Couldn't we all be a little kinder to ourselves?

Find out how self-compassion can influence us and hear about how compassion focussed therapy helped Chris with depression.

Prof. Paul Gilbert and Chris Winson talk 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 about the British Association for Behavioural and Cognitive Psychotherapies, or about Compassion Focussed Therapy here are some resources...

Websites

babcp.com is the British Association for Behavioural and Cognitive Psychotherapies website and it links to the CBT register of accredited CBT therapists in the UK (or go straight to cbtregisteruk.com). BABCP also has a Compassion special interest groups which members can join.

https://compassionatemind.co.uk/ is the website of the Compassionate Mind Foundation.

https://underwaterbreathes.wordpress.com/ is Chris Winson's blog.

On Twitter, the hashtag #365daysofcompassion was created by Chris and connects you to other people using principles from CFT to help with everyday life.

Books

Gilbert, P. (2010). Compassion focused therapy: Distinctive features. Routledge.

Welford, M. (2016). Compassion focused therapy for dummies. John Wiley & Sons.

Irons, C., & Beaumont, E. (2017). The Compassionate Mind Workbook: A step-by-step guide to developing your compassionate self. Robinson.

Welford, M. (2012). The Compassionate Mind Approach to Building Self-confidence Using Compassion Focused Therapy. Constable & Robinson.

Papers

Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6-41.

Gilbert, P. (2015). Affiliative and prosocial motives and emotions in mental health. Dialogues in clinical neuroscience, 17(4), 381.

Transcript

Lucy: This is Let's Talk About CBT and I'm Dr Lucy Maddox.

This episode is all about a type of talking therapy called compassion-focused therapy. It sometimes gets called CFT. This is one of the family of cognitive behavioural therapies or CBTs.

For today's podcast I went to Derby to speak to Professor Paul Gilbert and Chris Winson.

Paul: Yes, so hello. I'm Paul Gilbert, clinical psychologist. Retired from the health service but still work as a professor at the local university and also the University of Queensland where we're doing research on compassion-focused therapy.

Chris: My name's Chris Winson and I've gone through a CBT form of therapy called compassion-focused therapy, CFT. And that was to help with depression.

Lucy: I asked both Paul and Chris how they described CFT.

Paul: So compassion really is about the way in which we turn towards suffering and try to alleviate suffering where we can and prevent it. Learning to have the courage to face the pain that we need to face with the wisdom to know what to do to actually help ourselves and prevent it.

Chris: CFT is all about really kind of engaging with a lot of the thoughts that we all have and that depression particularly kind of amplifies. And kind of not shying away from those emotions but engaging with them with a kindness and an encouragement to perhaps work with it rather than reacting perhaps as you would do intuitively.

And in my instance with something like depression, compassion-focused therapy really does help towards those self-critical, self-judgemental, perfectionist kind of thoughts that depression really kind of takes and turns the volume up on to maximum.

Lucy: Paul was the first person to develop CFT.

Paul: During the 70s and 80s we were all pursuing cognitive therapy, and quite well too I think. So we were working with very complex and severe people with depression. And they could be quite good at developing alternative thoughts to some of the more difficult beliefs and attitudes to self-help.

But they would often say, "Yes, I can see the logic in these alternatives, like I think I'm a failure but in reality I can see I've achieved this, that and the other. I can't really feel any different."

So one day, and I'd like to tell you it was because it was wisdom and because I was so clever, but unfortunately it wasn't. It was simply accidental. I asked this lady, "Well, how do you hear these alternative thoughts in your mind? Speak them out." "Well, what do you mean?" I said, "Speak them out as you actually hear them." And she said, "Okay. Okay, so you're depressed, so you've got a husband who loves you and he stands by you, hasn't he? You've got children who love you. For God's sake, look at the evidence!"

So I said, "Oh my goodness. Is that actually how you hear them?" And she said, "Yeah."

So I thought, "Ooh." So I said, "Well, what would happen, imagine that you had the same alternative thoughts that you could see that in reality your husband did care about you and you had children who loved you and were doing very well at school and so on. You'd been a good mother to them. And this was with a voice that was very kind and compassionate to you because it realised all the struggle you'd had in your life and the depression you'd been fighting against. What would happen if you thought about that or said that in your mind with that tone?"

And she looked at me as if I was mad and she said, "Absolutely not. I'd never been kind to myself. I can't see the point of it. It's just, that's weak, that's not going to work at all."

So that was the beginning really, it's where we began to realise that it's not just the content of people's thinking, it's also the emotional textures that they are relating themselves with.

Lucy: So how do you work on the tone that someone speaks to themselves in?

Paul: Slowly. (Laughs) Well, the first thing is a series of steps. I mean all successful therapy really takes people through stages, through steps, right? So the first step is really helping people think about why that would be useful. Why would it be useful for you to begin to change, pay attention to and change the emotional texture of your thinking, not just the content?

Chris: It's not so much initially changing the words that you might be saying to yourself, but it's changing the tone. It's very powerful actually to start to change that. From that you can then build and start to change some of the words that you say to yourself. So you then change that into a gentle encouragement.

Our brains are kind of evolved to protect us but often in modern life that kind of goes out of control a little bit. And we become constantly on alert, constantly kind of feeling threatened with a drive that can sometimes be out of control almost. And we start to work on reaction and emotional reaction rather than perhaps to the reality and with clear intention.

So for me CFT has just brought that different way of engaging. And it's almost a pause between the thought and then how I react to that.

Lucy: Compassion-focused therapy is based on evolutionary psychology. Paul describes three systems that we all have in our bodies. The threat system, the drive system and the soothing or affiliative system.

Paul: There are three types of emotional regulation systems. One of the functions of emotion is to alert you to dangers and trigger actions.

So fight and flight, obviously. Anger and anxiety. Their primary function is to threat. And they are designed to come on very quickly and they're designed to turn off all other emotions. So if you're walking in the jungle and hear the sound of a lion, you have to lose interest in what you're eating and who you're talking to and the nature of the conversation. You'd better pay attention and run you see.

So the threat system is the one that really causes us the rumination. We worry about so on and so. If you go Christmas shopping and you go into 10 shops, and in nine of the shops the assistants are really helpful to you then you go into one shop and the assistant is really rude, they make you wait. So you come out of a shop. Who are you thinking about on your way home? But 90% of the people were good, yeah?

So why don't we ruminate and go over and over in our mind about how wonderful people are, how kind they are? Partly because you're not biologically designed to do that because your threat system will always take preference, right?

So part of what being mindful is about is to notice when your threat system is running your show. Because it will.

Now you have a drive system and that's the system that's activated when good things happen to you. And sometimes with depression you're wanting to try and stimulate that because when you get depressed you lose the interest in doing things. You lose the pleasure in doing things. The emotion goes. Not necessarily the motive, you may still want to go to the party or whatever it is but you've just got no energy or you don't anticipate you'll enjoy it. Or you'll anticipate you'll be anxious. So that's your drive system.

But then there's another system which has often forgotten which is called arrest and digest, or a soothing system. Now very, very briefly you have a sympathetic nerve system which speeds up so you breathe faster, your heart beats faster, your blood pressure goes up. And you have a parasympathetic that slows you down. So it slows the heartrate, it slows your breathing, it brings your blood pressure down.

And these two systems are working side by side all the time. So these systems are closely, like an orchestra, they're working very tightly together, they're balancing each other.

So when animals are no longer trying to achieve things, do things, excited, going out and do stuff, and they're no longer under threat, the body goes into what is called this rest and digest. It slows down and it slows down because there's a parasympathetic system.

Now there are many things that stimulate that system, such as breathing, posture, thinking. But one of the things that's very important for stimulating the soothing system is affiliative signals.

Lucy: What's an affiliative signal?

Paul: It's like a friendly sort of benevolent signal like a signal of being cared about and taken an interest in. Affiliative means friendly. Unfortunately some of the people that we work with, that system doesn't work very well. They're not very able to accept kindness coming in. They don't see it. They may think they're not worthy of it. They'll have beliefs like, "Well, okay, you're wanting to be kind to me but if you really knew what went on in my head you wouldn't think I was worth it. It's only because you don't really know."

So that takes us into a shame dimension. The fear of shame and so on. And if I got close to you then I would see that maybe you're not as honest as you say. Maybe you're just doing this because you're paid to do it, you're a therapist and so on.

So the whole point really is that that system then doesn't work so well. So what CFT therapists do is they spend a lot of time focusing on how to help individuals experience of affiliative, friendly signals that will influence that, get that system working.

Chris: It's a very elegant model to be able to understand quite complicated neuroscience. The interesting thing when you look at that model for me is that it's understandable that our threat systems are often enabled. We don't have to worry about being eaten by a tiger anymore. But that's where it kind of came from.

And we live in a modern society where often there are threats around us in terms of, it could be doing presentations, and we don't relax from that.

Lucy: Compassion-focused therapists usually explain this model to their clients as part of the treatment tying the model to the person's goals.

CFT uses a range of different exercises which work on the threat, drive or soothing systems, either to calm those systems down or pep them up depending on what would be most helpful.

Chris: There's a few things that we did. So one was to look at that model and to kind of think about if I had to score on a one to 10 of how, which of those systems were kind of in play, drive and threat were probably at 10 and affiliate was probably down there at one or two.

And then it was understanding to bring balance around those. CFT does bring mindfulness practices in.

Lucy: Mindfulness is just about trying to keep our attention in the present moment instead of worrying about stuff that's already happened or that hasn't even happened yet, and trying to do this without judging yourself or having a go at yourself when your mind is hopping about.

Chris: It also helped to do some exercises around the concept of the different selves. So we all have our different selves or our different voices. And depression particularly brings out that critical and the judgement-type voices. And the perfectionist voices.

So some of the exercises sort of actually work upon the compassion voice and to develop the idea of a compassionate self. And that's actually something that I've really adopted. So when I am feeling anxious or concerned I try to bring to mind what the compassionate self would look like. And what would they be saying to me. Because we're very good at supporting our friends when they're feeling distressed, it's then bringing that to ourselves.

I found compassionate writing very helpful as well. So I now keep a journal which varies on day-to-day what I write in it, how much I write in it. But it's something that I can help to work through what I might be thinking about.

And there are some exercises around writing compassionate letters to yourself which again is not all saying, "Oh you're great, I love you." It's about reflecting on how you're feeling and really giving yourself some support and encouragement during those periods.

Lucy: And does it work? I asked Paul to talk us through the evidence base.

Paul: Yeah, people forget there are two types of evidence. Evidence of process, evidence of outcome. Right? So evidence of process means that we do understand how the system works. So the evidence is, is there such a thing as a parasympathetic system? Well actually there is. There's plenty of evidence for that. Is it true that affiliative signals influence…? Well actually, yes, it does. Is it the case that people who have been traumatised and depressed, that system doesn't work very well? Yes.

So in terms of the process we're probably one the better therapies in terms of process evidence. And in fact the whole basis of CFT is rooted in the science of how the mind and body actually work.

One of the issues that sometimes CBT is accused of, is being a little bit heady, a bit too much in the head and not enough in the body and not enough in the actual physiological mechanisms. But we're very into the… so the evidence of process is very good.

Evidence of outcome is more difficult partly because turning these insights and these gradual modules of how you work with different aspects of motivation and emotion is tricky. So we've now got quite a good set of therapies and we've got a number of people who've worked very hard at adapting the basic CFT for different groups such as like psychosis or depression and trauma and so forth.

Moving that into RCTs evidence of outcomes is very expensive. But there are a number of trials, good trials, RCTs now going on around the world which is showing that CFT is really acceptable, people like it. It does produce physiological change and it does produce benefit to people who have mental health difficulties.

Lucy: I asked Chris about his personal experience of whether CFT had been helpful or not.

Chris: I really liked the emotional systems model, those three; threat, drive and soothing, because I think that really helps to understand how and why we may think in a certain way. And then that compassion to yourself and that's the big one. The self-compassion is probably the big thing, to understand what that really means. And to understand that that's not selfish.

And actually it takes quite a bit of courage sometimes to do that self-compassion piece.

And I think when you're a leader, as I was a manager and a leader, you don't always want to express how you're feeling. Even though they were the messages I was giving out to my managers and my teams that it was okay to talk about things. I kind of kept it all behind a mask.

And I think natural reaction if you talk to men about compassion and self-compassion, sitting with your emotions, is going to be, "That's not what men do," or, "How is that helpful?" Or, "That's just giving in." It's not.

And actually it takes quite a lot of courage and bravery to actually say, "Actually I don't feel very good and I'm going to talk about why that is. And actually I'm going to ask for some help."

And being able to sit with your emotions whether it's whatever the feeling is, whether it's anger, whether it's impatience, whether it's that self-criticism and perfectionist, to actually really sit and engage with that and to actually say there are some parts of this that I don't really like that I'm feeling like this, that's not easy.

Lucy: Paul agreed that it takes a lot of courage to embrace compassion.

Paul: When we bring compassion into our own lives and we address our trauma compassionately, we address our criticism and our shame with compassion, things change. So compassion is not in any sense a weakness. In order to engage with suffering, because that's what it is, to really engage with suffering and turn towards it, be prepared to engage with it and try as best you can to do something about it, that's a courageous act. It's not an act of weakness. It's not a softness. Compassion is the courage to engage with suffering with the wisdom to know what to do.

Chris: I think it kind of has changed my life to address the depression. But it's actually allowed me to do some things that I would not have done before. I've been looking forward to doing this podcast from a couple of months back from when we first talked about doing it, for many reasons.

And then particularly overnight and then this morning I kind of thought, "Oh, okay, I'm doing the podcast today." And all those kind of thoughts start to come back to your mind. So, "I'm going to mess it up, I won't say anything that I want to say, it'll be a failure." All those kind of thoughts start to come into your mind. And what CFT has taught me is to say, "Okay, I recognise that, and that's kind of my anxious self and there's my judgemental self in there and the critical self. And I'm going to thank them for making those comments." And fundamentally my mind is, my threat system there is trying to protect me.

And then the other part of the CFT which I've not really probably mentioned yet is about values because I think you really start to understand what's important to you. And that doesn't mean it has to be some to light suddenly comes through clouds and hits you and it's like, "Oh okay, that's what my life's about." And so it's important for me, as it has been with my writing, to kind of try and share, both to raise awareness of depression, but actually also to share about CFT because that has for me made such a difference.

I'm so kind of passionate about sharing that that that offsets the anxiety and the natural concern to be doing an interview like this.

I think it's given me a different relationship with… first of all it gave me a different relationship with depression. And I think overall, however, it's given me a different relationship with my thoughts overall.

I think it's actually just allowed me to actually engage with myself in a different way. It's not just about handling distressing thoughts. It actually really does help you to be present and enjoy moments.

Lucy: Chris has been writing a blog about compassion-focused therapy and also running a Twitter hashtag, #365DaysOfCompassion, to share ideas about the therapy.

Chris: I've never really felt that I was a creative person. When you do the writing, when you do stuff like that and you put the blog out, it's incredibly vulnerable. But what self-compassion says to me is but this is important for you to share your story and to try and help and therefore it kind of encourages me and supports me through that process.

Lucy: I asked Chris and Paul if they had any advice for people considering compassion-focused therapy.

Paul: I'd obviously recommend it. I think it's a good therapy obviously. But people have to make their own decisions.

It's holistic. In other words it pays attention to people's motives, their emotions, their cognitions, their behaviours, their fantasies, hopes and wishes. And so forth. So all of those things. It doesn't privilege any one particular although it is probably now more of a motivational theory, motivational process that developing people's intentionality, being clear about one's intention in life. If you choose to be the person that at best, what kind of person would be choose?

Now people often start, "Well, I want to be successful, I want to be famous, I want money," blah, blah, blah, blah. But if you can help them also orientate themselves to a compassion intention, "I want to be a person that wherever I can I'll be helpful rather than harmful, and really hold that and I'm going to do that to myself wherever I can, I will be helpful to myself and not harmful to myself," that intentionality flourishes and we've treated a lot of people with CFT now and it just changes their values.

Chris: I think timing is important. So I didn't go straight into CBT. I probably would have struggled initially to have engaged with the idea of a compassionate part and sitting with emotions perhaps at the height of the depression and you've got to be receptive. And be prepared to work at it because it is hard.

I can remember one therapy session that came out of, and I have told my therapist this, that I've sat in the car afterwards very emotional and almost walked back in to say, "I'm not doing this anymore."

But actually that was a breakthrough moment because – which I recognise now – because I'd finally started to open up. And I'd finally started to understand and accept that depression was there and that actually I could there see how compassion and CFT was going to start to help.

Lucy: A big thanks to Chris and Paul for their interviews.

I hope that's helped explain some of the ideas around compassion-focused therapy. I think probably most of us could benefit from being a little kinder in the way we speak to ourselves.

If you'd like more information or resources, please check out the show notes for some references and links.

This podcast is brought to you by the British Association for Behavioural and Cognitive Psychotherapies, or BABCP. For more information about BABCP and CBT in general check out www.BABCP.com.

Thanks to Gabe Stebbing for the title music, Aaron Zimm for the incidental music, Paul Gilbert and Chris Winson for speaking to me, and Eliza Lomas for editing consultation.

Any feedback or ideas, please do let us know. And please rate us on iTunes if you've enjoyed the show.

Next time we'll be exploring another of the CBT family. So I hope you come back for that.

END OF AUDIO

How do we live with impossible dilemmas?

How can someone stop self harming when it's the only way they know of coping?

What is DBT and how did it help Louise?

Dr Michaela Swales and Louise Brinton-Clark talk to Dr Lucy Maddox.

This episode includes reference to self-harm.

Podcast episode produced by Dr Lucy Maddox for BABCP

Show Notes and Transcript

If you're interested in finding out more about the British Association for Behavioural and Cognitive Psychotherapies, or about Dialectical Behaviour Therapy here are some resources...

Websites

babcp.com is the British Association for Behavioural and Cognitive Psychotherapies website and it links to the CBT register of accredited CBT therapists in the UK (or go straight to cbtregisteruk.com). BABCP also has a DBT special interest groups which members can join.

https://www.sfdbt.org/ is the Society for DBT website which has a list of accredited DBT therapists in the UK

https://www.behavioraltech.org/ has research articles and a good video on "What is DBT?"

Books

Heard, H. L., & Swales, M. A. (2016). Dialectical behaviour therapy: distinctive features. Routledge.

Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. Guilford Press.

Linehan, M. (2014). DBT Skills Training Manual. Guilford Publications.

Linehan, M. M. (2014). DBT Skills Training Handouts and Worksheets. Guilford Publications.

Swales, M. A. (Ed.). (2017). The Oxford Handbook of Dialectical Behaviour Therapy. Oxford University Press.

Transcript

Louise: It is a life-saving treatment for some people.

I don't believe I would have graduated or got married or even, it sounds really daft, even have passed my driving test.

Lucy: This is Let's Talk About CBT and I'm Dr Lucy Maddox. This episode is all about a type of talking therapy called dialectical behaviour therapy or DBT. This is one of the family of cognitive behavioural therapies or CBT which was talked about in episode one. We talk a bit about self-harm today, so please take care of yourself, if you know that's a tricky subject for you.

To get away from the acronyms and try to understand what DBT is actually like I went to Bangor, in Wales, to meet with Dr Michaela Swales and Louise Brinton-Clark.

Louise: My name's Louise Brinton-Clark, I have been a member of a DBT group, dialectical behaviour therapy group, both as a service user and as a graduate facilitator.

Michaela: My name's Michaela Swales, I'm a clinical psychologist, I'm also the director of the British Isles DBT training team. So, as well as having delivered DBT for probably the best part of 20 years in my clinical practice, I've also spent the last 15 years or so training others to deliver DBT.

Lucy: Dialectical behaviour therapy is a bit of a mouthful, I asked Michaela to explain what it means.

Michaela: So, within the treatment, we do a lot to help people change things and we do a lot to help people accept things. And in a way, those two things acceptance and change, at least on the face of it, look like they're totally in contradiction. They're what's termed in a particular branch of philosophy – not that you need to know philosophy to do this treatment – a dialectic. They're two things that are in almost polar opposites to each other, but there's value in both of them.

And so constantly in the treatment we're always looking for both change-based ways to solve problems and acceptance-based ways to live your life. And being dialectical means looking at both of those things, and sometimes you have to do a mix of those things to really get things to work.

It is a behavioural treatment, so it focuses a lot on changing behaviours, both those things that other people can see that we do, but also those things that we experience internally. And as we know from lots of areas of life, changing our behaviour is hard, it takes a lot of hard work. And I think many of the people who come for this treatment have a lot of things in their life that they are really struggling with, multiple things. And so it is a tough treatment.

Lucy: I also asked Louise to explain DBT.

Louise: My understanding of what dialectical behaviour therapy is it's working with opposites but bringing them together. It's that thinking in extremes, isn't it? It's called black and white thinking.

Lucy: Which I guess we all get into sometimes.

Louise: We do get into. And that grey area, my god, the grey area is the size of the universe, really. It's immeasurable.

And I know what I typically used to do, and I guess I still do sometimes, is thinking in those extremes, that stereotypical, "I hate you, don't leave me." It's two total opposites of the same thing.

Lucy: So, like push-pull kind of… Two opposites, how do we reconcile them?

Louise: Or hurting yourself to stop the pain.

Lucy: DBT is a treatment that's often used to treat severe self-harm and huge ups and downs in mood. It's a pretty comprehensive treatment package as both Michaela and Louise told me about.

What does it look like when people are referred for dialectical behaviour therapy or for people who are thinking about having it?

Michaela: Typically, people have multiple problems when they come, and one of the things that the treatment tries to do is rather than parcel off these different pieces is to try to understand how all of these different behaviours relate to what the treatment considers the core problem, really, which is a difficulty in managing and regulating emotions. So, in order to do that, the treatment has a number of components.

Lucy: Full DBT has four main components, a skills group or class, individual sessions, skills coaching course, and something called a therapist consult. Louise was at university while she was having DBT and she found her skills group hugely important.

Louise: So, I don't think I would have graduated from university without group. Year three for me in university was a really, really tough year. When I was doing group then, was quite depressed, I was still abusing over the counter medications and stuff like that.

It was a really nice, honest environment, so perhaps talking about why we engage in some behaviours that actually might be, I don't like the term, attention seeking. Let's call it support seeking, for the purpose of this conversation. But we might be doing some behaviours for support seeking, and I felt like in the group, in that environment it was a really safe space to say, "This is why I've done this." And actually, it opened up the floor for other people to say, "Actually, I've done that as well."

It's like a massive relief, it's a freedom, it's a weight lifted.

Lucy: And skills group is just one part of the treatment.

Michaela: Anyone who's tried to learn anything new will know that just going to a skills class doesn't necessarily change your behaviour. Most people have tried at some point in their life to learn a language. And you can go to skills classes to learn language as much as you like, but that doesn't mean you'll get to be fluent. And in a way, we're trying to teach people to be fluent in a new language around managing their emotions and their relationships and so on.

So, in addition to skills class, people in DBT meet with an individual therapist once a week on their own. And each week, the therapist and the person coming for help will work together to try and figure out how to get these new skills to apply to the particular problems that their person is bringing to therapy.

DBT also has a mechanism where people in the treatment can contact their individual therapist for coaching in how to apply the skills actually in the moment when it's really difficult.

So, DBT from the person receiving it, that's what it looks like, they have those three different what we call modalities, skills training, individual therapy and skills coaching calls. But in addition, therapists who are working in this way meet together in what's called the DBT consultation team every week. And people coming for the treatment know about this consultation team. And the aim of that team is to make sure that the therapist is delivering the most effective treatment possible.

Lucy: And that's really full on, actually, isn't it? But also, what an incredible package to get.

Michaela: Yes.

Lucy: Sometimes services offer a kind of DBT lite.

Michaela: They do, yes.

Lucy: Is that still DBT? Or is it something a bit different?

Michaela: I think the evidence base that's emerging is that the best evidence for people who have multiple complex problems and are highly suicidal is for full programme DBT.

There is an emerging evidence now, looking at skills classes where therapists are trained in the full programme, but they're offering skills classes and they're still going to consultation team, and offering some kind of skills coaching that for people who have slightly less severe problems that might do well.

I think if we could get the benefits of this treatment with it being less intense, that's a win-win all round, because it would mean that more people could access the treatment. And at the same time, the best evidence we have is for the full programme.

Lucy: I asked both Michaela and Louise to talk me through the different skills modules.

Michaela: In standard skills classes there are four modules taught. One is mindfulness, another is distress tolerance, those are the two on the acceptance side. And then, there is a module called emotion regulation and another on interpersonal effectiveness, and they're on the change side.

Mindfulness really focuses on… our minds tend to gallop off into the future or gallop to the past. And often, if we think about it, we're rarely in any one moment.

Now, if in one's past and one's future there are things that are not particularly troubling or might even be quite pleasant, that's not really so much of an issue. But for many of the people, if not all of the people, who come to this treatment, there's a lot of pain and difficulty in their past. And also, they have a lot of worry and anxiety about the future and often not a lot of hope, given what's happened to them in their past.

And so, the fact that our minds do this bouncing around becomes really problematic, because it generates a lot of distress. And so, one of the things we work on is how to remain more in the present.

And so, the other thing we teach in mindfulness is to notice when judgements show up and to work on being more factual and describing things in a more factual way. Or at least just noticing judgements and trying to let them go, because they so often really crank up our emotions in unhelpful directions.

Louise: Mindfulness we do every week. And I think there's a bit of a misconception about mindfulness. We think it's just about looking at trees (laughs) and things like that, and I think that really puts people off. I actually really disliked the idea of mindfulness when I first started. But actually, as time went on, I learned it was more you could incorporate it into your everyday life.

Michaela: In distress tolerance, what we focus on there is the fact that lots of things happen in life that are really difficult, really painful things. And often we can't solve them, or we can't solve them now. And we all have to learn skills in life to be able to get through a crisis without making it worse.

Lucy: Easier said than done.

Michaela: Much easier said than done.

Louise: So, recently, I hit a bit of a depressive spot because I'm losing my job. My immediate response in my head is to, "Right, that's it, I'm going to bed, there's no point, blah de blah." If I'd done that, there would have been a whole heap of consequences. I would have lost my job a lot sooner (laughs) before the closure of the unit that I'm working in.

Whereas previously, if I had gone with my initial even just staying in bed, even if I'm not talking about self-damaging behaviours, just staying in bed, that just makes things worse. And we have to recognise that we have a choice. I don't have a choice in losing my job, but I have a choice in how I respond to that. It's recognising that choice and recognising consequences.

Michaela: On the change side, we have emotion regulation. We spend a lot of time talking about emotions in DBT. They're often the thing that cause the most pain and distress to the people that we work with. And we want to first of all start off by helping people understand the different emotions that they might experience, and how that connects to what's happening.

Many of the people we work with were raised in environments that didn't really help them understand the different sorts of emotions that they might have, and often they were criticised or even punished for having emotions at all. So, that's not going to help you learn.

So, we start off by really trying to help everyone get a better emotional vocabulary about the different emotions that you might have, like fear and anger and shame and sadness. And understand what might set those off and what thoughts go with that, what that feels like in your body, what it leads you to want to do.

And then, we have a whole set of skills that help us work on how to change our emotional responses, depending on what emotions we're having. And also, we think a lot about often emotions are giving us a clue to something that's happening, it's like a little warning sign that there's something to pay attention to.

So we also work a lot on trying to figure out how do you know when an emotion is telling you something that you should act on, versus when is actually your emotion somehow inaccurate to the context? Or it may be accurate to the context, so maybe somebody has said something that was difficult, they've given you some difficult feedback. Maybe they said they didn't like your new hairstyle for example.

But the level of your distress in response is more as if they told you you were a dreadful person. So, that although having a degree of anger would be perfectly natural in those circumstances, the intensity is just more than what you want to have to deal with. So, we try and help people figure out what would be a reasonable emotion to have in that circumstance, and also how much of that emotion would they like to be feeling, given the context? And to try and to be able to regulate emotions down to the level that they are useful.

Louise: Well, I guess I can regulate my emotions, my emotions still feel unregulated but I'm not responding to them in the same way, does that make sense?

Lucy: Yeah.

Louise: So, that would be things like acting opposite and stuff like that.

Michaela: And then, in interpersonal effectiveness we focus on how to interact with people to increase the chances that people will give you what would be helpful to you. So asking for what you want and also saying no to things that you don't want.

Louise: The other module is interpersonal effectiveness, which is probably my favourite because it's meant I've been able to maintain relationships. I've stopped arguing with people, I've stopped arguing with myself in my head.

Lucy: Wow, that's major.

Louise: I typically would ruminate a lot and argue with people in my head and it was exhausting. My favourite skill of that is the DEARMAN skill.

Lucy: What does that mean?

Louise: So, an example is, I've been invited to a party, and I don't want to go. D, describe, that's a description, I've been invited to this party, I don't want to go. So, the E is express, so I would express I don't want to go. (Laughs) A is assert, be assertive, not confrontational, not defensive, assertive, I don't want to go. And try not to apologise.

Lucy: So, just clearly stating what you want.

Louise: Yeah, try not to apologise, don't apologise for your wishes, because no apology is needed.

Reinforce, so just say you were saying to me, "Oh but I really want you to come, I really want you to come." "I really don't want to. I'd rather stay at home that night." Stay mindful, so keep the goal in mind, just be aware of your emotions, be aware of what's going on in your body.

You're doing the DEARMAN skill, but the person opposite you isn't. (Laughs) And the person opposite you also has a goal in mind, appear confident. You want to appear confident without appearing confrontational. So, perhaps it's sometimes better to do it in person.

So, if you're doing it in person, body language, head up, shoulders back, even if you don't feel it, that other person does not know that you do not feel confident. And negotiate. I don't want to come to the party, but how about we meet up for a coffee in a couple of days? Compromise.

Lucy: That's sounds really useful.

Louise: I love this skill and it's actually really, really helped in a lot of situations, it's quite funny when you use it, because people who know me and who've known me for a long time, such as my brother, and he knows how confrontational or argumentative I can be. And then, I suddenly use this skill and he's like, "Um, okey dokey." (Laughter) People typically respond quite well to it.

Lucy: DBT is particularly recommended for severe self-harm. And this often comes along with a controversial diagnosis, which I asked Michaela and Louise about.

You mentioned that this approach, although it can be helpful for anyone, is perhaps particularly helpful for individuals who have quite complex difficulties going on and maybe are engaging in self-harm.

Michaela: Yeah.

Lucy: And sometimes that comes along with quite a controversial diagnosis of borderline personality disorder.

Michaela: Yes.

Lucy: Which people may or may not have heard about who are listening to this. I just wondered if you had a view or if DBT approaches had a view on the diagnosis itself?

Michaela: Yeah. DBT was designed specifically for people who have been given a diagnosis of borderline personality disorder. The main reason for that was that in order to get funding to study a treatment, the funders – it's changing slightly now, but certainly for the last 20 years – have only really funded things that were based on people with particular diagnoses.

But in fact, the treatment developer originally developed the treatment for suicidal behaviours. And then, started to think particularly about the problems that people who get given that diagnosis of borderline personality disorder have and how that linked to suicidal behaviour.

But DBT is a behavioural treatment and so, what that means is that it really sees the problems that end up being labelled as borderline personality disorder as really a set of behavioural patterns that people have learned. Like we all learn as we're growing up in our environment.

We learn ways of behaving and responding and experiencing the world so that really the patterns that end up with this label are ways the people have learned to cope. So, that what we're trying to work out in DBT is what of those behaviours are problematic for the person? What do they want to change? And it's like what is it that they want out of treatment? And how are these behavioural patterns getting in the way of that?

So, whilst it's the case that often people who come into this treatment have got that diagnosis or could get that diagnosis, what we're really interested in as DBT therapists are what are those behaviours that are causing somebody trouble and suffering? And how can we help change them?

Louise: I have this massive conflict about the diagnosis, they were talking about the BPD diagnosis with me when I was 15, which is far too young, I was 15. I was diagnosed when I was 18. I had a life of loads of trauma, I responded accordingly (laughs). I reacted normally to abnormal circumstances. Those reactions were a problem. But it was my reaction.

I will be forever on my medical record be down as somebody who has borderline personality disorder. You could say I meet one of the criteria or two, but I no longer meet the criteria, but I still have that diagnosis.

Lucy: So, both Michaela and Louise were really clear there about the limits and potential pitfalls of the diagnosis of borderline personality disorder. I should add just for balance, that there are some people who can find it a real relief to have a diagnosis that they recognise.

If you're interested, have a look at the show notes for a few more references and debates on this topic.

So, what if you're thinking of having DBT yourself?

Michaela: Just as in the skills that we're teaching, people who come for treatment there's acceptance and change. There is also that in the style of the therapy. Part of being a DBT therapist is to be validating and genuine and understanding of your client's difficulties and that's very, very important.

And there is also a component which is trying to challenge and motivate people to change. And sometimes in therapy it's called being irreverent.

Sometimes you might say things that therapists might not normally say, you might be a bit challenging. The reason for that is that there's lots of research to show that if we are really totally immersed in feeling overwhelmed, it's hard for us to pay attention to sometimes what people are saying or asking us. Whereas if somebody's a bit irreverent and says the unexpected thing, it is like a novel stimulus and we turn toward it, and then there's a little opening of being to think differently.

The treatment takes a very strong stance that getting a reduction and stopping suicidal and self-harming behaviour is top priority. And for most people in the treatment, from the research within about 16 weeks on average, that behaviour has come right down, is much more infrequent.

And then, what we then work on are other things that the person says are issues. And so, once that's out of the way, you could say we can then really get on with the business of helping with these other things, because we don't have be worrying that the person is going to die.

Louise: I think I would focus on the fact that it is a behaviour therapy, it's not going to resolve any trauma initially. So, imagine most people who enter DBT have experienced some type of trauma, because you speak to people with that BPD diagnosis, have actually had quite traumatic backgrounds. That's not to invalidate the trauma, but actually it's to get you stable enough to address that trauma.

That's what it was for me. You couldn't see the depression and the anxiety that I was experiencing because I was in this constant cycle of crisis and putting myself into hospital. The depression and the anxiety and the trauma couldn't be addressed.

The time will come when you will do that trauma work, it has to be safe for you and for the people working with you as well.

Lucy: And what are the things that you particularly like about the DBT approach? What got you into it?

Michaela: It tries to see people's problems as being ways that they've learned to cope. To me it normalises how people have learned to do things. There is a real sense that we are in this endeavour together to try and find solutions to very, very difficult problems, and it's not like just because I'm a therapist that I would necessarily have all the answers.

Lucy: So, getting alongside someone?

Michaela: Really, yeah.

Louise: It's helped my relationships as well, so I'm married now.

Lucy: Congratulations.

Louise: Yeah, I'm married. I got married on Christmas Eve of 2016. I said for years that I would never even be in a relationship because I couldn't cope with people and I wouldn't inflict myself upon anybody else.

I've been over two years since I last self-harmed.

Lucy: That's amazing. Well done.

Louise: I was actually discharged from the community mental health team in January. That's the first time in my life that I've gone… so it was a collaborative discharge. We worked together towards it. Previously, when I've been discharged, it's because I've not been engaging with the service or I've discharged myself in a fit of, "I don't need you." This was actually collaborative.

I don't believe I would have graduated or got married or even it sounds really daft, even have passed my driving test, because I wasn't safe to drive because of things I was doing. Living a life worth living, even things like contributing to society, I don't know that I would have been able to do these things without these skills.

Like I said before, even just in this past week, I've chosen to use my skills in order to get through some difficulties I've been experiencing, and it has got me through the past week. It has.

Lucy: Huge thanks to Louise and Michaela for speaking to me. I hope that's helped give a flavour of DBT. If you want any more information check out the show notes for some more links.

That's it from me, next episode, we'll be thinking about another member of the wider CBT family, so I hope you tune back in.

This podcast is brought to you by the British Association of Behavioural and Cognitive Psychotherapies or BABCP, for more information about BABCP and cognitive behavioural therapies in general, check out www.babcp.com.

Thanks to Gabe Stebbing for the title music, Jason Shaw and Entertainment for the Braindead for the incidental music. Michaela Swales and Louise Brinton-Clark for being interviewed and Eliza Lomas for editing consultation.

Any feedback or ideas please do let us know, and please rate us on iTunes, if you've enjoyed the show.

END OF AUDIO

What is cognitive behavioural therapy?

What's it like to have it?

How can it be useful?

Is it just 'positive thinking'? (spoiler - it's not).

Prof David Clark, Prof Sarah Corrie, Jo and Frank talk to Dr Lucy Maddox.

A mix of interviews, myth-busting and CBT jargon explained, this accessible podcast is brought to you by the British Association of Behavioural and Cognitive Psychotherapies.

www.babcp.com

Podcast episode produced by Dr Lucy Maddox for BABCP

Transcript

Lucy: Hello, and welcome to Let's Talk About CBT, a new podcast exploring cognitive behavioural therapy; what it is, what it's not, and how it can be useful.

My name is Dr Lucy Maddox, and I'm a consultant clinical psychologist. I use cognitive behavioural therapy, or CBT, a lot in my work, alongside other therapeutic approaches. I also work as senior clinical advisor for the BABCP, which stands for the British Association for Behavioural and Cognitive Psychotherapies.

I thought that a podcast might be a great way of explaining CBT to people who are curious to know more about it. I'm getting lots of experts in the field to come and help me do that. In this episode I'll be interviewing Prof David Clark about what CBT is, I'll be speaking to Jo and Frank, two people who have experienced what it's like to have CBT first hand, and I'll be busting some CBT myths with Prof Sarah Corrie. I'll also be picking a bit of CBT jargon to explain.

First, let's hear what David Clark has to say about what CBT is. David Clark is a professor of experimental psychology at Oxford University, and national clinical advisor to the Department of Health. I caught up with him at the annual conference of BABCP in Manchester, back in July. I started by asking him to explain just what is CBT?

David: So CBT is a psychological therapy which is designed to help people who are troubled by excessively severe or persistent negative emotions.

Emotions are part of everyday life; things happen to us which make us feel happy, make us feel sad. That's an intrinsic feature of just being a human being. But for some of us we get into phases in our lives where we get excessively down or excessively anxious, in a way which persists. And CBT is based on a very old idea about what might be happening in that situation.

It really goes back to the Greeks. And there was a Greek philosopher, Epictetus who said we are not disturbed by the things that happen to us on their own, but rather the way we think about them. And so the central idea of CBT is that when we have excessive negative emotions, it's partly to do with distorted patterns of thinking. We see the world as much more dangerous than it really is, we view ourselves in a much more negative way than is realistic.

So the first thing in CBT is to help people spot their excessively negative and unhelpful thoughts. But it's called CBT because the second thing is behaviour – the first is cognitions, the second is behaviour – and that's because once we start thinking in a negative way, that changes the way we behave, and that can often keep the problem going.

If, for example, you are someone with one of the most common anxiety problems, social anxiety, you would really like to make new friends and things. But when you go to a party and you feel a bit self-conscious, you think maybe people don't like me, you'll leave the room immediately; you'll avoid. And then of course you don't get a chance to meet other people. And so the way in which your thoughts change your behaviour keeps the whole problem going.

And so your therapist will work with you to try and identify your negative thoughts, and also the way in which it changes your behaviour. Nowadays it has got quite elaborate, so there isn't really one thing that you would say is CBT. Really CBT is a lot of different therapies, all of which have a focus on the way you think, the way the thinking changes your behaviour. And also two other things: the way it changes what you remember – and in some conditions, like post-traumatic stress, that's very important – and also what you pay attention to.

In life there are lots of things going on, and we can choose to attend to some things more than others. And when we're distressed, we tend to focus on the things which fit with our negative view. What we do in CBT is try and work out, for the particular problem that you're coming to therapy for, how does your thinking affect your attention, your memory and your behaviour. When we find unhelpful patterns, then you work with your therapist to change those patterns of thinking and behaviour.

It's very practical. You don't just sit and chat; quite often you'll leave the office with your therapist and test things out.

Lucy: So more of a doing therapy, really?

David: It's a doing and thinking therapy.

So what are the doings you could do? Well, if you get sudden attacks of anxiety, what we call panic attacks, which are quite common for some people, they might think in a panic attack, when they notice their heart racing and a tightness in their chest, they might think they're having a heart attack. As a consequence they may tend to avoid exercise now and keep on ruminating that there's something wrong with my heart.

In therapy, your therapist would discuss with you all of the evidence there might be to say your heart's actually fine, it's more just an anxiety problem. But then they would test it out in action. They might pop out of the clinic with you and do a bit of jogging in the street. And if you focus on your chest and start to feel a little bit of tightness in your chest, instead of just stopping – which is what you might normally do – they would encourage you to do more, and then discover that actually my heart is absolutely fine. So it's testing things out in action.

Similarly, in social anxiety, people it turns out often have very negative pictures in their mind or images of how they think they look to someone. If they're worried about blushing, they might when they feel hot in the face think they look beetroot-red and very humiliated, and everyone must have thought they looked very odd.

Your therapist actually might, with your permission, video you while you're having a conversation with someone. And when you think I look really dreadful, they will then review with you afterwards what you looked like in reality, on the video. And people find that an incredibly helpful thing, because they discover they looked very different from the way they felt.

So these are all very practical things that you do, to test out your beliefs.

Lucy: What's the most unusual think you've ever done with anyone?

David: I think the nice thing about cognitive behavioural therapy is that everyone's beliefs are slightly different. And as a consequence, often your therapist will work with you to develop very specific tests of those beliefs.

So what would be a nice example? A while ago I was treating someone who was very worried that in a panic attack she would run out of air. She breathes very quickly, and thought if she was in a closed space then there would be no oxygen left. And we discussed this a bit. And I said, "Well, that's really not likely to happen, because in any normal room there's always air coming in, even with the doors and windows closed. Through the keyhole, under the doors and things. And so we could spend a year in the room and we wouldn't run out of air." And she said, "I don't believe you." And that's always a good point in therapy, if the patient says they don't believe you. Because they're being frank with you, they're explaining what is unconvincing, and then you can work together to sort it out.

So I said to her, "Well, you might be right, but let's test it out. How could we find out whether air comes into the room even with all of the doors and windows closed?" And we thought for a while, and we said, "Well, if a smell can come in then air could come in." So we agreed I would go out of the room, we closed the doors, and then I would just let off an air freshener in the corridor. And after just about 30 seconds, the lady said, "Oh that's a disgusting smell. Who bought that air freshener?"

And this really tested for her this belief that she had. And she realised she was never going to run out of air wherever she was.

Lucy: I was just thinking about what you said about it's the way we think about things that matters. Some people might wonder what if things just are quite difficult in life, or for some reason they're up against quite a lot of things that are challenging or hard. Is there a way of thinking out of that or is that just that things are difficult for them?

David: Well, the first thing to say is that cognitive behavioural therapy isn't about the power of positive thinking. It isn't saying just think positively and then there won't be any problems. We often are in difficult circumstances in life, and it's very important in therapy to accept that and acknowledge that. But then what we can do to deal with those difficult circumstances depends very much on our thinking patterns and our behaviour.

So the CBT therapist really works with you to look at what you can change, and help you do that, rather than trying to get you to ignore the realities. And we do know, in all circumstances, that there are things that we can do; that's one of the great powers of human nature.

CBT isn't a one-size-fits-all. You only get the best results if your therapist works with you to get you an individualised formulation of exactly how your problem pans out, and what we can do to very precisely target the traps of thinking and behaviour that you're involved in at the moment.

Lucy: Do you think CBT ideas can be useful for everyone?

David: The evidence is that we don't have any psychological therapy that works for everyone. So on a straightforward answer, no. For many of the conditions that CBT is used for, if you have a well-trained therapist who does a careful formulation, and you're at a point in your life where you feel you also want to work with them to do the work. We get very high response rates, depending on the condition, between 40% and 70% of people recover, and many more people show worthwhile benefit.

But CBT isn't the only psychological therapy around, there are other ones which have also got an evidence base. And for some people they may do better with a different approach.

Lucy: Do you think CBT ideas can be useful not just as a diagnosed problem, but do you think there are ideas that people can draw from it in their everyday lives?

David: In general in CBT we see severe emotional problems as just at the extreme end of a dimension. And that many of us find there are times when we get quite upset about something or other, and we can spot in retrospect maybe I got that out of perspective. And so a lot of the key ideas of CBT can be used on a much more daily basis, but some of us perhaps aren't so motivated to use them unless we're feeling really upset.

Lucy: And are there top tips you would particularly recommend, or that you yourself draw on in your life?

David: It depends a bit on the emotional reaction. So if you're angry, then a good strategy is to actually just pause and withdraw from the situation; don't take action immediately. Because often you find that this sort of hot emotion eases down after a while and your thinking becomes much more in perspective. So if someone sends you an irritating email, don't fire off a response straight away. So for anger that's really very important I think.

For fear, I think a key thing is to try not to go with the feeling of escape and avoidance, but to stay in the moment and to ask yourself, "Is it really going to happen and can I test it out?"

And for depression or when we're sad, it's very important to realise that we're usually excessively hard on ourselves. When you feel depressed, it's really quite important to think I need to be a bit kinder to myself, a bit more self-compassion.

Lucy: Would you say something about improving access to psychological therapies?

David: Yeah. So in almost all countries in the world we have a strange situation at the moment. So the prospects for people with mental health problems have vastly improved in the last 20 to 30 years. There have been really big advances in developing effective psychological therapies; CBT and some other treatments. And the public want them.

So there have been surveys where people have been asked, if you had a choice between a psychological therapy and a drug therapy, both of which work, which would you prefer? And in a ratio of about three to one, people prefer psychological therapies. But there isn't a country anywhere in the world where the public is getting what they want. Nowhere have we got three times more provision of psychological therapies than drugs. And in most countries you get much less provision of psychological therapy.

So we have this extraordinary gap between scientific advance and public benefit. And here in England, as you know, we've been trying to address that with the government's Improving Access to Psychological Therapies programme, which has now been running for almost 10 years and has changed things a lot.

So we now have what we call IAPTs, or Improving Access to Psychological Therapies services, in all 209 CCGs in England. And around about 560,000 people a year have been treated in those services. And they've revolutionised public transparency about mental health, because the services take objective measures of how anxious and depressed you are at the beginning and end of treatment, and they publish that data. That's never been possible before.

So this is closing the gap between science and public benefit, but there's a long way to go. Before the IAPT programme started, we estimated less than 5% of people with anxiety and depression would get an evidence based psychological treatment. We are now at 16%. That's great; a threefold increase. But 16% is still very much a minority, isn't it? This government has committed to moving up to 25% by the end of this parliament, and we need to keep them to that commitment.

It is a very big project, the IAPT project, but it's very big because we have an enormous number of dedicated professionals who are working in these services. So we have nearly 8,000 therapists working in these new IAPT services, and they've achieved an extraordinary amount.

It had very ambitious targets. When it started we said 50% of people who had a course of treatment would recover, would get completely out of the clinical range for their symptoms, and many more would show worthwhile benefit. At the time that was considered an almost outrageous target; people thought no. But the ambition was there, and in the last three months the government has got to that target, which is wonderful.

It has taken a lot of hard work to get there. But people have learnt a lot from the data we are now getting, and we discover much more about how we should optimally organise a service to get really good results for people.

Lucy: Sometimes I've heard people wonder whether people get better but then need to come back.

David: The research evidence shows that if you follow people up after a course of psychological therapy, some people just stay very well, some people have quite a big relapse in the next year, and some people are sort of going along with somewhere in between.

The key thing is to monitor that, and to give people the necessary support they need to build on the initial gains that are made in therapy. And so for some people I think the ideal is some continuing support, and allowing them to learn extra things in the process.

Now at the moment many IAPT services are not really well organised to do that. Commissioners have been very reluctant to fund some continuing follow-up and support. And I think that needs to change; I think in the future commissioners will see that it makes much more sense to follow people up, and if there's a bit of a setback developing, to intervene early. And then very modest intervention can ensure that someone stays well. So I think there's work to be done to set up our services so they really focus not only on recovery, but also on what we call relapse prevention.

But the reason why psychological therapies are so interesting is that when you compare them with medication, there is pretty good evidence that they have much lower relapse rates than medication. And that's because in a psychological therapy you learn something new about how to deal with emotional setbacks and difficulties. And that learning stays with you.

So that's really the magic of psychological therapies; they don't just help you recover from a bad time in your life, they give you some new knowledge, some new learning, that you can apply to the future.

Lucy: Do you think people should be taught these techniques early – in schools, for example?

David: Well, it's certainly true at the moment that very little of the time in our national curricula is devoted to the things that are most important for people later in life. Of course it's very important to learn to read and write, and to develop your numeracy skills and to study what you want to do for GCSEs and A Levels. But throughout our lives we're going to have emotional challenges, and it does seem very strange that very little of our education system is devoted to preparing us for that.

We certainly hope that in the future there will be two things that would happen in schools. One is much more education about what we understand about emotions and how to manage them; what's normal about them, when they get out of hand and what you can do about it. Secondly, I think we need much more opportunities for young people to have psychological therapy that's evidence based, early in life when they're developing their problems, rather than having to wait until they're adults. Because there are some things that getting depressed or anxious as a child can do, that you never really recover from in life.

If you take one of the problems we deal with, social anxiety. If you're very socially anxious as an adolescent, you will feel very self-conscious in the classroom. You won't hear much of what the teacher says, you'd be lost in your head. However high your IQ is, if you don't get to hear much of what the teacher says, you won't do so well in your exams. It's actually very difficult to recover from that later in your life.

We need an initiative which makes the best treatments available to people in schools and in local settings, where they can easily access them, and involving parents and teachers as well. And I hope that that's a direction that our next few governments will take. Because there's nothing more important to a nation than looking after the next generation.

Lucy: Is there anything that you would recommend that people read if they're interested in this podcast?

David: Something that I would strongly recommend is a Penguin book, that Richard Layard and I wrote recently, called Thrive: The Power of Psychological Therapies. That has quite a lot in it about the ideas behind CBT. It talks about how different treatments are developed. But it also puts out the very strong economic and clinical arguments for why we as members of the public should have much increased access to psychological therapies in the NHS; why the whole of society benefits from that.

So for those people who are interested in learning a bit about how therapies help your own emotional responses, but are also interested from a more political angle, about how can we help improve the mental health of the nation and allow us all to achieve our potential in the way that we'd like to.

Lucy: And actually some of the political context has been quite controversial hasn't it? About the idea of therapists perhaps being provided in job centres for example. And concerns around whether that is coercive in some way; feeling like they have to have a therapy in order to get their benefits. Do you have anything you'd like to say on that?

David: Yeah, I mean it's very clear; psychological therapies only work if you want to do the therapy. We should never be in a situation where people are being coerced into having therapy. It's just a silly direction to go in, because the therapy isn't going to work. Psychological therapies involve establishing a good, collaborative relationship with your therapist, and you working together.

So no one should feel forced into having a psychological therapy. They're there to free people from difficult emotional problems when they want to do that work, but not otherwise.

Lucy: A big thanks to David Clark for being interviewed.

Next up let's hear from some people who have experienced CBT for themselves. I went to meet with Jo and Frank at the Centre for Anxiety, Disorders and Trauma, or CADAT, which is part of South London and Maudsley NHS Foundation Trust in Camberwell, London. First up is Jo.

Could you just say a little bit about what CBT is like?

Jo: I think the main thing about CBT, in my experience, is that CBT isn't really talking therapy, CBT is doing therapy. Unlike the idea that people have about therapy as the couch and the man in the white coat and all of that, what CBT does is go, "Okay, well we have this problem, we can't change what has happened, but what do we do about it moving forward?" And I think that can apply to CBT, whether you're having it for a depressive disorder, for an anxiety disorder, or for something else.

CBT is time limited. Most people get 12 sessions as an average. Here at CADAT we get up to 20, which is great. But it should be time limited, because what CBT does is it teaches you how to deal with the issues that you are having on your own, without the need to constantly keep going back to a therapist. My therapist is wonderful, and humorous and warm, but it's quite scientific; so we have an agenda, we catch up from last time, we'll go through the homework that I was set, and what I managed to do. And then we'll talk a bit more about what I'm going to do next week.

Another point that I wanted to make was that with OCD specifically it rarely sleeps alone. I had severe depression as well. So it wasn't, with Fiona, just dealing with my specific OCD fears but about ways of being kinder to myself and enjoying leisure time, and finding things that I wanted to do for fun.

A really good CBT relationship would begin with a genuine understanding of the actual problem. The specific OCD worries which I had, which centred around harm, it was a case of something called exposure therapy, where you put yourself in those positions where you feel uncomfortable. Let's say for example that my problem was I thought I would stab my boyfriend every time I was holding a knife – that's not what my problem is, but let's use that as an example.

So I'd have to just pick up a knife and not get freaked out at first, and then just get comfortable holding the knife. The next step would be that he might come into the kitchen whilst I was chopping vegetables with the knife. The next step might be that we would eat dinner together with the knife right in front of us. And so on and so forth, until you get to the point where you could hold a knife to his stomach and just know that you're not going to, you know…

So that's one prong of the approach. But the other one was very much about my lifestyle and things I had to change basically about the way I thought about myself really.

Lucy: What were the bits that you found particularly useful about CBT as an approach?

Jo: I like the way that you're not asking someone else to get you better; it's you getting you better, really, with the guidance from an expert professional. So it teaches you to be self-reliant. And I've found I've been so much more self-reliant recently, since having my treatment and being on the right medication as well, but that that's a different aspect of it.

A good therapist will always have a variety of different approaches. So another thing that I did was to keep a positive data log every night of things that I'd done that day, things that I'd achieved, or if someone had said something nice to me, or I'd got a nice text message – all of the positive things that had happened. Because when you're depressed you tend to think about the negatives. So loads of things. And Fiona's always got ideas.

Lucy: Are there things that you wish were a bit different about it, or that you would critique a bit about the approach?

Jo: There's nothing I would critique about the approach. What I would critique is the postcode lottery – which I have quite clearly won. I would criticise the lack of availability, particularly in peripheral areas, like Pembrokeshire, where my parents live. We all know CBT works, but it's people being able to access it which is the issue. I might get a bit political here.

Lucy: That's fine.

Jo: I think it's very much worth stating as well that if you cannot access any NHS CBT, and you're looking to go private, that you must always check that your therapist is accredited by the BABCP. I'm not just saying that because of who's conducting this podcast. But I do have experience of a private therapist who wasn't accredited, and I hadn't checked, and lo and behold it hadn't worked out so well.

Lucy: Is there anything else that you would like to add that you think people should know?

Jo: The sooner you get on any waiting list the better. Don't delay. Try not to take no for an answer. Don't forget that OCD UK and OCD Action provide an advocacy service for people who have been denied treatment. That's specifically for OCD obviously, but Mind and charities like that, do have an advocacy service, if you've been denied the treatment that you need. And that's not just for CBT, that's for anything.

There's a BABCP website where you can search for accredited therapists in your area. I think a big tragedy is that sometimes people get the NHS therapy, and they get maybe online CBT or they get maybe a CBT therapist that doesn't really know much about their specific condition. And again, I'm thinking specifically about OCD here, and that isn't necessarily particularly helpful.

Lucy: Massive thanks to Jo for sharing her experiences. Next up is Frank.

What was CBT like for you?

Frank: I mean it was massively helpful. It starts with talking; you just give the therapist more of an idea of the particulars of what's troubling you. Then my impression is that they go away and form for themselves a kind of strategy, a treatment plan. That's followed up by a kind of schematic diagram of the way you think and act, so that you can see the thoughts you have, the things you do in response to them, and the effect of those things.

So you see it as a kind of circuit. It makes it clear that the things you might be doing, what you think is helping yourself, in fact is just making things worse. And gradually, as it goes on, there are elements of exposure introduced where you are encouraged to face some of your worries – some of your ritual behaviours in my case – head on.

Once you start doing it, you're very much helped to see the anxiety as something that will pass. It does reduce as well; the first time that you try something it feels like a huge barrier, the next time the barrier doesn't seem so tall. As you take things on, it makes you feel stronger and more in control of your life.

Lucy: What did you find particularly useful about sessions of CBT?

Frank: There was a notion of theory A and theory B thinking, which is you look at your way of thinking. With OCD, which is theory A thinking, it will be things like if I do this something dreadful is going to happen. Theory B is more evidence based, the truth of the matter, which is that bad things happen whatever you do; there's no magic force that you can summon up to stop bad things happening to you. So that was really important.

I think most people who do have OCD know that the condition, it wants to survive. That makes it sound a bit like the alien living in your chest or something. And it is part of you, it's not a third party, but it feels like it is tweaking your good intentions to carry on being in control.

I think the notion of not just non-OCD behaviour, which would be not doing your compulsive rituals, not trying to repair things, but also going out and actively almost being provocative really, almost challenging the thought process. So you would go out and actually do the things that scare you, quite deliberately. And that's an important step I think because just avoiding them or ignoring them, it really isn't enough.

Lucy: Is there anything you would have wanted to be a bit different?

Frank: With this particular course, no. I've had CBT before that hasn't been so precisely aimed, I think, and it perhaps hasn't been by people who have a specific training in the OCD state of mind. And I think in the end no therapist can understand every condition. I think it does help if you go to a place that specialises.

And I also think it would be brilliant if younger people could have access to it. Because I mean I've been living with OCD for 40 years, and I feel I've made real, great progress in the last year with the CBT I've had here. But it would have been just fantastic if I could have had this treatment when I was 17 and this thing was just coming on, and I didn't know what it was, and I didn't know how to deal with it.

I wouldn't actually change the experience I had here, because it was great. But I would change it countrywide, if possible, to give more people access to a more precisely guided form of CBT.

Lucy: So really important for it to be specific to your thoughts and feelings and behaviours?

Frank: I think it works better that way, yeah.

Lucy: And is there anything you would want to add?

Frank: For people who are thinking about it, who might be feeling it sounds really scary to address whatever condition you have, it isn't as difficult as you might think it's going to be. You will be helped, you will be encouraged, you'll be comforted sometimes, if that's what you need. Do it, I would say. You can't lose.

Lucy: Again, huge thanks to Frank for sharing his thoughts on CBT.

Right, now it's time for a bit of myth busting. I met with Prof Sarah Corrie, programme director of the postgraduate diploma and MSc in CBT, and consultant clinical psychologist at Central and North West London Foundation Trust, in her clinic in London, and we went through some CBT myths.

So I've got a few myths here. I wondered if we could think about them one by one.

Sarah: Let's go for it.

Lucy: The first one is: CBT is just positive thinking.

Sarah: I think if we stop and think about it for a moment, it's easy to see that positive thinking if taken to its extreme is just as problematic as negative thinking.

So the example that sometimes gets talked about, and which I use quite a lot, is it's a bit like getting into your car on a cold, snowy morning. And you have a drive to do, maybe a drive to get to work, and you're thinking it's going to be a great day, I won't bother with my seatbelt today because I know I'm going to be fine. Actually that would probably be something that puts the person at risk, if they're going to do that.

And there are a lot of really good decisions that we make in life I think, that are based on healthy negative thinking; so taking out life insurance, insuring your house or your car. The idea of negative thinking being problematic is a myth, as indeed, if we take it to the other extreme as well, positive thinking becomes really problematic.

So the question then is what is it that we're really trying to do. And the way that I try and think of my role as a therapist, is to help people really maximise their choices. And there are certain ways of thinking and certain types of thought that we tend to fall foul of, that can really limit our choices and exacerbate our distress.

Lucy: Because it can be quite irritating, can't it, to be thinking you have to think in a certain way, whether that's positive or negative. A bit like someone telling you to relax; whenever anyone tells me to relax it makes me really tense.

Sarah: Exactly.

Lucy: That kind of opposite. Second myth: CBT relies on techniques but forgets the person.

Sarah: Techniques are there to be used, but they're there to be used in a creative way, in line with the formulation that we have of the client who is sitting in front of us.

If we are in a position where we are so focused on techniques, as therapists, that we're forgetting our formulation, we're forgetting the person, we're not actually engaging with them in thinking around what role these methods have, then I think we're doing bad therapy. And I think that's something that we really need to watch against.

Lucy: Myth number three: CBT does not deal with feelings.

Sarah: In therapy people come to see us because they're experiencing distress. So it's really hard to imagine how we somehow give the message that we're not at all interested in how people feel; it's the heart of what we're doing. And what we're trying to do is to think with them about what is the most effective, most time efficient, most enduring way of helping people change how they're feeling.

And obviously within cognitive behavioural therapy, what's really key to our thinking always is the interaction, the interrelationship, between how we feel, what's going on inside our bodies, how we think, how we process information and how we behave. So there may be a number of instances where, when we're working with someone, we might make an informed decision as therapists, that to encourage them to dwell more and more on how they're feeling may actually be disadvantageous to them.

Lucy: Myth number four: CBT does not address the real causes of distress.

Sarah: So almost as though it's like sticking an elastoplast over a bullet wound?

Lucy: Yes, and that's exactly the metaphor that's sometimes used, isn't it? That it's a sticking plaster, and that it might not be that helpful longer term.

Sarah: Yes. What I think is really important is the idea that the set of factors that get a problem going in the first place, may or may not be the same set of factors that maintains it in the here and now.

Again, I'm just thinking of a metaphor here that sometimes gets talked about, which is the idea that if you're in a position where you have an accident at home. Say you fall down the stairs and your arm is in agony and you can't move it; you suspect you've broken your arm. The first thing that you need to do is to attend to the broken arm – the arm that you can't feel or move; there's something in the here and now that needs looking at. You probably wouldn't sit there thinking, "I really need to figure out why I fell down the stairs; what was it at that particular point in time?"

These are really important questions, and you need to attend to those, but probably the first and most important thing is to get yourself to hospital. Then later on you can come back and look at your house; was there a nail sticking up or has the carpet come loose, or did something else happen?

So this idea of differentiating what causes something from what keeps it going in the here and now is something that we tend to talk with clients quite a lot about, I think. Of course that doesn't mean we're not attentive to the past, and that's where the myth bit comes in I think.

People don't come to us as blank slates, they come to us with personal histories, with stories, with narratives about who they are, about their lives, about other people, about life and how the world works, and we have to take account of those. The question for us is where are we going to pitch our intervention, and that's going to vary from person to person.

Lucy: And I guess that goes a bit into the next myth which I've got, which is: CBT isn't interested in people's pasts. Which I think you've addressed really clearly actually.

Sarah: Yeah, that's just not true. (Laughter)

Lucy: Yeah. So myth number six: CBT is a single psychotherapy.

Sarah: What I would say about cognitive behavioural therapy is that it's a family of therapies, fundamentally. And those therapies would probably coalesce around certain assumptions. So one assumption might be the importance of investigating our hypotheses through the scientific method.

Another principle around which this family of therapies might coalesce would be around the causal importance of cognition. Now different therapists would have different ideas around in what ways it might be causal, how it exerts and influence, and how we should think about and work with cognition. But there would be an assumption that that's a pretty critical idea.

But beyond that I think it's really important to recognise that there are some really significant conceptual differences. Human beings are complex, their stories are rich and complex, and there isn't any single solution, as far as I'm aware.

Lucy: So the next myth I've got is myth number seven, that CBT is simple.

Sarah: Yeah, I wish it were. (Laughter) I have some sympathy for how this misunderstanding might come about. It's actually based on a very simple principle.

Lucy: Quite common sense, actually.

Sarah: Exactly. And I think that's both a strength and a little bit of a pitfall when it comes to engaging stakeholders. Because there is a degree of common sense about it, it is then very easy to start thinking along the lines of, "So, if I just eliminate my negative thinking and think more positively, everything's going to be fine." Or, "This will be fairly straightforward," or, "Just a bit of CBT will sort this person's problems out."

Lucy: Or, "I've been to a one day workshop, I can do CBT."

Sarah: Exactly, exactly. And I think again that's a real challenge, to not confuse what's a really clear, beautifully simple idea, and how that translates into the delivery of particular interventions.

And when you come together to do some therapeutic work together, there are hopefully two forms of expertise coming together. So there's what you have to offer as a therapist, but at the same time the only expert in the room on the client's experiences, is the client.

And I think the danger within that myth – well, I think there are several dangers, including the idea that it's possible to do a one day workshop and suddenly you're qualified to do CBT. But also for clients as well, that there's an expectation that it takes just a couple of meetings with someone, and that's all they really need, and everything is going to be resolved. That can be problematic in terms of just the nature of change, and the nature of effort that might be required.

Lucy: Myth number eight: CBT works for everything.

Sarah: Again, of course we just know that that's not true. Of course it doesn't. To the best of my knowledge, I don't think there's any single intervention in any field that seems to be 100% effective, for 100% of people, all of the time. The field has progressed so significantly I think, partly because of people being willing to ask difficult questions about why isn't this person recovering, or why do people with this particular kind of difficulty not seem to respond to our existing interventions in the way that others do?

I think it's that ability and willingness to ask difficult questions, to gather data in a careful, thoughtful, and systematic way, that enables us to extend CBT into new and emerging areas. So I think that's a real strength of the discipline, and I would hate for us ever to lose that.

And therefore we can say, with some degree of confidence I believe, that we are discovering that cognitive behavioural principles and methods can be adapted to an increasingly diverse range of client groups. I think that's wonderful, and I think that would be perfectly accurate. But that's very, very different from saying that CBT works for everything.

Lucy: Thanks to Sarah Corrie.

In this next section of the podcast, I'll be taking a bit of CBT jargon and breaking it down. Today's jargon is a hot cross bun.

The hot cross bun is a way of drawing out the links between our thoughts, feelings, behaviours, and our bodily sensations. These four things are all linked to each other in a way that tenuously looks like a hot cross bun, and the cross is surrounded by a circle that represents the situation.

So to take a classic example, say I am in the situation of watching a film at home alone at night, and I hear a massive crash outside the window. I have the thought that that's a burglar, and I leap off the sofa to look out of the window; my heart is pounding and I feel scared.

The same situation, on the sofa, a massive crash; I have the thought, "Oh, that's next door's cat again." My heart rate slows down again, I feel mildly annoyed but slightly amused too. I stay sitting down and carry on watching the film. The thing that happened was the same but my thought about it was different, which affected how my body responded and what I felt and chose to do.

A key idea in CBT is that changing any one of these four things – thoughts, feelings, behaviours, how my body feels – can change the others. So changing my behaviour can change how I feel. Challenging my thoughts can change how I physically react; changing my physical state might also change how I feel, and so on. Trying to draw out these hot cross buns can be helpful, particularly in helping us to spot the patterns of behaviour or thinking which have become less useful for us. So there we go, a hot cross bun.

Right, that's it from me. I really hope you've enjoyed this podcast. Please do let me know how you found it, whether you'd like to know more on CBT topics, and whether you have a specific aspect of CBT that you're curious about. You can contact me on Twitter, or at [email protected]. And as Jo mentioned earlier, if you're looking for a CBT therapist and want to check that they are BABCP accredited, you can do this on BABCP.com. That's all for now. Thanks for listening.

You've been listening to Let's Talk About CBT, with me, Dr Lucy Maddox. Thanks to all of the interviewees, to Gabe Stubbing for the music, and to Tim Ruffle for editorial assistance. Let's Talk About CBT has been brought to you by BABCP.

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