HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT DEPRESSION
Depression can often be brought on by life stress, or by a sudden loss, such as relationship breakdown or the loss of a job. It is characterised by low mood, pessimistic thoughts, hopelessness, poor sleep and the thought that life is not worth living. People with depression are often also anxious; they can feel restless and irritable, worried that they have too much to do but unable to settle to any task. They may also feel so low and unable to do anything that they stay in bed and stop doing even the smallest tasks.
Research has shown that depressed people suffer from negative and pessimistic thoughts. They often feel that they are bad or worthless, that their situation is hopeless and that the future will be worse. This can make it difficult to tackle any task because one feels that one will not be successful. For example, many sufferers will not open their post or will put off the simples household chores. At the same time, sufferers feel too low and pessimistic to enjoy themselves.
As in all CBT, therapy begins with a Formulation, which is developed in collaboration between patient and therapist. The formulation helps both patient and therapist to understand what has caused the depression and what is maintaining it.
One part of Cognitive-Behavioural Therapy can involve Behavioural Activation, which involves helping the depressed person to begin a programme of more positive activities. Initially, the therapist may ask the sufferer to keep an Activity Schedule, to see what activities are most helpful in raising their mood. Exercise, even very moderate exercise can be very helpful, and activity also helps the sufferer to feel that he or she is achieving something.
Therapists will often ask patients to keep records of their thoughts, especially those thoughts that seem to trigger changes in mood. Thought Records are used to understand what negative thoughts are important in maintaining the depression, and therapy can help patients to take a fresh look at these thoughts.
Depression can begin to lift after a few sessions of CBT. As the client’s mood improves, patient and therapist can look at long-term factors that might cause depression to recur as well as client strengths and ways of preventing relapse.
HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT ANXIETY
Anxiety is one of the most common features of modern life. Anxiety can be normal, and even helpful, encouraging us to take sensible precautions against dangers and to avoid unnecessary risks. However when it is excessive it can be very unhelpful: we may lose sleep through worry, avoid people and situations unnecessarily, and lead to embarrassment and shame. When it is very excessive, it can dominate our lives.
Anxiety can manifest itself in feelings (dry mouth, pounding heart, butterflies in the stomach), thoughts (worries, images of danger and harm) and actions (unnecessary checking, avoiding things that are not dangerous). When someone avoids a great deal, we speak of a phobia. Some phobia sufferers may not feel very anxious, but that may be due to the fact that they avoid anything that might make them anxious, causing them to lead a very restricted life. Social phobia is one of the most common phobias; people with this phobia are excessively shy and self-conscious and terribly worried about how they appear to others. Health anxiety is also common; here the sufferer might fear he has some terrible disease, in spite of medical tests that show the contrary.
As in all CBT, therapy begins with a Formulation, which is developed in collaboration between patient and therapist. The formulation helps both patient and therapist to understand what has caused the anxiety and what is maintaining it. The thoughts of sufferers are almost always of threat and danger; usually this idea of danger is greatly exaggerated, and CBT has techniques to help anxiety suffers see these dangers in a more realistic way. Often these thoughts are fed by the actions people take to make themselves feel safer. We use the term Safety Behaviours to describe these actions. Guided by the formulation, client and therapist work to modify these thoughts and actions, and sometimes anxieties can disappear in a matter of weeks.
HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT PHOBIAS
A phobia is an excessive fear; sometimes it is focussed on an object like spiders, or situation, like going to the dentist; sometimes, as in social phobia, it involves a fear of social situations, and sometimes people with a phobia will also suffer from panic attacks. Having a phobia can be very embarrassing, and many sufferers will go to great lengths to conceal their phobia from others.
As with all forms of CBT, therapist and client will first create a Formulation. It will explore the history of the problem, but also look at factors in the present that maintain it. Often thoughts of threat and danger are key. People with phobias often have a vivid image of the danger that they fear, and far less fear of many other things that are more dangerous. Fear of flying is a good example; driving is much more dangerous than flying, but fear of flying is much more common. Actions are often the key factor maintaining a phobia. Many people with phobias engage in Safety Behaviours; these are actions that make them feel safer, without actually being safer. Exploring these thoughts, actions and images helps to understand the phobia. Therapy will often the proceed with Behavioural Experiments, in which the client, either with the therapist of by himself, is able to learn more about how dangerous the thing he fears actually is. These behavioural experiments will be carefully devised by client and therapist, working in collaboration, to make sure that the client can do them, and that the client will learn important new information from them. Many phobic clients are amazed at how quickly they can make progress thought CBT.
HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT SOCIAL PHOBIA
Social phobia refers to an excessive anxiety about social situations. Someone with social phobia might be afraid of blushing or stammering in conversation, and believe that if he does these things, others will judge him harshly, or he may believe that he seems boring or unattractive to others. Sufferers often describe a vivid image of themselves as seen by others, with all their faults exaggerated. A sufferer might employ Safety Behaviours; for example, someone with fear of sweating might always wear loose, cool clothing, or a person who fears to be thought boring might always say as little as possible. CBT techniques can help the sufferer to evaluate her thoughts more realistically, and Behavioural Experiments can help her to form a more realistic view of how others might judge her.
HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT PANIC ATTACKS
Panic attacks are sudden, intense periods of anxiety. The sufferer will suddenly feel very anxious and may fear that he is about to have a heart attack, go mad, or do something very embarrassing in public. He will often also leave the situation where the attack happens and may avoid it in future. These frightening thoughts, along with actions intended to protect the sufferer from harm (often called Safety Behaviours) can increase anxiety and make attacks more common. They can also lead to a very restricted lifestyle, as the sufferer avoids public places, public transport, supermarket queues and other places from which escape might be difficult. If such avoidance becomes extreme, it may be referred to as agoraphobia (the fear of public places). CBT has well-developed techniques for treating panic disorder. Patient and therapist will together develop a Formulation, or model, showing why the attacks happen and what effect they have. The patient’s thoughts are explored using a Thought Record, and Behavioural Experiments can be devised to help the patient think about her panics in a new way. When treatment is successful panic attacks can be reduced or eliminated in a very short time.
HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT TRAUMA
The experience of a trauma can have a variety of effects. One term that is used for some of the effects that are often seen is Post-Traumatic Stress Disorder. Someone who had been in a car accident, for example might experience recurring frightening images of the experience of the accident (referred to as flashbacks). She might also avoid travelling by car or show other safety behaviours, for example driving more slowly or not driving at night, and she might also have unhelpful thoughts, for example feeling guilty about some aspect of the accident that wasn’t her fault. Such experiences might make her feel that she is going mad or that she is likely to lose control. CBT techniques can be directed at all these different symptoms, and can often produce a real improvement in a relatively small number of sessions. Traumatic events in childhood can also create a variety of symptoms, including ones similar to those described above; someone who was often beaten as a child might experience flashbacks of those beatings, but he might also suffer with depression and low self-esteem. CBT techniques exist for addressing these different problems.
HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT LOW SELF-ESTEEM
Self-esteem refers to how good we feel about ourselves. Most people feel that they do reasonably well most of the time, though self-esteem can fall with a mistake or failure in some particular area. However, some people suffer with low self-esteem, the feeling that they are of lesser worth than others. They tend to focus on their failures and weaknesses, and if they succeed at something, they find reasons to think that their success is not very important. People with low self-esteem have often had difficult childhoods and sometimes suffered trauma; they are at risk for depression, though low self-esteem can also affect them when they are not depressed. CBT has developed techniques to help those with low self-esteem hold a more balances view of themselves. The process starts with a Formulation, a model that patient and therapist design together that explains how low self-esteem started and why it persists. Self-critical thoughts are explored using a Thought Record, and Behavioural Experiments carried out to see if acting in a different way can have an effect on self-esteem. At the end of therapy a long-term plan is devised to help the sufferer continue to do those things that boost her self-esteem.
WORK STRESS: HOW COGNITIVE-BEHAVIOURAL THERAPY CAN HELP
Most of us spend a great deal of time at work: work can be a great source of satisfaction, but it can also lead to worry, anxiety and even depression. Sometimes this can be because work is going badly, but change and pressure seems to characterise most work places today. However, it can also be due to a person’s own style of coping, which may not suit her work situation. CBT can look at cases of work stress, putting both work factors and individual coping style into a model or Formulation that explains the source of stress. Patient and therapist, working together, can develop new strategies, exploring thoughts about work and possibly unhelpful actions that are making stress worse. Stress can never be eliminated, but the goal of CBT would be to make it more manageable on an ongoing basis.
HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT HEALTH ANXIETY
It is a paradox that, although modern medicine has made huge improvements, people are more worried than ever about their health. This is especially true among those who suffer from health anxiety. This involves a strong belief that one is suffering from a serious illness. The sufferer is troubled by thoughts of what might happen and images of disability or death. Safety Behaviours are common, especially in the form of monitoring of possible symptoms, and this monitoring usually makes the sufferer feel worse. Someone who fears a heart condition might check his pulse and avoid exercise, while someone who fears cancer might study every mole or discolouration on her skin, for fear it might be malignant. CBT therapy begins with developing a model, or Formulation, so show where these fears might come from, and also an alternative model, which shows how such fears can be a product of anxiety rather than of physical illness. A Thought Record may be used to help the patient look at reasons why he might think he is ill, and Behavioural Experiments are used to see if different actions can reduce or control health anxiety.
HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT EXCESSIVE WORRY
Everyone worries, but some people worry to excess, so that worrying interferes with their lives. This can result in physical symptoms like muscle tension and insomnia, and can also lead to reduced pleasure in life. The term Generalised Anxiety Disorder is sometimes used for worry of this sort. CBT has well-established techniques for deal with such problems. Patient and therapist will develop a Formulation that looks at the role of worry in the patient’s life, including positive and negative thoughts about worry and helpful and unhelpful actions that result from worry. The goal is to teach the patient to worry in a productive, helpful way and avoid the negative effects of excessive worry.
HOW COGNITIVE-BEHAVIOURAL THERAPY CAN TREAT OBSESSIONS AND COMPULSIONS
Well-established research suggests that a large majority of people sometimes experience unwanted, intrusive thoughts. Most people are able to ignore such thoughts, but for some they can cause difficulties. In such a case we speak of obsessional thoughts or obsessions. A common thought is that the sufferer, either through carelessness or deliberately, might harm someone, perhaps someone he loves. People will generally find these thoughts distressing and, needless to say, in such cases the person is not actually going to harm anyone. Often the sufferer will fear such thoughts and try not to think about them, but this can often make things worse. He may try to do something to prevent the harm from happening. This might be something mental, such as repeating a certain phrase for a number of times, or some action, such as checking the gas taps repeatedly. We speak of these actions as compulsions; the problem with them is that they often prolong the sufferer’s distress. Someone might check their gas taps or front door numerous times or clean their kitchen surfaces many times a day with strong chemicals. Such actions can be thought of as Safety Behaviours; they don’t usually make harm any less likely, but they can cause real difficulties for the sufferer. In CBT treatment patient and therapist will first devise a Formulation and look at Maintenance Cycles, to see how the obsessional problem is maintained. Thoughts about harm and possible bad outcomes are carefully evaluated, to help the sufferer think about risks in a more realistic manner. Behavioural Experiments can then be devised to check and modify risk beliefs. Collaboration is used, so that the sufferer does not feel pressured to change but can modify her evaluation of both obsessions and compulsions at her own pace.