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How CBT works |
Everything seems to be cognitive therapy these days!
Asif, 30
Cognitive behavioural therapy (CBT) has developed enormously over the past thirty years. It has been adapted in a lot of different ways to address different problems, so there are a lot of different versions of it. This is good in fact, since it means that CBT is developing and improving all the time!
In order to explain CBT as it applies to anxiety, we are going to look at a number of key ideas. We have called them the ‘key principles’ of cognitive behavioural therapy for anxiety, since they are the bedrock of all the treatments that are outlined in this book.
In this chapter we will briefly describe the five key principles, and we will look at the first of these in detail. In the chapters that follow we will go through the remaining four.
How do you imagine therapy? Many people still imagine that therapy involves them lying down on a couch and saying whatever comes into their mind (possibly something to do with their childhood and feelings towards their parents). This is not cognitive behavioural therapy. You may have had some experience of psychotherapy where a warm, empathic therapist is silent, and just lets you talk about whatever you would like. This is not cognitive behavioural therapy either. In CBT, the therapy often takes place around a table (or on chairs with a low coffee table between you). The therapist explains something about the therapy, and asks you what problems you are having and what you would like to be different. What the therapist does, which is very different from earlier forms of therapy, is to structure what happens in the therapy sessions. Rather than just talking about whatever comes into your mind, you and the therapist will concentrate on the aspects that are most helpful and important for you. As therapies have developed, we have realized that structure is one of the most important things that make them helpful. Structure refers to how the therapy progresses from session to session – from beginning to end – and also what happens within each session.
You may be reading this book and using it to help yourself without a therapist or anyone else involved. Even so, following the same practice of structuring how you do the exercises will make a big difference to how well you do.
What this means is that therapy has a clear beginning, middle and end.
In the beginning stages, the aim is to understand your problems. This means learning about the role of thinking in your anxiety problems (see Chapter 2), and then looking at the ‘maintenance factors’ – the vicious cycles that keep anxiety going (see Chapter 3). The beginning sessions also involve thinking about what changes you’d like to make – the changes are often described as your ‘goals’.
Once you have set the scene for working with your problems, therapy moves on to the next stage – the middle sessions. The aim of these sessions is to think about what strategies will help you to start implementing these changes, and see how you get on.
The final sessions focus on how to keep those changes going even when therapy has ended, and on how to prevent problems returning.
The first session or two will have a slightly different structure. In these sessions, the structure is geared towards the following aims:
1. Getting a good grasp of the problem, including all the aspects that are problematic.
2. Starting to work out the ‘formulation’ – the map of the problems that fits them together and explains how/why they keep going.
3. Defining goals for therapy.
4. Working out the best way to monitor the problem and keep track of progress.
Following this introductory phase, each individual therapy session has a clear beginning, middle and end. Each session begins with making a plan (or ‘agenda’) for the session and reviewing progress since the last session. The middle part of the session involves discussion about the problem, sometimes adding to or changing the formulation, and deciding on how to take things forward. Sometimes the middle part of the session will involve the therapist doing ‘behavioural experiments’ with you (see p. 62). The last part of the session usually involves summarizing what has been discussed and clarifying what the ‘homework’ will be.
It is important to realize that the structure is flexible – hence we talk about it as being ‘semi structured’. If something important comes up, then it needs to be addressed, regardless of the original plan. Throughout therapy the basic structure is constantly adapted to fit what is important to you.
CBT is based on the principles outlined above, but it also has techniques – specific tasks and suggestions for how to tackle problems. Using the techniques and learning how to apply the principles are both important. Learning how to apply the principles means that there is a lot of flexibility in how therapy is conducted, which is good, since no two people are the same and no two CBT sessions are the same.
Normally when we talk about the ‘style’ of CBT we mean the techniques the therapist uses during the sessions. Even if you are using this book on your own, it is helpful to consider the style with which you want to conduct your sessions with yourself and how to proceed. ‘Firm but empathic’ is our favourite style. Some people might also describe this as ‘tough love’! You are not harsh or self-critical, but nor do you let yourself get away with things that you know in your heart you were really able to tackle or perhaps that you could tackle another day with some additional support. Self-criticism rarely helps. A recent development by Paul Gilbert, and many others, talks about trying to have compassion for yourself and your circumstances. We think this is a helpful attitude.
If you do have a supporter helping you overcome your problems with anxiety, your supporter should also be firm but empathic. Working together with your supporter should be a collaborative exercise – that is, together you can bring different expertise and experience to bear on your problem. Overcoming your difficulties is a joint venture between the two of you. Whether or not you have a supporter, the style of therapy reflects that you have a specific task ahead of you – understanding what is keeping your anxiety going and then making changes to reduce it. Keep your focus on the prize at all times. The prize is freedom from anxiety.
At the time that CBT was being developed there was a strong tradition in psychotherapy of open-ended therapy, sometimes going on for years. CBT, on the other hand, is time limited, and for most anxiety problems this means that it tends to last for somewhere between ten and twenty sessions. If the problem is mild, then it can sometimes take even fewer sessions – maybe only five or six. Therapy is also time limited in the sense that each therapy session lasts around fifty minutes.
Although the therapy itself is time limited, its effects last for much longer than the therapy itself. One of the advantages of CBT is that it gives you skills for life – it teaches you a new way of thinking and coping with your problems that you can use when times get tough. This is why the techniques are often called a ‘toolkit’. People tend to keep the benefits they make during CBT. This is not to say that there aren’t times when the anxiety does return, and some periods are certainly more stressful than others. It does mean, however, that people are able to spot when their anxiety is getting worse, bring out the CBT ‘toolkit’ they learned to use before, and then stop the anxiety from becoming as big a problem as it was previously.
The concept of ‘science’ in CBT is critical. Cognitive behavioural therapies are scientific in two ways. Firstly, a lot of research has been carried out on what makes us anxious, and why anxiety can be so persistent. These ideas have been tested in research studies, and the treatment has been tested with thoroughly scientific methods.
The second way in which CBT is scientific is that you have to learn to be a scientist yourself – you have to put on a white coat (though not literally!) and learn to examine the problem as objectively as possible. Although some people might laugh at the idea of themselves as scientists, you do need to learn to ask yourself: ‘What evidence do I have for my way of thinking? How can I gather evidence to assess the validity of this belief? How can I gather evidence to see if another belief might fit the situation better?’ Once you have the evidence, you then need to be able to assess it and decide whether there is a better explanation for that situation than your anxious one. Being able to be such a scientist will help your heart and head become allies in the fight against anxiety.
If you absolutely hate the idea of science, then think about it in another way: doing CBT is also a bit like being a lawyer. In a court of law the jury is asked to decide between two versions of events. So the lawyer’s job is to find the evidence that backs up their point of view, and persuade the jury that this is the truth. In a sense, tackling your anxiety is a bit like this – like the lawyer trying to gather evidence to show the jury the true situation; you are trying to gather evidence to establish the most accurate account of events.
Given the structure of CBT is so important, we will spend some time describing how to do this – whichever specific chapters you read, the principles of structure will be the same.
The self-help programmes described in Part 2 of this book are mostly designed to be completed over four to five months or about twenty sessions. You should see some changes in your anxiety after around six sessions of working through a specific chapter. However, if your anxiety shows no sign of improving after six sessions of using the chapter, then it would be sensible to think about what to do next. If you have a supporter who is not a professional helper, then you and they could think about whether it is time to seek professional help. It is important not to be discouraged if you think you’re not making progress. Self-help isn’t for everyone, and there are a lot of other options that your family doctor can discuss with you.
Many chapters in Part 2 contain information on how to keep track of your progress; measuring your progress weekly will help you gauge the extent to which your anxiety is improving.
Having decided which chapter in Part 2 seems most appropriate to how you are feeling, we would suggest that you plan to have sessions twice a week for the first three weeks. This may seem like a lot to ask, but it will help you to kick-start the process. Once your therapy plan is up and running, then once a week would be fine.
A ‘session’ should last around fifty minutes or so and is the time that you set aside to focus on the exercises in the book, go through what you have done since your last session and think about what to do next. If you have a supporter, it would be good to do the session with them, if you can. Sessions should be planned in advance, and kept like any other appointment, even though it may only be with yourself. It’s a good idea to find a quiet place where you will not be disturbed for an hour. If that sounds too difficult, then plan for shorter sessions. Use a notebook or laptop to help plan how you can use the book to help yourself, and to make notes as you go along. This is what happens in face-to-face therapy and the same principles apply when using this book.
If you have a supporter, then we usually say that it is not a good idea to start the self-help programme if either of you will be going on holiday soon, as breaks will interrupt the momentum of change. This is the same for you on your own – if necessary, it is better to delay starting to work through this book until your children are back at school, work is a bit easier, or your partner can help take care of some responsibilities, so that you can really commit yourself to change when you start.
Your first couple of sessions will have a slightly different structure to the remainder of the sessions, since they are aimed at helping you to get a good understanding of your problem, and to set goals, before starting to use the techniques and strategies described. We will describe the process of understanding your problems later in this book.
Many self-help books talk about goal setting and there is a useful acronym to consider: goals should be ‘SMART’ – Specific, Measurable, Achievable, Realistic and Time limited. This is to stop oneself setting unrealistic goals such as ‘I want to be the best at everything I do’. This is not an achievable goal for any therapy. In the same way, setting yourself the goal of ‘I never want to be anxious again’ is neither helpful nor realistic. We do know, however, that many people overcome their anxiety disorders after both face-to-face CBT, and following specific self-help programmes with or without the help of a therapist or a supporter. A reasonable goal to set yourself therefore might be:
By the end of twenty sessions of treatment/self-help, I want to have normal levels of anxiety and be able to get on with my life. That means I’ll be able to take the children to school, shop in the supermarket without feeling panicky, and go out with my husband without feeling anxious. I could also start to look for a part-time job.
This sort of goal is challenging but realistic if you work hard and focus on the task in hand. If you stick to the sessions you have planned, set yourself an agenda for each session, do the homework, and assess your progress every step of the way, you are likely to achieve your goal. You will know if you have achieved your goals by measuring your anxiety levels before and after completing the self-help programme.
Stefan’s goals
To start with, Stefan found it really hard to say what his goals were. In the ideal world, he would have liked to have somehow earned enough money to be able to go back to the Czech Republic and not to need to work away from home. He knew, however, that he needed a more realistic plan as well. After a while he was able to write down the following goals:
1. Regain confidence in the quality of my work – stop looking for and exaggerating tiny flaws in everything I do.
2. Stop assuming that no one will recommend me any more, and go back to actively asking people if they know anyone who needs work done.
3. Be able to sleep at night.
4. Be less tense and tired in the day.
5. Be more of a support to Magda.
You can either start each of the middle sessions with setting the agenda or with reviewing your progress so far – the order does not much matter as long as you do both. See the Appendix for an example of a session plan.
‘Agenda’ is a good word as it implies business – and CBT is about getting down to the task in hand, focusing on it, and achieving change.
When setting your agenda, there will be some regular items such as:
1. Reviewing progress (0–5 minutes) refers to whether your symptoms are getting better, and whether you are closer to your goals.
2. Reviewing homework (0–5 minutes) refers to looking at what therapy strategies and techniques you used in your homework, and whether these worked.
3. Moving forward (most of the session) is the point where you would use the book to get new information and think about the next stage of your self-help programme.
4. Homework (0–5 minutes) means setting yourself precise tasks to carry out before your next session, so that you know exactly how and when you will implement the strategies.
5. Summarizing (0–5 minutes) means making sure that you know what you are doing and why.
When reviewing your progress it is helpful if you can use clear measures of how you are doing. This will enable you to compare how you are now with how you were at the previous session, or when you started your therapy. Using questionnaires is one way of doing this – you can add up scores and compare them with your previous scores. Sometimes progress can be measured by looking at what you have been able to do, and comparing this with what you could do before your therapy started. Several of the specific chapters in Part 2 include questionnaires and forms that you can use to measure progress.
Reviewing the work you have done between sessions is important but it is likely that you will be critical of both your efforts and your achievements. We say this based on our experience of hundreds of people who suffer from anxiety who turn up to therapy having done fabulous work and then apologize for their efforts! While it is true that you can always do more, the point is not to do your homework perfectly, or necessarily to do huge amounts; the point is to do what you can between sessions to facilitate your learning and change the beliefs and behaviours that are keeping your anxiety going. Anything you can do towards this goal is a real achievement and if you can recognize it as such, it will help boost your confidence and self-esteem, and that in turn will motivate you to continue making changes. If you have done any homework that is consistent with your goal of changing, then please pat yourself on the back and acknowledge it.
When you are reviewing your homework, keep one thought uppermost in your mind: What did I learn from this? Did you learn anything about what is keeping your problem going? Did you learn anything about the validity of your thoughts and beliefs? Did you find out something new about yourself or how your emotions work? If you ask yourself these questions, even if the homework went badly, it can still be useful as a way of understanding things better.
The next questions to ask yourself are: How can I build on this? What do I have to think about next? What do I have to plan next? Make sure that the answers to these questions are put on your session notes either under the item to do with homework for this week, or else somewhere within your main agenda item.
Exactly what you cover here will differ according to the type of anxiety problem you have, what kind of person you are, and the stage of the self-help programme you are at. CBT is a bit like Lego – you need to build on good foundations and add new layers slowly and carefully. Moving forward could involve a test to see if an alternative new belief, which you might have learned in the previous session, applies in a different situation or under different circumstances. It may involve another attempt to change thinking patterns and view situations more objectively but in more challenging circumstances than before. It may be about doing something you have not done for a long time and that you know would improve the quality of your life if only you could do it. Whatever the specific item, it is about moving forward slowly but surely.
There are certain ways to approach homework that make it more likely that you will actually do it. Firstly, if possible, it is better to do it straight away while it is uppermost in your mind. Secondly, it is better to do it when you are feeling strong and fresh, rather than after a bad day when you feel tired, hungry and irritable. It can also be a good idea to ask someone to help you with it in case you get stuck. Lastly, it is generally a good idea not to do too much in any one go because you may end up feeling overwhelmed. Of course you may be good at making time to do homework, but in any case it is important to do a reasonable amount of work between sessions so that you can build on your learning in lots of different situations.
It is important to summarize what you have covered at the end of each session, to think about what you have learned and what you are going to do next so that you have clear in your mind what will be the focus of your work between this session and the next one.
Stefan’s agenda
Stefan found that he liked the idea of structuring his therapy in a focused way. After he’d worked out his problem and goals, his agenda for his next ‘session’ was as follows:
1. Review my progress. I’ve been using a measure called the Intolerance of Uncertainty scale. My score has come down a bit this week, so I think that just deciding to tackle the problem is starting to have an effect. I do feel a bit more hopeful.
2. Review homework. My homework was to look up information about anxiety and see if I could make sense of my thoughts and feelings. It was really helpful to find that my symptoms do all fit the GAD description – makes me feel less of an outcast.
3. Moving forward – OK, now I have to make a plan! I’m going to work on trying to stop picking faults with myself all the time – it just makes me feel worse.
The chapter on generalized anxiety disorder says that I’m worrying because I find uncertainty so difficult, and I can’t tell the difference between ‘real’ worries and ‘hypothetical’ worries. I think this is really helpful – a lot of what I’m worrying about is what I’m imagining could happen, but I can see that my imagination is really running away with me – these aren’t things that are happening now.
4. Homework
Every time I start worrying, I’m going to ask myself whether this is a real worry or a hypothetical one. I am then going to tackle the real one and NOT worry about the hypothetical one. I’ll write it down to help think about it, and talk to Magda too.
I’ve learned that I have generalized anxiety disorder, and that everything I am feeling is pretty understandable. I’ve read about worry, and the difference between real and hypothetical worry, and I’m going to work on this.
Next session: I’m going to have my next session in five days time when I’ve had a chance to notice whether this is making any difference or not.
• Try to help keep the person you are supporting on track but don’t be bossy.
• You are supporting them in their effort to make change, but you should not try to force change.
• If they feel a lot worse, again think about whether this might be to do with events in their lives, rather than being a ‘failure’ of therapy.
• Remember that starting to tackle problems can sometimes make people more anxious to start with, particularly if they have been avoiding thinking about the problem. Don’t be discouraged, and don’t let them become discouraged either.