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.  

 

END OF AUDIO 

How do you talk about something in therapy when all you want to do is avoid thinking about it? And why might it help to be able to tackle it? 

Nick Gilbert talks to Dr Lucy Maddox about how he sought help for post traumatic stress disorder (PTSD) and his therapist, Dr Jen Wild, explains the theory behind the treatment, and dispels some myths about what it's like. 

This show includes reference to suicide.

 

Show Notes and Transcript

Podcast episode produced by Dr Lucy Maddox for BABCP

Some more sources of information are listed below.

Websites

For more about BABCP check out: www.babcp.com

To find an accredited therapist: http://cbtregisteruk.com

NHS Website about treatments for PTSD are described here:

https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/treatment/

Support for veterans can be found here:

https://www.combatstress.org.uk/

Books

Overcoming Traumatic Stress by Claudia Herbert

Trauma is Really Strange by Steve Haines

Jen has a book coming out soon too - watch this space for details. 

Transcript

Transcript

 Lucy: Hi, and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. The podcast all about CBT, what it is, what it’s not and how it can useful.  

In this episode we’ll find out about post-traumatic stress disorder, known as PTSD. I went to Oxford to record this episode and apologies in advance for the drilling, there were some building works going on outside where we were recording. We did try recording in the bathroom but it didn’t really work.  

I met Nick Gilbert who was diagnosed with PTSD in 1990, six years after the event that triggered it. This is his story.  

Nick: I’d reached a point where I was sat in my car and had no idea what I was going to do next. I was actually considering ways of ending my life.  

So I’m sat in the car considering these things and I phoned my GP who was aware that I’d got issues – got some problems. He put me though to or put me in front of Talking Heads I think it’s called. And they phoned me and said would I be prepared to take part in a study. And, quite frankly, I was so desperate at the time, if they’ve have suggested witchcraft I’d have probably gone along with it.  

Lucy: Nick started having CBT in 2012.  

Nick: And then I met Dr Jennifer Wild and I don’t think it’s too much to say that that lady changed my life.  

Jen: The people I work with are suffering from post-traumatic stress disorder and the treatment I’m giving is trauma-focused cognitive behavioural therapy.  

Lucy: Jen Wild is a consultant clinical psychologist at the Oxford Centre for Anxiety Disorders and Trauma.  

Jen: Post-traumatic stress disorder, or PTSD as it’s commonly known, is a severe stress reaction that can develop after natural disasters like a tsunami, a physical assault, sexual assault, car accidents, really unpleasant events where people flooded with unwanted memories and can’t get them out of their head. It’s very debilitating, it’s very terrifying, it takes up their concentration. They feel very hyperalert.  

Lucy: What does hyperalert mean? 

Jen: Hyperalert is feeling very on edge, very aware of your surroundings. And I think what happens with PTSD is people’s focus of attention shifts. So instead of being very absorbed in their environment or with their work or their family, for example, suddenly people are very focused on something bad could happen, “I could lose my life at any moment. Something might happen to my kids.” 

So the shift of attention is from being absorbed in the environment to something terrible could happen. And when people are focused on danger they notice danger. 

Lucy: It sounds just like it’s very scary all of the time.  

Jen: It’s very scary, it’s very unsettling. There are four clusters of symptoms with PTSD.  

So the first cluster called the reexperiencing symptoms, and that really means people are reexperiencing the trauma in the form of unwanted memories or nightmares or physical reactions in response to trauma reminders.  

The second cluster of symptoms are the avoidance symptoms. So understandably when we’ve been through something horrendous, we want to push it out of our mind, avoid reminders, avoid people who remind us of the situation, avoid TV programmes that might remind us of the horrible trauma. So the second cluster of symptoms are the avoidance symptoms. 

The third cluster of symptoms are what’s called, in our language, negative alterations in cognition and mood. That basically means people feel and think more negatively. So they might have thoughts like, “I’m permanently changed for the worse,” or “This trauma happened and it’s 100% my fault.” So they may be excessively blaming themselves.  

And then the fourth cluster of symptoms are what we call the hyperarousal symptoms. So that’s the sleep problems, the concentration problems, that feeling of being on edge, hyperalert to danger. And that they’re usually caused, these hyperarousal symptoms, by the trauma memory, so the memory of the trauma keeps people feeling like danger is just around the corner.  

Lucy: This was Nick’s experience of PTSD. 

Nick: I sometimes burst into tears for no reason. And in my head I know I’m crying and I can’t understand why I’m crying and I don’t want to cry but I do. I feel angry and frustrated. I have no idea why. Little things upset me a lot. Stupid things.  

You know that you shouldn’t react in the way that you do but you're almost a spectator. You don’t have any control over it. And you try very hard to break out of that but it sometimes is very difficult to do.  

It goes after a while. And lots of other things, different reactions to things, triggers you see on TV and things.  

And one of the weird things actually is not reacting. The incident that triggered my condition involved climbing down a cliff. For a long time I couldn’t even consider looking at a cliff. But now I see it on TV and it doesn’t bother me. And that bothers me.  

Lucy: That bothers you that it doesn’t bother you?  

Nick: Yeah. Because does that mean I don’t care anymore? Because there was a fatality. Should I feel that way?  

For me, I don’t know about others, but for me there’s a, if you like, survivor guilt. And shame for surviving. And not understanding why I was the one that survived and other didn’t. So you almost feel offended on their behalf.  

Lucy: Is it right that quite often feelings of shame might come along with it as well?  

Jen: People can feel ashamed after their trauma when they start to question what they did during their trauma, if they have thoughts, “I should have acted quicker, I shouldn’t have been in that situation, I’m not happy with how I responded in that particular trauma.” Then that can lead to feelings of shame.  

Of course people can also feel ashamed with trauma like sexual assaults where they felt very violated and very ashamed to talk about what happened. Maybe they were humiliated by their perpetrator and they may internalise the voice of their perpetrator and it may become very difficult to talk about what happened because they think their clinician or their therapist will judge them in the same way.  

Lucy: So it sounds like something that’s understandably really difficult to seek treatment for actually. What is the treatment like?  

Jen: The treatment is very effective. That’s the first point to make. And it has a scary title; it’s called trauma-focused cognitive behavioural therapy. The therapy is really looking to update the horrible trauma memory. 

When we go through something horrendous we’re really focused on surviving and we don’t always pay attention to information at the time that is really helpful to link to the trauma memory.  

So, for example, somebody might have had a horrendous car accident and thought they were going to die at the time. And then when they’re reminded of the trauma today they see a car, they get that feeling they’re about to die again. They may have unwanted memories coming to mind of the moment just before impact. And then in their mind the memories will stop at the worst moment, the moment before impact, for example.  

And then what treatment would do is help to flesh out that memory in a little bit more detail. So we know if somebody’s sitting in our office that they have survived the trauma. So we want link that information, “I’ve survived,” to the memory of the car accident.  

So by the end of treatment the trauma memory would be so much less threatening and it would be something around, “I’ve had a car accident, I thought I was going to die, I felt very afraid, I was injured, I now know I have recovered from some of the injuries, I’m safe and I have survived. It’s in the past.” 

And you can see how that new information gives context to the trauma and makes the meaning much less threatening, which is what helps people to feel a lot better. 

Lucy: And so does it involve sort of talking through the trauma quite a lot?  

Jen: I think the common misconception is that the trauma-focused CBT really is about talking about the trauma a lot. But I’ve just looked at a case series where I counted the number of times I actually went into the trauma memory in a lot of detail with clients. And in a 12 session treatment I actually went into the trauma memory in a lot of detail in one session. So it is a misconception.  

Of course we work with the trauma memory but we’re often working with trauma triggers. And that’s really breaking the link between the present and what’s going on now when the trigger appears to what happened in the past. And that’s not really talking through the trauma memory. It’s really about, “What’s going on now that’s different to the past that shows me that I’m safe?”  

Lucy: So anyone listening to the podcast who’s thinking about having trauma-focused CBT could be quite reassured by that, that it’s not every session at all that you’re going through the trauma in detail.  

Jen: It’s not every session that you’re going through the trauma in detail and I would say that one of the ways that CBT for PTSD is effective is you're helping to change the meaning of the trauma.  

Of course we can’t change the facts of what happened. If something horrendous happened, it happened. But we can change how we interpret it and the meaning that we believe it says about ourself or other people or the world. We can update that. And that’s why I like to think of the therapy as an updating therapy.  

Lucy: And is that kind of how it works? Is that the kind of main way that it changes how people feel, by changing the meaning of what has happened?  

Jen: I think there are three ways in which the treatment works. I think one of the most important ways is changing the meaning of what happened so it’s less threatening to somebody.  

The other way is we help clients to change some of their behaviours that might be increasing their anxiety. For example, if somebody is really worried about being attacked when they’re out and about, they might have one or two mobile phones with them. They might have them ready to call the police. And they might be really focused on danger. And, of course, that’s going to increase their sense of danger just by having their phones on a quick dial to the police.  

So what we would want to do is to go out with people and get them to drop these specific strategies so that their brain discovers that they can walk out and about without having to take extra precautions. So that helps to change their behaviour, reduce anxiety.  

And the other area is breaking the link between the present and the past by working with trauma triggers.  

And there is actually another area and that is working with the thoughts. This is the meaning more or less that we touched on. And updating the memory. So we update the memory so it no longer stops at the worst moment.  

Lucy: What sort of things should people expect if they were coming for CBT for PTSD?  

Nick: I think the expectation is a very important thing. You're in so much pain – I don’t mean physical pain – that you’ll do anything. But some people expect it to be like taking a drug. And that all of a sudden you’ll feel better. Well that’s not the case. It takes time. And energy. And effort. And pain.  

There were times I left Jen’s office and I felt like crying. I was so emotional – it’s so emotionally charged that I’m absolutely shattered afterwards. Absolutely shattered.  

Lucy: Why do you think people put off talking about it?  

Nick: Because once you’ve opened Pandora’s Box you can’t close it. Once you start the process you can’t not do it anymore. It’s something you’ve got to do. You’ve got to see it through to the end.  

Lucy: And did you have to talk through what happened quite a lot? Were there other things you talked about as well or…?  

Nick: You talk about lots of aspects of your life. And, yes, you talk about whatever the trigger incident was. And I say a trigger incident for a reason.  

In actual fact for many years if I even mentioned it I would tear up. I talked to somebody about it the other day and it was just like any other conversation. Which again amazes me but also shames me because a part of me still feels that I should be suffering on behalf of Annie and because I’m not there’s an element of guilt there.  

But you see that’s the PTSD. That’s not me. I’ve reasoned that. I know what it is. Therefore I can deal with it. I think a striking indication of maturity is when you realise that life isn’t fair.  

Lucy: I asked Jennifer about what people should expect from CBT for PTSD. 

Jen: The treatment’s a very active treatment. I would say I try and get out of the office as much as possible with clients because that’s where life happens. And we want people to kind of reclaim their life as well.  

So in the first session I would be working with people to think about their longer-term goals and we would touch on their goals in every session and making sure that they're working towards them. And picking up activities that they may have dropped because of the trauma.  

Lucy: So what sort of places do you go to?  

Jen: Well, you might be surprised to hear that we would go back to where the trauma happened. And that is very important for a number of reasons. It helps people to discover that the site has moved on. There’s no one still there suffering. That the suffering is over, it’s in the past.  

It also helps clients to feel that they can cope with it. Often people understandably are incredibly anxious about going back to the site of the trauma but once they’re there they can focus on what’s different and how it’s changed since the time of their trauma. And that really helps to give a sense of movement in terms of their life, but also with the fact that the memory’s in the past. It’s a quite clear distinction between what’s going on now and the memory being in the past. 

Lucy: Jen also sometimes uses Google Maps with people so that they can look at the place where they trauma happened online instead of going there in person.  

Jen: And if clients have developed anxiety or avoidance about different situations, about shopping, about walking down the road, for example, we would go out and about with them, walk down the road, go to a shop. And really test their beliefs about what they think will happen and then find out what actually happens and the outcome is always good. They usually realise that bad things don’t happen when we leave our house and that actually it’s safe to do so.  

And they also typically experience a boost in mood. So it’s good motivation to keep doing those behaviours, like leaving the house, for example.  

Lucy: That sounds really important. It sounds like there’s potential to make huge change for people’s lives there.  

Jen: The efficacy of trauma-focused CBT for PTSD is incredible. The majority of patients will recover with treatment. We normally offer up to 12 sessions, but many patients don’t need 12 sessions. So they may have a fewer than that.  

Lucy: So it’s got a really strong evidence base.  

Jen: It has the strongest evidence base of any treatments for PTSD. I highly recommend it but I think any of the clients that we treated would highly recommend it as well.  

It helps people to reclaim their life and to lead a life that matches their dreams rather than their fears.  

Lucy: Nick reclaimed his life in ways he would never have imagined.  

Nick: I’m a funeral director now.  

Lucy: Are you?  

Nick: And I enjoy it immensely. And the reason I do that is because I’m able to help families through a very difficult period. I can understand how they’re feeling. And I say to them quite often, when they say, “I’m going to miss them,” I say, “Well, for as long as you talk about them they’re never not going to be there. They’re still alive in your memories. So talk about them. Don’t avoid talking about them.” Because people do because it might upset grandma. But as long as you talk about somebody they’re going to be there.  

So I find that extremely helpful for me. And I think for them because I get good responses. People say that I’m good at what I do, etc. But I think I wouldn’t be anywhere near as good as I am, dare I say, if I hadn’t experienced what I had in the first place.  

I know I’m a very different person to the person I was before the incident. And I know again that I’m a different person to the person I was before I went into CBT.  

Lucy: It’s really striking the image of you in the car that you talked about at the start and now how you're doing a totally different career and you're feeling really good at that and enjoying it and getting really good feedback from people. Could you say just sort of how you feel like you're life has changed from one point to the other? 

Nick: At that time I’m pretty certain, it was probably the lowest point in my life post the accident. You can’t see any further. But you move on. And then one day you suddenly realise, “Actually life isn’t too bad, is it?”  

And then you feel guilty because you think, “If I think this will it all go horribly wrong again?” But the reality is you end up in a better place. 

Lucy: What do you like about working with PTSD?  

Jen: I love working with people who have developed PTSD. I know that it’s a problem that people can recover from. It’s very common. I know that most people I work with are going to recover with this treatment because it is an effective treatment. 

But I also am very passionate about the idea of people reclaiming their life, and possibly going one step further. So it’s an opportunity when we go through some horrendous trauma to take a step back and re-evaluate our life, look at our symptoms, get some help and make a choice to lead not just an ordinary life but an extraordinary life. And that’s what I love most about this treatment.  

Lucy: I asked both Nick and Jen if they had final advice for people thinking of doing the therapy.  

Jen: The decision to have treatment is an important one and understandably people put it off. I think it can be more difficult when we’re feeling really ashamed about our trauma or the symptoms that we’re having to reach out for help.  

And I would just like to invite people who have had trauma and are feeling ashamed to take that step and reach out because the treatment is so helpful and there’s so much relief from reducing that sense of shame and that can happen within one or two sessions. So I would really encourage people to reach out.  

Nick: Well, first of all, if you're suffering with PTSD then I do feel for you. There’s almost a brotherhood of it.  

Be careful of who you talk to about it. But if somebody is offering you this treatment, then do it, because once you’ve done it, if it works for you you’ll be in a far, far better place. And, to be honest, if it doesn’t you're no worse off than you are now.  

But if you do it you’ve got to be committed to it. It’s like being on a diet. But you will feel the benefit.  

Lucy: What kept you committed to it? How did you stick with it? Because it sounds hard.  

Nick: I knew I had to do something because I honestly didn’t feel that I would be able to cope much longer and I would probably have taken my life. It was a turning point. 

Lucy: That’s great. Thanks so much.  

Nick: You’re very welcome.  

Lucy: Thanks to both of my experts, Nick and Jen. If you’d like more information on CBT for post-traumatic stress disorder have a look at the show notes.  

For more on CBT in general and for our register of accredited therapists, check out BABCP.com. And have a listen to our other podcast episodes for more on different types of CBT and other problems it can help with, including obsessive compulsive disorder and psychosis. 

 

END OF AUDIO 

 

What are 'intrusive thoughts' (we all have them) and what has CBT for OCD got to do with a polar bear? People sometimes talk about being "a little bit OCD", but the reality of obsessive compulsive disorder is much more difficult than a tendency to line your pens up or be super tidy. 

Ashley Fulwood talks to Dr Lucy Maddox about his journey towards recovery from OCD with the help of CBT, and Professor Paul Salkovkis explains how CBT works.

 

Show Notes and Transcript

Podcast episode produced by Dr Lucy Maddox for BABCP

Want to know more? 

Websites

For more about BABCP check out: babcp.com

To find an accredited therapist: http://cbtregisteruk.com

Ashley's charity, OCD-UK is here, and there is a lot of useful information on their website: https://www.ocduk.org/

And another OCD charity, OCD Action, is here: https://www.ocdaction.org.uk/

Books

Break Free From OCD by Fiona Challacombe, Victoria Bream Oldfield and Paul Salkovskis

Overcoming OCD by David Veale and Rob Wilson

Transcript

Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. This podcast is all about cognitive behavioral therapy, what it is, what it’s not and how it can be useful. Today we concentrate on cognitive behavioral therapy for obsessive compulsive disorder, or OCD.  

Before we meet this week’s interviewees I’d like you to try really, really hard not to think of a polar bear. Do not imagine a polar bear. What did you notice? Did you see a polar bear in your mind’s eye? We’ll come back to that later.  

For one of this episodes interviews I took a train up to Belper, near Derby to meet with someone who has had personal experience of OCD.  

Ashley: My name is Ashley Fulwood and I work for the charity, OCD UK. OCD UK is a charity founded by me and a colleague in 2004. We’re completely service user led. So everybody involved in our charity at the moment has been affected by obsessive compulsive disorder, either directly, sufferers like myself, or through a loved one.  

But it’s been good because through my work the charity is how I’ve actually made progress with my OCD and I’m now certainly on my recovery journey.  

Lucy: Life for Ashley now is really different from how it was at the height of his OCD.  

Ashley: I thought I was managing my OCD and it’s only years later when I started working with the charity that I realised, actually I wasn’t managing my OCD. I was able to go to work and hold a full-time job, so that’s why I thought I was managing it, compared to other people. But looking back, it tainted every aspect of my life, so it became a very regimented day. I would get up, go to work, avoid eating or drinking during the day. Obviously as a guy we can urinate without having to touch the toilet, so I could just about do that.  

As my workday ended at 6pm, my colleagues who I’d got on brilliantly with, they would all go off to pubs and restaurants and clubs and they would always invite me but I would make excuses because I knew that I’d have to go home and go through my rituals.  

So I’d head off home, I’d probably grab a takeaway or something to eat on the way home so that I was ready to use the toilet when I got in. I would use the toilet. By the time I’d finished doing my shower rituals it would be 9:00/10:00 at night, which is more or less time for bed and repeat-repeat-repeat.  

Lucy: Ashley is not the only person I spoke to for this podcast. I also spent an afternoon in Oxford speaking to the current president of BABCP board and international expert in cognitive behavioural therapy for OCD.  

Paul: I’m Paul Salkovkis, I’m the director of the Oxford Centre for Psychological Health, which includes various bits, but particularly the Oxford Centre for Cognitive Therapy and the Clinical Psychology Training Course.  

Lucy: I asked Paul to explain what OCD is.  

Paul: OCD is much misunderstood. What it is, is people experiencing really unpleasant intrusive thoughts, things which pop into their head, but also images, impulses or doubts which upset them. And those are the things we call ‘obsessions.’  

They’re things which pop in the head which are unacceptable and then compulsions that are actually related in the sense that they’re things that people do to try to prevent bad things from happening. For example, to wash their hands that feel contaminated or say a prayer if they’ve had some sort of very unacceptable thought. Try to wipe thoughts out and so on. And those are compulsions.  

Together they both occur actually in everybody. So everybody experiences occasional upsetting thoughts and do things that perhaps are driven by those kinds of thoughts. The disorder bit is when it interferes with their life and stops you doing things that you want to do. So it’s not just the obsessions and compulsions, but it’s the interference with life, taking time, distress to the point of torture sometimes. And at its most extreme. This is a life destroying problem.  

Lucy: Could you say a little bit more about what sort of intrusive thoughts people might experience? 

Paul: Classically obsessional thoughts are often thought of being about contamination and so on. But actually they hit you wherever you’re most vulnerable. So if you’re a religious person, you tend to have obsessional thoughts, say blasphemous thoughts. Clean people have thoughts about being contaminated. Careful people have thoughts of being careless. People can have thoughts of sexually abusing children, including their own children and so on.  

They’re the thing which you’re most afraid of and then the compulsions are pretty much logically related. There is always a rational link, it’s just you need to get it from the perspective of the person who is experiencing those obsessions and compulsions.  

Lucy: Right and so the compulsions are kind of to cancel out or neutralise the upsetting thoughts?  

Paul: Compulsions in my view divide into two types. There’s those which are meant to prevent bad things from happening, so you wash your hands to make sure that you don’t pass contamination to other people. And there’s others that are meant to undo things. You say a prayer because you had a blasphemous thought and so on. You have an image of your mother dead, so you then try and form an image of her alive.  

There’s things which are designed to really check whether or not something has happened and then the other things are called restitution, like putting it right.  

So they’re either meant to forestall it or undo it basically.  

Lucy: You said it’s only a disorder if it gets in the way of somebody’s life. Sometimes people say they feel a little bit OCD or that kind of thing. What would you have to say about that?  

Paul: The idea of being a little bit OCD is kind of quite controversial and you get people claiming they’re a little bit OCD. OCD is of course a life destroying problem and so to say that your, say your preoccupation with putting things in a straight lines is OCD, is probably unhelpful in terms of the way that we think about things.  

That being said, the roots of OCD, as far as I’m concerned, sit in normal behaviour. So I’m a little bit OCD in the sense that I experience intrusive thoughts, which map on very closely to things that are experienced by people with OCD. I absolutely don’t have OCD myself though, and I’m not claiming that.  

So it’s a bit of a tricky one, it’s a bit more complicated than it just being insulting to say you’re a bit OCD. The way it’s often used though is essentially belittling those people who suffer from the problem. And I think it’s best avoided really.  

Lucy: Is it okay to ask what sort of intrusive thoughts you have?  

Paul: Sure. Over the years I had to explain to people that I’ve worked with, about the normal intrusive thoughts that I have, which are not at all normal.  

So I’ve had thoughts about harm coming to my children, me harming my children, me sexually abusing my children and so on. It sounds horrific stuff. Most people though will have experienced something like this. Perhaps in a fleeting way and they kind of think, oh, there’s a funny thought.  

Other examples, when you’re standing in the tube and you think about either jumping in front of the tube or pushing somebody else, off a cliff. Ideas of being contaminated, of course lots of people have lots of intrusive thoughts about being ill. They notice a blemish on their skin and think it might be the first sign of cancer and so on.  

I’ve had all of those things and I think, well, I know that the majority of other people have something like that and so on. At one level they’re every day, they don’t terrify me, but for somebody who has OCD, they are hell, they’re just torture and they consume the person’s life and destroy it. So they’re something and nothing, but for the person with OCD, they’re a lot more than nothing.  

Lucy: I get the one about pushing people down the stairs actually, quite frequently (laughs), promise not to do it! (Laughter)  

Now Paul and I were able to have a bit of a laugh there about that intrusive thought that I get, but these thoughts are no laughing matter when they’re part of OCD. I asked Ashley to tell me about his experience of OCD and the impact that it had on his life.  

Ashley: Yeah, of course. So obsessive compulsive disorder, most people call it OCD. And for me I had intrusive thoughts and fears and worries around germs, around using the toilet. Often it wasn’t a case of washing until I saw that I was clean, I would have to feel clean and of course the more you try and feel something, the less certain you become.  

And it’s the same with any type of OCD, whether it’s checking or other parts, the more you try and convince yourself that you’re okay, the less certain you become.  

My OCD meant that throughout my 20s and 30s effectively I couldn’t use the toilet, I couldn’t even use my own because I couldn’t touch the toilet lid or seat without then having the urge to shower. So it meant I avoided eating and drinking when I was out and about so that I didn’t have to use a toilet, and even my own. And when I did use the toilet it then meant two to three hours of shower rituals, on a bad day, five/six hours. Thankfully that was rare, but on average a minimum of 90 minutes was the norm.  

So I’d have to wash my left leg, right leg, left arm, right arm, my body, my torso, my genital area, everything had to be cleaned and of course if during that ritual something didn’t quite feel right, maybe I’d missed a bit, I’d have to start all over again.  

Lucy: It’s impossible really to over emphasise how much of an effect OCD can have on somebody’s life. Ashley was really candid about some of the things that he’s experienced and the impact that they’ve had on him and also how he came to realise that OCD is what was going on for him.  

Ashley: It was actually an episode of Casualty in my mid-20s when they covered a guy with a germ phobia who couldn’t go out. And I realised that was actually partly what I was doing for a while, that each time I went out, I’d have to shower when I come back. That’s when I realised what I was going through was OCD.  

And typically – maybe it’s a typical guy thing, I don’t know – I didn’t actually do anything for another few years because I was too embarrassed to actually bring it up and talk about it. Back then of course there was no internet, so there wasn’t really any resources for me to go online and look up what I should do.  

So growing up, I didn’t really socialise, I didn’t have, what most people do in their 20s is go out and have fun. So although I’m conquering my OCD now, possibly as a consequence of my OCD I still find social interaction quite a challenge. I still feel very uncomfortable when I’m in social situations; going into pubs, even just walking into a pub fills me with anxiety.  

Because I didn’t have a lot of social interaction in my 20s – this is embarrassing to say, but it’s part of what OCD does to you – I didn’t have girlfriend until I started making recovery, well into my 30s. And as a consequence, I didn’t lose my virginity until I was well into my 30s.  

That is the factor of obsessive compulsive disorder, that people might recognise the compulsions, the symptoms, the surface, but what they don’t realise is, and often why OCD is trivialised is because people don’t recognise the fact that the ‘D’ in OCD stands for disorder.  

They don’t realise the impact it has on people’s lives, whether it be relationships or education, if it’s a young person, or careers. And sadly sometimes with tragic consequences, as we know only too well through the work with the charity.  

Lucy: Paul also spoke about the huge collateral damage that’s done by OCD.  

Paul: I’ve worked throughout my career really with people with very severe and very persistent OCD. I would say that about 20% of what I do is helping people with their OCD and the remainder is helping people with the collateral damage.  

Because 40 years on, after you’ve been washing or checking or neutralising, or whatever, that’s taken a massive toll on your life and quite deep grooves have been worn and so on. And people have lost a great deal.  

And so a lot of what we do later on with these folks is yes, help them with the OCD but then help them undo some of the harm.  

The other thing you see with that is some people, immense grief about what they’ve lost. And I sometimes feel that very acutely. Sometimes it’s both myself and the patient crying about it because it wasn’t necessary in the first place.  

Now what that says is that firstly, we should continue to help those folk, but we should get in much earlier. The average time between people first having full blown OCD and it interfering with their life, it typically starts age 20; typically people get their first treatment, on average, 32. Which means 12 years of not being helped, the damage that’s being done and so on, and that is appalling. That’s unbelievable.  

Lucy: So what is the treatment like for this problem? What does CBT for OCD look like? 

Paul: What should happen is that for CBT for OCD, as for anything else, you should walk in the room and the person should explain who they are, how they’d like to be called, what the interview is about. And then they should sit down and listen to your story.  

And I think that’s a really important thing because in the end people walk into our room and we kind of expect them to tell us everything about themselves and their really deepest, darkest secrets in some way, or all the things which cause the most pain.  

What amazes me is that people do, and I think that’s a real privilege as a therapist to get that. But I don’t think you have it as a right, I think you have to earn it and you have to show essentially that you can be trusted.  

What should happen next then is the person; the therapist should work with the person to find out a little bit about how the problem is affecting them and what form it takes. In OCD, what type of intrusions they have, what their compulsions are, how it impacts their life.  

And then go into a really quite specific thing and we’re probably a couple of sessions in now. This is not in your first session. What you then do is you then zero in on what actually happens. If you’ve got OCD, what happened yesterday at 3:00 when you were starting to experience this problem? And then piecing together from a combination of what the person remembers about what was happening yesterday when the obsession was bothering them. And then the expertise of the therapist in understanding roughly how obsessions and compulsions work.  

And then reaching this thing we call the ‘shared understanding.’ Me saying, “Let’s you and I sit down together, work out how this works. Is it possible it works this way?” And linking into the person’s lifestyle, values, their social situations and so on. Somebody is living in abject poverty or is being bullied or harassed or whatever it is. These are all things that affect it.  

The next step is not, “Oh, okay, we’ll just use that to treat you.” It’s, “Lets you and I work together to see how we might be able to change things, to try things out and see if this is true.”  

Because in OCD, if the thing is that you might be going to harm people, that’s your worry, and if that were true, then you should protect people and that’s, of course, what people with OCD are often doing. However, if the problem is not that you’re harming people, that you’re just a lovely person or a kind person or a caring person who is afraid of harming people, well, that has different implications.  

And you’ve got to then work out which of these two alternatives is true and how best to find out, other than test it out. So don’t trust me, work with me to find out.  

Lucy: That’s great. So it’s very much something that is done together, it’s quite a shared experience and it sounds like you’re very collaborative about how you set that up.  

Paul: I’d go even further than that. What I think a good CBT therapist does is empower people to choose to change. It is this process of choosing to change. It’s not my choice, it’s the person I’m working withs choice.  

And it’s really in that sense, everything we do is self-help with the support of a therapist. And that’s probably why self-help without the support of a therapist sometimes works, because people can learn similar things. And often can then implement that. But that’s extremely difficult and so having the support of a therapist who can go with you on the journey, I think that’s what a good CBT therapist does.  

Lucy: And how about Ashley? He’s had a few different experiences of therapy and not all of them have been positive. 

Ashley: My experience has varied over the years and I’m not going to name any names, but certain therapists have said to me, “I don’t understand OCD,” which in some respects I respect their honesty, but it didn’t exactly fill me with confidence in their ability to treat me.  

Other therapists have said to me they don’t believe in putting their hand in toilet water, which of course I knew that’s what I needed to do to overcome it.  

Lucy: In the end Ashley volunteered to be part of an intensive training day for therapists which Paul organised. As part of this day Ashley tried out what it would be like to face his fears of touching the toilet with his hands.  

Ashley: I actually became a guinea pig on a CBT therapist training day, and I was happy to do it because I knew that I needed to do it. And I had a lot of anxiety prior to doing it because I knew that I knew that I was going to be doing it a couple of months in advance.  

Ironically, because I’d prepared myself well using the CBT techniques I’d learned, the anxiety actually went very quickly, within a matter of minutes.  

By doing that exercise… And sometimes people say to me, “Why would you put your hand in toilet water, that’s not normal? Nobody, even people without OCD don’t do that,” and what’s important to understand is if we’re living at one end of the spectrum, which is the OCD spectrum, we have to go to the anti-OCD end, the opposite end of the spectrum to learn to live in that normal middle ground.  

Lucy: Ashley described what happened.  

Ashley: There were about four/five other therapists and the professor and myself crowded into this disabled toilet to do the exercise and they were all really encouraging.  

And so the professor did it first and he said the brilliant thing which really empowered me, he told me that I didn’t actually have to do it if I wasn’t ready to do it and I think that was so powerful in that moment.  

And being the competitive person that I am with the professor who I know quite well, I was able to take that challenge and I jumped straight in there. And actually I didn’t do the exercise right because at first I thought he meant touch the actual inside the toilet bowl.  

I did that and felt really pleased with myself and suddenly Paul said to me, “Actually no, what I meant was put your hand in the toilet water.” And he did it again, if I remember rightly. So I was a little bit, “Argh, okay, I wasn’t expecting that,” but I did it.  

And I was standing there with wet toilet hands and I’m just going to stand up, obviously you can’t see because we’re not on camera, but I was actually standing like this. I was standing with my arms away from my body because subconsciously – I wasn’t even thinking about it – I guess I didn’t want my hands to touch my jacket. I was wearing an expensive jacket that day, so I didn’t want to throw it away.  

I didn’t actually even realise I was doing it, but the therapist recognised it instantly. He didn’t ask me a question, he realised what I was doing and he asked permission if he could take my hands and touch my hands. And I said yes, and I realise now what he did. He took my hands and he just rubbed my hands all over his grey curly hair. And again, that was just a powerful thing to do.  

And only by speaking afterwards, actually I recognised myself, about two minutes later, I realised why he did that, because I was standing with my hands away from my body. The moment he did that, my anxiety suddenly started to drop and I suddenly started putting my hands on my trousers and on my shirt. It was such a weird feeling because I expected to become really, really anxious.  

Lucy: Ashley was really clear that the way that the experiment was set up was really important.  

Ashley: Rather than just tell me to do the exercise, they experimented, they gave me the example of how the exercise should be done by doing it first, which was so empowering. I think that’s a great example of good therapy.  

Something else that people need to remember is that doing the exercise once is fantastic; give yourself a huge pat on the back. But to make recovery stick, to make recovery last, I believe you need to repeat the exercise regularly. In my case I did it daily for about three weeks until the anxiety was literally not even recognisable.  

Lucy: The theory that CBT for OCD is based on is very much to do with the meaning that we make of our intrusive thoughts and then the behaviours that we get into doing in response to that meaning. This is where the polar bears come in to.  

Paul: What the theory says is that intrusive thoughts occur to everybody, but it’s not those thoughts that are the problem, so you don’t tackle those thoughts. It’s what they mean. And in particular if they mean something bad could happen and you’re responsible for either preventing it or you might be responsible for making it happen or whatever, that then motivates the compulsive behaviour.  

But the problem is the compulsive behaviour then strengthens the feeling that you’re responsible. It also increases the likelihood that you’ll have more intrusive thoughts and round it goes in vicious circles.  

Much of what we see in cognitive behavior therapy are vicious circles. And that’s because in cognitive behavior therapy we’re not working with what causes problems because the reality is, we don’t know what causes mental health problems. And it’s really quite astonishing. We know a few things that make it more likely, but we can’t say, “That’s the cause,” or whatever.  

So what we work with is why it is that these problems are so severe. Because everybody gets anxious, but for some people it’s more severe, and then why are they so persistent.  

Lucy: And trying to minimise those or change the things that are keeping things going.  

Paul: Well yes, in OCD one of the things that people experience are ghastly thoughts which are torturing to them and so they try not to think them. But the process of trying not to think them, then actually makes you think it more. The famous, try not to think of polar bears, then you think of polar bears kind of thing.  

Most of the things we’re seeing in OCD, and actually all other mental health problems, are people doing really sensible things – if you’ve got an unpleasant thought, try not to think it – which are actually counterproductive.  

That’s kind of good news because what it says is that at least some of what’s going on is that people are trapped in a pattern where if people can fully understand that and then try it out, they might well be able to then get rid of the problem.  

Lucy: I asked Paul about the evidence base.  

Paul: The evidence base is very clear. In psychological therapy terms CBT is the only show in town. And on average about 50% of people with OCD will completely resolve their obsessional problems with appropriate length and intensity cognitive behaviour therapy.  

About 70% of people will show very significant improvement which leaves about 30% of people who are not necessarily improving very much, for whom there are new developments like intensive treatments and so on. And so I think there’s some optimism around there. 

Lucy: I asked Ashley how things have changed for him. 

Ashley: I’ve come a long way since then. I can use a public toilet; I can use my own toilet without having to shower multiple times. I do a lot of cycling and occasionally you have to use toilets, the backs of trees, where there’s no sink to wash my hands and it doesn’t bother me and I can do that.  

Yeah, I think good therapy can make the world of difference and it’s certainly helped me make the progress that I’ve made.  

I certainly am not completely recovered. I’ve got a little bit of work to do still but certainly there’s certain areas of my OCD that I believe in the ‘C’ word, which is frowned up, ‘cured’. I feel confident in saying I’ve cured certain aspects of my OCD. There’s one area that I’ve not yet tackled and I’ve just actually referred myself back into therapy to tackle that last part of my OCD.  

Lucy: Fantastic. It sounds like you’re in such a different situation now to how you describe things being before.  

Ashley: Yeah, I mean it’s just little things, we shook hands before when we met and all I’d be thinking at one time is, what has that person touched? Have they just been to the toilet? Did they wash their hands? Did they just pat that dog? Did they just pick something up off the floor? So an innocent gesture of shaking hands, there’d be a million thoughts going through my head.  

I believe that recovery isn’t necessarily the absence of intrusive thoughts or anxiety. I think recovery is the ability to continue with your day, with your activities regardless of intrusive thoughts or anxiety.  

Lucy: I asked both Paul and Ashley what they would want to say to anyone experiencing OCD and considering having CBT.  

Paul: The advice is absolutely clear. If you think you’ve got OCD then go and see your GP. If you’re lucky enough to be in one of the areas where the improving access to psychological therapies services allows self-referral, you can self-refer.  

The other thing is, to start to talk to the people, to your loved ones, the people around you, because this thing about OCD being a secret and all this is important. And people often feel that families won’t understand.  

My experience is when it’s opened up, that people actually do recognise and are more likely to help and support you. And it can be helpful in CBT, for example, to involve family members. OCD is a horrible stealer of lives; it really does destroy people’s lives. And I think it’s a real mistake to suffer in silence, to not seek help because it can and is helped a great deal by appropriate treatment.  

But also that that’s very hard work. I’m not suggesting that it’s a magic wand that’s waved. It’s well worthwhile, but in a sense one of the things I say to people when we’re starting treatment is this shouldn’t be a hobby, this should be a job. If we’re working intensively, say let’s just do two weeks of beating the OCD and nothing else and that’s what you do. That’s going to be really, really hard work but not getting better is harder work. So difficult, but do it.  

Ashley: It is scary, but if you’re ready for it, if you’re prepared for it, it’s not as scary as you expect. But also I sometimes use the analogy; it’s a bit like learning to drive as well. Sometimes people pass the test the first time, but other people need two or even three courses, or more of lessons to pass the test. It’s the same with therapy sometimes. You might need more courses, perhaps with a different instructor, different therapist who might be teaching the same principles but in a very different way of working.  

Equally as well, there’s the saying, you only learn to drive after you past your test and I think it’s the same with CBT. As patients sometimes we only really learn the CBT after the end of our therapy when we learn to put it into practice on an everyday basis.  

Lucy: And are there other things, apart from CBT, that you found helpful in your recovery process? 

Ashley: Yeah, I think understanding the condition is so important. OCD is one of those things where knowledge is power and probably the only other thing to add, or I do want to say is that recovery is possible. We can get better from OCD.  

Lucy: That’s all for this episode. There’s loads of information in the show notes. There’s books, there’s web links, including links to the BABCP resources on personal stories of people who have had CBT for OCD and also other podcast episodes.  

So if you enjoyed this podcast episode, you might want to listen to the very first episode we ever made, which includes two people talking about their experiences of CBT for OCD. Or you might want to listen to episodes on different sorts of problems that CBT can help with, for example, hoarding disorder.  

We’ve also got new episodes coming up about how CBT can help with chronic fatigue syndrome and with post-traumatic stress disorder.  

This podcast is brought to you by the British Association for Behavioural and Cognitive Psychotherapies, or BABCP. For more information about how to find an accredited therapist, check out babcp.com.  

 

END OF AUDIO 

 

 

Maggie's flat was so full that the council threatened to clear it out themselves. CBT helped her understand the reasons behind her hoarding disorder and start to let go of some of her possessions. 

Maggie and Dr Victoria Bream speak to Dr Lucy Maddox.

 

Show Notes and Transcript

Podcast episode produced by Dr Lucy Maddox for BABCP

Want to know more? Some useful resources are included here. 

Websites

For more about BABCP check out: babcp.com

To find an accredited therapist: http://cbtregisteruk.com

Hoarding UK's website has resources including support group listings: https://hoardinguk.org/

Centre for Anxiety Disorders and Trauma website:

https://www.kcl.ac.uk/ioppn/depts/psychology/research/researchgroupings/cadat

Books

Overcoming Hoarding by by Satwant Singh (Author), Margaret Hooper (Author), Colin Jones (Author)

https://www.amazon.co.uk/Overcoming-Hoarding-Self-Help-Behavioural-Techniques/dp/1472120051

Transcript

   

Lucy: Hello, and welcome to Let's Talk about CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT. What it is, what it's not and how it can be useful.  

In this episode, we're going to find out about hoarding disorder. I speak to someone who has experienced hoarding and the treatment for it and a clinical psychologist who specialises in CBT for hoarding disorder.  

Maggie: My name's Maggie and I've been fortunate to have received therapy in a group and individual therapy. So, I would like to be able to share some of my experience that I hope will be of help to people.  

Lucy: Could you say a little bit about how things were for you before therapy? 

Maggie: Hoarding is how I coped with life because it kept people out and it kept me in, where I didn't have to deal with the outside world. Being alone has always been my comfort zone.  

Lucy: So, it kind of kept you from having...  

Maggie: Kept things at bay. I saw the outside world and people as the ‘other’. The enemy. That's what I've had to deal with. There was a lot of pressure from the borough where I live with the fire risk that hoarding causes.  

Lucy: So, you were quite unsure about it to start with? 

Maggie: I wasn't happy because I was being challenged and I felt threatened. I had a way of life that suited me.  

Lucy: Is it okay to ask what your house was like? 

Maggie: It's a council flat that I've had for 18 years, now. It just built up and up. I just didn't try and stop it. I have always seen books as my best friend. I always felt books would be the solution to my problems.  

When I retired 13 years ago, I was able to indulge in a lifestyle that I'd always wanted, where I'd just ride around on buses and read what books I want. Go deep into things and study what my hobbies are.  

Lucy: It sounds quite nice, actually.  

Maggie: Well, it is. It's a selfish life. But family life didn't mean happiness to me and relationships didn't spell happiness. My comfort zone was living life vicariously. Learning about life and people through biographies, books, magazines, rather than going straight in to the physical reality. Which suited me.  

Lucy: I'm sure a lot of people can recognise that. There's something very nice about that, isn't there? But it sounds like it was really getting in the way.  

Maggie: Well, it doesn't give you deep, ultimate satisfaction. You're always on guard, in a way. When I first started individual therapy, it seemed very threatening. But it isn't threatening, now. It's almost like I can feel creative more instead of not moving beyond that defensive position.  

Lucy: We'll hear more about Maggie and her reasons for hoarding later. But first, here's Dr Victoria Bream, clinical psychologist at the Centre for Anxiety Disorders and Trauma and the Maudsley hospital.  

Victoria: Hoarding is characterised by a large volume of possessions in the home. Things can sometimes be somewhat organised but generally are in disarray. It can be a mixture of items, often paper, books. Also, food, clothes, bric-a-brac. Things inherited from other people.  

All these items are of such a volume that someone's home is difficult for them to use in the way for which the home was designed. So, the bathroom... The bath may be full of clothes. In the kitchen, there might be books all over the worktops. We'd characterise it as hoarding disorder when someone's life is actually impaired and they're experiencing a certain amount of distress from this.  

I think everybody has the capacity to form a strong attachment to any item. People with hoarding difficulties, for various reasons – some of which we understand and some of which I think we don't – form that level of attachment to a greater number of objects.  

Lucy: Has it made you think about your relationship with possessions differently, doing this work? 

Victoria: Oh, constantly. I think that might be one of the things that draws me to it. I really get it, with understanding how possessions can mean so much. My home is far from immaculate and I hang on to all sorts of things for sentimental reasons.  

If my children give me a picture that says, "I love you Mummy" on it, in that one second they give it to me, I feel very attached to it. I can't let it go. There's no way I could rip it up and put it in the bin.  

I think it's made me think about how we're all kind of battling with these beliefs about possessions. What is it that then tips it over into being something where it becomes a problem that takes on a life of its own.  

Lucy: What's CBT for hoarding disorder like? What does it look like? 

Victoria: At the moment, the main work we do is based on the work of Gail Steketee and Randy Frost and colleagues in the States. They've been working on things in the last 20, 30 years or so to come up with a CBT model.  

They have identified the main beliefs that people have about possessions. So, having an emotional attachment to possessions. Seeing the utility of an object far more so than other people might. So, everything would have a purpose. A yoghurt pot, once the yoghurt has gone, isn't just a container. It could be a plant pot. Also, the intrinsic beauty and aesthetic properties of objects. These things seem to be particularly potent belief systems in people with hoarding problems.  

The Steketee and Frost model also acknowledges the influence of past experiences, early experiences, whether there's a familial history of hoarding problems, whether people have experienced a trauma or other kind of life event that might precipitate hoarding in some way.  

Also, there's a component of information processing differences. So, that's much more tricky to investigate. There are a couple of papers that do look into that but there's a lot more we need to learn about the way that people handle information and how it affects their ability to order the items they do have, make decisions about the things that they do have in terms of discarding, and then how to carry that plan out.  

Lucy: That's really interesting. If I were sitting working at a desk that's really cluttered, say for example... (Laughter) I'm thinking of my desk, which is quite cluttered! That could have an impact on how our attention is? 

Victoria: When we're working with people trying to make decisions in their home, sometimes just the volume of stuff around them makes the decision process difficult. Peoples' attentions flip from object to object.  

We quite often get people to bring bags of things to the office and say, "You can take it all back home again if you want. But let's try and sort through it while we're here." People are usually quite effective at doing that. Not everybody. But we get people to stick things in the recycling and the bin or take them straight to a charity shop.  

Lucy: You mentioned about early experiences sometimes having an effect or an impact, or perhaps it being more likely for someone to have a hoarding disorder. Could you say a tiny bit more about that? 

Victoria: Yeah. What's in the literature so far is that, if people have had some family history of hoarding, that might be associated with hoarding themselves. They've just grown up not knowing another way of doing things but to have a lot of clutter. And then often inherit those items into their own home, as well. So, have two houses' worth of stuff in one go.  

Sometimes if people have come from very impoverished backgrounds where they haven't had enough when they were growing up, then when they have had the means to buy things and acquire things, it's felt very loaded to keep those items. It would be extremely wasteful to get rid of everything. Then it's working with people to update those beliefs and think, "Is that a helpful idea to have around at the moment?" 

Lucy: So, how did Maggie find CBT? 

Maggie: We looked at why I was doing this. First of all, the big change for me was being unconditionally accepted because I'd never had that from my parents. It was an emotionally cold upbringing, like some people have.  

I think the common element in hoarding is some sort of, I feel, very primal trauma. Where you're not given unconditional love and acceptance, for whatever specific reason. I think that is the basic that you have to feel because every baby really does need unconditional acceptance, otherwise it won't feel love. It's about replacing fear with love. It sounds simple but it's not easy.  

Lucy: No. I was going to say, how does that happen? What would I have seen if I was in your therapy sessions? What kinds of things did you do or talk about? 

Maggie: Well, we reviewed the week and set an agenda through how things had developed. And looked at what I had or hadn't done. I found it particularly helpful because it helped to ground me. Because I tend to be a bit above it all and beyond it all. I've had to look at those issues. To look at why I don't really want to be here.  

I think you have to face your fears realistically and see what can be done about them. I think the only way to deal with them is to deal with things in small amounts. Take a few steps at a time.  

Lucy: As part of the therapy, did you have to throw things away? Was that part of it? 

Maggie: Yes. Discarding. Which I did resist. I still haven't got rid of all my books and I think, "Yes, I must read this. I must read that." It's working to a system of priorities.  

It's quite surprising that things don't always have the effect you think they will. You don't know, until you've done it, whether you've done the right thing or not. I found it quite easy to discard clothes. As I got rid of a lot of books, I found I didn't really miss them.  

My clutter was really quite bad. It was all mixed up with clothes, books and food. I've just gradually and slowly had to learn to separate different classes of items. Paperwork... I don't like dealing with paperwork. If you don't get the mundane sorted out so it doesn't support you then that's going to make things even worse. Because you spend so many hours looking for things.  

Lucy: Is that what you found was going on before? 

Maggie: Yes. Very much. I was being hounded by my housing officer, as well.  

Lucy: So, discarding is one of the things that you worked on in the individual work. Were there thoughts that you talked about, as well? 

Maggie: Learning to come into... I keep saying, "The outside world" because that is the biggie, with me. That's the bottom line, for me. I belong to several social groups for retired people and I've joined a committee there that I would never have done a year or so ago.  

And, for the first time ever, I feel that I would like to help other people. That is a new one, for me. Because I never saw outside myself. Gradually, with the very good therapy I got, I realised that people are more important than books.  

Lucy: Victoria told me a bit more about CBT for hoarding.  

Victoria: It's often tempting to think that people need a practical solution to the problem. That someone like a support worker will come in and just say, "Right, where do we start?" For a lot of people, it's about unravelling quite a lot of distress and upset. Only then can you actually approach making some decisions to discard the items.  

Lucy: I guess because people might just then fill up again with other items? 

Victoria: Yes. I think, anecdotally, that's what... I work with the local councils around here. They've all said that they've done that. They call them, "Blitz cleans". They go in. They take everything out. Chuck it all in a skip. Scrub everything. The person whose home it is, if they haven't consented to that, is obviously really upset and unlikely to engage with services in the future, and reaccumulates possessions.  

We advise the councils around here to try and encourage a very understanding and psychologically minded attitude towards hoarding problems. As well as going through possessions with people and thinking about, "Do I really need it? Or do I want it?" Trying to get the distinction between the need and the want. This can be really tricky. So, trying to disentangle that very strong emotional attachment to a lot of things.  

Also, spending lots of time talking about whether the possessions do actually fulfil the function that people hope that they do. Objects connecting people to their pasts. Do the objects actually do that? Or do they hold someone back from getting on with their life and actually make them feel miserable, sad and less able to take new opportunities?  

Lucy: As well as individual cognitive behavioural therapy, Victoria is involved in a really exciting project set up by the local fire brigade, who were worried about local residents who were hoarding and wanted to help. 

Victoria holds group sessions at the local fire station using CBT principles. 60 people have attended over the last year. There's often about 15 people in the group.  

Victoria: It's been amazing to see the actual support nature of the group. The magic that's worked between the participants of... Someone admitted a couple of weeks ago that they'd blocked their front door. This was a very well-presented person who you wouldn't imagine would be in those circumstances. The other people in the group were so moved that he could say that.  

It then made other people sort of say, "Well, actually I've got to the point now where I can't use my bath." This kind of thing. Acknowledging the extent of the difficulty. Just being part of that process of people moving towards thinking, "Well, I'm going to have to face up to this problem."  

And describing the possessions that they're keeping to each other in the group. Saying, "Well, can't you give them away?" She was like, "Oh, no. They're too rubbish to give away." The penny dropping then about, "Oh, I can't give them away. And why am I keeping something rubbish for myself?"  

Trying to facilitate that group so that people then go home and take action off the back of these insights. Then, when they come back to the group maybe next week or a few weeks later, people take great pleasure in reporting back and saying, "Actually, I did manage to do this."  

Lucy: Maggie has attended the group.  

Maggie: It's fun.  

Lucy: It's fun? Really? 

Maggie: I had such a laugh at the last session. It was like, "Carry On Hoarding". (Laughter) 

Lucy: It sounds like it's really supportive and light-hearted, in some ways.  

Maggie: Yeah. Because I do think you need a sense of humour. If you can laugh at yourself a bit, it puts things more in perspective. There is hope out there.  

Lucy: What would you say, if someone is listening to this and they think they might have a bit of a difficulty with hanging on to things for too long or if they're experiencing—like you did—somebody telling them that they need to work on that? What sort of advice would you give? 

Maggie: I would say don't listen to people who don't understand what you're going through. It seems to be that one of the problems is other people find it incomprehensible. They don't understand. I think it's a silent neurosis. It's anti-social but it's hidden.  

It's very good to meet people who think similarly because there's an instant, unconditional acceptance. You've got the group support. People will listen to you and they will give you advice that will help you because they're in a similar position.  

It has changed, albeit slowly. Sometimes it's two steps forward, one step back. What I've learned is that I have to be compassionate to myself and realise it will take time.  

Lucy: I asked Victoria about the evidence base for CBT for hoarding.  

Victoria: Well, it's still the only treatment, really, that's recommended for hoarding problems. The way I always try and explain it when I'm talking to people in the wider public is... In the Centre for Anxieties and Trauma here, if someone came in with a phobia, a panic problem, OCD or PTSD, we'd be pretty confident at the beginning that someone would walk away with quite significant change in their distress and their symptoms. And, with any luck, actually losing the diagnosis entirely or certainly to be well along the road to that. Whereas with hoarding problems, we're definitely not in that position.  

Even the really wonderful studies that have taken place – Gail Steketee, Randy Frost and colleagues – are still looking at 50-70% of people reporting some improvement. But not radical improvement either, necessarily.  

Studies are coming out a lot at the moment, since the reclassification as a separate disorder. I think there's going to be some nice updates to the literature continuing in the next year or two.  

Lucy: It's a field that's still quite exciting, actually, isn't it? It's quite emerging and ongoing.  

Victoria: Yeah. And that is what I would say to anybody who has got an interest in hoarding. It's still something that a lot of services don't offer treatment for. It is in the DSM, now, as a separate disorder. It does cause people a lot of distress and upset. It perpetuates all sorts of other problems.  

We know from epidemiological data that people with hoarding problems are more likely to have a physical problem, like heart condition or diabetes. So, there's this big public health disaster, in a way, associated with hoarding problems. But it's still a problem that everybody is preferring not to talk about.  

What I think we don't understand at the moment is what's normal behaviour. What do most people do, in terms of keeping possessions? How do people decide how to have a clear-out and how do they do it? I'm hoping, if we could shed some light on those processes amongst people who don't have a problem with an accumulation of possessions, it might help us to further understand what happens when people do have difficulties discarding.  

Lucy: Are you doing research into that at the moment? 

Victoria: We're just working out a research question on that at the moment, which we think would be quite an interesting and a fun one to do. In terms of just being able to get it out there in the general population and say, "Well, how do you do it?" Like you say, it is sort of in the public eye at the moment. How we cope with our possessions.  

What we know is that, even within people who acquire a lot of things and who enjoy shopping, not all of them keep all those possessions. So, quite a big percentage of people who acquire a lot will then take those items back, sell them on or give them away or whatever.  

Whereas we know for hoarding... And it's a distinct thing. Also, people aren't always buying things, they're picking stuff up from the street. Picking stuff up out of bins. They are very good at knowing where free things are and accumulating things in that way.  

Lucy: I spoke to Maggie about how she thinks hoarding and decluttering is talked about in the media.  

Maggie: What I've noticed on television programmes, probably for entertainment purposes, is they tend to choose people with a fair amount of space. Probably because it's not so boring watching it. I don't know. It's the same with their financial problem programmes. They'll always have people who are on a middle-class income. "How to cut down."  

But they never deal with the grass-roots people on benefits or people in small places who are finding it difficult to cope. So, I feel those of us who come from that sort of background have a less visible impact.  

Lucy: And actually, it's really important, isn't it? There should be more about that. Thank you so much.  

Maggie: Good luck, everybody.  

Lucy: That's great. Is there anything else you'd want to say to people? 

Maggie: Just don't be afraid to ask for help. Because there is hope out there.  

Lucy: If you'd like more information on CBT for hoarding, have a look at the show notes. For more on CBT in general, and for our register of accredited therapists, check out BABCP.com. And have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with. 

 

END OF AUDIO 

 

 

 

Hearing voices is much more common than used to be thought, but what if they're cruel voices that seem to try to stop you from living your life? 

Chris Shoulder talks to Dr Lucy Maddox about how he uses CBT techniques to manage his experience of voices and Dr Emmanuelle Peters explains the theory behind the treatment. 

 

Show Notes and Transcript

Here are some resources if you'd like to find out more information. 

Podcast episode produced by Dr Lucy Maddox for BABCP

Websites

If you'd like to know more about BABCP check out the website: http://babcp.com

If you want to find an accredited therapist look here: http://www.cbtregisteruk.com/

Chris has also written about his experience of CBT on the BABCP website: 

https://www.babcp.com/Public/Personal-Accounts/Chris-S.aspx

Hearing Voices Network is an organisation providing a network for people who hear voices.

https://www.hearing-voices.org/tag/voice-collective/

PICuP Clinic where Emmanuelle and Chris work is here:

https://www.national.slam.nhs.uk/services/adult-services/picup/

NICE guidelines for service users/relatives are here: www.nice.org.uk

UK based organisation the Paranoia Network is here: www.asylumonline.net/paranoianetwork.htm

Mad Pride campaigns against misunderstanding and discrimination experienced by people who are seen as ‘mad’ or mentally ill www.madpride.org.uk

This website offers an alternative perspective, practical advice and email support to people who are interested in exploring the idea of spiritual crisis. There are some local groups, for example in London. www.SpiritualCrisisNetwork.org.uk,

 

Books and articles

Overcoming Paranoid and Suspicious Thoughts. Research suggests that 20–30 per cent of people in the UK frequently have paranoid thoughts. This is a practical self-help guide.

https://www.amazon.co.uk/Overcoming-Paranoid-Suspicious-Thoughts-Books/dp/1845292197

Overcoming distressing voices, Mark Hayward, Clara Strauss, and David Kingdon, 2012, London: Constable and Robinson. A self-help guide based on a cognitive behavioural approach.

https://www.amazon.co.uk/Overcoming-Distressing-Voices-Books/dp/1780330847

For an article about CBT for psychosis by Lucy click here: https://www.theguardian.com/science/sifting-the-evidence/2014/may/20/cbt-psychosis-cognitive-behavioural-therapy-voices

 

Other media

A History of Delusions - radio 4 series by Dr Dan Freeman

https://www.bbc.co.uk/programmes/m0001d95/episodes/player

Voice hearer and psychologist Eleanor Longden talks about her experiences in this TED talk.

https://www.ted.com/talks/eleanor_longden_the_voices_in_my_head

 

Credits

Editing consultation from Eliza Lomas

Music by Gabe Stebbing

Image by Justin Lynham via Flikr Creative Commons

Produced by Lucy Maddox for BABCP

 

Transcript

Lucy: Hello, and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not, and how it can useful.  

In this episode we’re going to find out about CBT for psychosis.  

I went to a specialist clinic in London called the PICuP Clinic which stands for Psychological Interventions Clinic for Outpatients with Psychosis.  

I spoke to Chris who works there and who’s experienced psychosis himself and the treatment for it.  

Chris: I am Chris Shoulder and I manage the peer support network. I get together with people as well and we sort of kind of try to see what we can do for people who are waiting for the therapy, and with people who’ve had their therapy and get them together. A bit of mentoring kind of thing really.  

But it’s also that they can speak to somebody who actually knows that the therapy’s about and they’ve been through the whole process. And they can allay any fears that anybody might have.  

Lucy: Oh that sounds great. So it’s perfect to be speaking to you because this podcast is trying to sort of help explain to people what CBT for different sorts of problems is like. Some people might not know what psychosis is actually, and it’s quite a kind of technical word. Would you give your definition of it?  

Chris: Well, psychosis I think is like the umbrella term for lots of different things. You may be experiencing kind of things that are not considered the norm, whatever I guess what the norm is. You might feel like you’re being watched or as one person I worked with thinks they’re being “surveilled” as she puts it. Or you might be hearing voices. You just don’t feel right. You feel kind of maybe that you're being victimised or there’s people talking about you or people can read your mind.  

I mean there’s so many kind of anomalous things that make up what psychosis is. And then apart from that you might feel really anxious. You feel depressed. You feel confused as well with it.  

And it’s quite a baffling thing to experience and to kind of describe because there’s a myriad of things that go with psychosis. Yeah.  

Lucy: For people who aren’t sure what a dissociative episode sort of means or kind of feels like, would you mind explaining a bit what it’s like?  

Chris: Yeah. It’s this kind of feeling that you become detached from the environment around you. And I’d feel sometimes that I was almost like watching myself. It was like, I always describe it like being the star of the film and watching the film at the same time.  

You feel like the solid objects, maybe I’m quite solid and everything’s kind of like knocked slightly sideways. I always have difficulty describing it because it’s very abstract but it’s very terrifying when you don’t know what it is.  

And I still occasionally have them but now I’m kind of like twiddle my thumbs. I’m like, “Do-do-do-do-do, get on with it.” And carry on because I’m in charge of it. Even though it can come on randomly, I am in control of these things now, I feel.  

I mean I think the first time I had it I thought… I felt like there was another entity inside my body. That’s how strange it feels and it’s very disconcerting. It’s horrific actually the feeling, it’s terrifying.  

But with some quality CBT you can take it on head on and you can think, “Right, well I’m not having it, it might happen still but I’m going to own it and I’m going to be me.” And I let it kind of wash over me now if it happens occasionally and that’s it. It’s gone. I feel tired afterwards because it’s quite an exhausting experience. But afterwards that’s it and I get on with whatever I was doing at the time.  

Lucy: Wow. It sounds really intense actually and very frightening and, yeah, so to be able to kind of ride that instead.  

Chris: That’s a really good kind of way to describe it. You’re riding it. When it first happened it was like being on the top of a rollercoaster and you’re peaking at the top and you never quite go over the edge. It’s this feeling of, “Urgh, uh, uh.” And I could feel it. It’s like physical in the back of my head.  

And then I got to the point where I could actually tell when they were going to happen by this feeling in the back of my head. And I’d be like, “Okey dokey, right,” you know like? “Buckle up, it’s going to happen in the next day or two.” It’s still a little bit like that but it’s very, very rare now that I have it. But I manage it.  

I think it’s about talking about what like a healthy brain is. It’s whatever’s healthy to you I think and what you're managing, what you can live with and what you deal with properly and feel safe about.  

And I feel great. I feel like a changed person because I was absolutely so chronically ill with a various array of mental health issues. I feel great now though.  

Lucy: Yeah, you look great.  

Chris: Yeah, thank you.  

Lucy: Really spunky.  

Chris: Yeah, I feel it. (Laughter) 

Lucy: I also spoke to Dr Emmanuelle Peters, clinical academic psychologist and director of the PICuP Clinic.  

I asked Emmanuelle how common it was to have unusual experiences like those that Chris describes.  

Emmanuelle: So more people have anomalous experiences such as hearing voices in the general population than you might think. Most of them do not go onto develop psychosis. And for many people they have these experiences without actually causing distress. And that’s very important to know because it’s not necessarily the nature of the experiences which is abnormal. But it’s more the fact that they lead to distress that as therapists we need to take into account.  

The fact that we know that people have experiences without distress means that people that we see can actually learn to perhaps deal with their experiences differently or think their experiences differently if they want. So we’re not about just necessarily eradicating these experiences because people in the general population do have them and can live with them and be perfectly healthy.  

Lucy: Great. So it’s more about their kind of the meaning making, the sense that people make of their experiences rather than necessarily getting rid of them?  

Emmanuelle: Yes, absolutely. So we don’t aim to change anybody’s view necessarily. We don’t aim to change their view of the world. We don’t aim to necessarily get rid of voices although for some people that’s what they’d like. But what we aim to do is help people to cope with them, to think about them slightly differently, to learn to have a different relationship with them. And basically to try and reach the valued goals that they have and decrease the amount of distress that these experiences cause in their daily life.  

Lucy: Chris told me more about what hearing voices is like for him.  

Chris: The voices when they started, they were in – it was kind of in my head. However, my head felt the size of the TARDIS. It was like huge. It felt like it had expanded.  

A lot of people say the same thing. They’re down on you and they kind of say, “You're useless, you’ll never amount to anything,” or mine used to, I’d be doing something and they would say like, “You were trying to put the kettle on, weren’t you?” or something really random. And it would be, “Well I’m not going to let you. You’re not going to do that. You’re useless. You can’t even put the kettle on.” And there would be a lot of blue language as well that came with it obviously.  

And then it kind of, there was a mixture of stuff as well which is also hard to explain. It would say things but there wouldn’t be any words. It was just like you’d understand it as a whole without the thing. So you’d understand the meaning of what it was but there wouldn’t be any words. But it would be still kind of… that was still kind of negative. A lot of it was negative.  

And then there would be sometimes random sounds as well. So I can remember I was out once walking with my dogs when I had this episode came on. And it started to go, “Squish, squish, squish, squish, squish,” making this sound because it had been raining. So it was making these random noises.  

And then on the other hand, which was quite funny, I was walking down the road and I was thinking, “That’s odd, I’ve got my own personal stereo now.” And it started singing of all things a Fleetwood Mac song to me. And I was kind of like, “Oh yeah, this isn’t so bad.” Like then. So I was walking down the road, I was thinking, “That is just bizarre.” So it’s kind of, it was from one extreme to the other.  

And now it’s kind of I get it. The voices. It’s just such a strange thing to say ‘it’ but when the voices happen occasionally they come now with the dissociative episode at the same time. And I kind of let them say what they like because I know it’s all tosh, frankly.  

For me now it’s more interesting to think which part of my brain is doing this? I would love to know that. I’m more interested in kind of learning about where it happens than the actual event itself now.  

Lucy: I asked Emmanuelle what happens in CBT for psychosis.  

Emmanuelle: So cognitive behavioural therapy for psychosis is basically looking at the types of experiences that people have, seeing what kind of goals they want to reach, and trying to work together with the person to look at how they’re dealing with their experiences, how they’re thinking about their experiences. And perhaps learning together to find a new way of thinking about them or new ways of dealing with them such that they cause less distress.  

So a lot of CBT is about identifying the vicious cycles that people find themselves in and helping them to get out of these vicious cycles. And in psychosis often these vicious cycles will include hallucinations and paranoia and other distressing anomalous experiences.  

And so it’s quite similar to other types of CBT but the nature of what you’re working with can be different.  

Having said that, also for a lot of people who hear voices, for instance, they also have other emotional difficulties. Sometimes they’re very lonely or anxious. And sometimes they can deal with their voices better than actually waking up in the morning and sort of feeling despair of having no socially valued roles, sort of a lack of relationships and that can be more distressing for them. And we will always engage with the person with what is distressing for them, not necessarily what’s abnormal.  

So sometimes people will say the voices are fine but I would like some help with being able to go to the shops on a regular basis, to find some work perhaps or find ways of having more meaningful relationships with people.  

We’re very much about empowering people to lead the lives that they want to lead.  

And I guess one of the differences in CBT for psychosis and perhaps other types of problems is that it can be sometimes trickier or take a bit longer to engage people because they may not trust you, they may worry that you’re going to get them sectioned, or they may think that you can read their thoughts or that you’re part of the conspiracy. So we do work very hard at engaging people and seeing things from their point of view. Perhaps more so than you need to do with people who come with say my main problem is depression or anxiety.  

Lucy: You mentioned about vicious cycles that people can get into. Would you be able to give an example of a type of vicious cycle that might crop up with this type of problem? 

Emmanuelle: Often people get into vicious cycles because of what we call safety behaviours. So a safety behaviour is something that you do when you're scared of something to keep yourself safe.  

So, for instance, if you believe that you’re going to be killed when you go outside because there’s a conspiracy against you and there’s people outside waiting to basically kill you in some way, then the likelihood is that you’re going to keep yourself at home and you’re going to keep yourself safe.  

You’re going to be looking out for noises of people perhaps surrounding your house, or unusual noises that mean that there’s somebody outside with a gun.  

So, of course, if you're staying at home to keep yourself safe and you’re hypervigilant as we would call it, you’re looking out for noises, two things are going to happen. One is that the more you look out for noises the more you're going to hear them. And of course if you’re in a state of fright and state of being really anxious you’re going to notice all sorts of noises and they’re going to have a really sinister meaning. And that’s going to confirm your view that there’s likely to be somebody outside.  

And, of course, if you don’t go out then you never disconfirm your fear. So you never find out that actually there is nobody outside to kill you. And the more you then stay indoors, the more isolated you get and the more depressed you get. And you get caught up in this vicious cycle.  

So our job as therapists is to try and get the person to take risks so that they’re able to expose themselves to their fear situation so that they learn that their fears aren’t true.  

Now, of course, when somebody believes that they’re going to be killed that’s a tall ask and that’s why you have to go very slowly with people with paranoia. But nevertheless what it is is a vicious cycle.  

Lucy: That’s really useful. I was just thinking about voices and are there any particular strategies that CBT offers to help people manage voices? That must be just so hard having voices sort of chatting in your ear all the time, particularly if they’re saying things that aren’t very nice.  

Emmanuelle: We would work with coping strategies, helping people with coping strategies. But also very importantly with voices we would try to change their meaning.  

So you might have day-to-day coping strategies that might just be able to counteract the sort of voices that are going on and on and on at you. So you might, for instance, hum. Just the process of humming slightly might actually interfere with hearing the voice and might be able to get a bit of respite from the voices.  

Depending on which kind of situations people hear voices, you might be able to just listen to music to drown them out, listen to the TV or basically having another noise that counteracts them.  

And that can happen for a short-term basis. But of course you can’t hum all day long. And you can’t wear headphones all day long. So although they can offer some respite, it’s not necessarily a long-term strategy.  

And what’s very important though is to use the fact that people can actually stop the voices even if that’s temporarily to increase their sense of control over them.  

Similarly, the beliefs that people have about powerful voices can be extremely distressing. So they have the power to make things happen against you. So not only are they malign voices that mean you harm, but if they have the power to actually carry out their intent then that can be extremely distressing for people. And then they spend a lot of their time trying to mitigate the power of the voices.  

So there’s all sorts of different ways in which you can learn to cope with the voices with the ultimate aim of changing the beliefs that you have about the voices. And changing the relationship that you have with the voices that will allow you to be able to live with them in a less distressing way and in a better way and get on with your life despite the voices.  

Lucy: What is Chris’s experience of this? Was it enough for him to control the voices rather than get rid of them?  

Chris: I don’t think you ever get rid of things. It’s about accepting them and learning how to deal with them. And that’s what a good therapist does and that’s what CBT does, whether it’s bipolar or kind of hearing voices or kind of all the rest of it, psychosis.  

Lucy: Could you say a little bit about your experience of CBT?  

Chris: My experience of CBT, actually at the PICuP Clinic was incredible. It turned my life around. It revolutionised my recovery. And I mean I’ll always be in recovery. But it was just incredible and it was like a… it became less of a therapy session and more of a learning session. And it was a collaborative session.  

There was kind of a lesson plan, if you like, from the therapist. And we would decide what we were going to do each session. I began to feel really engaged with it. Because I was having things like dissociative episodes, and I was kind of hearing voices and I’d be kind of… or sometimes it was just like sounds. Occasionally I was having these kind of really weird delusions and imagining that I was being touched and stuff like this.  

And it made me make sense of that. And I think for the first time I understood that it was down to me to make myself better with the help of a therapist.  

Lucy: So it sounds like sort of quite hard work actually, isn’t it, along with it being a really beneficial experience. It sounds like there’s quite a lot you have to put in.  

Chris: Yeah. I mean, yeah, you can’t just kind of like sit back and kind of think, “Okay, well I’m feeling a little bit better.” You’ve got to keep on top of it.  

Lucy: Yeah. Yeah. So I’m really interested in how you describe it because recovery is sometimes a bit of a controversial word actually. I’ve read some stuff about people saying they don’t like the word because it feels like you have to get better, whatever better is. And if that doesn’t happen to you then you’ve kind of failed at that.  

But it sounds like the way you describe recovery it’s actually not like the things have gone away totally. It’s more like you have a different relationship with them.  

Chris: Yeah. I think it varies from person to person. And, like I said before, it’s what you can, not tolerate, but I guess what you can live with.  

It’s not about recovery because I don’t think you ever necessarily recover. But you learn to deal with it. Or you can learn to deal with it. And I think it’s one of these things that it doesn’t just happen. And even for me, I have to do a little check, think, “Oh yes, brain, how are you feeling today? How’s it functioning?” and things.  

Obviously I do still get depressed and I do get down. But I would think now it’s within normal parameters. I think it’s what generally most people would feel.  

Lucy: And are there any sort of particular strategies that you found really helpful?  

Chris: Mindfulness. And feeling like I’m in the present as well. And I think often people think too far ahead. I was talking to somebody yesterday who was having a really bad anxiety attack. And she was saying, “Oh I’m terrified about the future.” And I said, “Well the future hasn’t happened yet. Don’t think about it.” I said, “Do it in kind of like bite sizes if you like, small sizes. You don’t have to think about what’s going to happen in like 2021. Think about just what’s happening now.”  

So I think it’s taking charge of what’s happening in the present a little bit and that helps to kind of ground you, it helps to ground me because I was the same. I used to think, “Oh my God I’ll never work again, I’ll never do this, I’ll never do that.” That was all about thinking too far ahead. And now I'm in a place where I think, “My God, I never expected to be here.” And I actually love it. And it’s perfect for me. Completely different to what I was doing previously.  

Lucy: So what sort of evidence base is there for CBT for psychosis?  

Emmanuelle: So there is a reliable and consistent evidence base about CBT for psychosis. Most of the studies that have been done are for people who are already taking antipsychotic medication. So CBT for psychosis is very much adjunctive or on top of taking antipsychotic medication.  

And on the whole not everybody will benefit but around 50% of people will benefit in some way from CBT for psychosis. Whether that’s in terms of reducing the distress with their voices, or reducing them complying with threats or orders from their voices, whether it’s reduction of paranoia. But also reduction in depression or sometimes anxiety. Or other types of problems depending on what focus the CBT had. 

So in more recent trials people have used the outcomes that actually measure what’s happening in therapy. So, to give you an example, in one particular trial, what the trial focused on was reducing people complying with harmful hallucinations. So people who would hurt themselves or hurt others on the basis of commands that the hallucinations would give them. And the purpose of the trial was to reduce that compliance. And we therefore used a measure which was reducing compliance rather than seeing whether the hallucinations stopped or not. And we found that nearly 50% of people in the therapy group were 50% more likely to not comply with their voices than people in the other group. 

But their hallucinations continued. So we didn’t get rid of the voices which wasn’t the aim, but we did reduce the risk that they posed to themselves and others.  

And another movement in the evidence base is to just look at one problem at a time. Basically in CBT for psychosis in the clinic whatever the person has on their problem list is what you will do in therapy. So with one person that might be looking at how depressed they feel and like what motivation they have or the despair they feel in not having relationships. With somebody else I’d be dealing with voices. Somebody else with paranoia. And so on and so forth.  

So rather than trying to assess all of those things at once, the more recent trials have kind of targeted one area, one particular problem at a time. And then showed that these particular types of therapy for that particular problem was effective. And that literature has shown then much higher effect sizes.  

So to cut a long story short, there is a reliable evidence base for CBT for psychosis. And it’s getting stronger all the time.  

Lucy: I asked both Chris and Emmanuelle if they had any last remarks for people who are considering CBT for psychosis.  

Chris: Just to kind of reiterate, if you are scared, if somebody’s scared about having CBT, try it first of all and then if you don’t like it step away from it.  

I think also a good therapist, towards the end of the therapy should have things for their client to do afterwards. They should have places they could recommend for them to go and things they recommend for them to do or ways to get into voluntary work or just things that they’re not left high and dry when it’s finished. That’s what I think’s very important too.  

Emmanuelle: People have an idea of CBT in general being very much kind of thought police and it’s very short and it’s just like putting on a sticking plaster. But actually CBT for psychosis is not short. So NICE, the National Institute of Clinical Care and Excellence recommend a minimum of six months. So it’s not a short therapy.  

And it’s very collaborative and your therapist will be listening to your point of view and understand your point of view before trying to change anything.  

So it is worth thinking about just trying it out.  

Lucy: A huge thanks to both Chris and Emmanuelle.  

If you’d like more information on CBT for psychosis please check out the show notes.  

For more on CBT in general and for our register of accredited therapists, check out BABCP.com. And have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with.  

 

END OF AUDIO 

 

Most of us have some worries about how we look, but what if those worries get so bad they stop you being able to go out? 

Body Dysmorphic Disorder (BDD) is a serious problem but it can be overcome, as Gareth explains. 

Gareth and Prof David Veale talk to Dr Lucy Maddox.

This show includes mention of suicide.

Show Notes and Transcript

Podcast episode produced by Dr Lucy Maddox for BABCP   For more information have a look at...

Websites

The website of the BABCP is at babcp.com. 

To find an accredited CBT therapist go to http://www.cbtregisteruk.com.

The website of the BDD Foundation is at: https://bddfoundation.org/

You can find questionnaires, information, videos of people with BDD speaking about their experience and resources about where to seek help.

This Australian website has self-help booklets on BDD: https://www.cci.health.wa.gov.au/

Books

A really good book by David is this one: Overcoming Body Image Problems by David Veale and Rob Wilson.

Gareth recommends looking through when you're not too anxious, and persevering even if it doesn't reduce your anxiety straight away as it will help you hit the ground running with therapy.

Credits

Editing consultation: Eliza Lomas

Music: Gabe Stebbing

Picture: Vince Fleming from Unsplash

Transcript

Lucy: Hi, and welcome to Let’s Talk About CBT, the podcast made by the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not and how it can be useful.  

In this episode we explore CBT for body dysmorphic disorder, or BDD. BDD involves being really preoccupied with perceived defects in your appearance.  

Most of us will experience dissatisfaction about some aspect of how we look, but body dysmorphic disorder is much more severe. It’s really distressing and it really gets in the way of people’s lives.  

I went to hear first-hand about what it’s like to experience BDD.  

Gareth: Yes, my name is Gareth, I’m an ex-sufferer of BDD and I’ve had CBT for BDD in the past.  

When I had BDD I really believed that I was very ugly, that I had very deformed features and that other people would notice these and treat me differently because of them.  

I used to worry about my nose, that it was too big and that it was just sort of unattractive. That my face was too thin, this may sound funny, but that my head was too small for my body, proportionately. I guess there were some other concerns that my eyes bulged out of my head and things like that and that I was just too skinny overall. But I think the main things were nose and jaw.  

Lucy: Did it sort of creep up on you or did it happen quite suddenly? 

Gareth: No, I think it definitely crept up on me. It was interesting, in therapy, looking back and thinking where it started from; I had some very clear memories from earlier in life. When I was eight years old and then a little bit later, but then it crept in during my teenage years and it was only when I got to 17 or so that it really sort of mushroomed and the anxiety just became very disabling.  

I think because it becomes all encompassing, it starts to affect all areas of your life and a part of the condition is you develop a lot of behaviours in response to the preoccupation, I guess. So for me, I would often research surgical procedures online for hours on end or take photographs or videos of myself and analyse them for long periods of time. Or look in mirrors for long periods of time analysing my perceived defects and thinking about how I could change them or improve them.  

But also, avoiding a lot of things because of my concerns about the way I looked. I guess the two things operated in tandem. As the behaviours around mirror checking and things started to increase, then the avoidance did as well and I became more and more withdrawn from the world. It was really a very distressing and unpleasant period of time.  

Some of these activities, once you get hooked into it, once you look in the mirror and get the emotional reaction to how you look and start to check, or once you start to take photographs and get involved in that procedure, hours can just disappear and your mood just goes down and down as time goes on. So yeah, very time consuming.  

Lucy: Did it get in the way of you making friends and going out to social things?  

Gareth: For me I had a good group of friends up until age 19 or 20, but then it really did start to interfere with that and stopped me from seeing them and those relationships broke down, which made me feel more isolated and have more time to think about my appearance and sort of made the whole problem worse.  

But ultimately the anxiety was so bad that I couldn’t work for, I think seven years, which was probably a quarter of my life at that time. So it was a very long period of time.  

Lucy: It’s really hard for me to imagine you being so worried about that actually because I’m come to meet you now and you’re clearly professional and going about your business. It’s hard to fit those two together. So things seem to have changed a lot? 

Gareth: Yeah, they definitely have. I think they changed so much that sometimes I don’t… It can be hard to remember sometimes what it was like in the past, even though I only had the treatment, I think eight years ago now, no, nine years ago, sorry, I’m older than I thought. (Laughs)  

It’s hard to remember how things were sometimes because things feel very, very different now. I don’t really have BDD thoughts, maybe once a year at most, I look in the mirror, a thought will pop into my head and then I just think, no, I don’t do that anymore and that’s it. So yeah, I’m in a very different place.  

Lucy: I also spoke to an expert in the treatment of BDD.  

David: My name is David Veale, I’m a consultant psychiatrist at the South London Maudsley NHS Foundation Trust and a visiting professor at the Department of Psychology in the Institute of Psychiatry and Psychology and Neurosciences.  

Lucy: You’ve been quite a pioneer in the treatment of BDD, what got you interested in it? 

David: Well, actually in this building I remember treating, trying to treat somebody with BDD and being pretty hopeless. That was when I was a trainee, so it was at least, blimey, 30-35 years ago (laughs).  

I remember when I was first appointed as a consultant we did treat somebody with BDD who went on to commit suicide a few days after he was admitted. I think that did have a major effect on me. At that stage nobody really knew what BDD was or how best to treat it.  

The awareness of these sorts of problems is increasing; it’s a lot better than it was say 10-20 years ago, but there’s always more to be done.  

I think the problem is that it’s not taken seriously enough. I think often people treat it as body dissatisfaction. We’re all dissatisfied, but this is something quite different. What we’re talking about here is something that’s quite significantly distressing and interfering in their life and usually associated with many repetitive behaviours, particularly things like checking in the mirrors or checking their appearance in some way, or constantly comparing and ruminating all the time.  

It’s a different league to normal body dissatisfaction. I think if people recognised or understood how severe it was, or in terms of the suicide risk and so on, then I think it would be taken more seriously.  

Lucy: Is it similar to what people experience when they have an eating disorder or is it different?  

David: It’s not quite the same as an eating disorder. I mean there are a few people, usually with less severe problems who get very preoccupied by weight and shape and so on. And don’t necessarily have an eating disorder but then they have mild body dysmorphic disorder.  

But usually with body dysmorphic disorder people are much more preoccupied with features around their face, particularly the nose or their skin and their chin, their hair and so on. Although any part of the body can be the main features that [people] get preoccupied by.  

Lucy: It must be kind of hard to find out if you have it, if you feel like it’s an objective reality, that you really are very ugly or something is very unusual about the way that you look. How do people tend to find that they’ve got this problem? 

David: Well, by definition most people believe that this is a problem to do with their appearance and so they don’t generally tend to seek help from mental health professionals. They’re much more likely to seek help from cosmetic surgeons and dermatologists.  

And it’s only perhaps often that the pressure of family or friends to try to help them get the appropriate help.  

Lucy: How can cognitive behavioural therapy, or CBT, help with body dysmorphic disorder?  

David: Well, we’ve got a number of different studies now suggesting that cognitive behaviour therapy can help people to change their body image. In other words, prior to having CBT they may have very different body image in terms of what people see in their mind’s eye. After therapy then that body image can change, can be altered as such.  

But it is difficult. It is tough. It’s certainly not a wonder treatment and compared to other interventions in CBT for different types of problems, it’s not as powerful because it’s still a very difficult problem to solve.  

It may take 20-25 sessions to get a good treatment programme going. Very occasionally people who don’t make progress may be stepped up to a more intensive level of care. Very often it needs constant strengthening of more helpful ways of responding and dealing with the world.  

Lucy: What sorts of things would happen in the therapy room, if somebody was having CBT? 

David: The most important thing in CBT for BDD is first of all having an engagement, in other words, both having a mutual understanding of what the problem is.  

In this particular case the problem of course is the person with BDD believes that they have an appearance problem. Whereas the therapist and everybody else believes that they have a problem with being preoccupied and extremely concerned and worried about their appearance and having a different… in other words, a body image problem.  

And so individuals are invited to test out this alternative theory or understanding of the problem. And so that requires a lot of commitment in terms of trying to act and test out an alternative understanding of what the problem is.  

But we’re not going to directly challenge the content of those beliefs about the evidence for someone being so ugly or whether this person looks a particular way. What we’re going to mainly focus on is the processes that keep the problem going.  

And so in BDD we’ve identified a number of different thinking processes, particularly ruminating and the way you might analyse and go round and round and round, trying to ask yourself, why was I born so ugly or if only I hadn’t seen that surgeon and so on.  

In addition, people are constantly comparing themselves and socially ranking themselves compared to others. Of course they’re always at the bottom.  

They may be excessively self-focused on how they see themselves in that picture in their mind’s eye. They may be avoiding a wide range of situations or activities, or they’re using lots of what we call ‘safety seeking behaviours’. That is things that you do to perhaps try and camouflage or to constantly check on how exactly you do look.  

So there are lots of things that maintain and keep the preoccupation, the distress going and it’s these things that we try to target.  

Lucy: I asked Gareth about his experience of cognitive behavioural therapy.  

Gareth: So I had CBT and it was probably a little bit different from most people’s experiences of CBT in that it was residential CBT, so I lived in a unit for – ‘unit’ sounds very institutional doesn’t it? I lived there for five days a week, so Monday to Friday and went home on the weekends, for 12 weeks.  

The treatment really involved the therapist helping me to understand what sorts of things might be maintaining the anxiety in terms of my own thoughts, thought processes and how I engage with them. And then the things that then responds to those thoughts, or to the anxiety.  

So understanding how those things might be keeping the problem going and then starting to make some changes to those things and learning ways of doing things differently. A different relationship with my thoughts, I guess, and different behaviours, just to help me feel better.  

Lucy: Part of it was about understanding what might be keeping things going and then changing things. What sort of things were you asked to try to do differently? 

Gareth: I think the first step was to start to understand the thoughts, my feelings, the problem, and start to spot when they were coming into my head. And then to start to distance myself from those thoughts a little bit.  

I think in some therapy for other disorders you might try to challenge the thought, but in BDD, I think because the thoughts are so strong and the belief in them is so strong, that’s a bit of a futile task. So rather than trying to challenge the thoughts, learn to take a step back from them, see them just as thoughts and then not engage with them, not get on board with them.  

Lucy: That sounds quite useful for lots of different situations actually.  

Gareth: Indeed. It was.  

Lucy: What were the behaviours you mentioned that you were asked to do differently? 

Gareth: One of them was in relation to the use of mirrors. Rather than looking in the mirror and using that as a tool to scrutinise my appearance and critique my appearance, just using it in the way that normal people would. And I had to re-train myself to do that.  

That involved some relatively unpleasant experiments I have to say. So standing in a three-way mirror, which to me was the worst thing imaginable, but then learning to – when the thoughts came up – to detach myself from them by focusing my attention elsewhere. And then just to use the mirror just to do whatever I was supposed to be doing. And then walk away and switch off the thoughts. 

Lucy: When you say using a mirror like normal people, what do you mean by that? 

Gareth: I guess in the context of the three-way mirror, initially the practice was just to detach from the thoughts and distance myself from the thoughts. But I guess ultimately in that situation it would be to try on a jumper and see if it fitted properly. And then either buy it or put it back, but leave the mirror.  

Or with general mirrors in bathrooms and things, just to sort of, you might check your hair if you’re at work just to make sure it’s not sticking up. Or in the morning, just to brush your hair, to get a normal level of grooming that most people would, rather than spending an excessive time there simply focusing on what’s wrong and thinking about how you could fix that.  

Lucy: It sounds pretty full-on actually.  

Gareth: It was full-on. I remember when people used to ask me about the treatment, what it was like, I remember saying it was brutal. It really was. I think having to confront the things you least want to think about on a daily basis for weeks on end, it’s pretty tough.  

It’s just like you going cage diving with sharks every day. I think because some of the avoidance, there was so much avoidance in my life that having to challenge that and go against it and put myself in the situations that I had been avoiding, I was very fearful of, it did feel very, very hard.  

But that’s not to say that it wasn’t worthwhile because it’s completely changed my life. So I wouldn’t want that to put anybody off.  

Lucy: Did you experience changes in how you thought and felt by the end of those weeks? 

Gareth: Yeah, definitely. I think my anxiety level was greatly reduced in some situations, I think even after 6-8 weeks. After 12 weeks, things had markedly improved. But then some of the things had taken longer, obviously, for me to feel more comfortable with.  

Now years on, I have virtually no anxiety, which is a surprise from where I was back then.  

I also got quite involved with some support groups near where I lived in Bolton, for people with different disorders. It was just a support for people with self-esteem problems or depressions.  

I guess I’m mentioning that because it was really useful being able to speak with people who had similar problems at the unit where I had the CBT. It really normalised the way I was feeling, it made me feel that actually this is okay, this is on the spectrum of human experience. I am a person like everybody else, not some weirdo. I’ve got mental health problems.  

But I think for me that was started much sooner by getting involved with local support groups and some online support groups and things. I think that really helped.  

Lucy: Do you think it helps with worries – particularly about your appearance – does it help you to see other people who have a similar worry about their appearance, but that you don’t see in the same way? 

Gareth: Yeah, that was really interesting. I think particularly to see people who you find attractive who have BDD, I think that’s really like, “Oh god, really?” 

Lucy: I guess we live increasingly in a social media environment where there are a lot of selfies and you can airbrush yourself, even put ears on yourself and things like that. Do you think that change in the way we interact online has an impact at all? 

Gareth: I think it must do and thankfully I kind of missed this. I think Facebook was becoming more popular, maybe just before I had treatment or just after I had treatment, so it wasn’t a big issue. But I think it must definitely have an impact.  

I think there is research that shows that people’s concern about their image is becoming more prevalent with the rise of social media. But I think because it is essentially like a self-propaganda tool and nobody ever posts the worst picture, it’s all about trying to make yourself look good. It’s inconceivable that it couldn’t have an impact.  

Lucy: I also asked David what he thought about the impact of social media. It tends to get blamed for a lot, but David had some ideas about how it’s not the media itself, but the way it’s used that can be problematic.  

David: The way people with BDD tend to use selfies and so on is usually very much on their own. They’re not going to be doing it with others. And then they store hundreds of them on their phone or in a way that is unhelpful. It’s like a constant check as if you’re in the mirror.  

And so again, usually emotional criteria are used, that you may carry on doing it or looking at it until it feels just right or ‘just so’, in some way.  

It’s not used in the same way as it might be on Instagram or Facebook or something because they’re not going to post them anywhere. They’re primarily there to check exactly how they look.  

However, they may well be using Instagram and Facebook to constantly compare themselves in their own mind’s eye with what they see on other pictures on Facebook and Instagram.  

So this is another thing for constant ranking. And of course people with BDD tend to rank themselves at the bottom and other people are always better than them, so that it’s not helpful because it’s exactly the same thing they’re doing as they walk down the street and focusing in on a particular feature and then ranking themselves according to that feature. They see themselves as that feature or sometimes we call this, ‘I’m just a walking nose, that’s all that I am.’ 

Lucy: What’s the evidence base like for cognitive behavioral therapy for BDD? 

David: There’s been a few trials now, we’ve certain done one that compares CBT against a comparison like anxiety management, which was rated just as credible. But that was only 12 sessions. We were able to demonstrate that it was better than anxiety management and I and others have also demonstrated that it’s better than a waiting list.  

It’s not fantastic and that’s why we’re saying we probably need a lot more sessions, often treating other types of problems because by the time they get to see you, they often have additional problems.  

Lucy: Do you feel like there has been progress made in the treatment?  

David: I think we’ve got a much better understanding of what it is and the different variations and forms of it. And I think we certainly got some better interventions, particularly trying to identify some of the earlier aversive experiences that often people have had a lot of teasing and bullying and so on about being different in some way during adolescence.  

And we can sometimes try and focus in on those and try to help them, what we call ‘emotionally process’ them, a bit like trauma memories and that’s certainly been quite exciting.  

And sometimes helping perhaps a more compassionate approach to themselves, particularly those people who are very self-critical and ruminating all the time. Again, that may be more promising. I think these things are very slow, but it’s definitely, I think, the outlook is a lot better than it used to be.  

Lucy: Is there anything else you would advise people who are thinking about cognitive behavioural therapy for BDD? 

David: I think you do have to do it when you’re ready. In other words, it’s not worth doing if you’re just trying to get your parents or the cosmetic surgeons off your back.  

I think you do have to go into it being open and accepting that it may be a different problem to what you think of it as yourself. And just accepting that there’s maybe more of a body image problem rather than necessarily an appearance problem and just trust perhaps, the people that you love and love you, around you, that they have your best interests at heart.  

BDD is a recognised problem. It is treatable and sometimes if the therapy is not working, then sometimes you might add different medications as well. It’s definitely worth seeking help.  

Lucy: I asked Gareth what he would advise too.  

Gareth: I would have liked somebody to have said to me, “This is going to be very hard, but it’s going to be very worthwhile.”  

In terms of what it’s like, going back to what I said earlier about it being brutal. I also felt very supported through that, I had a really good connection with my therapist and I think that’s really important. I think if you don’t have a good connection with your therapist, I think it’s really important to try to talk to them about it if you can.  

What happened for me, before I had the effective treatment, I had therapists who I didn’t get on with very well or I didn’t feel able to talk to or who perhaps weren’t working on the right stuff and I didn’t feel able to say that.  

I think because of that I wasted time, I wasted my allocated resources from the NHS and I wasted years of my life, as well as I was stuck with the problem.  

I suppose I want to say that things can get better and it’s hard to know that sometimes. I think particularly with mental health problems, I think with physical health problems it’s a bit easier, but I think with mental health problems there’s a lot of stigma still.  

We all tend to grow up trusting our mind. I think when things get difficult or we become more anxious it can be very hard to feel stuck with the problem. So do get some treatment and give it your all if you can.  

Lucy: Thank you. This problem in particular has a huge impact on people’s mood doesn’t it? It’s really important that people are able to realise that there’s help out there.  

Gareth: It does, yeah, and I think there’s an increased suicide rate as well. I think it’s even higher than it is with depression, so I think for that reason it’s really important to realise that there is treatment out there that can help however catastrophic things seem, so get the treatment.  

Lucy: That’s great, thank you so much for sharing your experiences, it’s really appreciated.  

Gareth: That’s okay, my pleasure.  

Lucy: If you’d like more information on CBT for BDD, have a look at the show notes for loads of resources.  

For more on CBT in general and for a register of accredited therapists, check out BABCP.com and have a listen to our other podcast episodes too for more on different types of CBT and problems it can help with.  

 

END OF AUDIO 

 

Ever wondered how CBT fits with ideas about health and wellbeing from more spiritual perspectives? 

A BABCP outreach event held in a local Glasgow mosque in Summer 2018 explored just this. 

Saiqa Naz, Chair of the BABCP’s Equality and Culture SIG, Shayhk Abdul Aziz Ahmed and Dr Aman Durrani all speak to Dr Lucy Maddox.

Show Notes and Transcript:

Podcast episode produced by Dr Lucy Maddox for BABCP

If you want to know more, check out these resources...

Articles

Andrew Beck has written an article in the Sept 2016 edition of CBT Today, on page 14, available here: http://www.babcp.com/files/CBT-Today/cbt-today-september-2016.pdf on Helping To Deal With Racism As A Therapist.

Saiqa Naz has written an article on p15 of this issue of CBT Today, available here: http://www.babcp.com/files/CBT-Today/cbt-today-february-2017.pdf on Working as a BME CBT Therapist.

Books

Badri, M. (2013). Abu Zayd al-Balkhi’s sustenance of the soul: The cognitive behavior therapy of a ninth century physician. International Institute of Islamic Thought (IIIT).

Beck, A. (2016). Transcultural cognitive behaviour therapy for anxiety and depression: A practical guide. Routledge.

Videos

To watch the outreach event in full, you can access three videos here:

1) Coping with Stress and Anxiety 1/3: A spiritual and cultural perspective, Shaykh Abdul Aziz Ahmed

https://www.youtube.com/watch?v=7i4I8AgIO30&list=PLDRvEQKwDiOGDndWynElDmzqUFo8Pa_vI&index=7&t=0s

2) Coping with Stress and Anxiety 2/3: A psychological perspective, Saiqa Naz

https://www.youtube.com/watch?v=5FSWDWSJzXk&list=PLDRvEQKwDiOGDndWynElDmzqUFo8Pa_vI&index=9&t=0s

3) Coping with Stress and Anxiety 3/3: Q&A

https://www.youtube.com/watch?v=NQpAiktShBc&list=PLDRvEQKwDiOGDndWynElDmzqUFo8Pa_vI&index=5

Website

British Association for Behavioural and Cognitive Psychotherapies 

https://www.babcp.com/

Transcript

Lucy: Hello, and welcome to this bonus episode of Let’s Talk About CBT with Dr Lucy Maddox. In this episode, I’m going to introduce you to three people who put on a special outreach event in Glasgow back in July.  

This free event was open to the general public but aimed to reach out specifically to the Islamic community in Glasgow where the BABCP conference was being held.  

Data shows that Black, Asian and minority ethnic communities are under served by primary mental health services and are less likely than other groups to be referred for talking therapies like CBT. Research findings from Mind in conjunction with the Time to Talk coalition in 2017 highlighted a lack of culturally sensitive and tailored services to meet the diverse needs of many local populations. In addition, some significant cultural barriers can be present within communities which can prevent people seeking help or speaking up.  

The event was held in an Islamic community space and it involved talks about mental health from different perspectives, from a CBT therapist, a psychiatrist and an Islamic scholar. Dr Aman Durrani, psychiatrist, introduced the event and Saiqa Naz, CBT therapist, and Shayhk Abdul Aziz Ahmed, Islamic scholar, spoke.  

I spoke to Saiqa before the event. As well as being a CBT therapist, Saiqa is chair of the Equality and Culture Special Interest Group of the BABCP. I asked her to tell me more about why minority communities are not seeking mental health support. 

Saiqa: We’ve been hearing about this for many years, that people from BME communities aren’t accessing support, so we’re just trying to hopefully challenge the stigma by educating them about what mental health is and what kind of support is available to them, and hopefully that will encourage them to seek help.  

The whole idea, I guess, is to show people that psychology is at one with the faith and that might encourage people to seek help in the future.  

They say, don’t they, that if you love your job it’s not work, it’s a passion, it’s a hobby, and that’s how I see it. I love connecting with people. I love meeting people. I love being out and about in the community getting to know people, and that’s who I learn from. So, there’s the learning I’ve taken from the community and trying to bring it back into the profession.  

I’m really passionate about it because for me, CBT, I think everyone should be able to access it. You don’t have to be unwell to access it. I know services are set up in that way, but some of the tools that we use, and we teach people are really practical. I think that’s why I’m passionate, because you don’t have to be unwell to seek help. 

Lucy: So, it’s something that anyone can benefit from? 

Saiqa: Yeah, definitely, and that’s what I love about CBT. I always like to use the analogy of people being plumbers and just having extra tools in your toolkit to use when you need it. 

Lucy: Saiqa wanted to encourage therapists to seek out her workshops and talk to the special interest groups about any problems that they’re having, and if you’re going to therapy, feedback to your therapist any cultural issues you think are important.  

I spoke to Shayhk Abdul Aziz Ahmed before the event as well, about why he thought the event was important. 

Abdul: I’m Abdul Aziz Ahmed. 

Lucy: Just for people who might not know what the term ‘Shayhk’ means, would you mind explaining what it means? 

Abdul: I think the way they’re using it in the context of tonight is somebody that’s learned in Islam, and I’m quite happy to use that title under certain circumstances because it gives credibility to the argument. 

Lucy: Could you say a little bit about the event tonight? 

Abdul: It’s quite an exciting event because hopefully it’s an opportunity to raise issues which are relevant to one of the minority communities here, the Muslim community in particular, who have their own cultural barriers which are stopping a lot of people from accessing services to support their mental health. And I think anything that can remove those barriers is a positive thing and so I’m quite excited to be part of that. 

Lucy: Could you say a bit more about how somebody’s spirituality might present barriers to accessing mental health services? 

Abdul: I think the main barrier is not so much their personal spirituality but the cultural interpretations of the community here. There’s a larger reliance on very traditional scholars who would interpret mental ill health in a way that it’s powers beyond our reach and would interpret them as the jinn or some supernatural forces. And because those people have important roles within the community it makes it very difficult for people who are facing challenges to challenge the community as well.  

This hopefully will give an opportunity for people to really empower them, to be able to say, “Actually, I can find the sources. I can get out of this.” So, it’s not the individual spirituality that would be a problem; it’s more the cultural interpretation of that. 

Lucy: So, there’s room, in a way, for both? 

Abdul: Absolutely. And I think anyone that understands how to deliver services to any community will know that if they’re culturally sensitive, they will work because people will accept them, because it relates to them as individuals. And therefore the two things need to work together, which is the psychology profession and those who are supporting mental health in general and the community to make sure that those misconceptions within the community are removed. And hopefully we’ll be able to do that this evening, or contribute to that this evening. 

Lucy: Is this something that you think would be helpful for other communities around the UK to be doing? 

Abdul: Absolutely. I’ve done similar events in a couple of places and I’ve always found that the response was tremendous. I think that based on those responses, hopefully what will happen tonight is that we will see that this is something that really needs to be rolled out. And the more this is done, the more access people will have to mental health services, and that can only be good for the minority communities. 

Lucy: I know you’ve been travelling recently. Is there anything you wanted to say about the work that you’ve been doing abroad at all? 

Abdul: Yeah, I was in Malaysia and Singapore. Each community that I go to has different kinds of issues. One of the things that I was addressing in Singapore is about pressure, the pressure to succeed, and how that affects young people in particular. Each community has its own manifestation of this, so we do need to be sensitive to what each community needs.  

I think the most important thing for the community, all communities that are scared and there’s fear of the authorities and mechanisms, is just to try and put that behind you and make that first step. Because once you’ve made that first step to recognise that, “I need help and there are people to help me”, it’s all going to get better. We have to help people make that first step – and that’s for everybody: therapists, GPs and community leaders. 

Lucy: Lastly, I spoke to Dr Durrani about his hopes for the event. 

Aman: My name is Dr Aman Durrani and I’m a consultant psychiatrist based here in Glasgow. The event today is a good balance where we have the spiritual element from an Islamic scholar who can very much give the theological perspective, but also a trained therapist as well who can give a very practical method of how you can understand what’s going on in your body and your emotions and your thoughts and also what you can do about it.  

Glasgow has a majority Pakistani and Muslim background population and so there are many cultural issues, ranging from the earlier generations where language might be an issue, for example. But I think even second, third and fourth generation where they maybe think, if there’s something wrong mentally, what are the ramifications if I get help, both for myself and my family, for marriage prospects, for career prospects.  

Perhaps there are also issues in relation to, could this be something to do with cultural and religious issues such as possession from spirits, could it be black magic, could it be these other aspects. In my experience, people then will go and seek help from their religious leader, the imam, or community figures rather than going to their GP, for example, to seek help.  

So, I think there are these issues of where that understanding is. And I think the important thing I guess I’m hoping from events like today is very much making people understand that these are common mental disorders, these are things that there’s treatment and there’s help available. But the starting point is understanding that there’s an issue and what might be going on and then where you can go for help. 

Lucy: Is there anything you’d like to add for people listening who might be therapists or who might be people who are thinking about approaching their GP for help, anything you would like to say? 

Aman: I think in my experience always is getting help sooner rather than later is important. I think it’s also important to be optimistic that help is available – sometimes it takes times, sometimes it means trying different things, but at the end of the day there’s lots that can be done for a lot of these mental health issues, particularly anxiety and stress. 

Lucy: I was interested in recording this event because I think it’s really important that we do try and put on more outreach events that involve the public in the therapy that we’re offering them, and so that we can learn from them about what they best want or most need so that it’s really a two-way conversation rather than just explaining what CBT is to people.  

I learned a lot about how Islamic culture might be misinterpreted but also how some of the literature is very supportive of seeking out a psychological approach.  

These three people were speaking from quite different contexts that they were coming from, so psychiatric, psychological and more spiritual, but actually all of them were recommending that people seek help and were able to talk about how they feel. And all of them were talking about links between the mind and body and how those links can kind of go both ways.  

I guess the message for the audience was that they don’t have to feel that they can’t seek psychological support because of their faith, which I think is a very important message to get across.  

I think for therapists it’s particularly useful because maybe it might be quite tricky for a therapist who doesn’t necessarily have a great knowledge of Islamic literature to be able to reassure somebody that it’s totally all right to be seeking psychological support, but actually there’s a lot in the text that the Shayhk was talking about which would support somebody seeking help and that’s really reassuring.  

That’s it from me in this special bonus episode of Let’s Talk About CBT. This podcast has been brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP. For more information, check out BABCP.com and also the show notes.  

Thanks to Gabe Stubbing for the music, Eliza Lomas for editing consultation and Saiqa Naz, Shayhk Abdul Aziz Ahmed and Dr Durrani for their interviews.  

If you have ideas for future CBT-related topics you’d like covered by this podcast, please email me at [email protected]. 

END OF AUDIO 

How does mindfulness fit with CBT?

And is it all about sitting about on a yoga mat? (spoiler - it's not).

This episode delves into Mindfulness Based Therapies, including Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR).

Prof. Willem Kuyken and Chris Henry speak to Dr Lucy Maddox.

Show Notes and Transcript: 

Podcast episode produced by Dr Lucy Maddox for BABCP

If you’re interested in finding out more...

Books

This is book that Willem mentions in the podcast and it comes with a CD of meditations: Williams, M., & Penman, D. (2011). Mindfulness: a practical guide to finding peace in a frantic world. Hachette UK.

These books are also good:

Teasdale, J. D., Williams, J. M. G., & Segal, Z. V. (2014). The mindful way workbook: An 8-week program to free yourself from depression and emotional distress. Guilford Publications.

Segal, Z. V., Williams, M., & Teasdale, J. D. (2018). Mindfulness-based cognitive therapy for depression. Guilford Publications.

Websites

Headspace has lots of animations about mindfulness and an app you can download to your phone (they do a free trial so you can see if you like it). https://www.headspace.com/

This organisation are bringing mindfulness to schools with several specially devised programs: https://mindfulnessinschools.org/

Here is the organisation that Willem works at: http://oxfordmindfulness.org/

And in particular this page has lots of resources you can access for free: http://oxfordmindfulness.org/for-you/

British Association for Behavioural and Cognitive Psychotherapies website is here: https://www.babcp.com/

Transcript

Willem: Mindfulness is a human capacity that we all have in any moment of our life. So, in that sense, anybody can do it anywhere and anytime. There's no particular person or particular way of doing mindfulness. It's a way of meeting our minds, meeting our experience, meeting our world in a different way.  

Chris: If I'm anxious, at my wit's end, worried about things, then the one thing that I'm absolutely not is balanced or on an even keel, as it were. And the amazing thing is that that kind of pressure of stress and feeling there's no way out or no light at the end of the tunnel, in a worst scenario...  

Whenever I have practised mindfulness meditation, if I've been feeling a bit troubled or a bit down or, on occasion, very, very worried about something, invariably I always feel better afterwards.  

Lucy: This is Let’s Talk about CBT and I'm Dr Lucy Maddox. This series of podcasts, brought to you by the BABCP, explores cognitive behavioural therapy or CBT. What it is, what it's not and how it can be useful.  

Today, we're thinking about mindfulness-based therapies. These are some of the wider family of CBTs or cognitive behavioural therapies. I'll be talking to Willem Kuyken and Chris Henry about mindfulness-based stress reduction and mindfulness-based cognitive therapy. I met Willem in Oxford and asked how he would describe mindfulness.  

Willem: There's a short answer to that, which is that mindfulness is a capacity that we all have to bring a certain kind of awareness to our experience. An awareness that has curiosity, interest and care.  

A longer answer is that mindfulness is something that has three different elements to it. It's the ‘what?’ Our attention and our awareness. The ‘how?’ That is cultivating a certain mode of mind, if you like. A certain way of thinking. Of meeting our experience,  

 

meeting our world, with curiosity, kindness, care, equanimity and patience. We're not just reacting to the world, we're actually meeting the world in a very particular way. Meeting our experience in a very particular way.  

Then I think the third part of it is the ‘why?’ Why are we doing this? It's not just for fun or just for no good reason. In the case of mindfulness-based cognitive therapy for depression, it's to help people with a very long history of depression begin to see the patterns of thinking, the patterns of behaviour and the patterns of reacting that's lead to depression in the past. And learn new ways of responding. So, there's a what? How? And why? to mindfulness.  

Lucy: Could you say a little bit about what got you into mindfulness-based therapies? 

Willem: Yeah. When I was a young, clinical academic in my 20s, I became interested in mindfulness as something for myself. In those days, it wasn't really in the mainstream. It certainly wasn't in the mainstream of academia. I found it personally very helpful in all aspects of my life.  

It was then, in the late 1990s, I went to a conference called East Meets West. There were a range of people talking about how mindfulness could be applied in health. They were just beginning to think about mindfulness for depression. It was a wonderful opportunity for something that had been personally important to me for, at that point, more than 10 years, and was also a professional interest.  

Lucy: Who is mindfulness particularly useful for? 

Willem: Okay. I'm going to answer that question as a scientist and point to the areas where I think the evidence is strongest. I think the first area where the evidence is strongest is for people with chronic physical health problems. Jon Kabat-Zinn developed something called, Mindfulness-Based Stress Reduction, which is an eight-week programme that helps people to find ways to live better with long-term physical health problems for which there may not be a physical cure.  

The second area where the evidence is very strong is with mindfulness-based cognitive therapy for recurrent depression. This is for people with a long history of depression to learn ways to see how they can respond differently to the early warning signs of depressive relapse. To find ways to recover from depression in the long-term. And through our own work, as an alternative to staying on medication long-term.  

I think a third area where the evidence is pretty strong is for people with substance misuse problems and addiction. A programme called, Mindfulness-based Relapse Prevention helps people who are in recovery from addiction to learn ways to see their cravings, to see their addictive patterns. Again, the phrase that's used here is, ‘crave surfing’. (Laughs) To see the cravings for whatever addictive substance and to learn to surf on those cravings.  

Lucy: You mentioned, there mindfulness-based stress reduction and mindfulness-based cognitive therapy. Could I ask you just to explain, in a nutshell, what the difference between the two is? 

Willem: The way I think I'd describe it is that these different programmes have got different people in mind. Mindfulness-based stress reduction has got somebody with long-term physical health problems in mind. It's trying to help them find a way to navigate the stress of chronic pain or the stress of cancer, or whatever it might be.  

Mindfulness-based cognitive therapy has a very particular understanding of depressive relapse. Of what it looks like when somebody goes into a downward spiral of depressive thinking. It helps that group of people, people with recurrent depression, see those moments and learn to respond differently.  

Lucy: What do they look like, I guess, for people who might be signing up to one? What can they expect? 

Willem: They're both group-based programmes. There are groups of about 15 people with one mindfulness teacher. It's more like an adult evening class than it is therapy, in that sense. What people are doing is they are learning new skills. They're learning about their own minds, they're learning about their own behaviour and they're learning in a way that I think is actually – and it's a rather long word – emancipatory.  

What you're teaching people is the skills whereby they themselves can navigate themselves out of tricky situations. They can navigate themselves out of habits of mind that have, often over many years, got them into patterns of suffering and repeated negative thinking. That can be an extraordinary insight for people. An extraordinary change for people.  

The other thing that I think is very powerful about mindfulness-based programmes is a sense of common humanity that comes out. That people will sit around a table or a room and they will say, "Gosh, I thought this way of thinking was just me. That my negative thinking about myself as a loser or being no good was unique to me. But there's a primary school teacher, there's a builder, there's somebody who works in an office, and they look just like me and their mind is just like mine."  

There's a tremendous sense of common humanity that I think is also very healing about mindfulness-based approaches taught in a group format.  

Lucy: Although anyone can practise mindfulness, Willem told us there about two specific types of group programme. Mindfulness-based stress reduction and mindfulness-based cognitive therapy.  

Chris has experienced mindfulness-based cognitive therapy. I went to London to meet with him at King's College Hospital. Here's his story.  

Chris: I came to mindfulness meditation as a result of being diagnosed with a chronic heart condition and following open heart surgery. So, the potential for this therapy to help me keep my blood pressure at a reasonable level, to deal with the occasional stresses which arise in daily life and to avoid unnecessary stress is extremely helpful.  

I found myself, when I first learned the therapy... having been reasonably healthy, to be told that I needed open heart surgery. That, as for a lot of people, I think is fairly life changing. It's a big shock. Also, what's absolutely key and what every cardiac patient learns in rehab, is the importance of changing lifestyle to maximise heart health. That involves quite a lot of lifestyle changes.  

All of this upheaval, for me, and accommodating those changes was definitely helped by using mindfulness meditation. To put it into perspective, to not allow myself to panic or get things out of proportion. Also, not to succumb to the everyday temptations, either eating or drinking or whatever, which would be bad for my heart health.  

I think the major way that the therapy has helped me is because, whilst my surgery was very successful and I responded well to the rehab advice and support, what the whole process left me with was high levels of anxiety. I had problems with insomnia, simply becoming anxious. There were a number of changes around work that I needed to address. 

Gradually and over time, I think the centring effect – if I can put it that way – of the therapy, practising on a fairly regular basis, helped me deal with those challenges in a way that I would have found much more difficult had I not had that support.  

Lucy: I asked Willem to describe some mindfulness exercises.  

Willem: There are a range of different mindfulness practices. I'll describe one, which is the body scan practice. In the body scan practice, what people are invited to do is to bring their attention, with a quality of interest and care, to scan all the way through the body, from the very tips of the toes all the way to the top of the head.  

They're being asked to do that for a number of reasons. The first is to stabilise their attention so that they can actually choose where they focus their attention. It just happens to be the body in this practice.  

The second is to cultivate these different ways of being and knowing. So, to be curious. To be patient. To be present. To be non-judgemental. This sounds simple but actually, our normal way of thinking is often to be quite automatic. To be quite judgemental. We can often do that without being aware that we're even doing it. So, it's bringing a certain quality to our attention and awareness. That is a training that can then be used in all parts of people's lives.  

I, for example, am the father of two daughters. I remember when they were teenagers, it was very easy to be reactive. It was very easy to see things that they said or did and to find myself wanting to speak and act in a particular way. Mindfulness enabled me to see that. To see that happening and to say, "Actually, I'm not going to do that. I'm going to choose to bite my tongue." Or, "I'm going to choose to respond in a different way."  

These practices of focusing on the body, focusing on the breath, mindful movement – yoga, if you like – are in the service of helping us to better understand our minds, train our mind and actually transform our minds. Because, you know, it's a lifetime of practice. Because I've just turned 50, my mind has had 50 years to develop a particular way of thinking and reacting. To turn that around is not easy.  

Many people with mental health problems will recognise that. People with a background of generalised anxiety, depression or health anxiety. These are very sticky mental habits that people are trying to recognise, understand and transform.  

One of the practices that many clients find tremendously helpful is called the three-step breathing space. It involves three steps. The first step is to help people to recognise what's happening right now, in my mind, in my body, in my emotions? It's just a stopping and a recognition of what's happening.  

The second step is then an anchoring. People are anchoring their attention, anchoring their awareness. Typically, on their body or on their breath. "Okay, can I step out of reactivity and just anchor myself in my body and in my breath?" That can take 30 seconds. It can take a couple of minutes. It can take a bit longer.  

Then the third step, having anchored ourselves, is to broaden out to a broader awareness of what's happening in my body and in my wider world.  

What we're doing with that three-step breathing space is we're helping people to recognise automaticity and reactivity, to step out of it and anchor themselves, and then, in a way, re-engage or re-meet the world but from a different place. And in a place that I think can unlock a whole repertoire of different ways of responding.  

Lucy: That's a really nice example because that's actually quite a quick one, isn't it. That people could do and other people might not even know they're doing it, even in a public place, for example.  

Willem: Yes. Yeah. And I think it's the sort of place where, if you like, the rubber meets the road. People can do that practice and then they can apply it in all sorts of different places.  

For example, a young person at school going into an exam can be completely crippled by anxiety. At that moment, they could do a three-step breathing space and recognise the anxiety, the catastrophic thoughts, the contraction. Stabilise themselves, have this different way of being and knowing and go, "You know what I need to do right now, just before the exam? It's X, Y and Z." It's the shift that can make all of the difference.  

I had a teacher once who told me that she did this all the time at parents' evenings, when she knew that she was about to have a difficult interaction with a parent. She would take a three-step breathing space. And she would end the three-step breathing space, really interestingly, with having some compassion for the child and the parents. It just completely reframed the conversations for her.  

So, it's just a very simple tool that people who have learned mindfulness can switch from an automatic, reactive way of interacting with the world to a more intentional, embodied, compassionate way, if you like, of interacting with the world.  

Lucy: To recap, the sorts of mindfulness practices that you might do in a group include the full body scan and three-step breathing, although you can be mindful anywhere. What about the effects of the practice?  

A clinical psychologist recommended a mindfulness course to Chris whilst he was in hospital for cardiac rehab. So, his first experience was an eight-week course, two hours per week, in a group of around eight people from all sorts of different backgrounds.  

 

Chris: The teacher explained the process, a very simple and straightforward process, of meditating. And practised with us. Gradually, over the period of eight weeks, we built up both the length of time that we were meditating in the sessions and we also regularly, over the eight weeks, had homework, as it were, which we practised at home.  

One of the ways in which the therapy has really helped me is that, in being very anxious post-surgery, I also had difficulty deciding, as objectively as possible, how well I was doing. Was I recovering? Was I going to be okay? Were things going to go back to normal, as it were?  

Professionally, I had worked for a large organisation in the business of measuring standards. So, in my day-to-day work I had been judging performance, looking at how well people were doing, taking a hopefully even-handed but critical eye as to how things were going.  

And what mindfulness showed me was how easy it was for me, as I did at the time, to turn that critical eye of myself and judge myself. And, as it were, beat myself up if I didn't practise on my own each day and so on.  

Over a period of time, and also reading around the subject a little bit since completing the course, I have taken the approach that, although it would be great to practise every day, life happens. I'm not going to beat myself up if I don't. I shall aim to practise most days. That's what I do. And that's been quite a useful revelation.  

I think the other thing is that, to put in a straightforward way, it's helped me accept that I'm probably okay (Laughs). And also that, with the prospect of needing, as I now do, to monitor lifestyle and health issues in terms of my heart condition, it's helped me to take an approach to the future which is based around, "I want to enjoy time and value the people and the things that are important to me."  

And to try and not waste time being concerned, angry or critical of things over which I have no control. Also, to not judge when people are difficult, different, problematic, upset or annoying me in some way.  

Lucy: Could you explain, just to help people understand, how you got from the practice of meditation and sitting with yourself to having those understandings, which sound really important? 

Chris: The difficulties with which mindfulness meditation helps me are to do with anxiety and feelings of stress. The way I experience that stress and anxiety is largely by feeling that my mind is crowded with issues, I turn things over and over in my head, I lie awake at night worrying about something.  

What practising mindfulness helped me do is simply to provide, if you like, a quietness from all of those things. To actually, simply, mentally put them to one side. Understanding that they're still there. And to then methodically address issues in a way which is not hindered by the mental noise of a lot of competing factors.  

I used to put things off and I used to prevaricate hugely. I would have things that I knew I needed to do and they'd be playing on my mind. They'd add, obviously, to the stress. What I learned was that, actually, a good approach for me if I'm concerned about something – thinking about practical things – is just to deal with it at the time. To actually remove it from the mental or anxiety in-tray, as it were, and then it's out of the way.  

Lucy: As someone who has practised mindfulness for most of his life and who now researches its benefits, how does Willem see it? 

Willem: The question that arises sometimes is, "What is the purpose of mindfulness practice?" There's a story of that being asked of a sage, if you like. He answered, "Well, the point of a lifetime of practice is an appropriate response." What does that mean? It means that, in the midst of a challenging situation or in the midst of something important, knowing what the right thing to say or to do is.  

The practice, as I said before, has got a purpose. It's got an intention. The intention is to support people to lead a life that is aligned with their values, that feels meaningful, that feels enjoyable.  

Of course, mental health problems like anxiety and depression are very disabling. If people can learn to live with and to transform those conditions with mindfulness, not only does it help them with their mental health problem but I think it has a broader impact on their lives, on their relationships, on their work. On their life more generally.  

We hear that a lot from people going to mindfulness classes. That it's helped them with why they first came. So, when I ran mindfulness classes for depression on a regular basis, I would give people a form at the beginning and I'd say, "What are the three reasons why you want to attend this class?" I would say 99% of people would say, as their primary reason, "I don't want to get depressed again." Then they would have a couple of other reasons which were variants of that.  

When you then ask them at the end of the class what did they get out if it, it actually looks rather different. In fact, we wrote a paper in the BABCP journal and the title of the paper was a quote from one of the participants who said, "It changed me in just about every way possible."  

By starting to see his life through his mind and his life through a different lens, not only was the depression transformed but actually relationships were transformed, his work was transformed, in good ways and bad.  

I remember one participant once telling me that he had had Pot Noodles every day for lunch for years. What we ask people to do in a mindfulness class is to bring their full awareness to something that they do every day in a routine way.  

He came back and he said, "I'm really upset because I've discovered I hate Pot Noodles. (Laughs) They're chemically, they don't taste nice, it feels like I'm polluting my body. This awareness has ruined my enjoyment of Pot Noodles!" So, it changes the way we interact with many aspects of our life, I think.  

Lucy: I asked Chris about some of what was hard about practising.  

Chris: Halfway through the course, I was troubled because I was thinking about things and reading things to do with the course. Trying to take on board what we were being told and explained. It felt almost as though mindfulness was just about lying back and letting everything happen that happens. Not getting worked up and not caring about issues.  

Having spent time thinking this concern through, I realised that that was a misunderstanding on my part. I think there is a mindful way to express disagreement. There's a mindful way to resist. There's a mindful way to oppose. I hope that I can find that when the need arises, without either being aggressive or objectionable or whatever to the person I'm speaking to.  

Equally, particularly in my own health circumstances, not allowing that expression to be at the cost of my own heart health. So, not getting worked up by stuff, losing it, venting my disagreement with somebody and my blood pressure going through the roof.  

I'm 60. I'm a man. In society, and certainly in my generation, we have been, in the world of work particularly, expected to be fairly direct. At times, aggressive and so on. The process of this therapy has helped me to see how damaging those approaches are in our interaction with one another. And also in our interaction with the people we care for.  

Lucy: The impact of mindfulness is far reaching and varied. It's currently offered to MPs in Parliament, prisoners in high-security settings and now Willem's team are involved in researching whether teaching it to young people can help prevent the onset of depression.  

When mindfulness is so widespread, what are Willem's concerns for its use? 

Willem: I think one of the challenges for the mindfulness-based area is to proceed carefully and with humility. Because mindfulness-based approaches have been in the media quite a lot, and I think there are quite a lot of strong advocates of mindfulness, there can sometimes be... The enthusiasm gets ahead of the evidence.  

One of the challenges for the mindfulness area is to actually progress in line with the evidence and not to get too far ahead of ourselves.  

Lucy: Some people talk about, ‘McMindfulness’ don't they? It's a term that's used.  

Willem: Yeah. ‘McMindfulness’ is a term I've heard quite a lot. I think it's a real caution, isn't it, to think about, "If I'm going to offer mindfulness to this group of people in this context, what is the best format? What's the best way to do this? There's quite a lot of pressure in the health service to conserve resources. What is the minimum amount? The smallest format to effect this change?” That is a legitimate question. Of course it's a legitimate question.  

My own view is that, actually, the mind is a tremendously complex organ. If we are going to look at changes which are transformative, that can't be done with a sticking plaster. It can't be done with a brief intervention.  

I think some of these interventions, like helping somebody with a long history of depression stay well in the long-term, aren't going to be done with a sticking plaster or a really short form. We need sometimes to accept that, actually, this is going to be an intervention that takes more time, more energy, more effort.  

Chris: It's incredibly beneficial. It just makes you feel better. On occasion, not unusually, if things... we all have bad days now and again. If I've practised for half an hour or so, it's as though—and there may have been no change in the weather—the sun has come out. That might sound airy fairy or whatever but that's the only way I can describe it.  

It's been an incredible support through a very difficult period. It's one which I am sure has helped me deal with issues. It's something which I want to continue with into the future because I like the effects that it can bring. And, through one or two comments by my partner and family members, in their view it's having a positive effect, as well! (Laughs)  

Willem: I once had a client who said to me... She had had a heart and lung bypass and a history of depression. She said she would rather have another heart and lung bypass than another episode of depression. Absolutely. Depression is a devastating disorder.  

Many people's lives are really badly affected and, in some cases, ended through suicide. I think a world without the devastating effects of depression, where approaches like CBT and MBCT help people to recover and stay well, is absolutely an aspiration for us to work towards.  

Somebody once described mindfulness as being a bit like a lemon. It's really difficult to describe what mindfulness is. But actually, you can get a sense of what it is by tasting it. I think for people to actually experience mindfulness, to maybe buy a book like Mindfulness: Finding Peace in a Frantic World, which has got a CD set in the back, and trying it for themselves. And actually trusting their own experience.  

I think mindfulness is one of those things where practices are offered and people are then invited to learn from their experience. So, try it and see what you think.  

That being said, if you're looking for a teacher, I think it's really important to find a good teacher who can teach it well. The BABCP website has got a ‘Find a therapist’ tab on it, which is a way of finding a good CBT therapist, some of whom are now also trained in mindfulness-based approaches.  

Lucy: So, that's all from me. I hope that's been helpful in understanding more about what mindfulness-based therapies are. For more information, have a look at the show notes on the podcast website, which has got loads of links to lots of resources, including some links to free mindfulness meditations that you can try for yourself.  

This is actually the last episode in the current series about different forms of CBT. We do have one more bonus episode coming up for you, though. A short episode of interviews recorded at a special outreach event in a local Glasgow mosque up at the BABCP conference in the summer. That will be out next week.  

Meanwhile, if you've got any feedback or ideas for future podcast topics, please do let us know. I'd definitely like to make some more for you and I'd really like it if they were on topics that you wanted to hear about.  

Please share the podcast with people you think it might be useful for and rate us on iTunes if you've enjoyed the show. It helps other people to find us.  

This podcast is brought to you by the British Association for Behavioural and Cognitive Psychotherapies, or BABCP. For more information about BABCP and about cognitive behavioural therapies, including a list of BABCP accredited therapists, check out BABCP.com.  

Thanks to  Gabe Stebbing for the title music, Origamibiro for the incidental music, Professor Willem Kuyken and Chris Henry for speaking to me and Eliza Lomas for the editing consultation.  

 

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