Let's Talk About CBT – Détails, épisodes et analyse

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 podcasts@babcp.com.

Useful links:

For more on CBT the BABCP website is www.babcp.com

Accredited therapists can be found at www.cbtregisteruk.com

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

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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.

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.

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.  

END OF AUDIO 

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 lucy.maddox@babcp.com.  

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 

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 lucy.maddox@babcp.com. 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.  

END OF AUDIO 

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.  

END OF AUDIO 

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 lucy.maddox@babcp.com.  

END OF AUDIO 

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 

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 

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. 

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