What is digital CBT? How does therapy work over the internet? Can it ever be as good as face-to-face? Dr Lucy Maddox hears from Dr Graham Thew and Fiona McLauchlan-Hyde about an internet-based CBT programme for PTSD. Fiona shares her experience of how this therapist-supported programme helped her through traumatic grief, and also has some helpful advice for people trying to comfort those who are bereaved.

Show Notes and Transcript

Podcast episode produced by Dr Lucy Maddox for BABCP

BABCP website is at www.babcp.com

CBT Register of accredited CBT therapists is at https://www.cbtregisteruk.com

BPS Top tips for psychological sessions delivered by video call for adult patients

https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Top%20tips%20for%20psychological%20sessions%20by%20video%20%28adult%20patients%29.pdf

Resource from OCD-UK on getting the most out of online CBT

https://www.babcp.com/files/Therapists/Oxford-OCD-Making-the-Most-Out-of-Remote-Therapy-for-Patients-by-OCDUK.pdf

Graham's recent paper in the Cognitive Behavioural Therapist can be found on the podcast journal article page

https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/information/let-s-talk-about-cbt-podcast

Information from Cruse about traumatic grief

https://www.cruse.org.uk/get-help/traumatic-bereavement/traumatic-loss

The Good Grief Trust

https://www.thegoodgrieftrust.org

Image is by Cassie Boca on Unsplash

Transcript

Lucy: Before we get started, I want to remind you about the survey which I released at the beginning of August. I really would like to know more about who is listening to these podcasts and what you would like. The link to the survey is in the show notes and it takes about five minutes to complete. If you have time to fill it in I would be really grateful.

Hello, and welcome to Let's Talk About CBT, with me, Dr Lucy Maddox. This podcast is all about CBT, what it is, what it's not, and how it can be useful.

Today I am exploring digital CBT. I speak to a therapist who has been researching internet based CBT programmes that are supported by a therapist, and I speak to someone who has experienced this first hand.

The particular programme that we talk about is for PTSD, which we've heard about before in a previous episode. In this case PTSD was related to an experience of traumatic grief.

Fiona: I think I started last September and I finished just before lockdown, actually.

Lucy: Gosh, so in a way good timing.

Fiona: Yeah, it was great timing to finish just before lockdown. It put me in a good place I think, to be able to deal with what was going on, rather than if it had been six months earlier it would have been a very different experience I think.

Lucy: It took Fiona, who is based in Oxfordshire, a long time to find this type of therapy.

Fiona: It all started six and a half years ago, when my husband died of cancer.

Lucy: I'm so sorry.

Fiona: He was diagnosed in the June, and he died in the December, and it was really horrific. He was 49, I was 42 at the time. And so it was heartbreaking and I couldn't cope. I couldn't cope afterwards. We had a little girl, she was seven when he died. And my world was turned upside down.

And I got help at first. But then, as with all things, life goes on around you and everyone thinks you're fine. And I was still putting my lipstick on, so therefore everyone thought I was okay. And I felt I was getting worse and worse, and no one would believe me.

And it wasn't until I threw all of my toys out of the pram; after having therapy through my local GP – so this was last year, last summer – sitting in my car afterwards for about an hour just sobbing, because no one believed me that I was feeling as bad as I was.

And I asked to be put in touch with TalkingSpace. And they put me forward for a trial with Oxfordshire Mental Health, and it changed my life. It absolutely changed my life. Because I was drowning and no one believed me, it was awful.

Lucy: It sounds like such a dark time.

Fiona: It was a really dark time. And everyone just kept saying come on, you know, it's been so many years. And I was functioning, but I think it was last year… So I suffered from panic attacks; I suffered from panic attacks from before my husband died, and they got worse. They'd gone away for years and then they came back when he was diagnosed.

And last summer, around this time last year, I had such a severe panic attack, I was driving my daughter and she had to call an ambulance. And that was when I decided that come what may I needed help.

But it was still quite some time after that. I still had to go through about six weeks of people going, "Come on, you're fine. Take a pill." And I didn't want to take a pill. So yeah, I was lucky, eventually.

Lucy: It sounds like you had to be really tenacious to get access to the therapy?

Fiona: It was a real, real battle. And as much as I really liked my GP, and my GP was the person who was there when my husband was dying. So he knew what happened and how horrific it was. But in the end his last thing was, "No more therapy. You're lonely. You need to go out and find yourself another man." And that was when it just – that was when I sat in my car for an hour and a half and cried.

Because it wasn't that, I knew it wasn't that. I knew there was something really wrong, and that I really, really needed help. And TalkingSpace came in, and I had a huge amount of telephone conversations and meetings in person, just for them to try and work out which way to send me.

Lucy: Fiona was diagnosed with post traumatic stress disorder. Fiona's experience of losing her husband was deeply traumatic; not only the death but the lead up to it.

Fiona: I mean obviously it didn't just happen to me; a lot of us were affected by it. But it was a particularly brutal and nasty way to die.

And you see the other thing is I did most of the nursing when my husband was sick. I don't know how it happened like that, but it just did. So all of a sudden I became a nurse, which is not on my CV.

Lucy: Super, super hard. Yeah.

Fiona: And for us, Paul's death was so horrific. He had a lot of failed operations, there was a lot of emergency surgery, there was an awful lot of blood everywhere. There were ambulances called in the middle of the night. He didn't just have cancer and pass away, he suffered every day for those however many months it was.

And all of those things that we did automatically; like he had a feeding tube, because he had oesophageal cancer. So with me setting up the feeding tube every night, and flushing all of the feeding tubes out in the morning. And all of those things that you do automatically, because you're trying to keep your loved one alive, they hit you later.

So his death, apart from – it sounds terrible to say this – apart from his death being the trauma, his illness was a trauma too. Because I did everything I could, but I couldn't make him better. And this is part of my therapy, just my guilt at not being able to save him.

Lucy: The therapy that Fiona was referred to was a trial based at the Oxford Centre for Anxiety, Disorders and Trauma.

Graham: My name is Graham Thew. I am a clinical psychologist. And I do a job that's split between research and clinical work.

So my research work I do at the University of Oxford, at the Oxford Centre for Anxiety, Disorders and Trauma. And my clinical work I do at two different services that are part of the IAPT programme, the Improving Access to Psychological Therapies programme. So that's the Healthy Minds service in Buckinghamshire and the TalkingSpace Plus service in Oxfordshire. And both my research work and my clinical work all focus on digital treatment and digital therapies.

Lucy: Graham wasn't Fiona's therapist, but he's involved in the trial that she took part in. I asked him about what digital therapy is.

And when you say digital CBT, what do you mean?

Graham: Yeah, that's a great question, because I think terms like digital CBT can actually cover a range of different things.

So as we've just mentioned, we might be referring to webcam sessions; so video conference sessions that would perhaps cover the same content as a face-to-face therapy session. So you would still be able to see your therapist on webcam, and you both agree to meet at a specific time.

But digital CBT and other online treatments can be broader and look a little bit different to that as well. So for example there are some forms of CBT that still take place online with a therapist at a specific time, but instead of seeing them and talking to them via webcam, you'd actually be typing; you and the therapist would be typing to each other live, in real time.

Lucy: Like a kind of Messenger chat?

Graham: Exactly, like a sort of instant messaging chat.

And then another different category altogether is more of a sort of internet-based CBT programme. So that would be where there's a website or a programme that has a lot of the therapy content written, perhaps in the form of little treatment modules. So written texts, videos, that sort of thing. And you would therefore work through those in your own time, and perhaps have some support from the therapist every so often; maybe in the form of messaging or a phone call or something.

So it can be a bit confusing because terms like digital CBT can mean different things.

Lucy: Is your research looking at all of those types of digital CBT?

Graham: The work that I've done has mostly focused on the last category that I talked about; the forms where treatment is partly written down and put into an internet programme in a series of modules, but that there's support from a therapist. In the programmes that I've worked with most closely, the therapist would communicate with you by telephone, by messaging, and also occasionally via webcam as well.

Lucy: Fiona met her therapist at the start of treatment, but from then on she worked through online modules and she also had regular contact with weekly phone calls and messaging in between sessions.

Fiona: There were phone calls with the therapist, they were quite lengthy, but all of the way through it she would send me text messages, saying, "Don't forget to take a tea break." There was a lot of talk about tea. (Laughs) Or, "It's a beautiful sunny day Fiona, can you get outside for a bit?" Just little nudges, little reminders to take time.

I found it much easier to have a telephone call with her. I think it did help that I'd met her once, so I knew what she looked like. But there was a complete and utter trust and we got on, and I really, really liked her. And I liked the fact that she understood me straightaway. And it didn't bother me that it wasn't face-to-face.

And there was something that was really quite comforting about still being in my own home, and with my own surroundings, and with things that comforted me. And if I'd finished the modules, or I'd finished a conversation, and I was feeling low, then I was instantly able to do something.

I mean we had this one thing where I had this one particular piece of music that we actually played at my husband's funeral, but it's a northern soul track. And if I was feeling really low, I was told to put that on really loudly, which I did. I probably annoyed the neighbours, but anyway, it worked.

It just felt like someone had your back; that someone was just there who understood and was helping you along. It was sort of invisible support and it was fantastic.

Lucy: The content of the modules that Fiona was working through were developed to be as close to the content of the face-to-face therapy as possible. Graham explained.

Graham: I'm lucky to work with some very clever and creative people, who have been able to adapt certain treatment elements that we would do face-to-face, to think about how they could work online.

So the PTSD programme, again is really trying to faithfully replicate the same elements that would be done in face-to-face CBT treatment for PTSD. So the modules focus on a range of different topics. I guess beginning with some sort of information and explanation about what PTSD is, and why some of the difficulties that people might be experiencing are understandable, given what has happened.

And then the modules go on to help people start to think about the idea of reclaiming their life; trying to get back elements of their life that might have got a bit stuck, or have dropped off in terms of what they've been doing since the trauma.

And then as people progress through therapy, they would go on to actually working on the memory of the trauma itself. The idea being really trying to process what's happened, so that it can be put away in the past where it belongs, so that it doesn't keep popping back up and causing those difficult re-experiencing type difficulties.

Lucy: I asked Fiona what sorts of things she remembers from the modules.

Fiona: There was a lot about working on your triggers, which was great for me, although it was really hard to work out what the triggers were. So for instance one of my triggers was dark, rainy nights, because I associated that with driving back from the hospital. And wet leaves sent me into a… But then you don't think, "How can wet leaves possibly make me feel this terrible?" But it's true, it did.

And there are certain smells; the smell of copper coins reminded me of the smell of blood. Because my husband died of oesophageal cancer there was an awful lot of vomiting of blood. So things like that, that are in the back of your mind; you work on them to bring them forward and deal with them. It's hard. It's really hard. But when things start to make sense, you start to feel better. Or that's how it worked for me anyway.

Lucy: You said about being able to identify the triggers. What did you then do with that knowledge?

Fiona: If I just take you to an example of what happened for me, is that I was driving home from work; I picked my car up and I was doing my journey home, from getting off the bus from work. And it was a dark, rainy, winter's night, and I started to feel like I was going to have a panic attack. And I was on the dual carriageway, and there was not a lot I could do. And that's when we worked out that dark, wet, November nights, were a real trigger for me.

So what my therapist did was uploaded an image of a dark, wet street with wet leaves everywhere. And I then had to go and look at the image, concentrate on the image, until I could cope with it.

And the first time I looked at it, I fell apart. It was awful, it was the most awful feeling.

And then I'd keep going back to it. It was about taking yourself… You are no longer in that situation which I was in six and a half years ago. My daughter's at home, I'm doing this tomorrow, Paul's no longer suffering. So yeah, it was about the here and now, and not being in the past anymore. Not believing it was those same nights when my husband was dying.

Lucy: So some things that you could say to yourself that would remind you that you were safe now.

Fiona: Yes. A lot about being safe, and a lot of thinking that my husband was no longer suffering. That I was safe, my daughter was safe, he wasn't in pain.

Lucy: That sounds really important, yeah.

Fiona: I found it worked incredibly well for me, because I could keep going back to it. Or if I wanted time to think about something, I could stop, go and make a cup of tea, and let things in gradually, to try and work out why I was feeling the way I was.

So it was like 24/7 therapy, seven days a week. The modules were released for you, so you could never race ahead. My therapist released a module when she thought I was ready for that module.

There was a lot of work before we worked on the death of a loved one, which I was dreading. But it just meant that if it was 2:00 on a Sunday afternoon and I was feeling really, really low, I could go back in and go through something that I thought might help.

Lucy: And the module that you were dreading, the death of a loved one, what was that like when you got to it?

Fiona: It wasn't as tough as I was expecting, but that's kind of always the way, isn't it? The death of a loved one all made sense. And I think it was the right time that I did it, because I'd already started to feel better. So that's what was brilliant about it; it was all done at exactly the right time.

So there weren't any of them that weren't tough. I mean the toughest one of all was when I had to write my story. So you physically write your story, about what happened to you. And I had no trouble remembering the events and in which order they happened, but when you actually see it written in front of you, and you write it yourself; for me that was the breaking point, that was when things started to turn around. Because that's when I realised that I had been through something utterly horrific. And I was allowed to feel the way that I was, because anybody would do in that situation.

So it's almost like when I read my story, as hideous as it was, and as upsetting as it was, and I cried a lot when I wrote it. That was the point where I let myself off the hook a bit, for want of a better expression.

Lucy: Yeah, so you could kind of witness what had happened to you almost.

Fiona: Yes. Yeah, it's exactly that.

Lucy: The programme for PTSD that Fiona did, and another similar one for social anxiety, have shown promising results. I asked Graham to explain the evidence base for this sort of therapy.

Graham: Yeah, we have done a few studies so far, starting with some initial pilot studies, to test the programmes. And also some randomised control trials; so comparing them to other forms of treatment. And what's been really, really pleasing to see so far, is that the results that we've been getting are really encouraging. Really showing that people can make great improvements using this format of treatment, and actually can really overcome their difficulties.

So we're very excited about the potential for our programmes, and for this format of treatment in general. Because I think it really can change people's lives and make a real difference, in the same way that face-to-face therapies can.

One other thing to add perhaps is that another possible advantage of programmes that have some of the treatment content written down, is that they can be translated into other languages and shared around the world a little bit more easily.

So some of my work has been working with some teams in other countries to try and see how these treatments perform in a different culture to where they were originally developed. And I think the format there can be quite helpful in terms of translating and sending it to other countries and cultures who would like to use it, and feel that it could be helpful for them.

Lucy: Yeah, absolutely. And even different people in this country, who don't have English as a first language. That sounds really helpful, yeah.

Graham: Yeah, absolutely.

Lucy: In general, although some people sometimes worry about whether digital CBT will be as good as face-to-face, Graham thinks that the evidence is promising overall.

Graham: So it's quite an interesting one. I think there's a sense amongst many people, both members of the public, and therapists and researchers, that digital CBT and online treatments are quite a new development. But actually when you look at the literature, it's really quite extensive; these kinds of things have been being researched for over 20 years. There's now over 300 randomised control studies looking at the effectiveness of different internet-based programmes.

So there's actually a lot more evidence out there than people realise. There are a few things I guess that we can conclude from the evidence so far. Obviously it's a very rapidly growing area, and lots of people are doing more studies all of the time. But generally it seems that online treatments, when they're compared – they're most usually compared to people on a waiting list, or a group that aren't receiving any treatment at the moment. And so generally those studies will find that actually an online treatment is much better in terms of your clinical outcomes, compared to waiting or doing nothing.

Treatments that have support from a therapist generally do a little bit better than ones that are unguided; that don't have that therapist support.

Studies have generally done follow-up, usually up to one year, or the longest I think I've seen is up to five years after treatment. Those studies all generally seem to find that the gains that people have made during the treatment have been maintained over that time. So that's really encouraging.

Lucy: One limit to the evidence base is that there are not as many studies comparing digital to face-to-face treatment.

Graham: Generally what those studies have found is where the digital treatments have support from a therapist and have been compared to a face-to-face treatment, the outcomes are similar. It's really exciting I think to know that actually the outcomes might be similar; it could be just as helpful for you doing your treatment online as it is face-to-face.

There is need for more studies doing that direct comparison, because they're not quite as common as other forms of research in this area. Some of those review studies have suggested that maybe there are some studies within that that perhaps aren't the highest quality at the moment. So I think there is need to do more work on that.

Lucy: And is digital CBT better for any particular people, or any particular problems?

Graham: I don't think we have the evidence yet to know that. But I think there are a number of potential advantages that people might experience doing their treatment digitally. I tend to see it as being that we're not necessarily looking for digital treatments to be replacing face-to-face work. It might be a really helpful option for people.

They are quite flexible for people, so people can do them maybe in the evenings, at weekends maybe, if they're working, or they can fit it around other commitments that they have. I guess it avoids the cost and the time that they might need to take off work or travelling to an appointment.

And as I mentioned before, the idea of going at your own pace and maybe going back and re-reading, or re-looking at something from earlier in treatment, that you wanted to kind of refresh on.

Lucy: Fiona sometimes used her commute on a coach to London to work through the modules.

Fiona: It helped me doing that, because if I started to feel panicky or anxious, I'd then concentrate on my surroundings.

Lucy: And how have things changed since having had the therapy? Apart from there being a global pandemic and everyone going into lockdown.

Fiona: Well, for a start I wouldn't have been able to deal with the global pandemic and going into lockdown, I don't think. My mother did mention that to me the other day, how proud she was of me, because I was dealing with it. So that was a good thing.

I'm calmer. I'm not going to say that my panics have… I haven't had a panic attack since. I've nearly had them, but I can get out of them easily – well, easier. I'm calmer, I'm more relaxed. I've got a sense of wellbeing, apart from the global pandemic. I'm just happier.

I'm not saying it's all completely gone away, because I miss my husband, but it's not crushing anymore. And I can think of him and smile, whereas before all I saw was the illness and the pain. And it still flashes into my head, but it was flashing into my head all the time before, and it's not doing that now. And I think I'm better equipped to deal with things now than I was before.

Lucy: That sounds really different, yeah.

Fiona and Graham had some advice to share for anyone thinking about having digital CBT.

Graham: I definitely recommend asking what sort of studies or research had been done on that particular internet programme. Because as we've said they do vary a lot, and so I guess it would be good to know that what's being considered has been tested and shown to be helpful for people.

Then I guess the other questions; one would be what format is the treatment? Because I think even though it might be called digital CBT or something, that might still vary a lot. So is it going to be done over webcam sessions, or typing, or a written programme online?

And then I guess a last question to think about, or to recommend people ask, would be about what support there is from the therapist. So particularly what format that support would come in and how often they would get to speak or interact with their therapist in some way. Is it messaging once a week, or is it phone calls? Because I think it's important to get a sense of that.

Lucy: Graham has also been part of writing some guidelines, to help people know what to ask when they're offered digital provision of therapies. I've linked to this document in the show notes.

Graham: So I guess at the moment, in the context of the coronavirus, it might be the case that some people are a bit worried about seeking help, because of concerns about having to go and see someone, or meet them face-to-face. But I would encourage people not to put off trying to make contact and reach out to people.

Most services at the moment are offering a lot of digital and telephone options, so it really wouldn't necessarily be the case of having to go and see someone in person.

And obviously this is a tough time for all of us, placing many strains on our mental health. So I would encourage people to reach out if they're struggling and need some extra support.

Lucy: Graham also had a thought for people who might worry about the relationship that can be built with digital CBT and whether it can be as good.

Graham: Actually there have already now been a few studies looking at the idea of a therapeutic relationship online. What those studies have found is that actually the people who have been going through an online, digital treatment, do report a similar level of connection to their therapist as people who are doing their treatment face-to-face.

One idea I have about that, and that might be interesting to explore a little bit more in some studies, is I guess in online treatments you have the ability to send your therapist a message at any time. And obviously it's not possible for them to get back to you instantly all of the time. But I think for many people that can give quite a powerful sense of their therapist being there for them. That might go some way to really strengthening that connection.

Which perhaps is slightly different in face-to-face. Where you would perhaps have an hour together with your therapist, and then it wouldn't be common that you would be speaking to them or contacting them too much until your next session.

Lucy: It's really nice to hear about the difference between the two types of therapy. It's making me think it would be nice if people had the choice sometimes, between the different types, because they do feel maybe slightly different.

Graham: Yeah, definitely. I think it would be nice to move towards a place where we have these options easily available and that then people could be able to make a choice about what they think is going to work best for them.

I don't think we're quite there yet, because a lot of these programmes are still in the earlier stages of development. There is obviously also quite a lot of work to train therapists in how to use them and to actually get them embedded within clinical services. But certainly that work is happening, so hopefully we are moving in that direction.

Fiona: I would say do it. Even if you've got reservations, absolutely do it. You've still got someone there who's got your back and wants to help you get better. So I certainly wouldn't shy away from it just because it's a different format. It didn't seem any different to me, and it really did change my life.

But the fact that it was always there if I needed it was invaluable, absolutely invaluable. Because to be able to message your therapist at – it didn't matter what time. If I was awake at 1:00 in the morning, I mean she wasn't going to answer, but it didn't matter. I could still send that message because the next day she'd respond. And I'd got it out of my head and I wasn't dwelling on it, because I'd sent that question out there.

So just try. Even if it takes you out of your comfort zone, even more than you're already out of, because you're having therapy. I feel really lucky that I got that type of therapy, I really do.

Lucy: Do you have any advice for people who maybe are trying to comfort loved ones who are grieving? Do you have any advice for them?

Fiona: I think the awful thing about grief, everyone thinks – unless it's happened to them – the number of people who said to me, "Come on, pull yourself together." I mean it was absolutely astounding. A lot of people who didn't, but also their lives go on. And so at the beginning when someone dies you have an awful lot of support, and then it disappears.

Don't tell them to get over it, (laughs) don't tell them to pull themselves together. I think the thing is to listen; to listen and to be sympathetic. Just to not try and make it right. I think that's what I found, is a lot of people just didn't want me to be in pain anymore. So they tried to jolly me up or push it away.

And I think it's really hard if you haven't been through it to be really, truly, truly sympathetic. But I think the best thing to do is listen and comfort, and not try to make it better. Because the only thing that's going to make it better is for your loved one not to be dead, and that can't happen. So you just need gentle support, I would say.

What's so great about the therapy is I can say it was terrible, it was awful. But then in just a matter of fact way. My heart doesn't hurt any more. I know that sounds like a real Disney thing to say, but it's true. And it took ages to get there, to get the help, but I got it. And I'm just really grateful I got it. Yeah, I feel really lucky about that. Thank goodness. (Laughs)

Lucy: That's all from me. Massive thanks to both Graham and Fiona for sharing their experience and knowledge.

Both digital therapy and traumatic grief are very relevant at the moment, as the effects of the pandemic continue to impact. And I've put information in the show notes if you'd like to know any more about either of those things.

Take good care and please do fill out that survey if you get a moment, I'd love to hear from you.

END OF AUDIO

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Podcast episode produced by Dr Lucy Maddox for BABCP

Photo by Emily Morter on Unsplash

What does existing research tell us about the possible impact of the pandemic on children and young people's mental health? Dr Lucy Maddox speaks with Dr Maria Loades about Maria and colleagues' recent rapid review of the literature on isolation and mental health, and what CBT principles suggest can be helpful to head off problems, in particular with loneliness during the pandemic.

Show Notes and Transcript

Podcast episode produced by Dr Lucy Maddox for BABCP

Maria recommended lots of helpful resources on loneliness and social isolation which we've listed here:

Books

Together: Loneliness, Health And What Happens when we find Connection – Vivek Murthy https://www.amazon.co.uk/Together-Loneliness-Health-Happens-Connection/dp/1788162773

Overcoming social anxiety and shyness https://www.amazon.co.uk/Overcoming-Social-Anxiety-Shyness-Gillian/dp/1849010005

Overcoming your children's social anxiety and shyness https://www.amazon.co.uk/dp/1845290879/ref=cm_sw_em_r_mt_dp_U_6p13EbZ0ER2XD

Websites

Mind - https://www.mind.org.uk/information-support/tips-for-everyday-living/loneliness/about-loneliness/

How to cope with loneliness during coronavirus – https://www.verywellmind.com/how-to-cope-with-loneliness-during-coronavirus-4799661

TEDx talk by Will Wright 'Loneliness is literally killing us' - https://www.youtube.com/watch?v=ruh6rN5UrME&feature=youtu.be

Loneliness and isolation in teenagers – a parent's guide https://www.bupa.co.uk/newsroom/ourviews/2019/05/teenager-loneliness

As always if you want more information on BABCP check out www.babcp.com

If you want to find a CBT accredited therapist check the register of BABCP accredited therapists https://www.cbtregisteruk.com/

Articles

The rapid review we talked about is here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267797/

Podcast

That podcast episode with Shirley Reynolds on teenagers doing more of what matters to them is here: https://letstalkaboutcbt.libsyn.com/helping-teenagers-do-more-of-what-matters-to-them

Transcript

Lucy: Hi and welcome to Let's Talk About CBT with me, Dr Lucy Maddox. In this episode brought to you by the British Association for Behavioural and Cognitive Psychotherapies, we think about the possible effects of quarantine on children and young people's mental health. I'll let my guest for today introduce herself.

Maria: My name is Dr Maria Loades and I'm a clinical psychologist and I work at the University of Bath as a lecturer on the doctorate and clinical psychology programme.

Lucy: Maria and her colleagues have been especially interested in the effects of the pandemic on children and young people. She co-authored a rapid review of evidence to try to understand what this effect is likely to be.

Maria: What we wanted to do was to look at two things. One is the studies that have been done that have looked at social isolation in a pandemic context in children and young people and how that's impacted on their mental health. Secondly, we were also interested in thinking, okay, if these measures mean that young people experience this increase in loneliness, what do we know about how loneliness might be related to mental health for children and young people.

Lucy: So obviously there's not loads of pandemics to study, but you're trying to work out from what's been done before, how does loneliness impact on mental health problems for children and young people? You turned the review around really quickly didn't you, because normally it takes months to do something like this.

Maria: Yes, we really felt like it was particularly important to pull this together as quickly as we could to inform policy and practice going forward.

Lucy: And what did you find?

Maria: As we expected, there isn't much known about the impact of pandemics specifically. There was just one study that looked at mental health in children and young people in a pandemic context and it did find that there was significantly increased rates of mental health problems for those who had experienced disease containment measures like quarantine or social isolation. And the study focused on trauma symptoms and they found really much higher rates of trauma symptoms amongst those young people who had experienced those disease containment measures. But that is only one study.

More broadly though, there were over 60 studies that looked at loneliness and mental health. And we found that there is good evidence that loneliness increases the chances of developing mental health problems, both anxiety and depression, up to nine years later.

So there's not only a loneliness and depression and anxiety linked when we measured them at the same point in time, but there's good evidence that being lonely now will mean an increase in risk of mental health problems at a later date.

Lucy: Maria thought one study was particularly interesting. It looked at duration of loneliness compared to intensity of loneliness.

Maria: Now what we mean by that is how long the loneliness is going on for, as compared to how strong the loneliness is. And what this study found, and it was a big study, is that actually the longer we're lonely for, the more closely linked that is with mental health problems than how strong the loneliness is.

Lucy: What are some things that might be helpful to head off these problems?

Maria: We know that loneliness is that feeling we get when our social connections are not what we would want them to be. In the current context, of course, socially connecting in the normal ways, like at school or at college, for young people, is curtailed. But we can still connect in other ways.

Lucy: Maria emphasised how important connecting for play dates over video calls can be, as well as meeting up for play now lockdown is easing, and using more old school ways of communicating as well, like sending friends cards or letters.

Maria: The other thing we can do is more broadly to think about how we promote activities amongst young people that support wellbeing in every which way we can. As well as making sure we're providing a listening ear for young people and being open to hearing what they might be worried about or what they might be feeling sad about and problem solving that where we can. Actually giving them permission, this is a really unusual circumstance and it's okay and it's normal for it not to feel very good.

Lucy: Some things that we know promote wellbeing include regular exercise, good quality sleep, healthy eating and time spent on activities that young people enjoy and feel proud of.

Maria: As one goes for a walk you see rainbows in the windows and my little one looks and points and knows that those rainbows mean that there are other children out there. And I think that's incredibly helpful in terms of feeling a sense of community, connectedness, which also helps to overcome that loneliness.

Lucy: So although there may be an increased risk of mental health problems as a result of the pandemic, there's also lots and lots that we can do that would be protective.

Maria: Definitely. I think it's really important too that we make a distinction between young people who might be feeling lonely now and during this context, but who were pretty well socially connected beforehand. And of course, other young people who might have been lonely beforehand and this has maybe made things worse, or that their loneliness is ongoing at this stage.

For those young people who have maybe been feeling lonely for a much longer time, we might need to do something more individualised and more specific in terms of helping them to think about how they can make social connections going forward, as we resume life to some degree.

Lucy: I asked Maria whether she thought that as we are able to see people more, there might also be some anxiety around socialising.

Maria: You know, the reality is, we haven't been practicing socialising nearly as much as we'd normally do. So we might well feel rusty and we might well even be worried about connecting socially with each other again. Add into that, of course we've had a lot of messages in recent weeks about the risk of interacting with each other because of the risk of infection. And so I think anxiety about getting physically close to each other and interacting with each other is going to be really natural in weeks going forward.

And I think again, the CBT principles can really help us to deal with those social anxieties too. So the first principle that I think is really important to remember is: The first step to tackling fear is facing it.

Lucy: CBT principles suggest breaking down a scary situation into steps and gradually building the confidence to face the fear by conquering one step at a time. So starting with a text message to a friend and working up to meeting face-to-face, for example.

Another tip to help with social anxiety is trying not to focus on how we're coming across to someone but to focus on what someone is saying rather than getting caught up in thoughts about what they think about us. Thinking about thoughts, just as thoughts rather than facts is one thing that can help with this too, both for children and adults.

Maria: There's certain developmental reasons why children and young people may be struggling particularly and those are about the key importance of play and of social interaction to development at those ages. But actually this is something that everybody is experiencing.

I do think the majority of children and young people, and adults more generally, will have a few wobbles, but will manage and will bounce back as we go forward. But for some, I think it will be a little more difficult and they'll need to maybe engage in a bit of self-help using some of these CBT principles or indeed actually to go on and get some more professional help.

Lucy: Maria's review has implications for school policy.

Maria: What we're really encouraging, both schools but also policymakers to support is that as schools return and resume their normal activities, that they focus on allowing children and young people to reconnect rather than emphasising catching up academically. We know, again, from lots of studies and reviews that have been done that having mental health problems gets in the way of academic attainment.

We've got a strong rationale really for arguing, okay, let's make sure now that we try and overcome loneliness rather than prioritising catching up with school work in the short-term because actually in the longer term that's going to be beneficial to school work as well as to wellbeing more generally.

Lucy: I was curious to know if Maria thought any children and young people might actually have benefitted from lockdown. I see children and young people in my clinical practice and I've seen a real mixed bag of responses.

Maria: I do think that there are some young people who have actually found lockdown to be a real relief, particularly young people who struggled more with school and who struggled more with social interactions. Again, they're young people who might struggle particularly with the return to school as things get restarted again.

Lucy: Another group Maria highlighted were children and young people with particular transition points at this time.

Maria: People who, for example, had exams cancelled. Whilst in the short-term that might be a real relief not to have to study and not to have to face GCSEs or A-Levels for instance, I think again, going forward, then there's worries for those young people about what did that mean for them and how do they pick up from where they left off.

Lucy: Super hard isn't it, because there's such a range of experiences that will be going on in people's homes as well. I suppose one thing that has been really on my mind is children and young people who are from backgrounds where they will be disadvantaged by being at home, or perhaps even in danger for one reason or another.

Maria: I think that's a real problem and I do a lot of work with colleagues in South Africa, for whom lots of what we've been talking about as helpful strategies just don't apply. Most children and young people don't have access to the internet and can't continue to keep in touch by virtual play dates, for instance. So what do you do for those kind of populations who are disadvantaged in terms of being able to remain in digital contact with one another. It's really tricky.

I think we should all be concerned about those young people for whom home isn't a safe place. And that's a small minority of children, but a really big concern.

Schools often have a function of being able to do that check-in and that noticing of when children aren't doing okay and to pick up on that and we haven't had the ability to do that. So I think the needs of those children are going to be really important to thoroughly meet as we resume education contact and so forth.

Lucy: Maria's overall message was one of realistic optimism.

Maria: I think parents are understandably fearful about what this is going to mean for the wellbeing of their children going forward and, what's that phrase? Realistic optimism. I do think the vast majority are going to bounce back and a few wobbles, a bit of encouragement, a bit of a push sometimes, but they'll manage it. And the few who get a little more stuck, we do have things that we can offer to help.

Lucy: That's all for now. I hope you enjoyed this episode and found it useful. If you'd like to listen to more on children and young people, there's another episode with Shirley Reynolds, talking about how to help young people do more of what matters to them at this time. There's also loads in the back catalogue about different types of CBT and different problems it can help with. For example, compassion focused therapy or CBT for hoarding disorder.

As ever, if you have ideas for new topics, feel free to get in touch with me at [email protected]. Take care for now.

END OF AUDIO

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 [email protected].

Meanwhile, stay safe and stay well. We spoke in this episode about how the birds are still singing, so I thought I'd leave you with a little bit of birdsong recorded just outside of Bristol after the theme tune plays us out.

END OF AUDIO

Note: This episode was recorded before government guidance on restricting travel due to coronavirus.

We all experience ups and downs in mood, but what happens when the highs are so high and the lows are so low that it really interferes with your life? In this episode we hear from Cate Catmore and Professor Steven Jones about CBT for bipolar disorder.

Show Notes and Transcript

Podcast episode produced by Dr Lucy Maddox for BABCP

For more resources check out these links below.

Books

Coping with bipolar disorder by Steve Jones, Peter Haywood and Dominic Lam

https://www.amazon.co.uk/Coping-Bipolar-Disorder-CBT-Informed-Depression-ebook/dp/B07ZWQ877T/ref=sr_1_1?dchild=1&keywords=coping+with+bipolar+disorder&qid=1585237730&s=digital-text&sr=1-1

Overcoming Mood Swings by Jan Scott

https://www.amazon.co.uk/dp/B003GUBILQ/ref=dp-kindle-redirect?_encoding=UTF8&btkr=1

Online resources

NICE guidelines on bipolar are summarised here

https://www.nice.org.uk/guidance/cg185

Cate spoke about mindfulness. You can hear more about mindfulness-based cognitive therapies here

https://letstalkaboutcbt.libsyn.com/lets-talk-about-cbt-mindfulness-based-therapies

This BPS report is called Understanding Bipolar Disorder

https://shop.bps.org.uk/understanding-bipolar-disorder.html

Recovery toolkit for friends and relatives of someone with bipolar disorder based on research at Lancaster University

https://reacttoolkit.uk/

Guardian article on CBT for bipolar disorder by Lucy from a few years ago

https://www.theguardian.com/science/sifting-the-evidence/2016/feb/08/nice-critique-a-call-for-more-research-not-an-excuse-for-less-treatment-psychotherapy-cbt

If you'd like to read more academic journal articles this range of papers about bipolar disorder has been made free until 30th April 2020 from the BABCP journals

https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/bipolar-articles-from-bcp-and-tcbt

The photo is by Claire Satera on Unsplash

This episode was produced by Lucy Maddox.

Transcript

Lucy: Hello and welcome to let's talk about CBT, with me, Dr Lucy Maddox. This podcast brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP is all about CBT. What it is, what it's not and how it can be useful. As an aside, if you listen regularly to this podcast and like it, please do consider rating and reviewing it, it helps other people to find it.

And if you have ideas for other episodes that you'd like to listen to, just let me know at [email protected]. Right then, I thought I'd start this episode with a quote from Kaye Redfield Jamison, who's a clinical psychologist and writer. She writes, "When you're high it's tremendous, the ideas and feelings are fast and frequent like shooting stars, and you follow them until you find better and brighter ones.

But somewhere, this changes. The fast ideas are far too fast and there are far too many. You are irritable, angry, frightened, uncontrollable and enmeshed totally in the blackest caves of the mind." That was about Kaye's experience of bipolar disorder which is the diagnosis that this episode concentrates on.

For this podcast, I went to Lancaster and met Cate, who's experienced the highs and lows of bipolar disorder and what CBT can do to help. And Steve, whose research team works on a CBT-based intervention for bipolar disorder.

Cate: I'm Cate Catmore, I'm 64, and I live with my husband, got two children, two sons and two granddaughters. I did CBT a while ago and then I had a course of recovery-based CBT recently.

Steve: Hi, I'm Steve Jones, I'm co-director of the Spectrum Centre for mental health research at Lancaster University. The focus of our work is on trying to learn more about the psychological and social factors underpinning bipolar disorder and related conditions. And to use that information and learning to develop new interventions that are developed with the service user in mind. We've been in existence for about 11 or 12 years, and we've always had people with lived experience of bipolar disorder as colleagues as well as collaborators.

Lucy: Cate had her recovery-based CBT as part of a research study at Lancaster University, delivered by one of Steve's colleagues. It's not the first time Cate had CBT for bipolar disorder, but she felt she was more able to access it this time round.

Cate: In the very first place I had CBT when I was hospitalised about 10 years ago. I hadn't kept up with it, and I'd just let it slide, really. And then, I heard about recovery-based CBT through a bipolar support group at Lancaster University.

Lucy: I asked Cate about her experience of having bipolar disorder.

Cate: I didn't have too many manic episodes, but I have to say that was how it was diagnosed, and I must admit I did enjoy the manic phase.

Lucy: What did it feel like?

Cate: It felt free and exciting and I wanted to do everything that I could, and I felt that everything that I did I was doing very well. The main thing that I remember or being very enthusiastic at work and doing a lot more than I was called on to do. I was lucky that I didn't spend all that much, but I did give a lot of money away to charity.

But the best thing (laughs) and it sounds so self-important, but we went out a lot then, probably instigated by me. Me and my husband went out a lot. I used to say, "Oh got to get to this party early, because nobody will enjoy themselves if I don't get there."

Lucy: What a lovely feeling, though.

Cate: It was a lovely feeling, and sometimes I think I wish I could be a bit more like that. And I don't really get the highs anymore, I get the lows, but not the highs. And I know that they're dangerous and they're not healthy, but when you experience them, they are quite nice (laughs).

Lucy: Yeah, it sounds nice.

Cate: Mine wasn't destructive, I have to say, so I was lucky that I just had the nice inside feelings. I didn't gamble like some people do, and I didn't go out and buy a car or anything like that, just made me feel really good and bigger than I was.

Lucy: Yeah, that's a really nice way of describing. Bigger. Yeah. And what's the other end of the experience? So, the lower bit like?

Cate: Well, the lower bit was very low. Part of the manic bit eventually made things quite stressful because I was jumping from one thing to another. And so, work did become stressful and then home life became stressful because I was trying to do so much at home. And then, I got an eating disorder, and they both seemed to feed one another. So, losing weight so much made me more manic, I think.

And then, the more manic I was, the less I ate because I was doing so much, didn't have any appetite. So, it was that, really that led to me to be admitted to hospital. And then, I wasn't really high anymore after that. Then, the low bit started, which lasted a long time. So, I was in hospital quite a long time.

I think I left a lot of myself behind in that hospital. I don't really think I've ever been quite the same person that I was before. Even though I was assured I was, I think it does have a big effect. Yeah.

Lucy: Steve described the definition of bipolar disorder to me.

Steve: I guess bipolar disorder is typically defined in terms of experience of substantial variation in mood. So, most people with bipolar disorder will have experience of both periods of mania where mood is extremely elevated, people can feel very euphoric. They can have lots of energy, but often that can be mixed together with other things, which make it more complicated like feeling very irritable or frustrated.

And then, periods of depression, which are not unlike periods of depression, feeling rather hopeless and very down, and finding it really hard to get going and engage in normal life. And historically, bipolar has been seen as those two things, really. And what tends to be missed out is that often people are experiencing quite a lot of challenges in between those sorts of episodes, where they're not really experiencing mania and they're not really experiencing depression, but there's often quite a lot of mood variation going on.

And people are also working quite hard to make sense of the variety of experiences that they have. So, quite a lot of our work is targeting that middle period, which seems to be actually pretty crucial for people to then develop a platform for getting on with their lives.

Cate: Mood swings but extreme ones. Yeah, and they can last a varying length of time as well. So, people can be manic just for a short length of time, mine was relatively short, I suppose, two months. But then, I've found that the other side of it is quite dark, the depression can be quite dark. So, I think it's just like an exaggerated way of how a lot of people are, that just manage it normally in their day-to-day life.

I sometimes think that people are a bit wary of mood swings and think that something that they say that's wrong might cause a sudden up or a sudden down. And it isn't like that, at all. It's not so erratic as that.

Lucy: So, what does CBT for bipolar disorder involve?

Steve: An important part of any successful intervention with people with experience of bipolar and a core aspect of the recovery-focused approach is really working with the person initially, to get a shared understanding of their experiences that have brought them to the intervention.

Which isn't just a symptom history, because obviously with things like variable mood, the point, the continuum between something that's a problem and something that's normal experience and parsing those things out is one of the challenges people live with. So, people will often be able to for instance identify experiences where mood elevation has been in some ways amazingly good for them.

It allowed them to get a promotion or complete a task they otherwise might not have been able to complete. But then, there are also occasions when that's tipped over into something that's had a profound effect on their lives. And it's not hard to imagine how trying to pull all that together and make sense of it. Which bits do you want, which bits don't you want, which bits are you, which bits are some part of bipolar isn't something people find readily easily resolved without a bit of time and reflection, I think. So, getting that story clear and in a shared way can be a really useful platform for them working out, okay, so what do you want to change? And what do you want to have more of?

Lucy: So, anyone listening, who's thinking that they might want to try CBT for bipolar they could expect to have that kind of shared understanding at the start about what's happened for them and what they would like to work on?

Steve: We're not going to assume that it's about mood or it's about something else. We're going to work with you to find out what is the thing that's causing you difficulty and how shall we address that together.

Lucy: Cate told me a bit about what her most recent experience of CBT had been like.

Cate: Well, it was a talking therapy. We talked about issues that bothered me, and basically about ways to cope with those, identifying what they were, and what triggered them. And different ways of coming to terms with them and coping with them.

Lucy: If you were describing it to somebody who hadn't had it before, what would they see happening in the room? What was going on?

Cate: Well, two people talking together, basically in a chatting way, some writing going on to remind you what had been discussed with the therapist, and then to work on that during the week. I found it very helpful, I found it perhaps a bit stressful at first. And it did bring some things to the surface that were quite emotional, so sometimes there was a bit of crying going on.

But that was usually resolved during the course of the session, and then given ways to work on that. And why those feelings caused upset as well. The sessions lasted about an hour, sometimes a little bit over, not usually less. And it was a course of 12 weeks. And during that 12 weeks, I kept a diary of what we talked about. And then, kept a diary during the week, to keep a record of what had happened. And then, a memo to myself to talk to Lizzie about what had come up during the week.

Lucy: That's great, sounds really organised.

Cate: It was, yeah.

Lucy: And do you still use some of the techniques now?

Cate: I do, I was looking back at the diary that I'd made and yeah, I have kept it on board. It's not a therapy you do 12 weeks of therapy and that's it, it's finished, all your problems are gone, you get on with your life and it's all finished. You're cured sort of thing. It's something it's an ongoing process.

Lucy: Because recovery-focused CBT for bipolar disorder is focused on helping with whatever goals the person brings, it can include different CBT techniques, which help with different problems.

Steve: So, we use tools that we know from CBT for bipolar, CBT for anxiety, psychological approaches to substance use to bring together a package for that individual. So, the manual for recovery-focused therapy is quite a long document, because it encompasses all these possibilities. And it reflects what we were talking about, about quite individualised routes through therapy.

Lucy: What's your favourite kind of strategies to use from it? What sort of things do you use?

Cate: I use distraction, and something comforting that I find soothing, like sewing or seeing a friend or phoning my sister, but reading is a big thing as well. Sometimes even cleaning the cooker, something a bit mindless, really, just a distraction. But also, to remember that the feelings that I have aren't special to me. That not only people with bipolar or depression get feelings like that, that everybody does, the population does. And not to get too hung up on it, and I also use mindfulness as well, which is a big thing, yeah.

Lucy: Mindfulness is something that the episode on mindfulness-based cognitive therapy has loads more information about if you're interested. This is how Cate came to find mindfulness.

Cate: I did an online course in it which was great. It was to bring yourself back into the moment all the time, because so much time is spent thinking about the past, which I do and ruminating on things, which are big. That's gone, and if you're wasting your time now, now is all that you've got. And people miss so much in the moment. There was a lot of different ways to keep mindful.

A lot of it was just sitting and concentrating on breathing for two minutes. But also, when you're out walking, to look at the trees, to feel the ground underneath your feet, really ground yourself, literally to feel yourself walking. And I do notice things more while I'm out, and it makes it a pleasure. Exercise is often recommended for people, but you can go out for a walk and you can keep your head down and worry about things and just be walking.

You're in the fresh air and you're doing some exercise, but you're not really noticing what's going on around you, which is the soothing bit. Listening, mindful listening is a big thing as well. I tend to let my thoughts run away with me. So, when somebody's speaking I'm thinking about the next thing that I'm going to say rather than really listening to them. And that's been a big thing for me, to actually listen to somebody else properly.

Lucy: That's really interesting, have you noticed it makes a difference to the conversations you have?

Cate: Yeah, it has, I feel more involved with the person and what they're saying. And I think it probably makes me feel kinder towards the person, as well. Yeah.

Lucy: I've been reading some stuff about being kind to yourself recently, as well. Do you think that comes into it, too?

Cate: It does, yeah. I definitely think being kinder to yourself, not making too much of things, not thinking about all the bad things about yourself. But concentrate on the good things that you can do and the good things that you can do now and in the future. And not think about the bad things that you've already done, which are gone. You can't do anything about it now, it's finished.

Lucy: Cate talked about distraction, self-soothing and mindfulness strategies there. Other strategies that might be used in CBT for bipolar disorder might include trying out different behaviours to see what difference they make to mood. And sometimes gradually doing things that feel quite hard to do but that make someone feel better. There might also be ways of thinking that are getting someone stuck and Steve talked about some of these.

Steve: When people come in low mood, they may have a lot of negative thoughts and beliefs and tapping into those and looking at ways of finding alternative ways of thinking could be really useful. When somebody's mood is going up, you can also look at the patterns of thinking that are going on there. And work with the person to examine those in relation to how useful are they, how risky are they?

What elements of those do they feel that they want to retain? And how can some aspects that may be problematic be adjusted? I think one of the things that people will often struggle somewhat with is recalibrating. So, if somebody is at quite a low ebb when they come into therapy, and they've got an awareness of what they were previously able to do, which was often functioning at a higher level for anyone.

People will often come with a view that they either need to be there or nowhere. They either need to be right on top of where they were performing at their peak, or there's no point. And so, actually even fairly simple behavioural experiments, testing out, doing things that aren't meeting that criterion but are reasonable things to be doing. And the impact that that can have on subtle shifts in mood can be really useful on unsticking people.

Lucy: Cate told me a bit more about some of her experiences before and how she feels now.

Cate: I think I'm more on an even keel with some downs now. Yeah, and I try and think that everybody has that. And everybody finds a different way of managing it.

Lucy: I know you were saying you felt like you'd left a lot behind, but actually it sounds like you have gained a lot of different skills and strategies actually through your experiences as well.

Cate: Yeah, I think I have, and leaving work was a big thing, because I felt left work under a bit of a cloud, really, because it meant going into hospital.

Lucy: What were you working as?

Cate: I was a gynae nurse, and I worked on the gynae ward and in a bit of gynae oncology and in the outpatients as well. So, I did like my job and I had a lot of good friends, but I felt that I'd left under a bad situation, really. And I never did go back to work after, which used to worry me, because I didn't go back to work. Well, I stopped work when I was 51. So, it used to worry me, not working worried me for a long time. But then when all my friends started retiring, it felt a bit better (laughs).

Lucy: I asked Steve about that sense of loss that Cate had described earlier. Something Cate said really stuck with me, actually, just about how she really enjoyed some of the highs and actually not having those felt like quite a loss. How do you manage that in the therapy?

Steve: I think for a start, you deal with that by taking it seriously. So, I think a lot of people will have had the experience maybe with some other clinicians that they may have come into over the years of being slightly patronised in their valuing of these highs. That it's just you're not well, so that's just you not being well. You need to have something which makes you not go there.

I think working with the person to get a thorough understanding of actually okay, what does go on in those? Are there versions of that are dangerous to you and risky to you? And are there versions of that that are less so? And at what point do these things tip over? Can allow people to actually experience a range of mood states that are part of human experience.

So, on the one hand, yes being sleep deprived for three weeks while you do lots of things is probably for most people likely to lead them into challenging situations. But small amounts of changes in routine to accomplish a certain task, followed by a planned way of decompressing afterwards can actually work quite well for some people. So, that's why it's not a short therapy in a sense.

It's taking the time to be able to unpack those things for people, so that you're working together to see what you can take from that valued element of experience and what needs to be adjusted.

Lucy: Steve was really clear that someone shouldn't have to go to multiple services if they experience multiple problems. That CBT for bipolar disorder could flex to help people with not only ups and downs in mood, but also anxiety, substance misuse or other more functional goals. I was curious about how Steve measured change. Must be quite a challenge for measuring how effective therapies are, when there are quite a lot of different goals that each person might come with.

Steve: Yes, that's a very good point. And I think there's quite a debate about what's a good measure of an outcome. So, our position on that is that most people actually come for help because of subjective problems, their perception that they're experiencing something that's difficult. So, in the past, a subjective outcome has almost been regarded as not a proper outcome.

Whereas I think if it's done properly, they are absolutely important outcomes, because if people are happy with how they are functioning and where they're at, relative to where they want to be, in a sense they're doing what they need to do. And my view is as clinical psychologists, that's our job is to support people to get where they want to be.

Lucy: Cate now works in a range of volunteer roles.

Cate: With the voluntary work, I'm confident when I go out and do that.

Lucy: What's that? What sort of voluntary work are you doing?

Cate: Well, I'll go and read individually with the children at the local primary school. So, I did the five- and six-year-olds last year, but I was quite pleased really, because they said, "You're really confident with the children, and you know a lot about phonics. So, will you read with the little ones?" So, I've got four- and five-year-olds now. They're really sweet (laughs).

Lucy: Lovely.

Cate: Yeah, I think you're really giving something, because learning to read is so basic to everything else. And then, the other voluntary work that I do is through church. And it's street pastors, you'll have street pastors in Bristol but you'll never have seen them.

Lucy: No, I don't know them.

Cate: So, it's run through all the churches in Preston. And it was started in Birmingham as a response to gun crime. The police asked could churches be around and about and talking to people. And gun crime did go down, and it spread out from there, from gun crime the people the street pastors were meeting homeless people. And then, helping people who were on a night out, who couldn't help themselves, they'd drunk too much. So, yeah, we try and get homeless people to go to services.

Lucy: I also asked Steve about the evidence base for CBT for bipolar disorder. He mentions NICE guidelines here, which are from the National Institute of Clinical Excellence. I've put a link in the show notes if you're curious.

Steve: So, the evidence is pretty good for the impact of CBT on mood and relapse. So, the NICE guidance for bipolar disorder in 2014 recommends that everyone living with bipolar has access to the opportunity to engage with psychological therapy based on their systematic review of the evidence.

The evidence on enhancing personal recovery is not as large, partly because it's an evolving field and it's more in the last eight years, I think, there's been a lot of interest in that. But certainly, as I mentioned with our recovery-focused trial, we've got evidence for that being beneficial. And it does seem as though there are a range of ways you can improve those sorts of outcomes.

Lucy: Cate described therapy as being like a river.

Cate: I've seen it described as a river, and the therapy is on one side, but one day you've got to swim across that river and get to the other side.

Lucy: I've not heard that before, I like that. Yes.

Cate: Yeah, it's quite nice, I did think at one time when I was still having therapy and thinking about getting to the other side, what if I get swept away? Which is a bit of a risk, but you've got to keep the image set in your mind that it will be calm waters that you swim across.

Lucy: I think there's something in that, though, isn't there? That fear of what are you stepping into? And is it going to be worse not better?

Cate: Yeah, I don't think any therapy is a one size fits all. And I think you have to be in the right place to engage with it, as well.

Lucy: Steve thinks views on CBT for bipolar disorder have come a long way.

Steve: I remember when we were first doing one of the very early trials of CBT for bipolar. There was a lot of resistance to it from clinical colleagues in the sense that their argument was when people are manic, you can't work with them. When they're profoundly depressed, you can't work with them. And if they're not in either, what problem is left? It's a very simplistic view of people's experience, but that's where we were maybe in the mid 90s.

Now, there are a range of studies going on internationally in bipolar and I think there's a gradually increasing recognition that the psychological dimension to experiencing bipolar isn't a nice to have. But is a crucial aspect of both improving outcomes for people with bipolar, but also helping them with the human task of making sense of what's actually gone on.

Lucy: Cate was encouraging about trying CBT for bipolar disorder if you're considering it.

Cate: I'd definitely give it a go. I think perhaps the name cognitive behavioural therapy sounds a bit off putting. But it's a way of getting to understand your feelings, getting to understand different phases of bipolar and how to cope with them. They're actually quite simple, and it's good to have some help.

Lucy: I asked Steve why he likes working in talking therapies for bipolar disorder.

Steve: Bipolar if you like is pretty rare in terms of being a condition where some of the cardinal symptoms actually can confer an advantage. And I also find it personally fascinating working with people who are living alongside these experiences. I think actually living with the turbulence that bipolar can generate is pretty challenging.

And frankly, I admire the way a lot of people actually fold that into their lives and get on with a really engaged life. And if we can do something to support them in that, I think that's a worthwhile thing to do.

Lucy: That's all for today. Thanks so much listening. There are links in the show notes to more resources, and if you liked this episode, there are lots more you can listen to. Series one went through different types of CBT and series two is working through different types of problem that CBT can help with, including recent episodes on self-harm and perfectionism.

If you're thinking about having CBT and you want to find a BABCP accredited therapist, check out www.babcp.com and look for CBT register.

Thanks so much, lovely chatting with you.

Cate: Is that it?

Lucy: That's it.

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 [email protected].

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.

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