different in their lives. We would work together to meet a young person or a person's goals. So, that might be that they come in and they're clear that they want to stop self-harming. Or that they come in and they want to feel better and to feel happier or manage situations differently.
So, the first session would be about exploring what's brought them here. If it is a bit of a case of they are mixed about being here or someone's brought them here then we would spend some time thinking about motivation.
It's important when you're coming to CBT that you feel you want to make that change, even if it's a very small part of you that wants to make that change. And then, think through, particularly with self-harm, what the triggers are for self-harm.
Lucy: I asked Jane about whether she had been motivated to tackle self-harm or whether she'd wanted that to be left alone.
Jane: I think at first, because my panic attacks were I couldn't go outside, I couldn't take the bin out, I couldn't go to the shop. I'm a girl in my 20s and I've just moved to London and I can't go out with my friends. My mum has to take me places.
I just felt extremely dizzy, I thought I was going to faint all the time. I thought I was going to be sick, I thought I was dying. I had really bad intrusive thoughts, so I would be like, “What if I go outside and what if I'm crossing a road and what if a bus hits me?” And I would see the bus hitting me, so I just didn't. And then, as soon as you start not going outside, it's very, very easy to get stuck. Really easy.
So, I think initially it was definitely more for that. But that's again the good thing about CBT, is they connect the dots, well they let you connect the dots. And you're able to see that your feelings and emotions especially with self-harm never really go away. And it's more about controlling them, which was really, really important, I think for me, anyway.
Lucy: Here's Lucy talking me through the idea of maintaining factors, things that inadvertently keep a problem going and how she tends to formulate self-harm with young people that she works with.
Lucy T: The other thing that we know can happen with self-harm is that it tends to be maintained, it tends to keep going when there are other problems going on. So, for example, if someone's very low in mood or depressed, or they're anxious or they have anger problems or relationship problems, CBT focuses on the things that might be maintaining the self-harm for that person.
And we talk in CBT language about formulation, which is a full understanding of the person themselves. So, why are they in this position at this point in time? So, what early experiences might have led to that? What are their beliefs about the world and themselves and others? What might have triggered this episode or the use of self-harm? And what keeps it going? And so, a full understanding of the person, to be able to then start saying, “What do we need to do?”
Lucy: That's really hard to do if you're stressed about something, actually, isn't it?
Lucy T: Yeah. So, what we know about CBT is that for all of us, the way we interact with the world is influenced by our thoughts and our thoughts influence our feelings and our feelings influence how we behave. And they all work on each other, so the thought/feeling/behaviour link is really important in CBT.
What you're doing in CBT is highlighting where these beliefs and thoughts are and what they might be. And having a look at them and checking them for how real they are, testing them out. Is it just a habit that somebody tends to think like that because of stuff that happened a long time ago? And giving them ways and tools to challenge or let go of some of these unhelpful thoughts.
Let's say somebody feels very anxious about social situations and tends to avoid social situations. And then, when they get home, they might feel very ashamed or self-critical about that, and that might lead to self-harm.
So, one of the behaviours you might work on if that's your formulation, that's your understanding is how to manage those anxious situations. So that you can instead of avoiding, you can start to learn ways to manage those situations.
So, the behaviour might be what we call exposure, so starting with something that is easy-ish to do, and then moving up towards things that are harder.
What we know about anxiety for example is that if you avoid, your brain starts to develop a link that actually it's dangerous and you can't do it. So, by exposure therapy, which is facing the fear in a staged way, you're unlearning that, so the anxiety doesn't stop you doing things. So, that would be an example of a behaviour.
Lucy: Now, Lucy wasn't Jane's therapist, but Jane had this type of exposure as part of her treatment for anxiety, too.
Jane: I was given really little tasks, and even the routine of ‘I have to leave the house once a week’ was so helpful. And my mum came with me the first couple of times, then she said, "Okay, next week get your mum to walk you halfway. And then, get her to leave you at the station, and then just come by yourself."
And as I did it more and more, I would have moments of oh my god, I’m outside, I'm just on my own, and it was still terrifying, but I was doing it.
I almost had to train myself to be a person again, see, this is the thing for me anyway, it was never me sitting with her and her going, "Well, what makes you feel good? Maybe do that instead."
Lucy: That'd be quite annoying, actually.
Jane: Yeah, because it's like obviously I would love to, but that's not how it works. But it was more her trying to get me to understand why I was thinking about self-harm in the first place, and before I even got to that, how to redirect my thought pattern. And then I obviously had to decide something I would do instead. And you do replace it, I went through a stage where every time I thought about self-harming, I would go make a cup of tea.
But I was like well, it's five minutes where I'm going to go and do something for myself, I'm going to stand there, I'm going to drink my tea, and then see how I feel. And it worked. Not forever, but it's just having little things to do before. Because once you're in that mindset, nothing is changing, nothing is going to change your mind. There's full intention to do it, yeah, because like I say, once you're set on doing it, you can't get it out of your head and until you do it, it's not going to go away, for me anyway.
Lucy: So, CBT offers quite a few different strategies to help with some of the different things that can keep self-harm around or can trigger it.
If someone's feeling low and finding it hard to work out how to get out of certain dilemmas, then problem solving skills or concentrating on doing small things that make them feel better might be helpful. If someone's feeling anxious, like Jane described, then gradually testing out feared beliefs might help.
Having some alternatives to self-harm is also really important, we all have coping strategies we use to manage big feelings. Some of them more or less helpful than others. Retail therapy, a glass of wine, having a shout, imagine if someone just told you that you had to stop using whatever your coping strategy for stressful situations is and offered you nothing to use in return.
Lucy had lots of ideas or alternatives to self-harm. Again, different ones work for different people.
Lucy T: Something that's really important is to recognise when that emotion is going up and have some strategies and skills to bring it down, so that the part of our brain that we want to engage which is our thinking brain can be re-activated, which goes offline if you like when we're feeling overstressed.
The other thing that comes up with self-harm is that self-harm can often be triggered by social situations, so that might be an argument with a friend, an argument with Mum, feeling left out, for example. So, we know that social situations can trigger self-harm.
And some of the problems that people face is being able to get their needs met effectively with other people. So, some people might resort to being quite aggressive and angry and pushing people away, whereas others might be a bit more passive and just hold it in themselves.
So, one of the things that we think is really important is teaching the skill of being assertive, so being able to – without being aggressive – get your needs met, or say no to somebody or problem solve a situation where you've fallen out with someone.
So, we might focus on someone's social network and thinking about who's supportive, who's not supportive, how do you deal with situations that are difficult? How do you deal with arguments? Are there other ways you could manage that difficult feeling, like being assertive? And not just punishing yourself or hurting yourself because you're feeling it.
Another example of an alternative to self-harm is if a young person or a person is saying that they feel particularly angry, and self-harm manages that anger.
You might think with them about other ways, what could they do which would manage that anger, might that be writing down their thoughts and ripping it up? Or setting fire to a piece of paper with their thoughts on it? Or punching a pillow? Or screaming in the back garden? Something that feels like it might be a way to deal with their anger behaviourally to see whether there's other ways of dealing with that that don't hurt yourself.
Some people, if they feel that for example the sight of blood is soothing, then some people feel that if they draw red or they draw red on their arm, that that might be a way of recreating that sensation without again hurting yourself.
The other thing is we know that self-harm is hurting our bodies. One of the strategies that we think about is having a little bit more self-compassion, and thinking about looking after yourself a bit more, which may be difficult for some people because of what's happened to them or because they've never learnt how to do that. So, helping them to learn to self-soothe, and that might be instead of cutting, rubbing cream into your arm. Or it might be making sure that you're increasing the pleasure and fun things in your day, so that you're feeling a little bit happier about yourself and looking after that side of things.
Lucy: Earlier on, we heard about the thought/behaviour/feeling link. Sometimes the thoughts that we have are related to experiences we've had back in our past, or more recent experiences.
Lucy T: What we also know about thoughts is that how we interpret and think about events can be influenced by our previous experience, our beliefs, our personality. And sometimes in CBT you might go down that route with a person to understand where this might have come from.
Lucy: For Jane, grief over the loss of her gran was really important.
Jane: My gran dying was a massive thing for me. And I remember maybe my third session she said, "If your gran was here right now, what would you say?" And I was like, "I don't know." And she was like, "No, but if she's sitting here right now with us, would you tell her you miss her? Would you tell her…?" And I just started crying and I hadn't really cried about it. I had at the funeral, but I'd never really acknowledged that that was a part of it.
And I think something that I got from therapy was understanding that those thoughts are never going to go away. And when we talk about triggers, such a relevant statement, because anything can trigger you. And mine was a big life thing, but it doesn't have to be. I've been triggered by little things sometimes that have just sent me on a spiral. I've had big life events that I've actually dealt with really well and not really thought about. I think it's just something that's always there.
Lucy: Lucy told me about the evidence base for CBT.
Lucy T: Well, we've got a lot of evidence base with adults that CBT is more effective than nothing or other treatments. However, we've got less data for adolescents but that is about really not having as many studies that we can look at.
What we do know is that a lot of these strategies that are used with adults that I've talked a bit about, like challenging thoughts, managing some of the maintaining factors, the depression or the anxiety that might be fuelling the self-harm, from studies that we've got, we know work well with adolescents. The problem is we haven't got lots and lots of studies at this stage. But I think we're hoping that that will come. But reviews of the literature suggest that it's a definitely worthwhile treatment to try and to give a go to. And the NICE recommendation is to use CBT for self-harm is a recommendation.
Lucy: That's the government guidelines for what works best?
Lucy T: Yes, so it stands for the National Institute of Clinical Excellence. There's a body of people who look at the evidence base that we've got and make suggestions to therapists and teams about what we should be aiming for, it's a guideline. But actually, it's quite encouraging that we know that we're not just making things up. And that actually, we're doing something that feels like it's supported.
Lucy: For Jane, it took time, but things changed radically.
Jane: When my 18 sessions ended, I was a lot better and I could go outside.
Lucy: Were you still using self-harm or had that stopped?
Jane: No, that had stopped. But then, after maybe about a month… So what I had done was I joined Open University, because it was something that I could do at home. I explained to them my situation and they said, "We have a class once a week, you don't have to come to it." But the first one I went to I went with my mum, and it was the first time that I openly told people that I had an issue.
I sat at a table with 15 other people who I didn't know and said, "My mum is here because I have really bad anxiety, and so she's just here to help me." And even saying that out loud, I was like, "Wow. I’m not embarrassed of it anymore and I'm not ashamed of it anymore." And that's why it's such a taboo subject because people are so, it's a weakness, and it is.
But talking about it is so difficult, but you just have to own it and be like, "This is a problem for me, and if you're going to judge me on it, then that's a shame for you." So, I did that, and then after I think three weeks I went on my own. Terrifying. I sweated the whole time. I think I went to pee like 95 times (laughs), but I did it. And so, the next time it was a little bit easier.
And then, I went back to therapy because I spiralled very, very quickly.
I think this is another thing is as soon as you start to feel better, you go too far. It's a slow, slow process. And when you try and fill your day with too much, you kind of forget and then it all hits you at once. So, I went back to therapy for another six weeks.
And then, that's when I applied to work in a little juice bar, and I got the job. And then, yeah, that was that. I started working, I was offered a managerial role. And I have stayed in management ever since. And it's hospitality, which is not easy when you're terrified of people.
But it's just funny, because people who know me now would never imagine that I'm someone who would be scared to speak to people.
Lucy: I asked Lucy if she had anything to add.
Lucy T: I think the relationship is very important, when you're working, it's very important that a person trusts you as a therapist. That you are non-judgemental, that you are open with what you're doing, and it really is a joined-up process. And that you're very clear from the beginning that it's their goals, within reason, if you don't think that their goals are helpful to them, then you might have that conversation.
But generally, they're steering where the therapy goes. And that's probably what I quite like about CBT is that you're working as a team. And you are coming with some expertise, if you like, as a therapist about what can work and what we know can work. But actually what you're doing is you're exploring that together.
Lucy: What about what Jane would say to people thinking about having CBT?
Jane: That you're not going to feel judged. That this person is genuinely trying to help you.
I do understand why people don't go to therapy. I think people imagine that you lie on a big black sofa and have someone with a clipboard sit there and ask you if your mum loved you. It's not like that. It's more like this. (Laughs) This is way closer than what I just described.
Lucy: So, just two people having a conversation?
Jane: It's just two people having a conversation. And you can say what you want, and you can not say what you want.
I think the main thing I would have liked to have known beforehand is that it was on me to give the therapist information. Because I almost was quite taken aback at first. Because I was like, "They keep asking me how I feel, and I feel like I'm here because I don't know how I feel." But they can't tell you how you feel, you have to do that on your own. But it's not this big scary thing.
Lucy: That's all for today, huge thanks to Dr Lucy Taylor and to Jane. And thanks so much for listening, thanks also to those of you who have left ratings and reviews on iTunes. It's super nice to hear your comments and see your ratings there. And I think it also helps others to find the podcast, so thanks.
There are links in the show notes for this episode if you want more resources about self-harm, including a web address for YoungMinds and for MindEd, if you're either a younger person yourself or worried about a young person you know.
If you liked this episode you might also be interested in the previous episode we did on DBT for self-harm.
We've got new podcasts planned on CBT for depression, bipolar disorder and perfectionism, so lots more coming soon. And if you have ideas of what you'd like us to cover, just drop me a line at [email protected].
END OF AUDIO
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Striving for achievement has got to be a good thing, right? But what if it starts to get in the way of our happiness? What if the standards we hold ourselves to are unattainable or unrealistic? What if we feel like we'll never measure up?
In this episode, Sam and Professor Roz Shafran speak to Dr Lucy Maddox about CBT for clinical perfectionism - what it is, what it's not, and how it can be useful.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
For more information here are some resources.
Books
This is Roz's book on Overcoming Perfectionism
https://www.amazon.co.uk/Overcoming-Perfectionism-scientifically-behavioural-techniques/dp/1845297423
Or for a shorter booklet this is also written by Roz and published by the Oxford Cognitive Therapy Centre
https://www.octc.co.uk/product/booklets/changing-perfectionism-2
Other Reading
This is a short article on clinical perfectionism by Roz and colleagues
https://nopanic.org.uk/perfectionism/
For some free ACT resources from Dr Russ Harris check out his website (Sam talked about ACT)
https://thehappinesstrap.com/free-resources/
The bullseye worksheet in these resources is the 4 quadrant image that Sam talks about:
https://thehappinesstrap.com/upimages/The_Complete_Happiness_Trap_Worksheets.pdf
The clinical perfectionism questionnaire is on p39 of this article - it is 12 items long and gives you an idea of the sorts of problems that clinical perfectionism can exacerbate. If you are worried speak to your GP:
https://www.researchgate.net/publication/259530421_The_Clinical_Perfectionism_Questionnaire_Further_evidence_for_two_factors_capturing_perfectionistic_strivings_and_concerns
Some worksheets are available here on clinical perfectionism
https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Perfectionism
Podcasts
Check out other podcast episodes on ACT
https://letstalkaboutcbt.libsyn.com/lets-talk-about-cbt-act-episode
And compassion focused therapy
http://letstalkaboutcbt.libsyn.com/lets-talk-about-cbt-compassion-focussed-therapy-episode-0
Websites
For BABCP accredited therapists visit www.cbtregister.co.uk
For BABCP visit www.babcp.com
Transcript
Lucy: Hi, and welcome to let's talk about CBT with me, Dr Lucy Maddox. This podcast is from the British Association for Cognitive and Behavioural Psychotherapies or BABCP. It's all about CBT, what it is, what it's not and how it can be useful.
In this episode, we'll be finding out about clinical perfectionism, it's a bit of an unusual episode, because clinical perfectionism is not a typical diagnosis. It's a problem which can go alongside many different diagnoses, for example, depression or anxiety.
To understand more, I met with clinical perfectionism expert, Professor Roz Shafran, and Sam, who's experienced CBT for perfectionism. Sam currently studies for a master's in psychology in London. Before this, he worked for a couple of years, and before that studied English at Oxford. Through all of it, he experienced perfectionism-based anxiety, this is where it started.
Sam: So, I think I've always been interested in academics and I know a lot of people aren't. But it meant that at school I enjoyed working hard, but I think the praise I got as a child for doing well became quite addictive. And so, the more I did well, the more I wanted to continue to do well. And then, pressure mounts, and I think I wasn't aware of that as a child.
But suddenly, it wasn't just about doing the best I could in class, but doing the best that could possibly be done, getting full marks. And that's unreasonable, and I think an unhelpful aim. And then, I also felt there was an uglier side of that, which was more comparative, doing better than people around me because I think I found the education system very relative. And it was about being judged against others as well.
And I think while that in itself is stressful, I think what was perhaps most difficult was the way it then grew and eclipsed other aspects of life, resting or doing hobbies, or socialising. Even at a young age was tinged with guilt, or it was in the shadow of the work I could be doing.
Lucy: So, hard to stop?
Sam: Yeah, I think so.
Lucy: How would you describe perfectionism? What does it mean to you?
Sam: So, for me, it's only recently that I’ve viewed it as a potentially bad thing. I think generally it meant to me doing my best at things and striving to feel devoted to things. And I think certain aspects of that feel quite rewarding and energising to feel motivated is good. And I think a lack of that can feel unsettling or depressive.
But recently, especially through therapy, I've started to relate to the more harmful sides of my perfectionism. And the way it relates to my anxiety, and so I feel it's not just about having high standards, but unreasonably high standards and inflexibly high standards. So, it's not just about trying hard, but needing to try my hardest and needing to do my best. Or a conception of my best that is sometimes beyond what I have the energy or the capacity for and that is really draining.
In different ways I think I've experienced perfectionism, so I think academia and education particularly flares it for a lot of people, because from such a young age we're rated and ranked. I've certainly felt sorted by the way we perform, and I think that even now is being flared up by being back in education.
Lucy: Roz Shafran is professor of translational psychology at the UCL Great Ormond Street Institute of Child Health. She's been working in the field of perfectionism for a decade and got interested in it first of all in relation to eating disorders.
Could you start off just by explaining what perfectionism is in a clinical sense? Because it's the sort of thing people sometimes say they have in a job interview maybe. But actually, we're talking about something a bit different, aren't we?
Roz: You will get different answers from different people and different researchers. So, I think many people would view perfectionism as a personality characteristic, it's something that's you're born with, you're a perfectionist, and it has that positive context to it of striving for excellence and trying to do well and an eye for detail that can be very helpful to people. But it's long been recognised it's also got a dysfunctional or unhealthy kind of element to it.
And some researchers think about perfectionism in the interpersonal domain, so perfectionism in relation to other people. But when I was beginning my work with Chris Fairburns, Afra Cooper and the team in Oxford, we were working with people with eating disorders. So, the sort of perfectionism that we were seeing was really very self-driven. And we called it clinical perfectionism because it was the type of perfectionism we were seeing in our clinical practice.
That's not to say that other forms of perfectionism can't also be a clinical problem. But the area we focused on was the clinical perfectionism that was around your own striving for success and achievement, and your own reaction to failure.
And the reason that we put it in a CBT context rather than the personality context, really is because we know that the treatments that are successful have taken that approach. And we wanted to have a treatment that worked, so we wanted to have a formulation and a model in terms of maintaining factors, to give us ideas about where to intervene.
So, we took the same approach to perfectionism that had been taken to bulimia nervosa, that had been taken to panic disorder and we saw it in terms of cognitive behavioural maintaining mechanisms.
Lucy: By cognitive behavioural maintaining mechanisms, Roz just means patterns of thinking or behaviour that inadvertently keep a problem going.
How would you recognise perfectionism that's really causing a problem? What sort of problems do people come with?
Roz: So, sometimes people themselves find it very difficult to recognise and it's other people are telling them that they have a problem with perfectionism. But people do recognise it's interfering with their lives, when we started the idea of being the best at losing weight is actually inherently more problematic than necessarily being the best at work or being the best at sudoku or something like that.
So, the domain in which the perfectionism is expressed is important and can raise alarm bells. But it makes people very unhappy, they don't often come in saying, "I'm a perfectionist." But they come in, they're depressed, they're anxious, they're stressed.
And then, it is the common theme for all of that might be that they have these very high standards for themselves, they constantly feel like they're failing. Nothing they do is ever good enough. They're not sleeping because they're spending so much time on various tasks. And it's just not working for them anymore, even if it did work for them in the past.
Lucy: And is it that the standards are too high? That they're unrealistic or unachievable?
Roz: So, for many people, the standards are not necessarily unrealistic or unachievable, for many they are. But for some, they're not, but it's the striving and the effort that needs to go into them that makes it dysfunctional in that way.
So, we do often have very successful people, the work was started at the University of Oxford our patients were often students or staff members at Oxford. So, objectively, they had reached and attained very high standards, so the dysfunction comes in in terms of the reaction to failure and the importance of it to their self-evaluation.
Lucy: So, something about the amount of effort that goes in and something about the reaction if that standard isn't met.
Roz: So, the central point for us was the way we defined it, clinical perfectionism, is that people's self-worth is overly dependent on striving and achievement of personally demanding standards. And you're not a perfectionist on Monday and Wednesday, it's consistent and persistent and people will strive to achieve those despite adverse consequences.
Lucy: For Sam, despite achieving high academic success, he felt trapped in a myth he'd created for himself.
Sam: (Laughs) I had such a tight grip on how hard I tried at everything. I felt that if I stopped gripping so tightly I wouldn't relax, I would melt, I don't know quite what I imagined. As if I'd just halt completely and become comatose and demotivated, that only by incessant, compulsive striving could I keep a grip on regularity and functionality. And it felt like stepping back from perfectionism could be more of a cliff edge than sitting on the sofa.
Lucy: I can imagine it feeling potentially catastrophic to give it up. But it sounds like that didn't come to pass.
Sam: It surprised me how relaxing and relieving it was to loosen my grip. But also, in a way how little changed. It wasn't like pulling the carpet from under my feet, it was actually just twisting the tap slightly, changing the water temperature, just letting myself off the hook slightly. And that those degrees of forgiveness weren't catastrophic, they didn't make me melt, I just felt I had a little more energy and perspective and optimism about ways to enjoy the things I was doing.
Lucy: So, what does CBT for perfectionism look like? Here's Roz.
Roz: The key part of it is about understanding your perfectionism, so you've got a maintenance model, understanding what's going on. And it's about having some psychoeducation, so many people have beliefs, “The harder I work, the better I'll do.” But actually, that's not supported by data, it's not just a linear relationship that goes on exponentially and just carries on.
There's some surveys, so understanding where the benchmark is, beginning to set a more realistic standard in that sense. It's not about lowering standards, I think that's probably the key. It's not about we're going to turn you into a slob. Because then people won't engage, and it doesn't need to be that.
And people value achievement, so it's about how can you achieve your standards realistic or adjusted standards in a way that is less detrimental to you? So, essentially, challenging the belief that this is the best way to go about getting self-esteem and self-worth and to build up other domains.
And so, lots and lots of behavioural experiments to test beliefs, lots of behavioural experiments to try things another way, to get the information about the best way that the person wants to live their life in a more balanced, sustainable way.
Lucy: Could you give an example of a behavioural experiment? Because people might not know what that is.
Roz: So, if you're gathering evidence about different ways of thinking then you want to have personal experience of doing it differently.
So, for example, if someone was a perfectionist in the domain of their work, and they were say a university student. They might have two assignments, and the first assignment might encourage them to really do it like they normally would, but even more. Even more intensely, put every effort in, stay up all night, open up all your 20, 30 PDFs, really strive as you normally would, even more so if possible. And record and rate their predictions about how well they think they would do, but also in terms of their emotional wellbeing, how happy do you think you will be with the result, etc.? Whatever the variables are that are important to them.
And then, we might encourage them the next time when they got an assignment to do it in a different way. And we might even create two different assignments for them, if it was too risky for them to do it with a real university piece of work. And in that, not to do it in an hour or something that's completely unrealistic, but to maybe – based on the survey when they find out how much their peers do – to try to do it in a reasonable amount of time, the same sort of time as their peers, maybe with a little bit extra and see how worried and how anxious they were.
And they predict that they'll be much more worried and much more anxious, because it's not what they want to do. But many times that's not the case. And to compare their marks.
And I would like to say that what always happens is they get a much better mark for the second one than they do for the first, but the reality isn't like that. And sometimes they do get better marks for the first, but they've also got the experience of doing it differently.
And they might say, "Well, I know, maybe I got 95 for the first, but actually with the second I predicted I would get 50, and I got 87. So, there was only a seven-point mark in it, but actually there was eight hours difference in it. So, I've decided that actually it's okay to perhaps do a bit less. I might not get exactly the right mark that I want to get, but I won't be as anxious as I thought, I won't be as low as I thought, and I won't be as tired. And I can go out with my friends. So, on the whole, doing it that way is better for me."
So, that would be an example of a behavioural experiment. And just to emphasise these experiments can't go wrong. Because if they really did very badly in that and they were more anxious and more stressed, then we would work together to find a different way of working or a different pattern that was more helpful to that person.
Lucy: So, this behavioural experiment could apply to all sorts of things, music practice, schoolwork, work reports, you can gather data yourself in what's called a contrast experiment. For example, how do you normally clean your kitchen? Try doing it a bit more one day, a bit less another day, and write down how you feel. Repeat it over seven days. What does the data show in terms of mood, anxiety, what works best for you?
Roz: It is about I think trying things differently and testing your beliefs and testing your predictions about it, in the workplace, in the social domain, information gathering to test your beliefs and find out whether or not they fit with reality or if there is a different, better way for the person.
Lucy: I asked Sam what his experience of CBT was like.
You mentioned having had some cognitive behavioural therapy, is that right? Could you say a bit about what that's been like?
Sam: That was a really interesting experience, and it wasn't quite my first experience of CBT. When I was doing my undergrad, I became very, very anxious about lots of things, but I'm sure compounded by the workload. And about again, wanting to judge myself by those standards. And that was low intensity CBT through IAPT and looked at more generalised anxiety, from the way I thought to the way I breathed.
And actually when I went back for CBT more recently, I thought it would also be dealing with more generalised mood things. But it was my CBT therapist who thought a lot of what I had brought to the space was actually being shaped and driven by perfectionism. For example, I was worried that I was quite energised and motivated and almost manic at certain times, and then quite absent and numb in other times.
And so, it felt by chance, for me that suddenly it became perfection-oriented CBT where we were discussing things through the lens of perfectionism. So, it was me when I was feeling fresh, I would max out my energy, my capacity and do as much as possible to meet all of the demands that I'd set for myself in recent memory.
And then, suddenly, I'd feel unsettled and very troubled by being too tired the next day or perhaps two days later, to do more of the same. And it was suggested to me that I was so troubled by feeling tired because I had so many high standards for myself that I wanted to meet, and I was punishing myself at every turn for not meeting them. And that was made worse when I was tired.
So the image that really stuck with me, which I share with friends now as well is that exerting myself so much in those highs and trying to meet my standards and then continuing to do so when I'm exhausted is like trying to run a race after having run a marathon. We just need more rest than we give ourselves time for, or certainly I feel that way.
Lucy: Yeah, that's a really great metaphor. What sort of standards were you holding yourself to in those times when you're working, is that on university work or other stuff, or a mix?
Sam: I think for me, a lot of it is work based, and maybe just because of my past experiences also I worked in office jobs for a couple of years, and I think certainly the businesses I experienced, it's perhaps not in their best interests to make you feel relaxed and rewarded all the time. Those high standards are useful, but I think it was up to me to draw some boundaries and find some space for myself.
But the funny thing is that perfectionism can spread into all sorts of areas of my life, and I get bounced around from one area to the other, so if I strive to feel my work standards are sated, then the next moment I'll realise with alarm that I've neglected my friends, or I'll get ill because I haven't rested, or I'll feel guilty or incomplete for not having practised my hobbies. And it feels like a constant juggling act to stay satisfied perfectionistically about all of those.
Lucy: Maybe impossible.
Sam: Yeah, I think it is impossible, and that was a really helpful image that my therapist gave me, was I think drawing on ACT, actually.
Lucy: ACT is Acceptance and Commitment Therapy, a third wave CBT. If you want to know a bit more about that, have a listen to the earlier podcast episode called Acceptance and Commitment Therapy.
Sam: Russ Harris' four quadrants for life, you have work, I certainly feel I have work. But also, my health and leisure and relationships, your family and friends. And what that image of the circle carved into four made me realise is that if I let one expand to more than a quarter, then the others would shrink. And then, I'd feel that shrinkage and feel guilty, and I'd leap to one of the others and grow that out.
And I think it's impossible to have any of them as large as I wanted them to be. And so, actually, it takes a real I don't know, a courageous kindness to let them be slightly smaller, each quadrant, than I want them to be.
Lucy: Were there particular things that you remember talking through in therapy or particular sessions that stick in your head at all?
Sam: This one session that really sticks in my mind that we had, because it was the only time my therapist was a little firm with me, because she felt I was being resistant to the therapy. I was trying to talk about my mood and this and that and various other things I was worried about. And she just put it to me whether I was attached to my perfectionism (laughs) and finding ways not to confront that.
She gave me the myths of perfectionism that if I'm perfectionistic, if I worked to 100% of my capacity, I would do better. And she urged me to question whether that's true or whether actually I'd burn out. And so, that was an important moment for me, because it showed me that the therapy wasn't just a box of tools or a book of information that she'd share with me. It was actually a process where I was going to have to stand up to beliefs and habits that I'd held for so long and kind of do battle with them a bit.
And again, that left me feeling very disarmed, and out in the cold with new ways of being, and that's scary. And I think for me that was very much the value of therapy, it was having a guide through that, that period of unknown.
Lucy: And what things do you try and do a little bit differently now?
Sam: Well, a lot of it is cognitive for me. Some is behavioural but a lot is cognitive, it's letting myself off the hook. It's noticing when I am worrying and criticising myself. It's actually just changing my internal dialogue and saying, again, more compassionate things to myself.
More practically, the quadrant, where you map out work and relationships and health and leisure. And I try to keep track of which ones I've been enlarging, which I've been shrinking, which I'm feeling guilty about, which I can forgive myself about. I find that a really useful tool for remembering the parts of life that might feel nourishing that I've been forgetting.
And purely behaviourally, I try to rest more. I force myself to see friends when I might continue working. Or to stay in, if I'm feeling perfectionistic about socialising, but actually feel rundown.
That said, I feel it's worth saying that I get a lot of it wrong still. And I think I imagined therapy would be an instant cure and you walk out of it a completely changed person. The habits are very much still there, it's just the perspective and the permission that's changed. I’m now much more aware of what I do. And sometimes I lean on old habits, because it's really tiring to try out new habits.
And now that I’m doing a master's for instance, I sometimes have to lean on old ways because I don't have the cognitive space to do the work and manage the trials of life while also trying to manage my own thoughts and behaviour. But I now have the experience of therapy, and the knowledge of those changes when I have experienced them to fall back on or feel can warn me if I need them.
Lucy: I asked Roz what the evidence base is like for CBT for perfectionism.
Roz: So, there have now been randomised controlled trials. And there have been meta-analyses showing that CBT for perfectionism works both on the perfectionism but can also be helpful for other problems like anxiety and depression. So, that's very encouraging.
Our version, Tracy and Sarah and my way of working with perfectionism, but it hasn't been really compared to more of a Hewitt and Flett's way of treating perfectionism, which is more interpersonal domain type of perfectionism. So, they have a treatment, too.
There haven't been many active comparisons, so it's not like you've got CBT for perfectionism against something else active treatment. So, IPT for perfectionism for example, you haven't got those active treatment comparisons. So, a lot of it is against weightless controls. But the data we have are positive and encouraging. And the qualitative feedback is positive, too, even from our online intervention.
We have to increase its access, I think. It's still quite niche and think about how it can be used when people have multiple difficulties. So, for us, if someone has anxiety and depression, given the state of the data you wouldn't say, "Oh well, I think it's perfectionism holding them together. I'm not going to do treatment for depression or treatment for anxiety, I'm going to go straight in with perfectionism." It can be tempting, if your clinical judgement is that's what's linking them.
But for us, I would recommend saying, "You go with your evidence-based treatment for anxiety, you see the impact. If that doesn't work, if you find that perfectionism is a barrier to change, then you come out of the existing protocol, you treat the perfectionism and then you can see what's left and go back in." So, given the state of the research, I would view the perfectionism treatment as something that you do when it's a barrier to change.
Lucy: Has your attitude towards meeting deadlines and that sort of thing changed at all through doing this work on perfectionism?
Roz: I think no, not in terms of my deadlines. But I think that I'm more forgiving of mistakes. And sometimes I use it as an excuse, I say, "Oh I work in perfectionism and it's funny to make mistakes." And I use humour, but everybody does make mistakes. I find it really difficult to use them as learning opportunities immediately. But when my emotional response to the mistake has settled down, then I'm more accepting.
Lucy: Sam calls this kind of self-forgiveness courageous kindness.
Sam: Any opportunity to forgive myself was really hard to do, but actually I think that the nastier side of perfectionism where it's harmful or dysfunctional or that kind of clinical perfectionism is driven by a kind of self-criticism. A self-punishment, if I don't meet those inflexible standards then I feel really low or angry at myself or at the world. And actually, it's hard work and feels quite crunchy to look at myself and say, "You're doing okay, that's fine." Letting myself off the hook.
I think so much of the world makes me feel that self-compassion is lazy or indulgent. And political attitudes or just I think the attitudes we all soak up, I feel that relaxing is a luxury. But the more I think about helping others, which is a much more rewarding aim for me, the more I feel I can't pour from an empty cup. And actually, forgiving myself is a cleaner, deeper kind of energising myself than this kind of slave-driven perfectionism could be.
Lucy: Thank you. Is there anything else you'd like to add?
Sam: I think for me, one of the advantages of CBT was that it could be quite clear and theoretical. My therapist showed me a map of the different ways I could fall into perfectionistic traps. So, if I met my high standards then I might raise them, and that rang so true that I'd decide they weren't high enough, that what I'd achieved wasn't that great. Or if I didn't meet the standards, which is more likely, then I'd beat myself up about that and feel low.
Or there's another fork in the road, which is not trying in the first place because it feels safer not to take the risk, that somehow adhering to some strict vision of perfectionism keeps me safe when in fact it keeps me boxed in.
And so, the clarity of that map, that I was given was a really good guide along with lots of other diagrams about the values that I felt and what I wanted to act towards.
I think talking to friends and family and reading and thinking and writing diaries and all of that is really helpful and valuable. But I think for me there was something about the complexity of different angles I could take, voices I could hear meant it was really hard for me to look at myself clearly or focus on one track to drive down.
And actually, almost the simplicity of the perfectionism model I was given in therapy, the beauty of that simple diagram – even if it feels reductive, even if some of it resonates more than others – it gave me something to focus on. And I think sometimes we need a clear path.
Lucy: Yeah, lovely. Thank you so much. That's fantastic.
Thank you to both of my experts, Sam and Professor Roz Shafran.
If you'd like more information on CBT for clinical perfectionism have a look at the show notes where I've put links to lots of the resources that Sam and Roz spoke about. I've also put a link to a questionnaire, if you're worried that you might have clinical perfectionism.
For more on CBT in general and for our register of accredited therapists, check out www.babcp.com. And have a listen to our other podcast episodes for more on different types of CBT and other problems it can help with like OCD and body dysmorphic disorder.
END OF AUDIO
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How can a talking therapy help with a problem that feels as physical as chronic fatigue syndrome?
Ben Adams talks to Dr Lucy Maddox about overcoming his initial scepticism about CBT and why he's glad he did. Professor Trudie Chalder explains the ideas that cognitive behavioural therapy for chronic fatigue syndrome is based on.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
More information is in the the links and books below.
Websites
For more about BABCP check out: www.babcp.com
To find an accredited therapist: http://cbtregisteruk.com
NHS Webpage about treatments for CFS:
https://www.nhs.uk/conditions/chronic-fatigue-syndrome-cfs/treatment/
Books
Overcoming Chronic Fatigue Syndrome by Mary Burgess and Trudie Chalder
Note
At the time of recording all information was accurate. NICE guidelines are currently being reviewed and due for release in 2021
Transcript
Lucy: Hi, and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, or BABCP. This podcast is all about CBT, what it is, what it’s not and how it can useful.
In this episode we’re going to find out about CBT for chronic fatigue syndrome, also known as myalgic encephalomyelitis or ME. Throughout the podcast you might hear ‘chronic fatigue’ sometimes used instead of the full name. But it’s chronic fatigue syndrome or ME that we’re talking about.
I went to a specialist clinic at the Maudsley Hospital in London to meet Ben who’s experienced chronic fatigue and its treatment. I was there on the hottest day of the year so the tube was pretty horrific.
Ben: I’m Ben Adams and I was diagnosed with chronic fatigue syndrome back in, gosh, 2015 I think it was now.
To give a little bit of a history I was healthy, broadly healthy, in as much as anybody is, until about sort of 2012. Then I became… I had a period of depression, there was difficulties in my personal life and relationships and all sorts of family things. And I think my body sort of chose to break down in some way or stop me a little bit.
And I started feeling very tired, really unwell, my brain wasn’t clear. I thought originally it was the depression, but actually I think that morphed into the chronic fatigue. I think one sort of caused the other. And they can go hand in hand quite a lot.
It took me about a year or so – or a bit longer – to actually get the diagnosis of chronic fatigue as opposed to trying to treat depression which wasn’t really doing it. Because I wasn’t actually that depressed (laughs). My mood was actually fairly good. I was just concerned about why I felt so weak and so feeble all the time.
And, yeah, it had a lot of impacts on me. I missed a lot of work during that time. I was working full-time beforehand, had rarely had any sickness over the last sort of 20 years of work. The odd day off here and there but I had… I mean over about four years or so, I had about 18 months off totally in sections. And when I was at work I was on phased returns and doing short hours and not doing a great deal to be honest.
So I had a really long period of sort of getting worse and worse, trying to get back to work, making myself worse. And I actually felt that each time I’ve tried to get back to work after a long period of sort of being unwell and being off sick, it would be hard and after a while it would be… it would feel like I was making myself worse. Like the activity, the mental and physical activity of going to work, each time there’d be a sort of a breakdown afterwards and I’m thinking, “God I’m getting worse and worse, that my baseline is getting lower each time of what I can do.”
And so it was getting to the point where I was almost housebound when I was at my worst. I think, yeah, I’d had about nine months off sick in my longest sort of period off sick at once. And it felt like it was getting up to the end really.
I’d tried all sorts of things beforehand. I’d had a very short period of CBT at the start of my illness, but that was also a bit sort of to do with depression as well. So maybe it wasn’t targeted as well.
And so that didn’t work brilliantly and so during those four years I was trying all sorts of remedies that you read on the internet. Vitamins, testosterone, I don’t know, everything I could try. And nothing helped. And then eventually I got into the Maudsley Hospital.
Lucy: We’ll hear more from Ben and his experience of therapy. At the clinic I also met Trudie Chalder, Professor of CBT at King’s College London, and Director of the Persistent Physical Symptoms Research and Treatment service.
I asked Trudie, who’s treated lots of people with chronic fatigue, what it means to have the condition.
Trudie: Chronic fatigue syndrome is defined by, obviously, its symptoms. So the primary symptom has to be fatigue, but it’s also associated with lots of other physical symptoms such as pain, painful muscles, so myalgia, sleep difficulties, concentration and memory problems to name but a few.
It’s also associated with lots of disability. So people who have chronic fatigue symptoms are often unable to carry out normal activities that we all take for granted.
Some people are not able to go to work, even though they would like to. Other people manage to go to work but are not managing much else in the way of social activities or being able to do things at home – the hoovering or washing up or whatever.
So it has a very profound impact on people’s lives. There are some people who seem to be managing it reasonably well at one end of the spectrum, and then there are other people at the other end of the spectrum who are very severe, who may be in a wheelchair or may even be bedbound.
Lucy: Before starting the therapy, Ben had reservations about whether it was right for him.
Ben: I was incredibly cynical at the time. I’d been on the internet a lot. I’d been looking for cures, looking for hope for a long time and I was very much of the thought that extra activity, increasing my activity, would make me worse as it seemed to have been doing throughout those phased returns to work.
Lucy: That sounds quite scary actually. If you get worse every time you go back that sounds quite frightening.
Ben: Yes, it was. It was really frightening. And so that was, when Antonia was saying we could have a treatment here and I was like, “Well, I don’t want to get any worse and at the moment I’m housebound but I can just about live on my own.” And I have friends who would come round and empty the bins for me and things like that and do heavy stuff. But I could sort of potter around my flat and get out occasionally for a little walk.
There was a few emails going back and forth with Antonia at the start. And I was saying sort of, “What guarantees can you give me? I’m really scared.” And she said she couldn’t really give 100% guarantee that it wouldn’t get any worse but she said in all her sort of 10 years of treatment in this field at the Maudsley that none of her patients had ever got significantly worse. A lot have got better to various degrees. So I thought, “Well, weighing it up I’ll give it a go.”
And so I started treatment with her. I think that was towards the end of 2016.
Lucy: There was something else that concerned Ben before trying CBT which is quite a common concern for people experiencing chronic fatigue.
Ben: I think as a chronic fatigue syndrome sufferer, when you come into the Maudsley Hospital it’s a sort of mental health unit. And you’re kind of thinking, “Hang on a minute, I feel like I’ve got really bad flu all the time. Why does somebody want to talk to me about my mind?” Some people get really angry about on the internet. We all know about that.
And I can understand that. You kind of think, “Why are you trying to treat my head when I feel my body’s so awful?” And so I think maybe trying to get over the fact that the CBT, even though it’s talking therapy, your physical symptoms are there and it’s a slightly different way of managing them as opposed to taking a pill.
But it’s a hard thing to explain to people who think, “I feel very ill, I need some sort of pill, there’s something wrong with me physically. I need a… talking to somebody’s not going to help.”
Lucy: Yeah, it’s a really, I can totally understand how frustrating that must feel if you’ve got very physical symptoms then you're being asked to come and talk about it.
Ben: Yes.
Lucy: Trudie explained a bit more about this link between physical symptoms and how CBT can affect them.
Trudie: Well I suppose the first thing to say is that the fatigue is not the sort of tiredness that we all feel on a day like this when it’s nearly 100 degrees.
Lucy: It’s really hot.
Trudie: Yeah. (Laughter)
The fatigue that people are feeling is abnormal. It feels very out of control and it feels extreme. And there’s no doubting the fact that the symptoms are real and they’re physical. But that real physical symptoms, which will be potentially perpetuated by physiological factors, so hormones and all sorts of different things that are happening in your body, as well as what do you, that those things can be altered by you doing things differently.
Lucy: What is cognitive behavioural therapy for chronic fatigue syndrome? What’s it like?
Trudie: Well, cognitive behaviour therapy is a practical approach primarily. It’s a talking therapy. And it helps people to reengage with some of the things that they value very highly. And gradually build up their activities over a period of time.
Obviously at the start people feel very daunted about any change. And at the beginning they may feel very sceptical about whether it’s going to even work. But obviously with all CBT everything is negotiated with a therapist, so nothing is imposed upon anybody unless they decide that that’s what they want for themselves.
And at each session, which is usually an hour long and occurs weekly or fortnightly depending on what the person is able to do, it can be face to face or over the telephone. And at each session the person will discuss any goals that they’ve set with the therapist and any difficulties that they’ve had. And then those difficulties can be discussed with the therapist in a problem-solving kind of way.
Lucy: I asked Ben a bit more about his experience of CBT.
Ben: I think I had… let me think, was it about 10 or 11 sessions with her maybe? Every couple of weeks. And so it would be a combination of CBT and discussions of how to increase my activity.
So I think the CBT, it was mainly aimed at how to – not differentiate between physical and mental symptoms – but sort of understand how the body and the mind interact. And stop me thinking that I would necessarily make myself worse by doing physical things.
And that was key. I was terrified that every time I did extra physical activity it was making me worse. And she was saying, actually the opposite, could be okay and actually make me better. But to do that you had to get through the mental barrier, I think, of the perception of my experiences.
Lucy: At some point did you have to start doing more? Or not have to maybe but choose to?
Ben: Yes. I mean, well every session I had, I think they were every two weeks to begin with, we’d sort of set targets.
And so one of the first ones would be just to go out of the flat and sort of walk around the block. And then, and I’d do that every day. And I think that that was the key, one of the key things was doing it consistently, not thinking, “Oh I’ve done that, I’m exhausted. I need a long rest now. I won’t do that tomorrow. I’ll give it a few days.” To do it every single day, however I felt, and make it a consistent repeating pattern. And it did slowly get easier.
Lucy: That’s so hard to do, isn’t it? I mean anyone who tries to make a change of any kind, that’s really difficult to get that consistency.
Ben: Yes. Yeah, definitely. And it was difficult but I… I think having her to guide me and to meet her every two weeks really helped because there be some times I’d come in and think, “I feel really awful, this isn’t getting anywhere. We’ve made some gains in the first few weeks but now I’m not feeling great. Should I keep going with this? Is it going to hit me hard in a couple of weeks’ time and then suddenly I’ll be even worse than I was?”
But I think having somebody to guide you through it, to talk to you when you're down or feeling unwell really helped.
Lucy: Trudie described what she often sees happening during a course of CBT.
Trudie: What we tend to see in the beginning is that people become more consistent in what they’re doing. So they’re less driven by their symptoms, as it were, and they become more in control of their lives. So rather than the symptoms controlling them they become more in control of what they’re doing.
So they develop a more consistent approach to things and then their fatigue usually starts to reduce a little bit.
Sometimes things get slightly worse before they get better. But on the whole, if they can stick with it and they're consistent in the way in which they approach things, they do improve.
Lucy: Consistency is really key. Ben gradually increased the amount of activity that he was doing.
Ben: Over the weeks I would extend my exercise, so I’d walk further and further round the block. I’d walk to my local park, Burgess Park.
Initially I’d sort of… (Laughs) I’d have places to stop that I knew so I could, there’s benches that I would lie down on, have a bit of a rest, get a bit further. And then make my way back. And then gradually I was getting further and further away from my flat.
And then it was a combination of doing that with taking my fold-up bike. I think you’ve just seen that earlier.
Lucy: I did just see, very impressive, you cycled on the hottest day that we’ve had this year. (Laughter)
Ben: I'm in a first floor flat and I used to pick up that bike, about 13 kilos, and I hadn’t ridden it for a long time. And I remember the task was, not even to take it down to ride, it was just take it down the front stairs to the ground floor and then take it back up. (Laughs) And it was very heavy and I was very weak. But I did it and then again I did it every day and every day.
And then I got on it and then I cycled round the block, so I have a cycle and a little walk every day. And it’s just really building that up until I was able to then return to work to a degree as well.
Lucy: Right, how did that go?
Ben: It was okay. My employer, Transport for London, I’ll give them a plug now actually because they sort of looked after me quite well during all this period. I think a lot of other companies after that amount of sickness I’d have been given the heave-ho. But they were very good. And they let me come back on a phased return.
The first week, I think it was one hour a week working from home. So it was the minimum amount of work you could possibly do. And I was doing some sort of very basic admin sort of data entry type stuff. Just to get into the habit again of looking at a screen and typing and getting into that sort of mode and that mindset.
And then gradually again that increased more and more work from home, longer hours, longer hours. And eventually I would come into the office on one day a week. Again gradually I built that up so I’d come in and do longer hours and actually do some work.
Probably about two and a half years ago now I got back up to 21 hours a week. Which was my part-time number of hours. So like a three-day week effectively. I’d been a five-day a week, 35-hour week beforehand, but I’d sort of been moved on to a part-time one as part of trying to make me manage it.
The good thing was I could then actually do that and I have been able to do those hours since then without any illness really.
Lucy: Amazing.
Ben: So it’s, yeah, so it’s been really good. But it’s a long hard slog and… (Laughs)
Lucy: Yeah. Going from seeing you cycling in today and then you talking about sort of being stuck in your flat before it seems so, so different.
Ben: So once I sort of understood how my mind was reacting to the physical symptoms I was experiencing, and then I could then change my actions based on that and start doing more exercise. But in this very regimented sort of safe way that wasn’t a sort of a boom and bust I think that happens to a lot of people. They think, “Ooh I'm having a good day, I’ll do quite a lot today.” And then you feel awful the next day.
It’s still there. I know that using excesses of energy is going to hit me hard. And even actually when it’s hot like this I think I’m definitely more susceptible to extremes of heat or exercise or temperature or those sorts of things. So I’ve just got to be a bit more careful. So I’m not cured but I’m a lot better.
Lucy: Yeah.
Trudie talked about boom and bust as well.
Trudie: Sometimes people have inadvertently got into that pattern of doing a lot when they feel very energetic and not doing very much at all when they’re very symptomatic. And this is totally understandable. But I suppose it can perpetuate the problem.
So in the first instance we ask, as far as is possible, given the demands of everyday life, that people try to be more consistent in their approach to activities to try and avoid that booming and busting. Which is quite a common thing. I mean people do it with all sorts of different illnesses. But, of course, it does leave even a healthy person feeling exhausted if they go at things like a mad thing. (Laughter) And then collapse with exhaustion. It can be more effective to do things in a more consistent way.
Lucy: I was just thinking we could probably all learn something from that.
Trudie: Yeah. (Laughs) Exactly.
Lucy: As well as regulating activity, Trudie and Ben both agreed that it is helpful to develop a sleep routine.
And is there anything else that you think people should know?
Trudie: Well I think the most important thing is that nothing is forced upon them. Everything is negotiated, it’s a talking therapy, so the therapist will be hopefully warm and empathic and understanding. And will really take a problem-solving approach but together with the individual.
And usually things are never simple. So there will be lots of problems along the way and hopefully the therapist would help the person to sort those things out.
And also I think the other thing is that if at first you don’t succeed, keep trying. Often it’s that life, other life events have got in the way or it’s been difficult to be consistent. But I feel sure in terms of having been in this field for more than 30 years that it is possible for people to change and that it’s possible to be hopeful.
Lucy: That’s great.
I asked Trudie about the evidence base for CBT for chronic fatigue.
Trudie: Well there are lots of studies now carried out in different countries around the world, but in particular the UK and the Netherlands, showing that CBT is an effective treatment in terms of reducing the symptom of fatigue and improving disability. So at the end of treatment people are much better able to carry out their normal lives than they were at the beginning.
Obviously it’s not a cure for everybody. And people are often still left with some symptoms. But a lot of people do improve. And there are, as I say, lots of randomised control trials demonstrating its efficacy.
Lucy: To end I asked both Ben and Trudie if they had any last remarks for people who are considering CBT for chronic fatigue.
Ben: It’s good in that it’s quite focused and practical. I mean I’ve had a lot of sort of talking therapy in my life for various things over the years. And so I sort of delved into my background and my family and all those sorts of things. And it’s always quite interesting. But I think you can sort of go too far with that, dwell too long on that.
And actually I think CBT’s a bit more, “Let’s get to the nub of the problem and try and sort out your thinking so that you can improve in a more focused way.” You generally don’t have too many sessions of CBT and it’s – it is more practical and more focused and I think that’s something that is good actually.
Trudie: I would suggest you go along to the GP and hopefully if your GP is supportive they could potentially refer you to a specialist centre. There are a few around the country but also the IAPT services are now seeing people with chronic fatigue syndrome and chronic fatigue.
Lucy: And IAPT, is that Improving Access to Psychological Therapies services that are nationwide now?
Trudie: Yes. That’s right. And they should or could potentially be able to see the person as well. So I think in the first instance go along and talk to somebody about what it entails. And take it from there.
Ben: It definitely helped me. It’s not going to cure everybody obviously, but it’s certainly a very good and focused way of changing your mindset I think and helping you to think about things. But I know it can be used in all sorts of different illnesses and different ways, particularly where the mind and body sort of overlap. It’s been a good experience for me.
Lucy: Oh that’s great.
Trudie: I suppose to finish on a note of optimism I would say that the majority of people that I’ve seen over the years, and it’s a long time, have really wanted to change and have demonstrated to me that change is possible.
Lucy: That’s great. A hopeful message to end on. Thank you.
A really big thank you to both of my experts there, Ben and Trudie. If you’d like more information on CBT for chronic fatigue have a look at the show notes. There’s lots in there.
For more on CBT in general, and for our register of accredited therapists, check out BABCP.com. And have a listen to our other podcast episodes for more on different types of CBT and the problems that it can help with. There’s one on obsessive compulsive disorder, post-traumatic stress disorder, psychosis. There’s lots there.
That’s all for now. Bye.
END OF AUDIO
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How do you talk about something in therapy when all you want to do is avoid thinking about it? And why might it help to be able to tackle it?
Nick Gilbert talks to Dr Lucy Maddox about how he sought help for post traumatic stress disorder (PTSD) and his therapist, Dr Jen Wild, explains the theory behind the treatment, and dispels some myths about what it's like.
This show includes reference to suicide.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Some more sources of information are listed below.
Websites
For more about BABCP check out: www.babcp.com
To find an accredited therapist: http://cbtregisteruk.com
NHS Website about treatments for PTSD are described here:
https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/treatment/
Support for veterans can be found here:
https://www.combatstress.org.uk/
Books
Overcoming Traumatic Stress by Claudia Herbert
Trauma is Really Strange by Steve Haines
Jen has a book coming out soon too - watch this space for details.
Transcript
Transcript
Lucy: Hi, and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. The podcast all about CBT, what it is, what it’s not and how it can useful.
In this episode we’ll find out about post-traumatic stress disorder, known as PTSD. I went to Oxford to record this episode and apologies in advance for the drilling, there were some building works going on outside where we were recording. We did try recording in the bathroom but it didn’t really work.
I met Nick Gilbert who was diagnosed with PTSD in 1990, six years after the event that triggered it. This is his story.
Nick: I’d reached a point where I was sat in my car and had no idea what I was going to do next. I was actually considering ways of ending my life.
So I’m sat in the car considering these things and I phoned my GP who was aware that I’d got issues – got some problems. He put me though to or put me in front of Talking Heads I think it’s called. And they phoned me and said would I be prepared to take part in a study. And, quite frankly, I was so desperate at the time, if they’ve have suggested witchcraft I’d have probably gone along with it.
Lucy: Nick started having CBT in 2012.
Nick: And then I met Dr Jennifer Wild and I don’t think it’s too much to say that that lady changed my life.
Jen: The people I work with are suffering from post-traumatic stress disorder and the treatment I’m giving is trauma-focused cognitive behavioural therapy.
Lucy: Jen Wild is a consultant clinical psychologist at the Oxford Centre for Anxiety Disorders and Trauma.
Jen: Post-traumatic stress disorder, or PTSD as it’s commonly known, is a severe stress reaction that can develop after natural disasters like a tsunami, a physical assault, sexual assault, car accidents, really unpleasant events where people flooded with unwanted memories and can’t get them out of their head. It’s very debilitating, it’s very terrifying, it takes up their concentration. They feel very hyperalert.
Lucy: What does hyperalert mean?
Jen: Hyperalert is feeling very on edge, very aware of your surroundings. And I think what happens with PTSD is people’s focus of attention shifts. So instead of being very absorbed in their environment or with their work or their family, for example, suddenly people are very focused on something bad could happen, “I could lose my life at any moment. Something might happen to my kids.”
So the shift of attention is from being absorbed in the environment to something terrible could happen. And when people are focused on danger they notice danger.
Lucy: It sounds just like it’s very scary all of the time.
Jen: It’s very scary, it’s very unsettling. There are four clusters of symptoms with PTSD.
So the first cluster called the reexperiencing symptoms, and that really means people are reexperiencing the trauma in the form of unwanted memories or nightmares or physical reactions in response to trauma reminders.
The second cluster of symptoms are the avoidance symptoms. So understandably when we’ve been through something horrendous, we want to push it out of our mind, avoid reminders, avoid people who remind us of the situation, avoid TV programmes that might remind us of the horrible trauma. So the second cluster of symptoms are the avoidance symptoms.
The third cluster of symptoms are what’s called, in our language, negative alterations in cognition and mood. That basically means people feel and think more negatively. So they might have thoughts like, “I’m permanently changed for the worse,” or “This trauma happened and it’s 100% my fault.” So they may be excessively blaming themselves.
And then the fourth cluster of symptoms are what we call the hyperarousal symptoms. So that’s the sleep problems, the concentration problems, that feeling of being on edge, hyperalert to danger. And that they’re usually caused, these hyperarousal symptoms, by the trauma memory, so the memory of the trauma keeps people feeling like danger is just around the corner.
Lucy: This was Nick’s experience of PTSD.
Nick: I sometimes burst into tears for no reason. And in my head I know I’m crying and I can’t understand why I’m crying and I don’t want to cry but I do. I feel angry and frustrated. I have no idea why. Little things upset me a lot. Stupid things.
You know that you shouldn’t react in the way that you do but you're almost a spectator. You don’t have any control over it. And you try very hard to break out of that but it sometimes is very difficult to do.
It goes after a while. And lots of other things, different reactions to things, triggers you see on TV and things.
And one of the weird things actually is not reacting. The incident that triggered my condition involved climbing down a cliff. For a long time I couldn’t even consider looking at a cliff. But now I see it on TV and it doesn’t bother me. And that bothers me.
Lucy: That bothers you that it doesn’t bother you?
Nick: Yeah. Because does that mean I don’t care anymore? Because there was a fatality. Should I feel that way?
For me, I don’t know about others, but for me there’s a, if you like, survivor guilt. And shame for surviving. And not understanding why I was the one that survived and other didn’t. So you almost feel offended on their behalf.
Lucy: Is it right that quite often feelings of shame might come along with it as well?
Jen: People can feel ashamed after their trauma when they start to question what they did during their trauma, if they have thoughts, “I should have acted quicker, I shouldn’t have been in that situation, I’m not happy with how I responded in that particular trauma.” Then that can lead to feelings of shame.
Of course people can also feel ashamed with trauma like sexual assaults where they felt very violated and very ashamed to talk about what happened. Maybe they were humiliated by their perpetrator and they may internalise the voice of their perpetrator and it may become very difficult to talk about what happened because they think their clinician or their therapist will judge them in the same way.
Lucy: So it sounds like something that’s understandably really difficult to seek treatment for actually. What is the treatment like?
Jen: The treatment is very effective. That’s the first point to make. And it has a scary title; it’s called trauma-focused cognitive behavioural therapy. The therapy is really looking to update the horrible trauma memory.
When we go through something horrendous we’re really focused on surviving and we don’t always pay attention to information at the time that is really helpful to link to the trauma memory.
So, for example, somebody might have had a horrendous car accident and thought they were going to die at the time. And then when they’re reminded of the trauma today they see a car, they get that feeling they’re about to die again. They may have unwanted memories coming to mind of the moment just before impact. And then in their mind the memories will stop at the worst moment, the moment before impact, for example.
And then what treatment would do is help to flesh out that memory in a little bit more detail. So we know if somebody’s sitting in our office that they have survived the trauma. So we want link that information, “I’ve survived,” to the memory of the car accident.
So by the end of treatment the trauma memory would be so much less threatening and it would be something around, “I’ve had a car accident, I thought I was going to die, I felt very afraid, I was injured, I now know I have recovered from some of the injuries, I’m safe and I have survived. It’s in the past.”
And you can see how that new information gives context to the trauma and makes the meaning much less threatening, which is what helps people to feel a lot better.
Lucy: And so does it involve sort of talking through the trauma quite a lot?
Jen: I think the common misconception is that the trauma-focused CBT really is about talking about the trauma a lot. But I’ve just looked at a case series where I counted the number of times I actually went into the trauma memory in a lot of detail with clients. And in a 12 session treatment I actually went into the trauma memory in a lot of detail in one session. So it is a misconception.
Of course we work with the trauma memory but we’re often working with trauma triggers. And that’s really breaking the link between the present and what’s going on now when the trigger appears to what happened in the past. And that’s not really talking through the trauma memory. It’s really about, “What’s going on now that’s different to the past that shows me that I’m safe?”
Lucy: So anyone listening to the podcast who’s thinking about having trauma-focused CBT could be quite reassured by that, that it’s not every session at all that you’re going through the trauma in detail.
Jen: It’s not every session that you’re going through the trauma in detail and I would say that one of the ways that CBT for PTSD is effective is you're helping to change the meaning of the trauma.
Of course we can’t change the facts of what happened. If something horrendous happened, it happened. But we can change how we interpret it and the meaning that we believe it says about ourself or other people or the world. We can update that. And that’s why I like to think of the therapy as an updating therapy.
Lucy: And is that kind of how it works? Is that the kind of main way that it changes how people feel, by changing the meaning of what has happened?
Jen: I think there are three ways in which the treatment works. I think one of the most important ways is changing the meaning of what happened so it’s less threatening to somebody.
The other way is we help clients to change some of their behaviours that might be increasing their anxiety. For example, if somebody is really worried about being attacked when they’re out and about, they might have one or two mobile phones with them. They might have them ready to call the police. And they might be really focused on danger. And, of course, that’s going to increase their sense of danger just by having their phones on a quick dial to the police.
So what we would want to do is to go out with people and get them to drop these specific strategies so that their brain discovers that they can walk out and about without having to take extra precautions. So that helps to change their behaviour, reduce anxiety.
And the other area is breaking the link between the present and the past by working with trauma triggers.
And there is actually another area and that is working with the thoughts. This is the meaning more or less that we touched on. And updating the memory. So we update the memory so it no longer stops at the worst moment.
Lucy: What sort of things should people expect if they were coming for CBT for PTSD?
Nick: I think the expectation is a very important thing. You're in so much pain – I don’t mean physical pain – that you’ll do anything. But some people expect it to be like taking a drug. And that all of a sudden you’ll feel better. Well that’s not the case. It takes time. And energy. And effort. And pain.
There were times I left Jen’s office and I felt like crying. I was so emotional – it’s so emotionally charged that I’m absolutely shattered afterwards. Absolutely shattered.
Lucy: Why do you think people put off talking about it?
Nick: Because once you’ve opened Pandora’s Box you can’t close it. Once you start the process you can’t not do it anymore. It’s something you’ve got to do. You’ve got to see it through to the end.
Lucy: And did you have to talk through what happened quite a lot? Were there other things you talked about as well or…?
Nick: You talk about lots of aspects of your life. And, yes, you talk about whatever the trigger incident was. And I say a trigger incident for a reason.
In actual fact for many years if I even mentioned it I would tear up. I talked to somebody about it the other day and it was just like any other conversation. Which again amazes me but also shames me because a part of me still feels that I should be suffering on behalf of Annie and because I’m not there’s an element of guilt there.
But you see that’s the PTSD. That’s not me. I’ve reasoned that. I know what it is. Therefore I can deal with it. I think a striking indication of maturity is when you realise that life isn’t fair.
Lucy: I asked Jennifer about what people should expect from CBT for PTSD.
Jen: The treatment’s a very active treatment. I would say I try and get out of the office as much as possible with clients because that’s where life happens. And we want people to kind of reclaim their life as well.
So in the first session I would be working with people to think about their longer-term goals and we would touch on their goals in every session and making sure that they're working towards them. And picking up activities that they may have dropped because of the trauma.
Lucy: So what sort of places do you go to?
Jen: Well, you might be surprised to hear that we would go back to where the trauma happened. And that is very important for a number of reasons. It helps people to discover that the site has moved on. There’s no one still there suffering. That the suffering is over, it’s in the past.
It also helps clients to feel that they can cope with it. Often people understandably are incredibly anxious about going back to the site of the trauma but once they’re there they can focus on what’s different and how it’s changed since the time of their trauma. And that really helps to give a sense of movement in terms of their life, but also with the fact that the memory’s in the past. It’s a quite clear distinction between what’s going on now and the memory being in the past.
Lucy: Jen also sometimes uses Google Maps with people so that they can look at the place where they trauma happened online instead of going there in person.
Jen: And if clients have developed anxiety or avoidance about different situations, about shopping, about walking down the road, for example, we would go out and about with them, walk down the road, go to a shop. And really test their beliefs about what they think will happen and then find out what actually happens and the outcome is always good. They usually realise that bad things don’t happen when we leave our house and that actually it’s safe to do so.
And they also typically experience a boost in mood. So it’s good motivation to keep doing those behaviours, like leaving the house, for example.
Lucy: That sounds really important. It sounds like there’s potential to make huge change for people’s lives there.
Jen: The efficacy of trauma-focused CBT for PTSD is incredible. The majority of patients will recover with treatment. We normally offer up to 12 sessions, but many patients don’t need 12 sessions. So they may have a fewer than that.
Lucy: So it’s got a really strong evidence base.
Jen: It has the strongest evidence base of any treatments for PTSD. I highly recommend it but I think any of the clients that we treated would highly recommend it as well.
It helps people to reclaim their life and to lead a life that matches their dreams rather than their fears.
Lucy: Nick reclaimed his life in ways he would never have imagined.
Nick: I’m a funeral director now.
Lucy: Are you?
Nick: And I enjoy it immensely. And the reason I do that is because I’m able to help families through a very difficult period. I can understand how they’re feeling. And I say to them quite often, when they say, “I’m going to miss them,” I say, “Well, for as long as you talk about them they’re never not going to be there. They’re still alive in your memories. So talk about them. Don’t avoid talking about them.” Because people do because it might upset grandma. But as long as you talk about somebody they’re going to be there.
So I find that extremely helpful for me. And I think for them because I get good responses. People say that I’m good at what I do, etc. But I think I wouldn’t be anywhere near as good as I am, dare I say, if I hadn’t experienced what I had in the first place.
I know I’m a very different person to the person I was before the incident. And I know again that I’m a different person to the person I was before I went into CBT.
Lucy: It’s really striking the image of you in the car that you talked about at the start and now how you're doing a totally different career and you're feeling really good at that and enjoying it and getting really good feedback from people. Could you say just sort of how you feel like you're life has changed from one point to the other?
Nick: At that time I’m pretty certain, it was probably the lowest point in my life post the accident. You can’t see any further. But you move on. And then one day you suddenly realise, “Actually life isn’t too bad, is it?”
And then you feel guilty because you think, “If I think this will it all go horribly wrong again?” But the reality is you end up in a better place.
Lucy: What do you like about working with PTSD?
Jen: I love working with people who have developed PTSD. I know that it’s a problem that people can recover from. It’s very common. I know that most people I work with are going to recover with this treatment because it is an effective treatment.
But I also am very passionate about the idea of people reclaiming their life, and possibly going one step further. So it’s an opportunity when we go through some horrendous trauma to take a step back and re-evaluate our life, look at our symptoms, get some help and make a choice to lead not just an ordinary life but an extraordinary life. And that’s what I love most about this treatment.
Lucy: I asked both Nick and Jen if they had final advice for people thinking of doing the therapy.
Jen: The decision to have treatment is an important one and understandably people put it off. I think it can be more difficult when we’re feeling really ashamed about our trauma or the symptoms that we’re having to reach out for help.
And I would just like to invite people who have had trauma and are feeling ashamed to take that step and reach out because the treatment is so helpful and there’s so much relief from reducing that sense of shame and that can happen within one or two sessions. So I would really encourage people to reach out.
Nick: Well, first of all, if you're suffering with PTSD then I do feel for you. There’s almost a brotherhood of it.
Be careful of who you talk to about it. But if somebody is offering you this treatment, then do it, because once you’ve done it, if it works for you you’ll be in a far, far better place. And, to be honest, if it doesn’t you're no worse off than you are now.
But if you do it you’ve got to be committed to it. It’s like being on a diet. But you will feel the benefit.
Lucy: What kept you committed to it? How did you stick with it? Because it sounds hard.
Nick: I knew I had to do something because I honestly didn’t feel that I would be able to cope much longer and I would probably have taken my life. It was a turning point.
Lucy: That’s great. Thanks so much.
Nick: You’re very welcome.
Lucy: Thanks to both of my experts, Nick and Jen. If you’d like more information on CBT for post-traumatic stress disorder have a look at the show notes.
For more on CBT in general and for our register of accredited therapists, check out BABCP.com. And have a listen to our other podcast episodes for more on different types of CBT and other problems it can help with, including obsessive compulsive disorder and psychosis.
END OF AUDIO
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What are 'intrusive thoughts' (we all have them) and what has CBT for OCD got to do with a polar bear? People sometimes talk about being "a little bit OCD", but the reality of obsessive compulsive disorder is much more difficult than a tendency to line your pens up or be super tidy.
Ashley Fulwood talks to Dr Lucy Maddox about his journey towards recovery from OCD with the help of CBT, and Professor Paul Salkovkis explains how CBT works.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Want to know more?
Websites
For more about BABCP check out: babcp.com
To find an accredited therapist: http://cbtregisteruk.com
Ashley's charity, OCD-UK is here, and there is a lot of useful information on their website: https://www.ocduk.org/
And another OCD charity, OCD Action, is here: https://www.ocdaction.org.uk/
Books
Break Free From OCD by Fiona Challacombe, Victoria Bream Oldfield and Paul Salkovskis
Overcoming OCD by David Veale and Rob Wilson
Transcript
Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. This podcast is all about cognitive behavioral therapy, what it is, what it’s not and how it can be useful. Today we concentrate on cognitive behavioral therapy for obsessive compulsive disorder, or OCD.
Before we meet this week’s interviewees I’d like you to try really, really hard not to think of a polar bear. Do not imagine a polar bear. What did you notice? Did you see a polar bear in your mind’s eye? We’ll come back to that later.
For one of this episodes interviews I took a train up to Belper, near Derby to meet with someone who has had personal experience of OCD.
Ashley: My name is Ashley Fulwood and I work for the charity, OCD UK. OCD UK is a charity founded by me and a colleague in 2004. We’re completely service user led. So everybody involved in our charity at the moment has been affected by obsessive compulsive disorder, either directly, sufferers like myself, or through a loved one.
But it’s been good because through my work the charity is how I’ve actually made progress with my OCD and I’m now certainly on my recovery journey.
Lucy: Life for Ashley now is really different from how it was at the height of his OCD.
Ashley: I thought I was managing my OCD and it’s only years later when I started working with the charity that I realised, actually I wasn’t managing my OCD. I was able to go to work and hold a full-time job, so that’s why I thought I was managing it, compared to other people. But looking back, it tainted every aspect of my life, so it became a very regimented day. I would get up, go to work, avoid eating or drinking during the day. Obviously as a guy we can urinate without having to touch the toilet, so I could just about do that.
As my workday ended at 6pm, my colleagues who I’d got on brilliantly with, they would all go off to pubs and restaurants and clubs and they would always invite me but I would make excuses because I knew that I’d have to go home and go through my rituals.
So I’d head off home, I’d probably grab a takeaway or something to eat on the way home so that I was ready to use the toilet when I got in. I would use the toilet. By the time I’d finished doing my shower rituals it would be 9:00/10:00 at night, which is more or less time for bed and repeat-repeat-repeat.
Lucy: Ashley is not the only person I spoke to for this podcast. I also spent an afternoon in Oxford speaking to the current president of BABCP board and international expert in cognitive behavioural therapy for OCD.
Paul: I’m Paul Salkovkis, I’m the director of the Oxford Centre for Psychological Health, which includes various bits, but particularly the Oxford Centre for Cognitive Therapy and the Clinical Psychology Training Course.
Lucy: I asked Paul to explain what OCD is.
Paul: OCD is much misunderstood. What it is, is people experiencing really unpleasant intrusive thoughts, things which pop into their head, but also images, impulses or doubts which upset them. And those are the things we call ‘obsessions.’
They’re things which pop in the head which are unacceptable and then compulsions that are actually related in the sense that they’re things that people do to try to prevent bad things from happening. For example, to wash their hands that feel contaminated or say a prayer if they’ve had some sort of very unacceptable thought. Try to wipe thoughts out and so on. And those are compulsions.
Together they both occur actually in everybody. So everybody experiences occasional upsetting thoughts and do things that perhaps are driven by those kinds of thoughts. The disorder bit is when it interferes with their life and stops you doing things that you want to do. So it’s not just the obsessions and compulsions, but it’s the interference with life, taking time, distress to the point of torture sometimes. And at its most extreme. This is a life destroying problem.
Lucy: Could you say a little bit more about what sort of intrusive thoughts people might experience?
Paul: Classically obsessional thoughts are often thought of being about contamination and so on. But actually they hit you wherever you’re most vulnerable. So if you’re a religious person, you tend to have obsessional thoughts, say blasphemous thoughts. Clean people have thoughts about being contaminated. Careful people have thoughts of being careless. People can have thoughts of sexually abusing children, including their own children and so on.
They’re the thing which you’re most afraid of and then the compulsions are pretty much logically related. There is always a rational link, it’s just you need to get it from the perspective of the person who is experiencing those obsessions and compulsions.
Lucy: Right and so the compulsions are kind of to cancel out or neutralise the upsetting thoughts?
Paul: Compulsions in my view divide into two types. There’s those which are meant to prevent bad things from happening, so you wash your hands to make sure that you don’t pass contamination to other people. And there’s others that are meant to undo things. You say a prayer because you had a blasphemous thought and so on. You have an image of your mother dead, so you then try and form an image of her alive.
There’s things which are designed to really check whether or not something has happened and then the other things are called restitution, like putting it right.
So they’re either meant to forestall it or undo it basically.
Lucy: You said it’s only a disorder if it gets in the way of somebody’s life. Sometimes people say they feel a little bit OCD or that kind of thing. What would you have to say about that?
Paul: The idea of being a little bit OCD is kind of quite controversial and you get people claiming they’re a little bit OCD. OCD is of course a life destroying problem and so to say that your, say your preoccupation with putting things in a straight lines is OCD, is probably unhelpful in terms of the way that we think about things.
That being said, the roots of OCD, as far as I’m concerned, sit in normal behaviour. So I’m a little bit OCD in the sense that I experience intrusive thoughts, which map on very closely to things that are experienced by people with OCD. I absolutely don’t have OCD myself though, and I’m not claiming that.
So it’s a bit of a tricky one, it’s a bit more complicated than it just being insulting to say you’re a bit OCD. The way it’s often used though is essentially belittling those people who suffer from the problem. And I think it’s best avoided really.
Lucy: Is it okay to ask what sort of intrusive thoughts you have?
Paul: Sure. Over the years I had to explain to people that I’ve worked with, about the normal intrusive thoughts that I have, which are not at all normal.
So I’ve had thoughts about harm coming to my children, me harming my children, me sexually abusing my children and so on. It sounds horrific stuff. Most people though will have experienced something like this. Perhaps in a fleeting way and they kind of think, oh, there’s a funny thought.
Other examples, when you’re standing in the tube and you think about either jumping in front of the tube or pushing somebody else, off a cliff. Ideas of being contaminated, of course lots of people have lots of intrusive thoughts about being ill. They notice a blemish on their skin and think it might be the first sign of cancer and so on.
I’ve had all of those things and I think, well, I know that the majority of other people have something like that and so on. At one level they’re every day, they don’t terrify me, but for somebody who has OCD, they are hell, they’re just torture and they consume the person’s life and destroy it. So they’re something and nothing, but for the person with OCD, they’re a lot more than nothing.
Lucy: I get the one about pushing people down the stairs actually, quite frequently (laughs), promise not to do it! (Laughter)
Now Paul and I were able to have a bit of a laugh there about that intrusive thought that I get, but these thoughts are no laughing matter when they’re part of OCD. I asked Ashley to tell me about his experience of OCD and the impact that it had on his life.
Ashley: Yeah, of course. So obsessive compulsive disorder, most people call it OCD. And for me I had intrusive thoughts and fears and worries around germs, around using the toilet. Often it wasn’t a case of washing until I saw that I was clean, I would have to feel clean and of course the more you try and feel something, the less certain you become.
And it’s the same with any type of OCD, whether it’s checking or other parts, the more you try and convince yourself that you’re okay, the less certain you become.
My OCD meant that throughout my 20s and 30s effectively I couldn’t use the toilet, I couldn’t even use my own because I couldn’t touch the toilet lid or seat without then having the urge to shower. So it meant I avoided eating and drinking when I was out and about so that I didn’t have to use a toilet, and even my own. And when I did use the toilet it then meant two to three hours of shower rituals, on a bad day, five/six hours. Thankfully that was rare, but on average a minimum of 90 minutes was the norm.
So I’d have to wash my left leg, right leg, left arm, right arm, my body, my torso, my genital area, everything had to be cleaned and of course if during that ritual something didn’t quite feel right, maybe I’d missed a bit, I’d have to start all over again.
Lucy: It’s impossible really to over emphasise how much of an effect OCD can have on somebody’s life. Ashley was really candid about some of the things that he’s experienced and the impact that they’ve had on him and also how he came to realise that OCD is what was going on for him.
Ashley: It was actually an episode of Casualty in my mid-20s when they covered a guy with a germ phobia who couldn’t go out. And I realised that was actually partly what I was doing for a while, that each time I went out, I’d have to shower when I come back. That’s when I realised what I was going through was OCD.
And typically – maybe it’s a typical guy thing, I don’t know – I didn’t actually do anything for another few years because I was too embarrassed to actually bring it up and talk about it. Back then of course there was no internet, so there wasn’t really any resources for me to go online and look up what I should do.
So growing up, I didn’t really socialise, I didn’t have, what most people do in their 20s is go out and have fun. So although I’m conquering my OCD now, possibly as a consequence of my OCD I still find social interaction quite a challenge. I still feel very uncomfortable when I’m in social situations; going into pubs, even just walking into a pub fills me with anxiety.
Because I didn’t have a lot of social interaction in my 20s – this is embarrassing to say, but it’s part of what OCD does to you – I didn’t have girlfriend until I started making recovery, well into my 30s. And as a consequence, I didn’t lose my virginity until I was well into my 30s.
That is the factor of obsessive compulsive disorder, that people might recognise the compulsions, the symptoms, the surface, but what they don’t realise is, and often why OCD is trivialised is because people don’t recognise the fact that the ‘D’ in OCD stands for disorder.
They don’t realise the impact it has on people’s lives, whether it be relationships or education, if it’s a young person, or careers. And sadly sometimes with tragic consequences, as we know only too well through the work with the charity.
Lucy: Paul also spoke about the huge collateral damage that’s done by OCD.
Paul: I’ve worked throughout my career really with people with very severe and very persistent OCD. I would say that about 20% of what I do is helping people with their OCD and the remainder is helping people with the collateral damage.
Because 40 years on, after you’ve been washing or checking or neutralising, or whatever, that’s taken a massive toll on your life and quite deep grooves have been worn and so on. And people have lost a great deal.
And so a lot of what we do later on with these folks is yes, help them with the OCD but then help them undo some of the harm.
The other thing you see with that is some people, immense grief about what they’ve lost. And I sometimes feel that very acutely. Sometimes it’s both myself and the patient crying about it because it wasn’t necessary in the first place.
Now what that says is that firstly, we should continue to help those folk, but we should get in much earlier. The average time between people first having full blown OCD and it interfering with their life, it typically starts age 20; typically people get their first treatment, on average, 32. Which means 12 years of not being helped, the damage that’s being done and so on, and that is appalling. That’s unbelievable.
Lucy: So what is the treatment like for this problem? What does CBT for OCD look like?
Paul: What should happen is that for CBT for OCD, as for anything else, you should walk in the room and the person should explain who they are, how they’d like to be called, what the interview is about. And then they should sit down and listen to your story.
And I think that’s a really important thing because in the end people walk into our room and we kind of expect them to tell us everything about themselves and their really deepest, darkest secrets in some way, or all the things which cause the most pain.
What amazes me is that people do, and I think that’s a real privilege as a therapist to get that. But I don’t think you have it as a right, I think you have to earn it and you have to show essentially that you can be trusted.
What should happen next then is the person; the therapist should work with the person to find out a little bit about how the problem is affecting them and what form it takes. In OCD, what type of intrusions they have, what their compulsions are, how it impacts their life.
And then go into a really quite specific thing and we’re probably a couple of sessions in now. This is not in your first session. What you then do is you then zero in on what actually happens. If you’ve got OCD, what happened yesterday at 3:00 when you were starting to experience this problem? And then piecing together from a combination of what the person remembers about what was happening yesterday when the obsession was bothering them. And then the expertise of the therapist in understanding roughly how obsessions and compulsions work.
And then reaching this thing we call the ‘shared understanding.’ Me saying, “Let’s you and I sit down together, work out how this works. Is it possible it works this way?” And linking into the person’s lifestyle, values, their social situations and so on. Somebody is living in abject poverty or is being bullied or harassed or whatever it is. These are all things that affect it.
The next step is not, “Oh, okay, we’ll just use that to treat you.” It’s, “Lets you and I work together to see how we might be able to change things, to try things out and see if this is true.”
Because in OCD, if the thing is that you might be going to harm people, that’s your worry, and if that were true, then you should protect people and that’s, of course, what people with OCD are often doing. However, if the problem is not that you’re harming people, that you’re just a lovely person or a kind person or a caring person who is afraid of harming people, well, that has different implications.
And you’ve got to then work out which of these two alternatives is true and how best to find out, other than test it out. So don’t trust me, work with me to find out.
Lucy: That’s great. So it’s very much something that is done together, it’s quite a shared experience and it sounds like you’re very collaborative about how you set that up.
Paul: I’d go even further than that. What I think a good CBT therapist does is empower people to choose to change. It is this process of choosing to change. It’s not my choice, it’s the person I’m working withs choice.
And it’s really in that sense, everything we do is self-help with the support of a therapist. And that’s probably why self-help without the support of a therapist sometimes works, because people can learn similar things. And often can then implement that. But that’s extremely difficult and so having the support of a therapist who can go with you on the journey, I think that’s what a good CBT therapist does.
Lucy: And how about Ashley? He’s had a few different experiences of therapy and not all of them have been positive.
Ashley: My experience has varied over the years and I’m not going to name any names, but certain therapists have said to me, “I don’t understand OCD,” which in some respects I respect their honesty, but it didn’t exactly fill me with confidence in their ability to treat me.
Other therapists have said to me they don’t believe in putting their hand in toilet water, which of course I knew that’s what I needed to do to overcome it.
Lucy: In the end Ashley volunteered to be part of an intensive training day for therapists which Paul organised. As part of this day Ashley tried out what it would be like to face his fears of touching the toilet with his hands.
Ashley: I actually became a guinea pig on a CBT therapist training day, and I was happy to do it because I knew that I needed to do it. And I had a lot of anxiety prior to doing it because I knew that I knew that I was going to be doing it a couple of months in advance.
Ironically, because I’d prepared myself well using the CBT techniques I’d learned, the anxiety actually went very quickly, within a matter of minutes.
By doing that exercise… And sometimes people say to me, “Why would you put your hand in toilet water, that’s not normal? Nobody, even people without OCD don’t do that,” and what’s important to understand is if we’re living at one end of the spectrum, which is the OCD spectrum, we have to go to the anti-OCD end, the opposite end of the spectrum to learn to live in that normal middle ground.
Lucy: Ashley described what happened.
Ashley: There were about four/five other therapists and the professor and myself crowded into this disabled toilet to do the exercise and they were all really encouraging.
And so the professor did it first and he said the brilliant thing which really empowered me, he told me that I didn’t actually have to do it if I wasn’t ready to do it and I think that was so powerful in that moment.
And being the competitive person that I am with the professor who I know quite well, I was able to take that challenge and I jumped straight in there. And actually I didn’t do the exercise right because at first I thought he meant touch the actual inside the toilet bowl.
I did that and felt really pleased with myself and suddenly Paul said to me, “Actually no, what I meant was put your hand in the toilet water.” And he did it again, if I remember rightly. So I was a little bit, “Argh, okay, I wasn’t expecting that,” but I did it.
And I was standing there with wet toilet hands and I’m just going to stand up, obviously you can’t see because we’re not on camera, but I was actually standing like this. I was standing with my arms away from my body because subconsciously – I wasn’t even thinking about it – I guess I didn’t want my hands to touch my jacket. I was wearing an expensive jacket that day, so I didn’t want to throw it away.
I didn’t actually even realise I was doing it, but the therapist recognised it instantly. He didn’t ask me a question, he realised what I was doing and he asked permission if he could take my hands and touch my hands. And I said yes, and I realise now what he did. He took my hands and he just rubbed my hands all over his grey curly hair. And again, that was just a powerful thing to do.
And only by speaking afterwards, actually I recognised myself, about two minutes later, I realised why he did that, because I was standing with my hands away from my body. The moment he did that, my anxiety suddenly started to drop and I suddenly started putting my hands on my trousers and on my shirt. It was such a weird feeling because I expected to become really, really anxious.
Lucy: Ashley was really clear that the way that the experiment was set up was really important.
Ashley: Rather than just tell me to do the exercise, they experimented, they gave me the example of how the exercise should be done by doing it first, which was so empowering. I think that’s a great example of good therapy.
Something else that people need to remember is that doing the exercise once is fantastic; give yourself a huge pat on the back. But to make recovery stick, to make recovery last, I believe you need to repeat the exercise regularly. In my case I did it daily for about three weeks until the anxiety was literally not even recognisable.
Lucy: The theory that CBT for OCD is based on is very much to do with the meaning that we make of our intrusive thoughts and then the behaviours that we get into doing in response to that meaning. This is where the polar bears come in to.
Paul: What the theory says is that intrusive thoughts occur to everybody, but it’s not those thoughts that are the problem, so you don’t tackle those thoughts. It’s what they mean. And in particular if they mean something bad could happen and you’re responsible for either preventing it or you might be responsible for making it happen or whatever, that then motivates the compulsive behaviour.
But the problem is the compulsive behaviour then strengthens the feeling that you’re responsible. It also increases the likelihood that you’ll have more intrusive thoughts and round it goes in vicious circles.
Much of what we see in cognitive behavior therapy are vicious circles. And that’s because in cognitive behavior therapy we’re not working with what causes problems because the reality is, we don’t know what causes mental health problems. And it’s really quite astonishing. We know a few things that make it more likely, but we can’t say, “That’s the cause,” or whatever.
So what we work with is why it is that these problems are so severe. Because everybody gets anxious, but for some people it’s more severe, and then why are they so persistent.
Lucy: And trying to minimise those or change the things that are keeping things going.
Paul: Well yes, in OCD one of the things that people experience are ghastly thoughts which are torturing to them and so they try not to think them. But the process of trying not to think them, then actually makes you think it more. The famous, try not to think of polar bears, then you think of polar bears kind of thing.
Most of the things we’re seeing in OCD, and actually all other mental health problems, are people doing really sensible things – if you’ve got an unpleasant thought, try not to think it – which are actually counterproductive.
That’s kind of good news because what it says is that at least some of what’s going on is that people are trapped in a pattern where if people can fully understand that and then try it out, they might well be able to then get rid of the problem.
Lucy: I asked Paul about the evidence base.
Paul: The evidence base is very clear. In psychological therapy terms CBT is the only show in town. And on average about 50% of people with OCD will completely resolve their obsessional problems with appropriate length and intensity cognitive behaviour therapy.
About 70% of people will show very significant improvement which leaves about 30% of people who are not necessarily improving very much, for whom there are new developments like intensive treatments and so on. And so I think there’s some optimism around there.
Lucy: I asked Ashley how things have changed for him.
Ashley: I’ve come a long way since then. I can use a public toilet; I can use my own toilet without having to shower multiple times. I do a lot of cycling and occasionally you have to use toilets, the backs of trees, where there’s no sink to wash my hands and it doesn’t bother me and I can do that.
Yeah, I think good therapy can make the world of difference and it’s certainly helped me make the progress that I’ve made.
I certainly am not completely recovered. I’ve got a little bit of work to do still but certainly there’s certain areas of my OCD that I believe in the ‘C’ word, which is frowned up, ‘cured’. I feel confident in saying I’ve cured certain aspects of my OCD. There’s one area that I’ve not yet tackled and I’ve just actually referred myself back into therapy to tackle that last part of my OCD.
Lucy: Fantastic. It sounds like you’re in such a different situation now to how you describe things being before.
Ashley: Yeah, I mean it’s just little things, we shook hands before when we met and all I’d be thinking at one time is, what has that person touched? Have they just been to the toilet? Did they wash their hands? Did they just pat that dog? Did they just pick something up off the floor? So an innocent gesture of shaking hands, there’d be a million thoughts going through my head.
I believe that recovery isn’t necessarily the absence of intrusive thoughts or anxiety. I think recovery is the ability to continue with your day, with your activities regardless of intrusive thoughts or anxiety.
Lucy: I asked both Paul and Ashley what they would want to say to anyone experiencing OCD and considering having CBT.
Paul: The advice is absolutely clear. If you think you’ve got OCD then go and see your GP. If you’re lucky enough to be in one of the areas where the improving access to psychological therapies services allows self-referral, you can self-refer.
The other thing is, to start to talk to the people, to your loved ones, the people around you, because this thing about OCD being a secret and all this is important. And people often feel that families won’t understand.
My experience is when it’s opened up, that people actually do recognise and are more likely to help and support you. And it can be helpful in CBT, for example, to involve family members. OCD is a horrible stealer of lives; it really does destroy people’s lives. And I think it’s a real mistake to suffer in silence, to not seek help because it can and is helped a great deal by appropriate treatment.
But also that that’s very hard work. I’m not suggesting that it’s a magic wand that’s waved. It’s well worthwhile, but in a sense one of the things I say to people when we’re starting treatment is this shouldn’t be a hobby, this should be a job. If we’re working intensively, say let’s just do two weeks of beating the OCD and nothing else and that’s what you do. That’s going to be really, really hard work but not getting better is harder work. So difficult, but do it.
Ashley: It is scary, but if you’re ready for it, if you’re prepared for it, it’s not as scary as you expect. But also I sometimes use the analogy; it’s a bit like learning to drive as well. Sometimes people pass the test the first time, but other people need two or even three courses, or more of lessons to pass the test. It’s the same with therapy sometimes. You might need more courses, perhaps with a different instructor, different therapist who might be teaching the same principles but in a very different way of working.
Equally as well, there’s the saying, you only learn to drive after you past your test and I think it’s the same with CBT. As patients sometimes we only really learn the CBT after the end of our therapy when we learn to put it into practice on an everyday basis.
Lucy: And are there other things, apart from CBT, that you found helpful in your recovery process?
Ashley: Yeah, I think understanding the condition is so important. OCD is one of those things where knowledge is power and probably the only other thing to add, or I do want to say is that recovery is possible. We can get better from OCD.
Lucy: That’s all for this episode. There’s loads of information in the show notes. There’s books, there’s web links, including links to the BABCP resources on personal stories of people who have had CBT for OCD and also other podcast episodes.
So if you enjoyed this podcast episode, you might want to listen to the very first episode we ever made, which includes two people talking about their experiences of CBT for OCD. Or you might want to listen to episodes on different sorts of problems that CBT can help with, for example, hoarding disorder.
We’ve also got new episodes coming up about how CBT can help with chronic fatigue syndrome and with post-traumatic stress disorder.
This podcast is brought to you by the British Association for Behavioural and Cognitive Psychotherapies, or BABCP. For more information about how to find an accredited therapist, check out babcp.com.
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Maggie's flat was so full that the council threatened to clear it out themselves. CBT helped her understand the reasons behind her hoarding disorder and start to let go of some of her possessions.
Maggie and Dr Victoria Bream speak to Dr Lucy Maddox.
Show Notes and Transcript
Podcast episode produced by Dr Lucy Maddox for BABCP
Want to know more? Some useful resources are included here.
Websites
For more about BABCP check out: babcp.com
To find an accredited therapist: http://cbtregisteruk.com
Hoarding UK's website has resources including support group listings: https://hoardinguk.org/
Centre for Anxiety Disorders and Trauma website:
https://www.kcl.ac.uk/ioppn/depts/psychology/research/researchgroupings/cadat
Books
Overcoming Hoarding by by Satwant Singh (Author), Margaret Hooper (Author), Colin Jones (Author)
https://www.amazon.co.uk/Overcoming-Hoarding-Self-Help-Behavioural-Techniques/dp/1472120051
Transcript
Lucy: Hello, and welcome to Let's Talk about CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT. What it is, what it's not and how it can be useful.
In this episode, we're going to find out about hoarding disorder. I speak to someone who has experienced hoarding and the treatment for it and a clinical psychologist who specialises in CBT for hoarding disorder.
Maggie: My name's Maggie and I've been fortunate to have received therapy in a group and individual therapy. So, I would like to be able to share some of my experience that I hope will be of help to people.
Lucy: Could you say a little bit about how things were for you before therapy?
Maggie: Hoarding is how I coped with life because it kept people out and it kept me in, where I didn't have to deal with the outside world. Being alone has always been my comfort zone.
Lucy: So, it kind of kept you from having...
Maggie: Kept things at bay. I saw the outside world and people as the ‘other’. The enemy. That's what I've had to deal with. There was a lot of pressure from the borough where I live with the fire risk that hoarding causes.
Lucy: So, you were quite unsure about it to start with?
Maggie: I wasn't happy because I was being challenged and I felt threatened. I had a way of life that suited me.
Lucy: Is it okay to ask what your house was like?
Maggie: It's a council flat that I've had for 18 years, now. It just built up and up. I just didn't try and stop it. I have always seen books as my best friend. I always felt books would be the solution to my problems.
When I retired 13 years ago, I was able to indulge in a lifestyle that I'd always wanted, where I'd just ride around on buses and read what books I want. Go deep into things and study what my hobbies are.
Lucy: It sounds quite nice, actually.
Maggie: Well, it is. It's a selfish life. But family life didn't mean happiness to me and relationships didn't spell happiness. My comfort zone was living life vicariously. Learning about life and people through biographies, books, magazines, rather than going straight in to the physical reality. Which suited me.
Lucy: I'm sure a lot of people can recognise that. There's something very nice about that, isn't there? But it sounds like it was really getting in the way.
Maggie: Well, it doesn't give you deep, ultimate satisfaction. You're always on guard, in a way. When I first started individual therapy, it seemed very threatening. But it isn't threatening, now. It's almost like I can feel creative more instead of not moving beyond that defensive position.
Lucy: We'll hear more about Maggie and her reasons for hoarding later. But first, here's Dr Victoria Bream, clinical psychologist at the Centre for Anxiety Disorders and Trauma and the Maudsley hospital.
Victoria: Hoarding is characterised by a large volume of possessions in the home. Things can sometimes be somewhat organised but generally are in disarray. It can be a mixture of items, often paper, books. Also, food, clothes, bric-a-brac. Things inherited from other people.
All these items are of such a volume that someone's home is difficult for them to use in the way for which the home was designed. So, the bathroom... The bath may be full of clothes. In the kitchen, there might be books all over the worktops. We'd characterise it as hoarding disorder when someone's life is actually impaired and they're experiencing a certain amount of distress from this.
I think everybody has the capacity to form a strong attachment to any item. People with hoarding difficulties, for various reasons – some of which we understand and some of which I think we don't – form that level of attachment to a greater number of objects.
Lucy: Has it made you think about your relationship with possessions differently, doing this work?
Victoria: Oh, constantly. I think that might be one of the things that draws me to it. I really get it, with understanding how possessions can mean so much. My home is far from immaculate and I hang on to all sorts of things for sentimental reasons.
If my children give me a picture that says, "I love you Mummy" on it, in that one second they give it to me, I feel very attached to it. I can't let it go. There's no way I could rip it up and put it in the bin.
I think it's made me think about how we're all kind of battling with these beliefs about possessions. What is it that then tips it over into being something where it becomes a problem that takes on a life of its own.
Lucy: What's CBT for hoarding disorder like? What does it look like?
Victoria: At the moment, the main work we do is based on the work of Gail Steketee and Randy Frost and colleagues in the States. They've been working on things in the last 20, 30 years or so to come up with a CBT model.
They have identified the main beliefs that people have about possessions. So, having an emotional attachment to possessions. Seeing the utility of an object far more so than other people might. So, everything would have a purpose. A yoghurt pot, once the yoghurt has gone, isn't just a container. It could be a plant pot. Also, the intrinsic beauty and aesthetic properties of objects. These things seem to be particularly potent belief systems in people with hoarding problems.
The Steketee and Frost model also acknowledges the influence of past experiences, early experiences, whether there's a familial history of hoarding problems, whether people have experienced a trauma or other kind of life event that might precipitate hoarding in some way.
Also, there's a component of information processing differences. So, that's much more tricky to investigate. There are a couple of papers that do look into that but there's a lot more we need to learn about the way that people handle information and how it affects their ability to order the items they do have, make decisions about the things that they do have in terms of discarding, and then how to carry that plan out.
Lucy: That's really interesting. If I were sitting working at a desk that's really cluttered, say for example... (Laughter) I'm thinking of my desk, which is quite cluttered! That could have an impact on how our attention is?
Victoria: When we're working with people trying to make decisions in their home, sometimes just the volume of stuff around them makes the decision process difficult. Peoples' attentions flip from object to object.
We quite often get people to bring bags of things to the office and say, "You can take it all back home again if you want. But let's try and sort through it while we're here." People are usually quite effective at doing that. Not everybody. But we get people to stick things in the recycling and the bin or take them straight to a charity shop.
Lucy: You mentioned about early experiences sometimes having an effect or an impact, or perhaps it being more likely for someone to have a hoarding disorder. Could you say a tiny bit more about that?
Victoria: Yeah. What's in the literature so far is that, if people have had some family history of hoarding, that might be associated with hoarding themselves. They've just grown up not knowing another way of doing things but to have a lot of clutter. And then often inherit those items into their own home, as well. So, have two houses' worth of stuff in one go.
Sometimes if people have come from very impoverished backgrounds where they haven't had enough when they were growing up, then when they have had the means to buy things and acquire things, it's felt very loaded to keep those items. It would be extremely wasteful to get rid of everything. Then it's working with people to update those beliefs and think, "Is that a helpful idea to have around at the moment?"
Lucy: So, how did Maggie find CBT?
Maggie: We looked at why I was doing this. First of all, the big change for me was being unconditionally accepted because I'd never had that from my parents. It was an emotionally cold upbringing, like some people have.
I think the common element in hoarding is some sort of, I feel, very primal trauma. Where you're not given unconditional love and acceptance, for whatever specific reason. I think that is the basic that you have to feel because every baby really does need unconditional acceptance, otherwise it won't feel love. It's about replacing fear with love. It sounds simple but it's not easy.
Lucy: No. I was going to say, how does that happen? What would I have seen if I was in your therapy sessions? What kinds of things did you do or talk about?
Maggie: Well, we reviewed the week and set an agenda through how things had developed. And looked at what I had or hadn't done. I found it particularly helpful because it helped to ground me. Because I tend to be a bit above it all and beyond it all. I've had to look at those issues. To look at why I don't really want to be here.
I think you have to face your fears realistically and see what can be done about them. I think the only way to deal with them is to deal with things in small amounts. Take a few steps at a time.
Lucy: As part of the therapy, did you have to throw things away? Was that part of it?
Maggie: Yes. Discarding. Which I did resist. I still haven't got rid of all my books and I think, "Yes, I must read this. I must read that." It's working to a system of priorities.
It's quite surprising that things don't always have the effect you think they will. You don't know, until you've done it, whether you've done the right thing or not. I found it quite easy to discard clothes. As I got rid of a lot of books, I found I didn't really miss them.
My clutter was really quite bad. It was all mixed up with clothes, books and food. I've just gradually and slowly had to learn to separate different classes of items. Paperwork... I don't like dealing with paperwork. If you don't get the mundane sorted out so it doesn't support you then that's going to make things even worse. Because you spend so many hours looking for things.
Lucy: Is that what you found was going on before?
Maggie: Yes. Very much. I was being hounded by my housing officer, as well.
Lucy: So, discarding is one of the things that you worked on in the individual work. Were there thoughts that you talked about, as well?
Maggie: Learning to come into... I keep saying, "The outside world" because that is the biggie, with me. That's the bottom line, for me. I belong to several social groups for retired people and I've joined a committee there that I would never have done a year or so ago.
And, for the first time ever, I feel that I would like to help other people. That is a new one, for me. Because I never saw outside myself. Gradually, with the very good therapy I got, I realised that people are more important than books.
Lucy: Victoria told me a bit more about CBT for hoarding.
Victoria: It's often tempting to think that people need a practical solution to the problem. That someone like a support worker will come in and just say, "Right, where do we start?" For a lot of people, it's about unravelling quite a lot of distress and upset. Only then can you actually approach making some decisions to discard the items.
Lucy: I guess because people might just then fill up again with other items?
Victoria: Yes. I think, anecdotally, that's what... I work with the local councils around here. They've all said that they've done that. They call them, "Blitz cleans". They go in. They take everything out. Chuck it all in a skip. Scrub everything. The person whose home it is, if they haven't consented to that, is obviously really upset and unlikely to engage with services in the future, and reaccumulates possessions.
We advise the councils around here to try and encourage a very understanding and psychologically minded attitude towards hoarding problems. As well as going through possessions with people and thinking about, "Do I really need it? Or do I want it?" Trying to get the distinction between the need and the want. This can be really tricky. So, trying to disentangle that very strong emotional attachment to a lot of things.
Also, spending lots of time talking about whether the possessions do actually fulfil the function that people hope that they do. Objects connecting people to their pasts. Do the objects actually do that? Or do they hold someone back from getting on with their life and actually make them feel miserable, sad and less able to take new opportunities?
Lucy: As well as individual cognitive behavioural therapy, Victoria is involved in a really exciting project set up by the local fire brigade, who were worried about local residents who were hoarding and wanted to help.
Victoria holds group sessions at the local fire station using CBT principles. 60 people have attended over the last year. There's often about 15 people in the group.
Victoria: It's been amazing to see the actual support nature of the group. The magic that's worked between the participants of... Someone admitted a couple of weeks ago that they'd blocked their front door. This was a very well-presented person who you wouldn't imagine would be in those circumstances. The other people in the group were so moved that he could say that.
It then made other people sort of say, "Well, actually I've got to the point now where I can't use my bath." This kind of thing. Acknowledging the extent of the difficulty. Just being part of that process of people moving towards thinking, "Well, I'm going to have to face up to this problem."
And describing the possessions that they're keeping to each other in the group. Saying, "Well, can't you give them away?" She was like, "Oh, no. They're too rubbish to give away." The penny dropping then about, "Oh, I can't give them away. And why am I keeping something rubbish for myself?"
Trying to facilitate that group so that people then go home and take action off the back of these insights. Then, when they come back to the group maybe next week or a few weeks later, people take great pleasure in reporting back and saying, "Actually, I did manage to do this."
Lucy: Maggie has attended the group.
Maggie: It's fun.
Lucy: It's fun? Really?
Maggie: I had such a laugh at the last session. It was like, "Carry On Hoarding". (Laughter)
Lucy: It sounds like it's really supportive and light-hearted, in some ways.
Maggie: Yeah. Because I do think you need a sense of humour. If you can laugh at yourself a bit, it puts things more in perspective. There is hope out there.
Lucy: What would you say, if someone is listening to this and they think they might have a bit of a difficulty with hanging on to things for too long or if they're experiencing—like you did—somebody telling them that they need to work on that? What sort of advice would you give?
Maggie: I would say don't listen to people who don't understand what you're going through. It seems to be that one of the problems is other people find it incomprehensible. They don't understand. I think it's a silent neurosis. It's anti-social but it's hidden.
It's very good to meet people who think similarly because there's an instant, unconditional acceptance. You've got the group support. People will listen to you and they will give you advice that will help you because they're in a similar position.
It has changed, albeit slowly. Sometimes it's two steps forward, one step back. What I've learned is that I have to be compassionate to myself and realise it will take time.
Lucy: I asked Victoria about the evidence base for CBT for hoarding.
Victoria: Well, it's still the only treatment, really, that's recommended for hoarding problems. The way I always try and explain it when I'm talking to people in the wider public is... In the Centre for Anxieties and Trauma here, if someone came in with a phobia, a panic problem, OCD or PTSD, we'd be pretty confident at the beginning that someone would walk away with quite significant change in their distress and their symptoms. And, with any luck, actually losing the diagnosis entirely or certainly to be well along the road to that. Whereas with hoarding problems, we're definitely not in that position.
Even the really wonderful studies that have taken place – Gail Steketee, Randy Frost and colleagues – are still looking at 50-70% of people reporting some improvement. But not radical improvement either, necessarily.
Studies are coming out a lot at the moment, since the reclassification as a separate disorder. I think there's going to be some nice updates to the literature continuing in the next year or two.
Lucy: It's a field that's still quite exciting, actually, isn't it? It's quite emerging and ongoing.
Victoria: Yeah. And that is what I would say to anybody who has got an interest in hoarding. It's still something that a lot of services don't offer treatment for. It is in the DSM, now, as a separate disorder. It does cause people a lot of distress and upset. It perpetuates all sorts of other problems.
We know from epidemiological data that people with hoarding problems are more likely to have a physical problem, like heart condition or diabetes. So, there's this big public health disaster, in a way, associated with hoarding problems. But it's still a problem that everybody is preferring not to talk about.
What I think we don't understand at the moment is what's normal behaviour. What do most people do, in terms of keeping possessions? How do people decide how to have a clear-out and how do they do it? I'm hoping, if we could shed some light on those processes amongst people who don't have a problem with an accumulation of possessions, it might help us to further understand what happens when people do have difficulties discarding.
Lucy: Are you doing research into that at the moment?
Victoria: We're just working out a research question on that at the moment, which we think would be quite an interesting and a fun one to do. In terms of just being able to get it out there in the general population and say, "Well, how do you do it?" Like you say, it is sort of in the public eye at the moment. How we cope with our possessions.
What we know is that, even within people who acquire a lot of things and who enjoy shopping, not all of them keep all those possessions. So, quite a big percentage of people who acquire a lot will then take those items back, sell them on or give them away or whatever.
Whereas we know for hoarding... And it's a distinct thing. Also, people aren't always buying things, they're picking stuff up from the street. Picking stuff up out of bins. They are very good at knowing where free things are and accumulating things in that way.
Lucy: I spoke to Maggie about how she thinks hoarding and decluttering is talked about in the media.
Maggie: What I've noticed on television programmes, probably for entertainment purposes, is they tend to choose people with a fair amount of space. Probably because it's not so boring watching it. I don't know. It's the same with their financial problem programmes. They'll always have people who are on a middle-class income. "How to cut down."
But they never deal with the grass-roots people on benefits or people in small places who are finding it difficult to cope. So, I feel those of us who come from that sort of background have a less visible impact.
Lucy: And actually, it's really important, isn't it? There should be more about that. Thank you so much.
Maggie: Good luck, everybody.
Lucy: That's great. Is there anything else you'd want to say to people?
Maggie: Just don't be afraid to ask for help. Because there is hope out there.
Lucy: If you'd like more information on CBT for hoarding, have a look at the show notes. For more on CBT in general, and for our register of accredited therapists, check out BABCP.com. And have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with.
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