In this episode, Helen Macdonald talks with CBT therapist Sally Tribe about the impact of menopause and how Cognitive Behavioural Therapy can help.

Sally shares her own experience of perimenopause, describes the wide range of symptoms people can experience, and explains how CBT can support those affected. The discussion covers the biological, psychological, and social aspects of menopause, the importance of awareness in workplaces and healthcare, and what reasonable adjustments and compassionate understanding can look like.

They also talk about the latest guidance from NICE, how to access CBT through the NHS or private routes, and why no two menopause experiences are the same.

Useful Information

The British Association for Behavioural and Cognitive Psychotherapies (BABCP) is the lead organization for CBT in the UK.

Find a NHS Talking Therapies service here

Read the article by Sally on the menopause here

Get in Touch

If you have any questions or suggestions for future episodes, please email the Let's Talk About CBT team at [email protected].

You can also follow us on Instagram and BlueSky at @BABCPPodcasts.

Remember to rate, review, and subscribe to the podcast wherever you get your podcasts. You can also listen to our sister podcasts: Let's Talk About CBT - Practice Matters and Let's Talk About CBT - Research Matters.

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This podcast was edited by Steph Curnow

It's World Mental Health Day 2025, and this year's theme is 'access to services - mental health in catastrophes and emergencies'. The theme highlights the importance of people being able to protect their mental health in times of global instability.

In this special episode of Lets' Talk about CBT, Helen Macdonald speaks with Kerry Young, a consultant clinical psychologist specialising in PTSD, particularly among asylum seekers and refugees. They discuss the impact of trauma on mental health, the challenges faced by asylum seekers in accessing mental health services, and the importance of community support. The conversation also touches on the role of interpreters in therapy, barriers to accessing services, and positive developments in mental health support for asylum seekers.

Useful Information

• The British Association for Behavioural and Cognitive Psychotherapies (BABCP) is the lead organization for CBT in the UK.
• For those interested in supporting or learning more, Kerry suggests looking up: Freedom from Torture, the Helen Bamber Foundation, Breaking Barriers, Host Nation and The Refugee Council
• More information from the European Association for Behavioural and Cognitive Therapies can be found here
• Find translated health information from Doctors of the World here and translated mental health information from the Royal College of Psychiatrists here

Links to services by region:

Find a NHS Talking Therapies service here

Wales:

https://sanctuary.gov.wales/refugeesandasylumseekers/healthandwellbeing#

https://www.mentalhealth.org.uk/our-work/programmes/refugee-programmes/refugee-and-asylum-seekers-wales

Scotland:

https://scottishrefugeecouncil.org.uk/health/#Mentalhealthsupport

Northern Ireland:

https://www.mentalhealth.org.uk/our-work/research/journey-wellbeing-refugees-transport-and-mental-health-northern-ireland

Ireland:

https://www.hse.ie/eng/about/who/primarycare/socialinclusion/intercultural-health/mental-health-supports/

Get in Touch

If you have any questions or suggestions for future episodes, please email the Let's Talk About CBT team at [email protected].

You can also follow us on Instagram and BlueSky at @BABCPPodcasts.

Remember to rate, review, and subscribe to the podcast wherever you get your podcasts. You can also listen to our sister podcasts: Let's Talk About CBT - Practice Matters and Let's Talk About CBT - Research Matters.

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

Ever heard of low Intensity CBT and wondered what it was all about? Or what it would be like to receive it? In this episode of Let's Talk about CBT, Helen talks to Laura Stevenson-Young, a cognitive behavioural therapist and Director of Low Intensity CBT Clinical Training at Newcastle University and Emily who shares her lived experience of low intensity cognitive behavioural therapy. Together, they explore what low intensity CBT is, what it's like to receive it, and how it can empower people to take control of their mental health.

Emily talks candidly about the challenges that led her to seek help, including grief, anxiety, fertility concerns and low self-esteem. She describes the impact of low intensity CBT on her life, and the practical tools she still uses today. Laura explains how this type of therapy works, who it's for, and why it can be so effective.

Resources & Support

Find an NHS Talking Therapies service: https://www.nhs.uk/nhs-services/mental-health-services/find-nhs-talking-therapies-for-anxiety-and-depression/

More about CBT and BABCP: https://www.babcp.com

Find our sister podcasts and all our other episodes in our podcast hub here: https://babcp.com/Podcasts

Have feedback? Email us at [email protected]

Follow us on Instagram & Bluesky: @BABCPpodcasts

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This episode was produced by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies.

Hello and welcome. Today, I've got Emily and Laura with me and we're going to be talking about low intensity CBT, what that is and what it's like to be on the receiving end. But first, I'm going to ask you both to introduce yourselves. Emily?

Emily: Hi, yeah, thank you for having me. I'm Emily, I live in Yorkshire with my fiancé. And in November 2022, I reached out to my local mental health service for a number of reasons, which I'm sure we'll cover in this podcast. I began with a four-week introduction to CBT program, which was in a group setting online. That was in December. And then by January, I began my CBT therapy and yeah, it was one of the best things I've done.

Helen: Thanks, Emily. And Laura.

Laura: Hi, Helen. Thanks for having us and Emily. So, I'm Laura Stevenson-Young. I'm a cognitive behavioral therapist and Director of Low Intensity CBT Clinical Training at Newcastle University. So this means that I train practitioners to deliver low intensity CBT interventions for many different types of mental health problems, namely depression and low mood, generalized anxiety disorder, panic, OCD and some other problems that can really affect the quality of people's lives such as stress or sleep difficulties and long-term health conditions. So I trained as a low intensity CBT therapist, mostly known as a Psychological Wellbeing Practitioner or PWP for short, well over a decade ago. And I then went on to further CBT training and became a clinical trainer in low intensity CBT. So this is probably really going to come out today, but I'm a real advocate for low intensity CBT, the practitioners who deliver it. I'm so passionate about the work that they do and how they empower people to manage their own mental health within NHS Talking Therapies.

Helen: Thanks Laura. So Emily, you said there were a number of things that led to you reaching out to the local mental health services. And I wonder if you're willing to tell us a bit more about what was going on?

Emily: Yeah, of course. Yeah. I mean, kind of looking back, I should have done it a lot earlier than I did. It was kind of a lot of things building up over probably a couple of years. My mood definitely was low after losing my granddad and then with different job roles, kind of things to do with that, it was an ongoing thing. And then in 2022, that's when I'd gained a lot of weight, I was losing a lot of confidence, and I was letting a lot of stress at work get on top of me, which then had an impact on my relationship. And then obviously we were just coming out of lockdown as well. So I think that had a massive impact on my mental health. It was definitely, there was a lot of low mood and also anxiety around all I wanted to do was see friends and family, but the thought of doing that was actually making me incredibly anxious and busy places were making me anxious, new surroundings were causing kind of panic attacks. We'd gone on a trip and we were getting on a plane kind of in 2022 and I had a full panic attack getting on the plane. And there was nothing within my brain that was pinpointing what exactly it was. But I think...overriding the kind of that sadness and that anxiety there was a lot, it was around, I looked in my notes when I knew that we were doing this podcast and on the 12th of January I'd written in my notes as I was about to start my CBT I'm scared because I might not have control over what the future will bring and that might in my head was asserting so health wise I'd had some news regarding I was diagnosed with PCOS and an underactive thyroid, which both have a big impact on fertility and kind of me and my partner were trying to conceive and every single month it was like you were failing at being a woman really because it wasn't happening for us. That's still an ongoing thing now, that's not kind of changed but my mindset has changed off the back of...having CBT and I kind of went into counselling after that as well. And my mindset then has started now. I'm learning to deal with different things in a more logical way instead of going with them thoughts and thinking that that's it kind of thing, if that makes sense.

Helen: Thanks, Emily. And it sounds like there was a combination of all sorts of really difficult things going on. I mean, you've talked about your physical health, you've talked about what was going through your mind, you were talking about the way that you were feeling. There's an awful lot that was going on for you there. And thank you for sharing that with us. And I'm just sort of really curious to hear about what it was actually like having that low intensity CBT? I'm going to come back to Laura and ask her to explain a bit more about what that really means. But from your experience of being on the receiving end, what was it like?

Emily: Yeah, I think it's so, you're thinking ahead and a lot of my thoughts was always, I kept thinking, I shouldn't be doing this, I'm taking that away from someone else who needs this more than me. I could go and talk to my friends and family about this, of how I was really feeling or my partner, even. And there's only so much I think that you're comfortable to open up and tell your friends and family and speak about and but actually talking through everything and kind of making them thoughts in my head a lot more logical and combating them unhelpful thinking styles that I was doing, what just helped me so much and kind of rationalizing everything in my brain. And I think with my CBT therapist, she spoke a lot about negative automatic thoughts with me. It's every time there was something that was happening my immediate thought was the complete, the most negative response to it. So combatting that was a big thing for me and speaking about that.

Helen: Thanks, Emily. And I mean, if I can just come to Laura now, Emily's just spoken really clearly about lots of stuff to do with thinking, negative automatic thoughts, thinking logically and so on. Can you say a bit more about that from the perspective of somebody who delivered those kind of interventions? Why is that helpful? What's that about?

Laura: Hmm, it's a good question I guess. So in Emily's case the therapist was working with her on how she was thinking about herself and her difficulties and there lots of ways to work with thinking and negative thoughts in CBT. So you can work on the content of thinking, what our thoughts actually are and what they're saying or the process of thinking which is how we engage with the process of those thoughts. And I guess the most common way a low intensity therapist will engage with negative thoughts, particularly in low mood presentations and people with confidence issues is content, usually through means of reality testing or a CBT therapist might call it cognitive restructuring. Because for many of us, and we'll all resonate with this, is that we can make assumptions of what others think about us, we can have untrue and negative appraisals about ourselves and our situation. So, for example, others think badly of me or I'm terrible at my job or like Emily said, I'm failing as woman and things will never get better. And our mind can really convince us of these things that aren't true. And even sometimes if there is some truth to our negative thoughts and maybe things aren't going so well, still having all or nothing thinking or having a hundred percent conviction in these negative thoughts is really unhelpful. So it's more helpful to balance our negative thoughts with evidence sort of against their truth, if you like. And this is really important because in any CBT format, whether low or high CBT, we're trying to help the person feel emotionally better through cognitive and behavioral change. If we could tell ourselves to stop feeling sad or anxious, well, I guess we would simply do it and I probably wouldn't have a job. But because that's not possible, we have to relieve our distress and emotions through how we're thinking and what we're doing that are worsening those problems. So cognitive therapy and working with thoughts can really help people pay attention to alternative facts and information that challenges their negative automatic thinking. And this is so important because when we feel bad, these emotions are like magnets. They start to attract information that fits them. So other things that aren't going so seemingly well tend to feel worse. But when we feel better, these things tend to have less power or less weight. So imagine if I asked you to go for a walk and come back and tell me how many blue cars you saw, you'd probably come back and give me a definitive number, so around about 10. But if I were to then ask you how many red cars you saw, you probably wouldn't be able to answer. And it's not because red cars weren't there, as there would have very likely been at least one. It's just that you weren't looking for them. And this is what sadness and anxiety can do to us. It gets us to pay attention to and dwell on information that fits them. And what Emily's therapist helped to do was pay attention to information and facts that didn't actually readily fit those feelings and might have said something else about Emily or her life that can very well start to lift distressing feelings by providing alternative ways of thinking.

Helen: Thank you so much, Laura. For me as a CBT therapist, that's a beautiful explanation, particularly of the cognitive bit of what we do in CBT. And I'm really curious to hear from your point of view, what's the difference between low intensity and other forms of CBT? What is it that makes it low intensity as compared to other ways of delivering or contexts for CBT.

Laura: Yeah, well, I guess the first thing I'd say is that low intensity CBT is a type of cognitive behavioural therapy. And I think actually the name in itself undersells it. It can often mislead a patient accessing this care to feel as though they're receiving something less. And actually, that's not the case at all. All low intensity means is that the practitioner is working with someone for a briefer period of time but still does all the things that other psychotherapies aim to do. For example, the formation of a meaningful relationship between the therapist and client, helping the client understand what their problem is and how it's been maintained and pave the way to alleviate and change that distress. It's how it's done in low intensity CBT that's slightly different to other therapies. So the real sort of emphasis in low intensity CBT is that, it is, as I said, brief. So usually around six to eight weeks of 30 minute sessions with a trained practitioner. And it's been found to be clinically effective for the problems that I mentioned there. So there's an evidence base that this type of therapy can support a person suffering from depression, anxiety disorders and various other difficulties and we can be reasonably confident that those people will respond to or benefit at least somehow from this type of intervention. It's different in that it's more suitable for those who have less severe symptomatic presentations and those that are maybe less chronic. So what I mean by that is the problem has perhaps a recent onset or hasn't been there for such a long time or for those where the impact on the person's function is not severe. And this is really because low intensity CBT involves educating clients on how to use CBT interventions and encouraging them to maximize the use of these interventions between the sessions. So, it requires the person really to have a reasonable sort of capability and opportunity and motivation to do those things. But it's really important that I say that this does not mean that those with more severe and chronic presentations won't benefit from low intensity CBT is we actually know that as the demand for mental health care increases, more and more people who do have a severe set of symptoms are undergoing low intensity CBT and they are responding well, even if they do need to go on to a more intensive therapy at the end of that brief term of low intensity interventions. And I think why Emily's case is quite notable is that she did go on to have further intervention. She had lots of different things going on and severe presentation of those. But what's memorable for her are the things from low intensity CBT actually. So the way in which she engages with her thinking for example is those takeaways for her. So the key difference really is it's its briefer and the emphasis is more helping people understand what their problems are and educate them how to use CBT interventions. So it's less sort of intense. And I think one of the key things about it is that it's incredibly empowering for individuals who have it. Because if they respond well, it conveys to the person that they can take control of their own mental health and that they can actually really help themselves, which is an important protective factor for future mental health difficulties because it facilitates this positive self narrative which I think you really get from low intensity CBT that you don't in other places.

Helen: Thanks Laura. And I realized that our listeners can't see you, but I can see Emily nodding. And I just wonder if I can come back to you, Emily, and ask you, when Laura's talking about that, what's coming up for you? What do you think of what she just said?

Emily: Yeah, I mean, kind of think back to a few minutes ago, I said I should have done it a lot earlier, but in my brain space, I was not ready for it. And I think that is a huge thing with anyone. I mean, I'm such an advocate for low intensity CBT now, and I will tell people if they're struggling with things, like I would always say to them,, give it a go. Like, there's no reason not to give it a go, but it is so important that you have to want to do it and you have to want to make that change and you have to put the work in. So my sessions were brilliant, but I had to go away and do a thought record and think about it out of them sessions. And it was that I was thinking about it constantly really, and arguing with myself in a way in my brain. So when I was having those negative thought automatic thoughts, it was being aware of that and changing the narrative in my own brain, which you have to be able to do yourself.

Helen: And I guess, hearing what you're saying there, there's quite a commitment. People who've had CBT out there will have heard of having to do your homework or between session work, things like that. I'm just wondering for you at the time, Emily, what was most challenging? I mean, were there aspects of it that were particularly difficult?

Emily: I think what I found most challenging was actually recognising those thoughts because I was so used to, at the time, having these negative thoughts and to me that was normal. So it was having to just use another part of me to look at it from an outside perspective and challenge my own thoughts and that is what I found the most difficult.

Helen: Right, I've got you. And I'm thinking about what you've said to us today. It sounds like there's quite a lot of what you did learn that you're still putting into practice now. So in terms of what you came away with, I mean, Laura's just described, it's quite a brief approach. And although you've said you went on to do other things, are there techniques, strategies? Things you tell yourself that you use particularly from that that is still relevant now?

Emily: Yeah, I mean, you know, with that comprehensive restructuring, it's challenging them thoughts and I'm not like, I wouldn't sit here and say that it is a hundred percent kind of all you need to do is these sessions and you're fixed because I think Laurie will agree that's not the case. But a lot of it is them distraction techniques. I got back into reading again, which really helps me mentally at the end of day sitting down with a book and not a lot of things that are used as distraction techniques and I am still bad for it, I'll hold my hands up, is scrolling on my phone. And I think when we're in this generation particularly, it's, your phone is attached to your hand for work, for socialising, for social media and you're getting a lot of information and all that information can be quite overwhelming, especially if you're kind of Googling the things that are in your, in your brain and, and then next thing you're flicking onto Instagram and you're seeing these influencers living these perfect lives. Then with me, another thing, it was like going on social media and I'm at that age where, you know, everyone's getting married, everyone's having babies. And at one point, and I hate saying it, but seeing people with baby announcements on social media, that would really affect me. And I hate saying it because on one hand I was so happy for them because I know how difficult it can be for some people. But then on the other thing, it was something that would really affect me. So I think one kind of distraction technique is to put the phone away, put the technology away and spend time face to face with people or with a book. I think that really does help me.

Helen: Thanks, Emily. And I think you've really drawn out there that you've done all that work on your thinking, but it really involves taking action as well, isn't it? You do things differently, like even something like putting the phone away. And as you just said about it being attached to your hand, that sounds simple, but it isn't always easy. And Laura, hearing Emily talk about the things that were most challenging and the things that she still uses from those low intensity interventions. Is that similar to your experience of other people who've had low intensity CBT?

Laura: Yeah, definitely. I mean, I always say that the hardest thing about any format of cognitive behaviour therapy is that you're sort of fighting your own mind with your own mind, aren't you? Which is quite a paradox, sorry. But I think what's important in particularly cognitive behaviour therapy, as you mentioned there Helen, is that behavioural aspect. Any therapy helps somebody focus on the things that are in their control. And I really appreciate Emily's honesty there and the things that would bother her and how she would then focus on the things that she could control to manage how she was feeling. I mean, when we do engage in the things that are within our remit to change and influence, it can bring good feelings, if you like, online. For example, we might feel a sense of achievement, enjoyment or connection to others when driven to engage in the things that we can actually control. And this encourages future behaviors or activity that influences the way we feel, and we call this positive reinforcement. So when we learn that something good or a good feeling follows a behaviour, we tend to keep doing that. And the more that we feel in control and motivated to engage in what we can control, the things that we don't have control over tend to lose their power and sort of fade into the background a little bit. They seem less important. And this can be so helpful for someone because as Emily says, it's not that these things aren't going to rear their head from time to time. It's not leading to someone into a false sense of hope that all of their problems are going to magically disappear or be fixed but that you do have the ability to experience happy times and good things in your life, and we need to focus on them and move towards them to gain the benefit of those things. And even in cognitive restructuring and in reality testing it's not about completely flipping narratives and thinking you know really positively about adversity or things that we're unhappy with in our lives and might want to change. It's more thinking in a more balanced way about those things that might neutralize how bad and intense feelings of sadness and anxiety can be. And when we do lift those feelings a little bit, people function better. They're motivated to engage more in the things that might be important to them or that might distract them. And this is all really helpful.

Helen: Thanks Laura. And I've noticed that you've really made the point there that this isn't just unrealistic positive thinking for the sake of it. You really brought out that there are potentially more balanced ways of thinking about things. It's not trying to convince ourselves that difficult things aren't difficult, but perhaps the way that we respond to them and how they make us feel doesn't have to be that way.

Laura: Yeah, definitely. And I think that's really important to facilitate in low intensity CBT as well. It's all about living better and improving the quality of your life by engaging in what you can control, thinking in more balanced ways, rather than dwelling on those things that you can't. And sometimes, you know, a negative thought can convince us that, you know, they're true to such an extent, you know, like failure, we actually start to behave as if those thoughts are true and they increase our conviction in them and low intensity CBT really helps somebody become educated on what their problem is and how it's being maintained in those cognitive behavioral terms. So we call this sort of socialization to cognitive behaviour therapy where somebody learns that actually and really sees how their thinking and what they're doing is maintaining how bad they're feeling. And the emphasis on low intensity CBT is really intervening in those vicious cycles by essentially showing someone or teaching someone how to use these interventions on themselves and encouraging them to do those things outside of the session. So they become almost like a skill that somebody might use all the time, which luckily, is how Emily has responded to her low intensity CBT, which I think is fantastic and a great example of how this works at its best.

Helen: And you're reminding me of one of my friends, colleagues and mentors from years ago who used to talk about giving it away in the sense of people that we work with. If you end up being essentially your own therapist, you have your own toolkit, you've got a lot of those skills and techniques for yourself to use. And it's not that people wouldn't ever need more help or to go back for some more of the same or something different, but there's something about the way that this type of therapy works.

Laura: Definitely Helen, it's empowering isn't it? When you feel that you do have the skill set to manage your own difficulties, your problems and adversities, it can create such a positive sense of self, how you move forward in your life with these problems and not get stuck in them. And I really like that analogy of becoming your own therapist, if you like. And I think that is one of the staples of low intensity CBT is its a real sort of teaching of these skills to clients so that they can use them. yeah, resonate with that very much.

Helen: Emily, I was going to ask you, if we are, you know, sort of being listened to by a range of people out there, if there's somebody who's got similar kinds of experiences to what was happening for you when you reached out, is there anything that you would want to say to someone who's maybe thinking they might benefit or might be thinking, I'm just not going to go there?

Emily: I think the most powerful thing that I can say is just always have an open mind to it because you might think that it's not for you, you might think you won't respond to it, you might think that you don't want to talk about your issues and talking is the most amazing thing to do and if you are comfortable to speak to your friends and family about these things, even opening up in that sense is amazing but actually having CBT, I would recommend to anyone even if you're not displaying kind of anxiety and depression to the extent that I was, it has changed my life really.

Helen: It's really great to hear you say that, Emily, and just a really great recommendation that so many people could benefit from taking that step and reaching out, seeking help. And I'm wondering, Laura, what you would say to somebody who may recognise some of the things that Emily's talked about, or some of the things that you've mentioned in terms of the broader range of things that low-intensity CBT can help with. What would you say to somebody who's contemplating it.

Laura: I would first of all say that engaging in these types of strategies can be in the end extremely rewarding and as I mentioned really influence your sense of self, your ability to manage your mental health in a much more positive way. As I said before, I think, you know, the name undersells itself, but the aim of it is to empower you to be able to manage your difficulties. It's feeling in control of your problems and the things that are happening to you can maximise your independence and overall the way that you think about yourself. So as Emily said, I really encourage you to give it a try. Sometimes you might feel as though things are so bad that nothing can change them. You might think that simply thinking or doing differently isn't going to change anything. But I really encourage you to take the risk and try anyway. If you imagine if you went to the GP with a seriously bad headache that you've had for a week and the GP tells you to take paracetamol, you think, well, there's no way something as simple as that's going to work. So you don't try it. And this means that you'll continue to suffer and likely never find out if it would have helped. And if low intensity CBT doesn't get you where you need to be, there are other things that are available in NHS mental health services that can support you past brief CBT if you need it. So, I really encourage you to give it a try. If you live in England and are over 18 and you're struggling with low mood, anxiety disorders such as lots of worry, excessive worry, obsessive compulsive disorder, feelings of panic, struggling to sleep, feeling overwhelmed with stress, then there is help available to you. This type of therapy can help. If you were to just even go on to Google and type in, find my local NHS Talking Therapy service and follow those links, it will take you to service that you can self-refer yourself to for an assessment. And I really don't want to go on but if I might touch on something that Emily said before actually because I think if you are feeling like Emily that your problems maybe aren't as bad as others and that people are worse off, I encourage you to think that that's not actually what's important here. Those people need help but so do you. The most important thing is you. All of our problems are relative to our unique and individual set of circumstances. And if those set of circumstances are causing you to feel distress, depressed or anxious for a prolonged period of time and you cannot manage it yourself, then you need help. Just as anybody else would regardless of how better or worse off they are than you. So if you're concerned about your mental health, please go to your nearest mental health service. Your therapist is never going to be concerned with who is worse off. They're only ever going to be concerned about you and how they can help you fight the things that are keeping you stuck on your problems and the quality of your life. So please remember that you're just as important as anybody else and go forward for help if you need it. If it's okay I may just also make a nod to some self-help things that are available online even if you were to type in NHS self-help for mental health problems actually one of our regional mental health trusts up here in the North comes up CNTW and they have lots of free self-help books online that you can work through and give this a go yourself perhaps if you wanted to before getting the help of a therapist.

Helen: Thanks Laura. And we'll put links to those in our show notes, along with some other links that people can find, perhaps if they're not in England. A lot of our listeners are in England and in the other UK countries and in Ireland. And we've got listeners further afield as well, which is great. But we'll put some links in our show notes that just give some pointers to where people can find both self-help materials and links to local mental health services. I'm aware that low intensity CBT is not necessarily available everywhere and where it is available, it can be called all sorts of things as well. You said you were a psychological wellbeing practitioner, which is a commonly used word in England. It might actually mean something else in other countries as well. But we'll put some links in our show notes so that people can find more information if they'd like it.

Okay, so, I mean, it just sounds like from what Laura's saying and from Emily's experiences, it's been largely really positive, even though we're talking about some really difficult stuff. Emily had got a number of different things that were happening together and Laura, you've expressed it really well about it doesn't have to be comparing yourself with somebody else who might be worse or better than you at having sort of a difficulty. What we're trying to do with offering relatively brief interventions is actually making it more available to more people. And I'm just wondering if there's anything else that either of you would like to say that our listeners might be interested to hear, whether that's about the therapy itself or any other information that you think is useful for people to know.

Laura: I think the last thing I would say on it, and I think Emily touched on this point earlier in the podcast, is that you do have to be in a place to try and move towards your distress and have a commitment to trying to change what's keeping those things going. Have some idea of how you want to be helped and what you want to achieve from therapy can be really useful in creating direction for your therapy when you start it. Even if you know that you're suffering from a mental health problem and you're not quite sure what to do about it, then that is also what a therapist is there for to guide you through it. That's not all the be all and end all, but with particularly low intensity therapy, having something that can create some direction of where you want to be in your life and what you might do to get there I think can be useful but that's not the be all and end all of it.

Emily: I think just off the back of what Laura's just said as well, like when I reached out to my local mental health service, I didn't know what I wanted from it. I didn't know that my thought processes would be reconstructing. I didn't know all these terms that I'm saying now. All I knew was that I'd got to a place where I had to do something about it and my situation in the sense of, you know, health wise, things are better. But I couldn't sit here and say everything got fixed. I got everything I wanted out of life right now. And all them feelings that I had just went away magically. It's not a magic wand. It's just about managing them feelings better and taking positive steps. It was like a brain fog was lifted off me in sense of being able to take them positive steps to help my situation. So I think it's just worth noting, it's not a magic wand and reiterating that fact that you do have to want to help yourself. And yeah, as Laura said, just give it a go.

Laura: And don't be fooled by the name. Low intensity therapy is hard work. You do engage in strategies that you have to use on yourself to alleviate that fog that Emily's describing there. And that is hard work outside of the sessions that you'll consolidate your learning with your therapist when you return. And, you know, I think Emily can, it's testament that when you put that work in, you can live better, you might not get all of your problems solved. I think if any therapy can do that, tell me what it is and I'll go for it. It's just about living better. Please try it if you think that you need it because it can make even a small difference to the quality of your life.

Helen: Thank you. So I'm just going to ask if you have any final thoughts that you'd like to share with our listeners before we finish.

Laura: No, just if you're struggling with anxiety and depression, get help.

Emily: I think what Laura's just said sums it up perfectly.

Helen: Fantastic. So I'd just like to say thank you again, both of you. I really value you spending time with me and I'm very grateful that you've been speaking about all these things with us today. Thank you.

Emily: Thank you, Helen. Thank you for having us.

Laura: Thank Helen. Thanks.

Helen: Thank you. Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at [email protected], that's [email protected]. You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested.

If you've enjoyed listening to this podcast, you might find our sister podcasts Let's talk about CBT- Practice Matters and Let's Talk about CBT- Research Matters well worth a listen.

In this episode, Helen Macdonald speaks with Chris Frederick- advocate, suicide survivor, founder of Project Soul Stride, and self-described "Mental Health Jedi." Chris shares his deeply personal journey, from childhood trauma and racial adversity to becoming a mental health advocate and what helped his recovery- and the things that didn't.

Resources & Support:

If you or someone you know needs urgent help, reach out to Samaritans at 116 123 (UK) or visit samaritans.org

Brent Recovery College- https://www.cnwl.nhs.uk/services/recovery-and-wellbeing-college

The Listening Place- https://listeningplace.org.uk/

James' Place- https://www.jamesplace.org.uk/

Find more information about CBT- www.babcp.com

Find our sister podcasts and all our other episodes in our podcast hub here: https://babcp.com/Podcasts

Have feedback? Email us at [email protected]

Follow us on Instagram & Bluesky: @BABCPpodcasts

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This episode was produced by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies.

Today I'm speaking with Chris Frederick. I'm absolutely delighted to have him here with me in the studio. He's going to share about his personal history and some difficult experiences that he had in his earlier life. How he ended up looking for help with his mental health and some of the things that helped as well as some of the things that were less helpful and how he's then started using his lived experience to help inform professionals, services and members of the general public about what helps and what helps people to access the kind of support that they need. He's also going to tell us how he ended up being known as the mental health Jedi.

Chris, would you just like to introduce yourself and tell us a bit about who you are?

Chris: So my full name is Chris Frederick. Born and bred in London, currently living in northwest London. I guess I like to introduce myself. Firstly, is I'm a suicide attempt survivor. I think it's important to get that out there. I'm an advocate and founder of Project Soul Stride, which we'll touch on a little bit later. And, also I'm a mad Star Wars fan.

Helen: Oh, fantastic. And you've just mentioned a couple of things, really important things about your background and who you are. Is there anything else that you'd be happy to tell people listening today about your background and challenges or barriers that you've experienced?

Chris: I mean I guess if I backtrack to the story that, that brought me to that point, very quickly in the barriers, because they might be things that listeners would identify with. I'm a twin, I'm 55. Growing up for us in the early seventies was a tough time. We lived as a small family of four in a flat in a council estate in Wembley and due to the pressures that my father and my mother who were very young, they were only 19 and 18, and they'd not long been in the UK from the Caribbean. So they themselves were carrying their own baggage, their own trauma, their own legacy and that transferred, I guess, onto us as young children.

My father was a very strict, sort of military type figure. A beautiful looking man- if you put a picture of Muhammad Ali at his prime and my father at his prime, they could almost be twins, brothers, because that's how you know, he was tall, statuesque, beautiful green eyes, but on the downside, he had a heavy hand. And you know what I mean by that Helen, he had a heavy hand. He was quite, he was an intimidating character. And that manifested itself in negative behaviour in the house, physical abuse of various descriptions. And we grew up watching and witnessing and being victim of that as we grew up, and this is all within a black community. And then we moved at the age of 11, we upped sticks and moved to Chislehurst, which was a suburb of Kent. So imagine now we've moved from an all sort of majority ethnic community to now an ethnic minority community where we were the only black family on the street. Elms Street Avenue number 60, remember it well. Went to Kenmore Manor, and I remember for the first three years we were two of only five non-white pupils in the entire school. So without going into too much detail, you could also now begin to identify with the certain trends, the recurring themes, the racism of course, the pressures from my family. My parents eventually split up and divorced. My relationship with my twin eventually split. And so we ended up the complete, the family was completely fractured and still is today. And you bundle all that up. I started to experience mental ill health probably at the age of 19. And I'll tell you what it was, it was alopecia. Because I used to have, I used to have, if you could see me now, I've bald hair. and I started to feel there were bald patches appearing in the back of the scalp. So I went to the doctors and you said, oh, you've got alopecia. we could inject you with steroids, give you some cream. I said, well, what's the underlying reasons? And he goes, oh, it's stress. you. What can we do? What can I do to overcome that? And again, that was in the late eighties so talking about counselling and therapy again wasn't really part of the dialogue back then. Right. And then at the alopecia came back 10 years later. So I was beginning to realise I had some problems. And then I took off to Asia, lived there for 20 years, had an amazing time, an amazing experience. Again, suffered racism, but of a completely different type in China, Beijing, Singapore, Hong Kong as a black man, very few in number, but I didn't let that deter me. I had a very good career. I had a lot of experience and beautiful people, travelling a lot. But it all came to a head. It all came to head, and it's something that I called the ripple effect because it almost as if there was an author I spoke to last year, he when he heard my story, he said, I'm sorry to say this, Chris, but it almost sounds as if it was inevitable that you would reach breaking point and attempt to take your life, based on everything that you told me and that ripple that had gone through, the desperation for wanting to find love, family, belonging, identity, all the things that have become so precious to me now manifested itself when I lost my last job in Singapore in 2018, and I tried to commit suicide later that year. And then that was the time for me to leave Asia. After nearly 20 years, I realised that I needed to close the book on that era of my life. And I moved to Los Angeles and then a few months later moved to London, and then I attempted suicide again a couple of years later during Covid. So, you know, I've looked into the precipice, I've looked into the darkness, and twice I wanted to disappear from the world.

Helen: And Chris, I'm really grateful to you for sharing so openly about what's happened to you and just such, such a combination of difficult life events and the circumstances that you were living in. And I mean, I will say that the show notes will have links to help and more information for people who may experience similar things or be concerned about risks and safety. But I'm really grateful for you to sharing so openly and you've said that all of these things really have brought you to where you are now. Tell me a bit about how you went from what sounds like a real, you said looking into the abyss, to accessing something that made a difference to you, or how you got the right kind of support, the right kind of help.

Chris: So I mean, if I tell you, Helen, that when I got admitted into Ealing Hospital after my second attempt, at that moment in time, it was like, oh, finally I'm about to get some help. Finally, I'm about to be recognised as an individual who needs support from the NHS. And then through that whole process of being in the hospital, the psychiatric team at the hospital were very good, they were very helpful. The clinical psychologist came to see me. She spoke to my mum separately and said, okay, we need to help your son. And when I got discharged, I got put into the hands of the community mental health team, the Brent Community mental health team, and they were smashing. They'd come around two, three times a week. They'd make sure I was taking my medication. And then I started to ask them, okay, where do we go from here because I've got you guys for about a month. I'm really concerned what happens then. I just don't want to keep falling back into these bad habits. So they started to say, okay, firstly we're going to start to give you some information, some literature and then we're going to start to talk to you about what was then, Helen, IAPT, now Talking Therapies. I said to them, look, I don't know if I'm ready to go into therapy quite yet. I'd like something just to, just as a teaser, just to start giving me a little bit of confidence, a little bit of awareness of even how to talk or be around people who might have experienced this stuff.

So they said, we've got the solution for you, the Brent Recovery College, the CNWL Brent Recovery College. I said, oh, that sounds interesting what do they do? Oh, they've got a curriculum of courses, and you go online, and they've been facilitated by lived experience, peer support trainers. You are going to be in classrooms of about 12 people, they've all got experience of mental illness. They're all there like you. They want to see other people on the screen. They want to connect with people whilst learning new skills. And I said, I've been a lifelong learner this sounds just a ticket for me to get things going. And when I spoke to the admissions clerk, she said something that really, we talk about that light bulb moment. She said to me, Chris, the mantra at the Recovery College is we turn recovery into discovery. And when, and I used that today because it was like, this journey I'm about to embark on isn't just about me getting well. This is about me learning about myself and about the world around me and how it impacts me. And I said, I'm really going to invest a lot of time in this model and, ironically, ImROC which is the organisation that does all of the training for all of these recovery colleges, I'm now a trustee on the board of directors of ImROC and I tell my story, why did I want to join this charity? It was because of my experience with the Brent Recovery College.

Helen: Right. Okay. So I can really hear that, that was something of a turning point going into the Recovery College. So can you tell us a bit about what you learned at the college? What courses did you do?

Chris: Oh yeah. Listen, I think I did about 12 courses from sleep, sleeping well, diet, writing about mental health, mental Health First Aid. There were all sorts of really interesting courses, each semester they come out with about 20 different courses and they're always being adapted and some of them might be just one or two hours. There might have been others that are spread over four weeks, and you've got to put two hours in a week, and they give you a certificate. I mean, there were many more, and most of them were really good. One or two maybe was not so good. But I think the main thing was it was the people. I was feeling that sense of connection and that sense of belonging. It wasn't just about me anymore. It was about being with other people, and I think that was, for me, that was the main purpose of it.

Helen: And I'm really hearing you about how important it was that sense of belonging and that sense of connectedness with other people as well as learning specific, I mean, it sounds like a combination of knowledge and skills that you were learning at the Recovery College.

Chris: Yeah, definitely. Yeah.

Helen: So tell me, out of all of those things, what was the best thing that you learned at the Recovery College?

Chris: Logical thinking about problems, problem solving. Being honest, even if you feel uncomfortable in a type of environment where you are talking about this stuff, which can be tricky with strangers. It's being honest, it's being articulate. And, if I look at my mind map now, some of the models that I learned from the Recovery College in terms of being able to segment information and data so that it makes sense with always thinking about the story arc. Where are you when you start? What's your, where are you at the midpoint and where do you want to end up? And when I went into the Recovery College program, I had, I already started to think about where I wanted to be at the end. And so I was building myself every time. I was building myself another pavement, another step in the journey and the journey now is very clear. It's crystal clear what I'm here to achieve and a lot of that was built from my time, with the CNWL.

Helen: So from that, given that some of our some of our listeners may be involved in services, or as therapists. Is there anything that you would like to see therapists and services doing more of? I mean, on the other hand, less of maybe, but is there anything that you would really want to see?

Chris: Yeah, I mean I, my first experience with CBT came after I started with the Recovery College cause that was, I was signed, actually, I was signposted to IAPT in Brent. My GP failed to do the referral, which I won't get into now cause it was a complete debacle. So I actually ended up doing my own self-referral and then I just had to wait and wait. So my early experiences of CBT were not great because I had response times are really slow, understandably, this was through covid and then waiting lists were very long. And then when I kept asking each time during the assessment what type of therapist can I get access to? Oh, can I speak to a black therapist? And the answer was no, we don't have any, or if you insist Mr. Frederick, you'll have to wait for an even longer period of time. So I was so used to hearing the word no, Helen. And then when I started to do research into therapeutic, sort of models and I challenged them. I said, look, I know what CBT is. I said, but for someone like me, I even wrote it down today. I was like, someone like me, what about something like EMDR, my friend's using in LA and says, Chris, it's perfect for you. What about ACT or solution focused therapy? And every time I kept saying to them, right. What are the chances? Can I get that instead- like a shopping menu. No. Mr. Frederick, no. We don't do that, you'll just, we'll have to funnel you down the CBT pathway and that's all you are going to be allowed. Six sessions with a therapist that we give you, and its only CBT.

So now imagine somebody who has been through suicide attempts, is still a risk as terms of assessment, and now I'm now the power shifts from me to this system that is just ignoring my needs. And then you have to just sit there and accept what they give you. You can, it's quite frustrating when you think about it like that, isn't it?

Helen: It really sounds that, and I mean I know that, nowadays you speak openly about being a suicide survivor, and you're saying about in that situation, having to wait a long-time and not being given the kind of choices that are supposed to perhaps be available to people. And I'm just thinking about that experience, that personal experience shapes your advocacy work now. And I'm just wondering about what you would say about reaching people who are under served. And I know that this is an audio podcast. You're speaking to a white woman from a British background here, and you asked, could I see a black therapist? And you were just told no. I'm just thinking how that all shapes what you do now and how you promote providing access to people from a variety of minoritised groups.

Chris: No absolutely, it's a great question. I mean, I'm not saying that because I've been through about 52 hours of therapy so far. Okay. I'm not saying, and that's across five therapists, only one of them was black, which I'll tell you how I found her in a second. So I'm not saying that the therapists, I'm not saying that they were not good, not at all. I'd say two of them were very good and we actually made quite a lot of progress. But I think the fact is that I kept repeating the CBT model every time with these therapists. It was like moving the needle, it was only fractions rather than inches. And I wanted to make some real progress. And the time came where, and in fact, before I tell you about that. it was while I was waiting, I needed to find something that I call buffer services so I'll quickly plug, The Listening Place, which were brilliant because when I called them in Kings Cross and I said, I'm experiencing suicidal thoughts. I've had two attempts. I'm on the IAPT waiting list for about six to eight weeks. Is there anything you can help me with in the short term, cause I'm really anxious. And they said, brilliant, you are just a type of client that we take on, come in to see us. We are going to give you eight, eight individual sessions with a volunteer listener. And you come in and you just talk about this stuff. And they specialised in speaking or hearing from people with suicidal thoughts. And I thought, brilliant. Now. The fact is though, Helen, I had to use Google to find The Listening Place, and it was only because I knew what keywords to search. So now I think about it, what would your average person on the street who doesn't know about this stuff, they're just going to sit and wait six to eight weeks and not realise that there are other services out there that can help them in the short term or in those gap moments. And I think that's one area that I do like to talk about in my work, which is we need to be more creative, we need to be more inventive, and we need to promote all services and let, and each of us, we can create our own menu because it should be bespoke for every single person. That's what I maintain. Yeah. Does that make sense?

Helen: Yeah, it's really helpful to hear you say that, Chris, because I know that a lot of the intention is to make sure that we are offering evidence-based therapies that are appropriately adapted to individuals and that we especially in some areas compared to others we've got a long way to go to really make that happen for everybody who might benefit from those services. And again, we'll put links on our show notes for some of those things that you discovered because you knew how to look for them and it could well be useful for our listeners to have that information out there.

Chris: And I'd also say, not that I've used them directly, I've visited them, but James' Place who are expanding really well, they've got a beautiful site in London and similarly to The Listening Place, they're not just listeners, they actually, again, deal with a lot of men with suicidal thoughts and their service is superb from what I can see online.

But let's talk about the turning point here, because this is where, it's the story arc you'll start to see where the transformation really started to take place. I was on LinkedIn, so you'll get, you're getting a sense now, Helen, that I'm a big user of technology that's helped me. But it does make you think though, because if you are an individual who's not confident on technology, you are already at a massive disadvantage. Right? Which is in itself is something needs to be addressed. But anyway, so I'm on LinkedIn and it was January last year and I happened to see this post from Black Minds Matter UK, which is a charity that I follow. And it had this poster, and it was saying we are now offering 10 free sessions for clients to see a black therapist. And it, and at that time I'd been about five, six months out of therapy and knew I was going to need some in the new year. And when I saw this, Helen, can you imagine the level of optimism and excitement? I jumped out of my bed, jumped onto my computer, quickly did the self-referral, and from the moment I logged into that website and did and filled in that form, right, it took seven days to get the response on email, acknowledging receipt of my form. It took just another seven days to get the assessment call done and then only another seven days before I was in session one of 10 with this black therapist. So it was totally seamless, and it was rapid response.

Helen: Yeah and it really sounds like that was going to meet a need, which just wasn't really being met.

Chris: Exactly, exactly. So the difference is it wasn't six sessions, it was 10. So that was one thing. Secondly, it was with a black therapist, and so we didn't have to go through the initial cultural familiarity aspect, she was happy to share some of her life story. We talked about parents from the Caribbean, we talked about food, we talked about music, and so we were beginning to build a relationship, a rapport, and that for me was fundamental because when I go into these types of therapeutic relationships, we talked about the power differential, the therapist and the client. And it was only until we got through to session eight, I made a note of this because I think it is quite important. I said to her, how is it that you are able to get so much out of me? How is it that we're making so much more progress than I've ever made before? And I was curious, I asked her, I said, what kind of me methodology, what kind of framework you're using? I think I understand roughly what this stuff is but just tell me. She said I'm an integrative counselling psychotherapist. I said, well that sounds interesting. What does all that mean? She goes, well, I use a combination of CBT, person centred, psychodynamic. And I was like, this sounds really cool cause nobody's ever told me about this before. I think I've only ever done the CBT, but the fact that we're using person centred and psychodynamic I think that's why we were really clicking. And I've circled that because I thought that was worth sharing with you today, Helen. I think this is very important.

Helen: Thank you. And again, it's the whole journey that you've been telling me about, the stages of what happened to you that meant that you did actually need to seek help. And then the whole journey of trying to obtain the right help and then really meeting somebody who's truly collaborated with you and really got it, really been able to, I don't know, it empowered you in that situation, which can be disempowering, especially if you're feeling vulnerable. And so really meeting somebody very skilled and the importance of that shared background as well.

So I mean, along this journey, you've also been very much focused on helping other people as well. And I know that you've told me before when we've spoken before that you've met people across the country and abroad as well. And this is Project Soul Stride that you've spoken about. So tell me about that project and things that you've learned or, what would you like to share about that?

Chris: Yeah. Soul Stride was born August 15th. I mean, I woke up one day. Listen, I hadn't washed for a week. I hadn't brushed my teeth for a week. I was smoking like a chimney. I was in a bad place. I was in danger of going back into some real bad depression and I woke up one morning and I said I've got to do something. So I sat down with a blank sheet of paper and I had my Chat GPT AI open, and I said, look, I started scribbling stuff down randomly, started circling stuff, and I was looking for a project for about three months that would force me to get my ass out of bed at least three times a week for about three hours a day. Number two. Connect me with people on the screen so that I could actually feel like I wasn't the only person in the world. Number three would force me to write and draw and highlight because I'm a very visual person and that's how I get my heart rate going. And so I put all of this stuff into Chat GPT, and it already knew about my mental health background. And I said, what do you think I should do? And it said, okay, why don't you do this lived experience project where you speak to 30 people and you tell them your story arc, and then you get their feedback, and then you ask them point blank questions like, what do you think about the state of the industry? Where do you think the opportunities are? Where are the gaps? What are doing to improve things for black people, blah, blah, blah. And because I came from recruitment into sales and business development, using my network to connect with people was a piece of cake for me. And so 30 people grew, it doubled and it tripled. And by the time I finished my Excel spreadsheet, I'd gotten to speak to about 185 people in 15 months from public health directors, academic professors, CEOs of major mental health charities, think tanks, talking therapy leadership up in NHS England. I mean, I mapped the entire sector, including grassroot, black owned organisations in London. And I think I'd written notes, maybe a hundred, 150 pages of notes.

Helen: Oh wow.

Chris: like, so half of that stuff I still haven't read back. I still don't even, so I'm sitting on a wealth of information and knowledge, but what it's told me, number one is that there is a gap. Number two, there is a distinct lack of strong black voices in this field, particularly men. Number three, if done well, this advocacy work can open so many doors into influential spaces, not just into terms of PPIE research projects, but also advisory board positions where you really are where the decision makers are taking are making critical decisions.

Helen: And I really hear you about that's an incredible number of people that you managed to contact and the influence that, that you have available to make a real difference to people's experience. And I know that you've been part of a recent evaluation, review of the organisation that I'm here as part of the BABCP, the organisation for CBT in the UK and Ireland. And one of the things that, that we've been doing as an organisation is reflecting on how we hear the voices of people who have personal experience, lived experience, expertise, however, whichever words we choose to use. Can you tell us a little bit about your reflections and what you would advocate in terms of involving people so that we really meaningfully include that?

Chris: Yes. I mean, when I've had such a joy in partnering with the BABCP from the 2024 annual conference in Manchester, which was just, that was probably the first time Helen, where I had taken myself out of the comfort of my bedroom because I do a lot of stuff online. But actually doing it in live in a, in an auditorium, God, it was shaking. There were maybe 40 people in that auditorium. But I knew that was such an important milestone in my advocacy work that I had to tell my story. I had to be totally and utterly vulnerable and let's, the chips were fall where they may, and you'd be amazed, the response was quite staggering. People were writing stuff down, they were looking at each other quizzically as if to say, we didn't know that, we need to be hearing more about this stuff and then when we had finished, we literally got mobbed from the audience because they, they started running down from the audience to take photographs of us., I wrote this article, from Panic to Paparazzi and I started to write it on the train coming back from Manchester because I wanted to capture the emotion.

And this leads back to your question, which I wrote a couple of things down here when I read that report about the BABCP, and it's not unique to organisation, but number one, more space for lived experience, particularly I feel in curriculum design and delivery, proves the point that Leila invited me to a three-four hour workshop that she delivered on cultural humility training, several weeks ago. And she had a spot in her training schedule for me to share my lived experience, and when she turned the microphone over to me, the response again was quite staggering, and so it made me again, reinforce the message. Having folks like me involved in delivery, design of training curriculums is important, and of course, leadership. Organisations such as yourselves to have voices like ours involved in decision making, leadership influence. It's not just about- and this might sound weird, but it's not just about ethnic involvement, actually. It's about lived experience involvement. If you can get the two together, brilliant. But I think lived experience for me is the most important and of course diversity, whether it's gender, race, neurodivergence, whatever that is.

Helen: Yeah and Chris, I mean, reflecting on what you've just said, and thank you for sharing that. I'm really hearing your courage and I like the panic to paparazzi, and your courage in being in a situation where we are wearing a hat where we are supposed to be being the helpful ones and helping people who need support, need mental health treatment and so on. And yet here we are learning so much from you and you actually teaching us a lot of things that we need to learn. And I just wondered if an organisation like ours had what a Mental Health Jedi might call a Yoda moment. What wisdom or lesson would you hope for us to take forward in terms of listening to lived experience?

Chris: The cultural humility and awareness aspect is essential, should not be taken lightly. I feel in some situations it can be given a tokenistic response. I think there must be genuine equity in the conversation, and co-production of we talk about co-production of solutions. Actually, I would like to talk about co-production of ideas right? Before we even get to solutions because quite frankly, folks like me never get to rubber stamp a service design model before it hits the market. Right? I understand that as somebody coming from private sector. But if we go back to the consulting and advisory part, I'd actually think we be involved in the earlier stages of discussion and investigation about some of these opportunities. Yeah.

Helen: And building on, what you've just said, you and I were talking about let's say certain film franchises before we started making the recording, but I would really like people listening to hear about how you became known as the Mental Health Jedi and what drives your mission. I know that one of the things that you've become very keen to do is to promote mental health access and particularly equity. Tell me how that happened.

Chris: You know, Star Wars for me and it's so strange that we're having an honest conversation cause when I started talking about this two years ago, I started to think, Chris, you're coming across as a real geek here, like a real nerd. Like, people were just not going to take you seriously. And I was like, no, no, no I'm going to stick with this. So when I started talking to this author, she said to me, Chris. I've seen some of your posts on LinkedIn and you are referencing Star Wars a lot. and she says like, you've almost become the Mental Health Jedi. And I said, say that again. And she said, the Mental Health Jedi. And I was like, I wrote it down on this piece of paper and I was circling it, and I said, I'm going to use that. And even when I started to sign off on my social media posts, Mental Health Jedi And I in one night I created the new Star Wars fans group. But what's really cool is when I look through the list of people and all the countries, I think at last count there was something like 35 countries or 25 countries around the world that people have joined this group. And I take great delight in creating some amazing content because what it does me is it helps me escape my advocacy work, because talking about suicide and mental health every week, Helen, you know what that's like, it can take a real toll. So when I down tools and just put on my Star Wars hat and my Star Wars gear and put on John Williams on my Alexa device, and I start typing stories and quotes and images and reels. It just helps me use all my creative juices. It's amazing.

Helen: And I, I mean it sounds amazing. It sounds really interesting. And also just that message that, in terms of looking after your own wellbeing, even though you are dealing with really difficult stuff as part of your work. You are also, you've got things that are rewarding. You've got things that are completely different that use your creativity and create connections with people. So you really are living what you are advocating in terms of looking after your own mental health.

Chris: Totally. I mean, people now connect with me on LinkedIn and say, Chris, we love the fact that you are an advocate and you are linking it with Star Wars because it's such a door opener. I love the darkness and the light story of Star Wars, that balance and that represents and reflects my life and the life of many. And the quote I had, which was the Jedi don't fight emotions, they learn from them. And actually that philosophy has really helped in my healing and my advocacy style of work. And so I really live it. I live it, Helen.

Helen: And that's a great quote. Thank you. And Chris, I mean, I'm really grateful for everything that you shared with us today, from your own personal journey and all the difficulties that you've faced and the things that you've done about it. What's been helpful, what hasn't, what we can do more. I mean, you've just covered so much. Is there anything else that you would really want to say that perhaps I haven't asked you about or that we haven't really covered properly.

Chris: I think to wrap up and I guess this message goes out to the clients because that's who I really want to look out for. So I have four things because I was going for four and they're very quick, rapid fire. Number one is you are not alone or broken. Okay? Remember that? Most important. Number two, you are only human. We are not infallible. Number three, please consider therapy. Okay? Become comfortable with feeling uncomfortable because that's when your body reacts, in a way, it's telling you are on the right path. No matter if you are feeling sick or you get a migraine, you know you're doing something right. And lastly, and this I think is also very interesting and I got this from therapy. Being in the courtroom feeling judged is only in your own head. So take ownership. Yeah. And be brave. Be curious, and please ask the help cause nobody really knows what's wrong with you until you ask for help. My friends made so many assumptions about the state of my mental health, but when I started to open up, it was only then they were like, why didn't you tell us before we could have helped you so many years ago? I just didn't know how to ask for help, but now I do.

Helen: Chris, thank you so much. I'm really grateful for you spending this time with me today. Really appreciate it. Thank you.

Chris: You're very welcome.

Helen: Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at [email protected], that's [email protected]. You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested.

If you've enjoyed listening to this podcast, you might find our sister podcasts Let's talk about CBT- Practice Matters and Let's Talk about CBT- Research Matters well worth a listen.

In this latest episode of Let's Talk About CBT, host Helen Macdonald is joined by two international guests- Tafi Mazikana and Sherrie Steyn who share their journey from CBT service user and therapist to CBT innovators.

Tafi, originally from Zimbabwe, opens up about his experiences with anxiety while working in a high-pressured job in finance and how a digital CBT intervention through IAPT (now known as NHS Talking Therapies) changed his life. He talks candidly about the cultural stigma around mental health, what it was like to try therapy for the first time, and his realisation that CBT is about learning practical, empowering skills.

We also hear from Sherrie, a clinical and community psychologist from South Africa and co-founder of the Vimbo Health app along with Tafi. She reflects on her friendship with Tafi, the surprising conversations that sparked their collaboration, and the importance of culturally adapted therapy.

Together, they describe how Vimbo Health was developed to meet the unique challenges and needs of people in South Africa, particularly in terms of language, cultural metaphors, accessibility, and affordability. They explore how therapy can be made more relevant and relatable, from replacing metaphors like "three-legged stools" with potjie pots to tackling barriers like mobile data costs and mental health stigma.

Whether you're a therapist or someone curious about accessing help in a different way, this conversation shines a light on how CBT can be tailored, inclusive, and transformative.

Resources & Links:

Learn more about Vimbo Health: https://www.vimbohealth.com/

Information on CBT and how to find a therapist

If you or someone you know needs urgent help, reach out to Samaritans at 116 123 (UK) or visit samaritans.org

Find our sister podcasts and all our other episodes in our podcast hub here: https://babcp.com/Podcasts

Have feedback? Email us at [email protected]

Follow us on Instagram & Bluesky: @BABCPpodcasts

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This episode was produced by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies.

I'm absolutely delighted today to have some international guests for you. And in a moment, I'm going to ask, Tafi and Sherrie to introduce themselves. We're going to be talking with them about the experience of having CBT and then some really exciting developments that have happened since. But first, let's start with some introductions. Tafi, would you like to tell people who you are?

Tafi: Yes, definitely. Thank you, Helen, really a pleasure to be with you today on this podcast. So I'm Tafi Mazikana and I'm Co-founder and CEO of Vimbo Health, a metal health app that's operating mostly out of South Africa. My background as I've shared, is not as a practitioner. My background is as a patient, of CBT who became very curious, perhaps too curious. So I was living in the UK working in banking and finance, and I was just very lucky to come across the services of IAPT which allowed me to self-refer in this area of mental health. I never knew that one could actually reach out and do something, so that was game changing in itself. But I was offered to have a digital CBT intervention, which was very transformative for me but obviously just left question marks as someone born and raised in Africa to say, well, who's thinking about the African context? Because, as I'll share later, there are things and ways of thinking and speaking that are different and I was just curious about who is going to think about that. And so became more and more involved, in this area of CBT, and in particular digital CBT.

Helen: Thank you so much, Tafi. There's lots that we're going to talk about there. Before we start that though, Sherrie, can I ask you to introduce yourself please?

Sherrie: Hi Helen. Thank you for having me. My name is Sherrie Steyn and I am from South Africa. I'm actually very fortunate to be from the East coast, so the sunny side, and my background is in clinical and community psychology. I tend towards the behavioural types of psychology. So I've done some ABA or as we call it VBA now and of course a special interest in CBT. So having done that clinical and community psychology, I then went on to do one of the allied CBT training courses through UCL. So I was very fortunate, to have done that. And that's a little bit about my background and, yes, I'm also the co-founder and CSO of Vimbo, I like to say I'm the science, because it sounds cool and yeah, just very happy to be here and share some of our experiences with you today.

Helen: Thank you so much. So if I can come back to you, Tafi, I wonder if you would be willing to just tell our listeners a little bit about what it was that made you actually reach out to access CBT. Do you mind telling us a bit about what was happening for you that meant that you were seeking some help?

Tafi: Yeah, absolutely. I think what I with hindsight realise is that it was difficulties that built up gradually over time and came to a point where they sort of caught me off guard. At the time that I reached out for help, I was working in the banking sector there in London on very stressful, large projects, which brought on a lot of anxiety, but I traced back my difficulties to over 10 years ago in terms of when those little moments of a negative self-talk, which started as innocent, and then grew into something of its own life, sort of started to happen and without the right tools then entering into that professional world, I do think I was at a disadvantage. I had some great tools in terms of being quite active and taking part in sports and exercise. So that's amazing but definitely what I came to realise is that I was actually lacking other tools that could have helped me to not get into a situation where I'm feeling like I'm in a lot of difficulty. So yeah, so I always describe it as, for me, in my case, not one thing in particular, but I feel like a gradual buildup of life just happening or that negative thinking pattern becoming something of its own.

Helen: And I think it's quite important to notice that, that it doesn't have to be some one particular dramatic event or something key that changes. It might be a combination of things or a buildup over time. So can I ask you a bit about when you did access the CBT, what did you actually get? What happened in CBT for you?

Tafi: Yeah, so I think for me, I grew up in Zimbabwe in Africa, and there isn't a tradition of seeking help. So for us, therapy is something that we saw in movies, we know that movie characters in Hollywood have therapists and get help. Or we associated it with people who we knew in the community who are undergoing inpatient care. And those are the forms of help that we knew to be there. Things that are not related to us in terms of early intervention, it is more something that happens when you are at the stage of acute care, which is inpatient. So essentially when I reached out for help, I was a bit sceptical of what was offered because it didn't fit the moulds of what I thought help looked like. And when I chose the route of going for the self-guided digital option that I was given there. I was, again, sceptical because it was not what I thought therapy looked like. I chose it because it was, it felt like a lower barrier because I was still quite afraid to talk about my feelings and to talk about my thoughts and experiences. But yeah, but, needless to say, I was actually shocked and quite impressed at how effective it was. And so that, that introduced me into the idea that help is something you don't have to wait until you are at that acute phase of need. But also, it taught me that CBT is about, in my opinion, I guess I'm not a practitioner, so please take it with a bit of salt, but it taught me that CBT is about building skills, which is quite a positive thing. It's actually quite empowering is what I learned then, and I think that's what resonated the most with me and got me hooked onto this form of help.

Helen: Thank you. And I just wanted to emphasise that there's several things that you've said there. I mean, firstly, you're coming from perhaps a cultural context that's less familiar to some of us. I suspect a lot of our listeners will be in the UK, although there are people from elsewhere. But that experience of really not being used to talking about feelings will be very familiar to a lot of our listeners, that sense that it's got to be really bad before you seek help, I think will also be something that people out there might feel. And yet what you've said, it was an earlier intervention, and it wasn't nearly as bad as it might have been. So I just wondered if I can talk to Sherrie for a moment and ask about what it was like for you, getting to know Tafi and,from the CBT therapist's point of view.

Sherrie: Well, I think what the first thing that strikes me is that Tafi and I socialised fairly regularly. We were a bit younger in those days. So the socialising honestly did tend to focus on large groups, at the pub, at a museum, at a place, and even when we do have dinner time, so if Tafi would come over and just hang out and have a meal, you are still so preoccupied with the day to day that unless someone brings something to you, you might not actually know what's going on. Whilst all this was going on, I had no clue what Tafi was going through. So the first time we actually really got talking about this was when he was visiting me, so after he had completed his treatments and we were hanging out on the balcony that I'm looking at, and we were just talking. He was talking about what am I going to do in America. And I was talking about having left the NHS and working in CBT and that's how the conversation started really was after the fact.

And like a lot of conversations between Tafi and I, we of course got down to the pragmatics first before we got around to hey, this realisation that how is it that we see each other all the time? I'm a therapist, you literally went through the same service I used to work at, the same type of service and I'm only learning this about you now. And I think that's very telling and I don't think that necessarily has anything to do with Tafi and I as individuals. I don't think this is unique. I think this is really common, that it's part of that stigma that sometimes it's even difficult to say it to ourselves. And if it's difficult to say it to yourself, how do you then say it to someone else? So I think that's part of what that, that process is, that Tafi was in a space where he was at able to also recognise that this is something I can talk about because it's not something I need to feel ashamed of.

And Tafi gave me the opportunity to ask the kinds of questions you don't get to ask as a therapist. So what was that process of waiting actually like? What did it look like when you got to the website and you were being directed? What did that look like and what did that feel like and was it difficult to navigate those kind of technical questions that I do think massively impact your journey, so that was also just really fortunate.

Helen: Thank you, Sherrie, and I mean, one of the things that, that it was really telling there as well. I mean, sometimes, if I let people know what I do for a living, they'll ask me, are you reading my mind? And the point that you've just made there is that you've got a friend that you socialise with, you've known for years, and yet you didn't necessarily know what was going on until it came up in, and I think you used the phrase after the fact, and I think that might be a lesson for us as therapists as well, that not to assume that people will tell us because it might be hard or it might not come up.

Sherrie: Or they might be concerned that we're going to try and push them into therapy because it's literally our job. So Tafi really touched on this, where he had an idea about what therapy was. And I think so many of our decisions are based on these ideas and it's not necessarily what therapy is. So in my own life, I remember having a conversation with a friend of mine. I was on my way to therapy because everyone should have therapy. And my friend was like, oh yeah, therapy, easy peasy, you go and lie in a sofa and talk about your problems. And I was like, what? what sofa? And I was not doing psychotherapy, unfortunately, there was no sofa involved. But my point is it's just genuinely not having an understanding and not being in a society where we can be comfortable talking about these things and me going, actually no, there's no sofa, I don't talk about my feelings. It's very different. And then I guess for me, that was an opportunity to explain to my friend what I did as a therapist. Not necessarily what I was doing in therapy, but I was like, hey, just so you know, my clients don't lie on a sofa either. So again, just I think dispelling a lot of the mythology of therapy is a big part of it. And yes, that stigma does cling on us as therapists with our mind reading, and our desire to treat you.

And Tafi was amazing. He was so real with me about it too, about how scary it was. And it's not something you spend a lot of time thinking about as a therapist cause you're spending so much time thinking about making everyone comfortable. But why are you spending so much time making people comfortable? cause it's actually really scary and uncomfortable experience at first, and we learn about it, but it hits differently when it's someone like really genuinely sharing that with you.

Helen: Thank you. So Tafi, no sofas. What did you actually have to do if you weren't? I mean, I completely agree with Sherri, that image of lying on the sofa, telling someone your deepest secrets, that's not actually what therapy is really like. So for you, what was actually helpful? What was it that, that you benefited from when you accessed the therapy if it wasn't lying on a settee?

Tafi: No, that's a great, great question. I think the first, was the normalisation of it for me because as someone who hadn't had any previous contact with the concept of mental health assistance or what help looks like. I actually assumed that everybody is going through the same experience as me, which is that they have these feelings, they have negative thoughts that they deal with internally and externally you are presenting strength and just being happy and getting on with things and getting on with people. And then what you deal with is your own problem that you deal with by yourself. And I just assumed that everybody is going through the same human experience where they have their challenges, their difficulties, but there are theirs to deal with.

So that's what I assumed was happening. So it was actually quite helpful in itself just to understand that, actually my experience is more severe with some of these feelings than I should have to put up with. So not to say that I am not normal, but it's more than I have to put up with, and I could actually get rid of quite a lot of these things, and it's normal for a lot of people to feel that way. So when I was at the height of feeling like, ooh, I could, I can say with hindsight now that I will say I was struggling. I just thought this was normal. But the tension was so high that when I got to that escalator at Bank Underground Station, I would feel a lot of these physical sensations of, I guess now that I know are associated with the anxiety of the challenges that I had to then go tackle. So these are things that I notice now, and I think the normalisation of that and just understanding that these are things that you don't have to feel basically, if you are willing to try and go through these steps. So I was already hooked at module one and I could tell this is for me.

Yeah, so I really think there's, I believe a lot of people out there, like me for whom a lot of their need is a gap in information, just a gap in knowledge about how normal it is and the fact that there are things that can be done. So just those two things, as basic as they are, I think can have a lot of a big impact for people like me who just haven't been exposed to any therapeutic techniques or language or discussion.

Helen: And it's really interesting to hear you talk about that. At the same time, I do wonder whether there were any steps that you were expected to take that were actually really hard. I mean, you did mention that it was hard to get on the escalator at the Bank underground station. Were there things in the therapy itself that were particularly difficult?

Tafi: To be honest with you, when I self-referred through IAPT, the first step was to have a phone call with someone and that was very uncomfortable for me because I had never discussed these inner things with anybody. So that was quite daunting but because I had chosen the self-guided program from there it was up to me. I think as someone who resonates with academic things or from the finance world, you're used to learning that I was in a comfortable space once I was meeting those topics in a place where I'm having privacy. What it has done for me though, is that I am now open to face-to-face therapy because I understand the context, the language, I'm more understanding of that is normal. And also I understand better what therapy is about and what I can get from therapy. So I just needed an introduction, which gave me, I think a sense of being in control and also the privacy that I needed at this time to be able to unpack a lot of these things and understand them so that, years later, I can talk openly with you now. So yeah, so I think for me there was just quite a good fit between the form of help for the stage of my journey, which I was in.

Helen: Well, I guess the next question then really is how did you get from that and finding the guided self-help materials? How did you get from that towards developing the app? So you know, you've gone from being somebody on the receiving end to developing something that helps other people.

Tafi: Yeah, I think when I was on the receiving end, one of the things that I found really shocking and I didn't expect myself was that, for me, I struggled with a lot of automatic negative thoughts. Those I'm useless, or I can't do this, or I'll always be like X, Y, Z. I struggled a lot with those automatic negative thoughts. So developing that skill around identifying how thought, feelings, behaviours are connected and starting to do that repeatedly for myself and then doing repeatedly thought challenging. I found that over time, naturally I was having less of the negative thoughts without intentionally trying to not have them. I just wasn't having them, and I was having more of the balanced thoughts being my automatic thoughts. So I found that really transformative. I found the mindfulness exercises to also be really powerful as I practiced it more and more. I just, again, it wasn't intentional that I was thinking different. I just three months later realised wait a minute, I'm thinking differently, I'm not having the same experience of life, if you like, that I was having before. So that's what gave me a deep sense of that the science that's behind this, really works because I can say what I want about my ability to read and to understand what I'm reading but definitely there's some science that's happening in the background that is doing something to me here. I believed in the method, I believed in the science through my personal experience but then I also, at times, although it was an amazing intervention, it worked for me. I did feel like, I'm a bit of an accidental user. They didn't imagine this Zimbabwean, crazed kid, coming through and, and using this, which is fine because I think the interventions are developed with their whole audience in mind. It doesn't mean they can't be used elsewhere but there is definitely a person in mind, as the audience, which for me triggered the question of saying, well, who will think about the African context? Who's going to have enough of an interest to say if this is made for, with the metaphors, with the ways of thinking, talking, that we have here in Africa, that from living in both places I know are quite different. It became a question of who's going to think about that, but that's not something that I did alone because of course, Sherrie was herself resonating with that question to say, well, who's going to think about it? And obviously yeah, that's how things came about.

Helen: That's fantastic and I'm really curious to hear from you both, have you got any examples of the kind of metaphors or analogies that I might use because I'm based here in the UK that are different from the ones that would resonate with people that are from where you come from originally?

Sherrie: Yeah, so one of the metaphors we frequently use in the UK is talking about a stool when we are talking about balance, the stool needs three legs. Okay in South Africa, we're going to tell you about a potjie pot.

Helen: You are going to have to explain that, Sherrie.

Sherrie: So a potjie pot, it's like a cauldron. It's a type of cooking pot. It's a very popular African cooking pot, it's used outdoors, but it's something that is a bit more familiar to us. It's a small thing. Of course, we have stools, but even the word stool is just very English. So yeah, we talk about potjie pots instead.And then just simple things like if we are talking about animals, I'm not going to talk to you about a fox, you don't have any foxes. I'm probably going to describe a different animal. Simple things like when we are talking about barriers, I'm not going to be speaking to people in London about rolling blackouts. They'll be like, what are you on about? But if I'm working with the clients or even within the app, if I'm guiding you through a particular skill where I need to think about your ability to follow through on that skill. I need to think about whether you have access and when you have access. And even if I don't think about that, I'm going to help you think about that. So when we're planning, we're going to think, okay, what are your barriers? Because they look different. Of course everyone has their own unique barriers, but I'm talking about social barriers. I'm not going to say, oh, pop down to the shops, if I know that you live in a location, and that you got to go to the spaza, I'm going to say go to the spaza. Those kinds of little differences. And then also in terms of broader differences, so acknowledging and bringing into the culture, bringing in those cultural aspects. So we are very big into Ubuntu, that's something I bring into the CBT. We put a lot of focus on, I guess more of a communal aspect and what does community mean to us as Africans? What do our networks look like because they might look a bit different. So for example, if I'm in England, I might suggest you go to a peer support group. If you're in South Africa, I might say, hey, go to your elders. We know what that means, there's someone in your community who's designated an elder, you can go and speak to them. That's kind of part of their role. So just thinking a little bit differently about what is life like for you? Yeah, we all human, but you know, these are the things that make us who we are, but also your environments. It's absolutely linked to everything. That's what the five areas model is. We don't put this all on you. This isn't all on you. You are part of this broader system. So we like to try and bring that in, and I think there's something about that is also quite African.

Helen: I'm loving what you're saying. And even though what you're saying, it is African, to me it's really relevant to everybody everywhere thinking about what actually is meaningful to you, in your context, wherever you are, whether that's the middle of London or the middle of nowhere, whichever continent you are in and something about using sort of images that are familiar to you, your community, your locality, and who are the people that you go to talk to that isn't the therapist, for example, who are the people who'll support you? To me it all sounds really relevant.

Tafi: Absolutely. If I could just add to or build on the cultural differences. They can be in ways that surprise us, I think people might not expect certain things. So for example, like Sherrie's saying, in our culture at a funeral, there are songs that are sung, and they're not necessarily downbeat songs as well. So it's just that idea that cultures can work dramatically differently. Another example is I always use this, my own experience of, we have the saying in the UK that a person changes like the weather. And for me growing up in Zimbabwe, I thought it meant that person is very reliable, isn't it? Because the weather hardly changes. It's 25 degrees, it's sunny. I can rely on that person.

Helen: That's a wonderful example.

Tafi: Yeah, it of course took one trip to Manchester and experiencing the weather changing in one day to know that, okay, that's not what that means. And so I wouldn't blame someone in the UK for assuming that statement has the same global relevance as it has in the UK, but clearly it would be a cultural disconnect for some of here.

Helen: Thank you. And I mean, as a therapist standing here, I'm making notes, about what you're saying and, we do talk about including people from different backgrounds and different cultures that always need to think more carefully and more broadly about what are the implications of the assumptions that I make without realising I'm making them. And I just love that one about being like the weather. I really love that one.

Sherrie: And again, I think the focus is as you said, I mean, it's not that it's not going to be relevant to someone else. I think that the process of therapy is hard graft. I don't still need you to put in the cognitive energy to figure out a metaphor that doesn't hit quite right. So again, it's not saying, oh, we need vastly different, no. All we are saying is, hey, let's just try and make it as accessible as possible and that does mean not spending an extra five minutes trying to figure out what on earth I'm talking about in a metaphor that is just weather.

Helen: So can you tell us a bit about how the app itself actually works? It's been developed for that context, but you said it may well have a broader relevance. Tell us a bit about what somebody expects if they're looking at the app.

Sherrie: So I would say it's important for us to think about our specific aims. So like most people, one of the big aims was to introduce some kind of intervention. So South Africa does tend to focus on, what I would call a late-stage intervention, so hospitalisation, inpatient care. And so we were recognising this massive gap. Obviously, Tafi and I are seeing that within our personal lives and that was one of the first things. So we really wanted to give something to plug the gap, so access. Tafi and I are absolute nerds, total geeks. We wanted it to be very scientific. Yes, we did want it to be something for the African context, but you know, specifically. we wanted it to be top quality for the African context. We didn't want it to be the forgotten, oh, okay, we made it for here, but you can have it anywhere, we wanted to actually do something that was ours. So I think that was the starting points which obviously leads you to thinking about the barriers. So what are the major barriers? Why is it that most people are receiving inpatient care? So you start there, you obviously start doing your research on the ground. Just ask people, don't make assumptions, what is your experience? Okay, do you have health insurance? Do you not have insurance? Those are two very different pathways, very different experiences. So starting to understand what that map looks like, and then thinking, okay, how do we plug this gap?

So our first iteration, we were actually looking at doing a completely text-based intervention. And we realised, look actually that's not going to be quite enough what for what we are trying to do. And so that's how we landed on the app. And then from the app, I basically just took therapy, it's not reinventing the wheel, honestly. There's no miracles happening here. I took what we do in therapy, so best practice and I applied that to an app. So the first point of call when you get to the app is to go through your symptom levels. We don't work with diagnosis, we tend to talk about symptom levels. Okay? I can't diagnose you, I don't know your whole history, but I also don't need to know your whole history at this point. So we get you to start thinking. So this is what Tafi was talking about introducing a vocabulary, so an understanding that's your first points already. We're saying, okay, let's talk about what you're experiencing. The user then gets feedback on those measures. We use the PHQ, we use the GAD, we use the WSAS of course. So that gives us an idea of what you're experiencing and that allows us then to streamline them into a particular treatment module. Okay. So the different modules are, of course, for different presentations. At the moment, the app focuses on anxiety, depression, and we have two comorbid groups depending on whether the user feels that they want to focus on the anxious symptoms more, or they want to start with their depressive symptoms more. So what is the bigger focus for the user at the time? We've also included what we call our wellbeing group, which is for people who have come to the app, they're presenting as subclinical in terms of their symptom levels. But clearly you're here because you feel you need something or you want something, you want to do something. So we focus on resilience there. So yeah, fine, you're not presenting, and again, I use the word presenting because we know that sometimes we can withhold information, but also no scale is perfect. So we sort of then direct those people to what I consider the more resilient focused stuff. So a lot of mindfulness, relaxation practice, so still getting something but not quite the full treatment.

The user then goes through a process in the app. So generally, it's exactly like face-to-face therapy. Basically, the modules mimic a one-to-one session. So we start off with a joke, a little bit of dopamine to get you hooked. Yes, shameless in that. Little bit of dopamine, bring a bit of humour, get you to feel a bit relaxed so you can really engage with the content. The content's very short, it's very modulated, and any session, we start by reviewing what you've done. I introduce a rationale for what you're going to learn, so that skill or technique, we go through that and most crucially, we then focus on the practice. So that's one of the things we're very big on. I think one of the things Tafi hit on is this amazing thing where CBT is crazy in that I don't actually need you to understand why you are doing what you're doing. If you just do the stuff, you will eventually notice the benefits. And that's not just based on the data, that's based on Tafi's experience, it's based on my own experience. So we very much focus on the behaviour because at the end of the day, it's, I do think it's not so much about what we think and what we say, it's about what we go and do. So we try to get the user to really focus on how are you going to integrate this? How do you make this part of your life? So very practice focused. We review the practice and the idea is that you get to a point where you feel you've mastered a skill before you move on. So that's where the self-guided part is. You can just go through it all, but the self-part is really in terms of thinking about, okay, I can give you all the tools, but you still have to make that decision for yourself if you've mastered it. And more importantly, do you find it helpful? Because you don't need to find everything helpful. We take least intervention first. I'm happy if you do one module and this is the thing that you need. Because I think that's the tricky part about any kind of therapy is finding what fits for you. What is your motivation. So for example, Tafi, he was very comfortable with the app because like he said, he likes learning so it was an environment he was familiar with. So that's really the focus on the app, is on those real world skills. And I guess ultimately we are trying to teach you that iterative process of being your own therapist. And that's really what the app is about. With some sign posting, of course, because I would be a terrible community psychologist if I didn't do some sign posting.

Helen: Tell me a little bit about what you mean by signposting, because I think I might have been about to ask you, sort of if somebody needs more or needs something different, how would they know?

Sherrie: Yeah. So one of the things about the app is we have designed it to be completely self-guided. So it can be a standalone intervention, but a tool should have more than one use. So it is also intended to be used as a therapeutic tool, not just with CBT therapists. So in terms of giving your client that literally in pocket support- you don't remember what I said in session. That's fine. Go to your app. So that's wonderful because it does free up a lot of space in your therapy sessions. We work with quite a lot of OTs. OTs absolutely love the tool. Again, it means that they can focus on something else in their session whilst also ensuring that their clients is getting that additional support because as we know, it's very rarely that you have some kind of long-term difficulty or even short-term health difficulty without that impacting your mental health. I think the main thing is find what motivates you. That's where the signposting comes in. So sometimes it's simple things like, I suggest some yoga stretching as part of your nighttime routine. Okay. I can literally signpost due to a YouTube video. Fabulous. Or I can signpost due to yoga institute that, and there are lots, that have free resources. That's the signposting.

Of course we also do crisis signposting. That's the reality if you're working with any kind of mental health. No intervention is everything and that's where I think signposting can come in handy is going, hey, we aren't actually everything. Here are some other options.

Helen: And I'm really pleased that you said that I was going to ask you about, if there was a reason to worry about someone's safety or if there was some kind of emergency really, your app helps people to go to the right place for help.

Sherrie: Unsurprisingly, it's one of the first things that we thought about. So when it comes to crisis support, most systems have their own particular way of dealing with it, who you refer to, who you deal with, you've got a supervisor, whatever the case is. An app doesn't necessarily perfectly fit into that, especially if you're an app working across multiple use cases So that was one of the first things that we thought about.So the app includes a little logo at the top of each page. So it's always there. It's quite subtle, but it's easily seen so it doesn't feel doom and gloom. It's just a little red phone, but you hit the little red phone and it's going to take you to that support immediately. And the first thing we do is we just give a normalising message. So simply say, okay, you've come to this page, you clearly need some support. You might be going through something that's absolutely fine. It's normal. But the important thing is that you get the help that you need. Here are a list of options. What do you want to do? I think it's also important that we don't just include telephones because again, I know that when we say one-to-one, we tend to think of that as a conversation, but that is, can be very generational. One to one can also be via an online chat. It can be via email. So again, I think just as a heads up to anyone who's thinking about getting into this, if you are going to be signposting, just think about different types of access. There are different ways that people like to communicate. So yeah, that normalising message and that instant support, and most crucially, make sure it's visible at all times.

Helen: You just mentioned there's a generational difference between people, so you are talking to me- I grew up listening to music on cassette players, so if you've got people out there who are maybe not so familiar with the technology, that they wouldn't necessarily automatically go to an app or might absolutely assume that if you need some kind of help, you need to talk to a person, even if you're not lying on the sofa. You might want to talk to a real person. What would you say to somebody who's maybe less comfortable with doing everything on their phone?

Sherrie: So I get the hesitation there. I think it's important to not get hung up on the delivery method. So in our research we actually found that, we had participants aged 18 to 69. And when we looked at the data, obviously we keep doing the research, but as it stands, age actually had no impact on usage or recovery.so I think a lot of the times this ties back into the ideas about therapy, is don't do yourself dirty. You don't know what your experience is going to be until you try. And it's okay if you try and it's just not for you, but you might be very surprised at just how easy and comfortable it is, and even though you're not talking to someone, one of the big things that we get in terms of feedback is that it feels like you're speaking to someone.

And then finally. We do have you in mind. We have everyone in mind. It's okay if you're not technologically advanced. I don't need you to be, that's Bernard's problem. By the way, Bernard is the other co-founder. He's the tech. It's Bernard's job to make it accessible, but we do really think about just making something that's easy. Again, it's always about reducing that cognitive load. So I would encourage anyone to just give it a try, and that goes for all therapy. So give it a try. If it doesn't work, that's also okay, but you might be very surprised.

Helen: Thank you Sherrie. And I think one of the things that you've told me before we started recording this Tafi is that one of the things that you were bearing in mind when you were thinking about accessibility, I think I understood from you that many people do have a mobile phone, but things like access to data can be an issue. So tell us how you address that as part of the project.

Tafi: Yeah, no, absolutely. And I think, I'll even broaden it to say when we think about our role, in a business journey, we are definitely not replacing face-to-face therapies or tele therapies. And actually, I always start a lot of presentations and conversations by saying if someone has the confidence, as well as the financial means to engage in face-to-face therapy, I 100% recommend it as because now at this stage in my journey I understand the benefit and the power that's to be gained from talking therapy, so that's the starting point. And then of course, for some people the confidence is an issue in which case perhaps regardless of their age, as Sherrie pointed out, they might persevere and figure out how the app works, even though we do try to make it simple. Unfortunately, in our African context, the affordability plays a bigger role because in the UK there's of course the very well, to us, very well resourced NHS to British people under resourced, which it is. but from our perspective, there's a well-resourced public health service that can give you a full dosage of help. And then maybe you can guide me in terms of when you have someone who typically has maybe moderate or moderately severe difficulties, how many sessions would they be allocated by the NHS.

Helen: Well, that's a very good question, but I would say a starting point of at least six and maybe 12 and sometimes more if the difficulties are more severe than that. Yeah, there, there is definitely the possibility of seeing someone who understands and can listen to you and even at what we call low intensity level, that would be probably six sessions. And then at high intensity, probably quite a few more.

Tafi: Okay. And, and so in South Africa we find that the people who do have access to that form of health are those who have private medical aid insurance, private health insurance, which I think is something like 20% or less of the population. And those people form pretty much the wealthier parts of society and they get typically three sessions of face-to-face therapy as what they get through benefits, unless of course unless it is, it's under what they call prescribed minimum benefits where they just have to help you. But if you are getting generally help, at an early stage, you're getting three sessions and that's often what you get either through your employer or your insurer. So there's a huge underdosing that's happening, which means people don't have the affordability barrier before we even get to the other costs. The affordability is just out of there for everybody. And then we do, as you mentioned, try to address other aspects of accessibility, and one of them is mobile data costs, because when I lived in London, you can sit next to someone on the train and there'll be streaming Game of Throne in HD, and watching the full hours episode. For someone in Africa that could be their entire year's budget for mobile data costs, the cost of streaming that. So then we have to make it sensitive to that with a lot of accessibility of the treatment when you're offline. So there's a lot of relevancy that we've built in, but I think the biggest issue we have is just sheer affordability and then the huge amount of underdosing that happens as a result of affordability. And then we also have, of course, the technical barriers of data costs, mobile phones that don't have a lot of storage capacity, things like that. So we address those challenges as well.

Helen: I mean, it sounds like an awful lot of thought has gone into the practicalities of it as well as including the science, and I'm just standing here thinking that although you've designed that for the African context, it really does sound like there's a lot of those things that could well be relevant in the continent of Europe, Britain, where I'm based. I know that Sherrie's not in Africa at the moment. How relevant is it to people who aren't in Africa or from African heritage, let's say?

Sherrie: Absolutely. I mean, as relevant as it was for Tafi when he was in the UK. At the end of the day, these are universal experiences. The only thing that's being changed is the way we communicate the ideas to you, but it's all based on the same science. I mean, none of the metaphors are going to be that wild especially in the age of Google. You might be like, what is a potjie pot? And you Google it and it says cauldron. You might say, what is a hyena? And you can be Google it and it's like an ugly dog, but you know the main idea is there. So I would say it's still relevant.

Helen: Thank you, Sherrie. I am really grateful to the two of you for coming to talk to me today and we're going to finish in a moment, but before we go, Tafi, can I ask you if there's people out there listening who are having similar experiences to the ones that brought you into contact with CBT and everything that's happened since, is there one key thing that you want people out there to know or to remember from our conversation today?

Tafi: Yeah, certainly. I think I can speak from the perspective of a man and our preconceptions of what reaching out for quote unquote help is, and it's just to say it is not a weakness, it's not a weak act. It's actually arming yourself with skills, with tools, that will only better you. So that was the key revelation for me. I always say to people, would you rather your plumber turned up with one spanner or a belt full of tools. And I think it's just gives us that belt full of tools to really just get through life better professionally, and personally as well. So I just encourage them to see it as an upliftment as opposed to an act of weakness.

Helen: Thank you so much. And Tafi and Sherrie, thank you again for coming to talk to me today. It's been an absolute pleasure speaking with you and a privilege to hear about your stories. Thank you.

Sherrie: Thank you so much for having us.

Tafi: Thank you Helen.

Helen: Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at [email protected], that's [email protected]. You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested.

If you've enjoyed listening to this podcast, you might find our sister podcasts Let's talk about CBT- Practice Matters and Let's Talk about CBT- Research Matters well worth a listen.

In this episode of Let's Talk About CBT, Helen Macdonald speaks with Phil Cooper, mental health nurse and co-founder of the charity State of Mind Sport, and Ian Knott, former professional rugby league player and State of Mind presenter.

Phil shares how State of Mind was born out of tragedy and developed into an award-winning mental fitness programme, now reaching thousands of athletes across the UK and beyond. Ian talks candidly about his experience of severe injury, depression, and suicidal thoughts after retiring from sport, and how CBT helped him to rebuild his life.

We hear how sports settings are being used to break down stigma, encourage conversations, and promote mental health support—particularly among men—and how brief interactions and powerful personal stories can save lives.

Resources & Links:

State of Mind Sport website

Information on CBT and how to find a therapist

If you or someone you know needs urgent help, reach out to Samaritans at 116 123 (UK) or visit samaritans.org

Find our sister podcasts and all our other episodes in our podcast hub here: https://babcp.com/Podcasts

Have feedback? Email us at [email protected]

Follow us on Instagram & Bluesky: @BABCPpodcasts

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This episode was produced by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen MacDonald, your host. I'm the senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies

Today what we've got for you is an episode about mental health, mental fitness and sports, and I've got Phil and Ian here to talk to me today. Phil, will you just introduce yourself?

Phil: My name's Phil Cooper. I'm a mental health nurse by background. I used to work as a nurse consultant in mental health and drug and alcohol misuse. I love sport. And, for some strange reason or quirk of random chaos, I became to be one of the co-founders of State of Mind Sport charity that focuses on mental fitness.

Helen: Thank you, Phil. Ian, please, will you introduce yourself?

Ian: My name's Ian Knott. I'm a former rugby league professional and I currently am a presenter for State of Mind. I talk about my story, my lived experience of having to retire through a serious injury and then developing mental illness. So I talk about that.

Helen: Thanks very much, Ian, and I'm sure our listeners will want to hear more about that later in this episode. Firstly though, can I ask Phil to tell us a bit more? Phil, will you tell us about State of Mind and how it came to be and what it does?

Phil: Sure State of Mind Sport began unfortunately on the back of a tragedy within the sport of rugby league, where a Great Britain Rugby League international called Terry Newton, unfortunately took his own life in September, 2010. Sent great shock waves, I think, through the whole sport for such a high profile player. At the time there was relatively little support or mental health support for players at that time. I suppose as a mental health nurse who loves rugby league and sport, I read a league paper on a Monday morning, somebody wrote an article saying how the NHS and the sport should get together to try and prevent suicide. Also, somebody also wrote a letter, again a mental health professional, called Malcolm Rae and Ernie Benbow had written the article and I saw this and thinking, wow, this is Monday morning, I shall write these two individuals- checked with my chief exec, of course, because obviously you have to be doing all these things- and then invited them to a meeting we were going to have in good old health style a conference, that soon changed when we invited a couple of players such as Ian, and they suggested, why didn't we ask the governing body for a round of fixtures to promote mental health at that time or mental fitness. I then found myself in the strange position being ferried to Hull Kingston Rovers Ground to be presented before all the chief execs of all the top divisions with clubs to say, this is a really good idea. It's free. So the sport love that bit and, we'll deliver a session to your players before the season and then a round of fixtures themed around that. So we had a State of Mind round in 2011 and player bought into it. There was very little support, as I said, and they began to talk about it on social media. They wore t-shirts in the warmup before the round of fixtures, but crucially, they knew what it was about, and they were all bought in. Things have grown massively since that time, which has been great for us. And also promoting mental fitness in rugby league, one of the toughest sports on the planet.

Helen: Thank you Phil. So can you tell us a little bit more about what you really mean by mental fitness?

Phil: Certainly, okay. I think language is crucial, as I'm sure all your members will realise and will think about on a regular basis. So for me, to get into a situation of encouraging men or engaging men into something that will help them, if I say, if I used to say, well, we'll come in and deliver a mental health session for you into a local grassroots sports club. I can imagine the reaction would be flipping heck, I'm not going into that. However, when you can make the case that actually you are going to go to training for physical fitness, what a lot of athletes will tell you that the mental fitness is perhaps the most important aspect of being a professional sports person or being the best sports person you can be. So therefore, if we go in and say, well, we're going to try and improve your mental fitness, men tend to sort of buy into that, especially if you go to them in their grassroots club, they wouldn't come to me in a community mental health team, but they would certainly go training two nights a week in their local club. And you have a captive audience potentially, especially when the weather's bad and they can't train on the pitch. And the coaches will want something different to either entertain or, keep the players focused on what they want to achieve. So State of Mind deliver mental fitness sessions so we look at anxiety and depression using a GAD-7 and a PHQ-9, as I'm sure your members will be very familiar with and again, we deliver that in a style that's not sat down in front of somebody asking them to fill in a questionnaire with a pen or online or whatever. So we'll do that. We will have two presenters usually. So Ian being one of those, I might have been the clinical dude once or twice with Ian, of course, and I'll ask him about how he's been feeling over the last few weeks using a PHQ-9 or a GAD-7. He'll tell me some strange answers, which he never used to tell me what they were going to be, I would then ask the audience how anxious or how low in mood Ian was based on those answers. So you keep all the information away from your audience, but you involve them to use all the different learning styles, so audio visual, kinaesthetic, all of those learning styles to get to as many of those people as possible. So we've been doing that for 10 years. Hundreds of thousands of people have attended sessions, which is ridiculous when I think back, but also numerous people have told us that they changed their mind about taking their own life and that's the sort of thing that keeps you going every week. And going to wherever we're going of a Tuesday or a Thursday evening, or even as I found myself in a dressing room last Saturday, so before a football match, just talking to players. So all of those things, we do mental health first aid. You can look on stateofmindsport.org if you really want to know. I don't want to want too much about that, but that's what we do. And we go to people where they are. We try to engage people where they are.

Helen: And I'm hearing you are reaching a huge number of people, probably people who wouldn't easily go and look for help, like perhaps men in maybe more traditional settings where we don't talk about mental health or mental fitness as you put it. That's really important. But also this work is saving lives and that seems to me as a really important piece of work that's happening here. And I wonder if I can ask Ian to come in now. And Ian, you said, about your lived experience and that's what's brought you into working with State of Mind Sport. Can you talk a bit about your experiences?

Ian: So my kind of story started in 2004 while playing for Leigh Centurions. At the time I probably had about 12 years I think at professional rugby. I played at the highest-level barring international level, and after 12 years of playing at the highest level, I dropped down division to play for Leigh Centurions And at the time, Leigh were making a massive push to get into Super League. I never played in Super League before, and halfway through the season, I can remember we played against Halifax away from home, and I ran with the ball, and I got tackled and there was nothing wrong with this tackle at all, but I felt these god awful pains in my lower back and it felt like my leg was, I don't know, it's like tingling and my foot was in like a bucket of water or something like that. So it felt, which was strange because we are really hot summers day. So obviously I came off reluctantly, because we are a bit stupid, old rugby players, we do play with injuries. But I did come off, and then a couple of days later the pain got worse, so I got sent for a scan. And I got told in no certain terms had a very large disc prolapse at the bottom of my back. So they said you can't play, you need to obviously get treatment and then you'll be okay for the next season. So I went back and had a meeting with the club, and we all came to the sensible conclusion to ignore the surgeon and played with a slipped disc for half a season. Now to say that was painful would be an understatement. During the week, I couldn't train at all, the pain was that bad. Then on a Saturday morning, I'd have a painkiller injection to do a ball work session. Then on a Sunday, I'd have two full syringes in for 24 places in the spine to try and get me through these games. I'd be throwing up on the pitch, the pain was that bad. It was very hard. It was very difficult, but it ended up being quite rewarding because we won the treble and we gained promotion to Super League, which was amazing. I was lucky enough to be captain and so I managed to lift all three trophies. So then two days after the grand final, I remember having an operation to relieve the disc, woke up in recovery and all the pain down my leg had gone and it felt amazing. I still had a bit of back pain but I could cope with that. So from there, I had rehab and then race to pre-season, and then the next season, like Leighs first year Super League. I think we were about 12 games in, and I think we played Halifax away again, coincidentally. And it's a similar story. I took a ball in but this time it was quite a bad tackle. I got clothes lined, so the legs went from underneath me, and I landed on my spine again. Now these pains came flooding back. I couldn't quite describe to you now how bad the pain was. because it was horrendous. But the best way to describe it would be, my wife was sat at the top of the stand, and I was in the middle of the pitch, and she would hear me screaming from where I was. The pain was bad. So I got stretchered off, straight to hospital. Again, another scan. So as I'm waiting in hospital for the operation, my surgeon came to see me, and he put my scan up on a whiteboard next to me. So obviously I asked him, you know what's the problem? So he said, look, he said, you're not going to be able to play rugby ever again. He said, in my opinion, you're going to struggle to find work again you know the damage is that bad and God knows what I'm going to find when I open you up and look in.

Now, at the time I was strong mentally, so I thought, so I'm thinking to yourself, obviously I'm going to start find work again because I need to, I have two young boys at the time, I have a wife I was supporting, so I need to find work. So I thought, I'll prove you wrong. I woke up in recovery, unfortunately for me, I was screaming in pain, the operation just didn't take, and I spent the next, I'd say roughly 12 months in that hospital. I had five operations on my spine in the space of probably two and a half years. To say that my mental health dipped in that period would be a massive understatement. I'd gone from being a full-time professional and I trained three times a day if I was bored when I got home, I go for a run. Basically, I was hyperactive, I couldn't keep still. I went from that to literally being that to being completely bedridden. My wife, she had her dream job, she absolutely loved it. She had to give that up to become my full-time carer. She had to wash me in bed, dress me in bed, she shaved me in bed. if I needed the toilet for a pee she'd help me pee in a bottle. If I needed a toilet for anything else, she'd help me with that. My wife was amazing how she did what she did, I do not know. But I did I appreciate her for it, not one little bit. I'd do nothing but shout and scream at her all the time. She'd be trying to talk to me, encourage me and I'd just shout at her all the time. Like I said, I had two young boys and they'd come off from nursery and I'd hear them coming upstairs to see their dad, excited and then that for me was like somebody putting the nails down the blackboard, they grated on me so much. I hate saying this now, I really do, my kids and my wife and my world, everything I do is for my wife and kids. But during this period, I wanted nothing to do with them because I was obviously very depressed. I did not know what depression was. And I come from an era and from a sport as well really, where you don't show any weakness. So, I took that into my normal life, and I just tried to put a brave face on things and I wouldn't talk about it, even if I did know what depression was because I was supposed to be a big tough man, so I'm not supposed to talk about the problems. So I didn't and it just got worse and worse. It felt like my head was stuck in a vice and every day this vice was just getting tighter and tighter to the point where I just felt like my head was going to explode. I was taking roughly 30 painkillers a day. I was on liquid morphine. I was on morphine patch. So if I wasn't screaming in pain or screaming at my wife and kids, I was doped out on drugs. That was literally my life in these same four walls all the time. I just, I wasn't living, I was just existing, if that's the right way to say it. And I just didn't know what to do. But I got a lifeline because I got a chance to have a device implanted in my stomach, a pain device, which is, it's called a morphine pump. It's got liquid morphine, it's got anaesthetic inside it, and it goes directly into my spinal fluid. Now, obviously, if we all have a headache or anything, you take tablets and it obviously goes down your body and then it goes to your head. With me, I was taking all this medication it had gone all the way around my body before it got to my back and by the time it got to my back, it wasn't doing anything. So I had a trial for this morphine pump and the pain relief was amazing. But it couldn't fit me in for an operation straight away. I had to wait another six months. So I had this kind of high of having this trial, which was amazing. And then the lows again the depression sinking in because you had to wait another six months. So, as I was waiting, obviously the depression got worse and worse. Again, shouting at my wife and kids again. And I'd say about three days before the operation. I can remember my spirits picked up and I was really buzzing thinking, I'm going to get my life back because that's the way they kind of explained it to me. This pump, you're going to be able to walk about more, you're going to be able to socialise more and things like that. So I was really excited. I was buzzing, so I went in for the operation thinking that's it, now my life's going to start again. But unfortunately for me, I woke up in recovery and I was screaming again in agony. The pain just didn't, so it was worse, the pain relief just didn't work whatsoever because during that six-month period, I was taking more and morphine patches, I was taking even more liquid morphine. So the dosage that they used in the trial, literally just didn't touch me. So again, I spent the next 12 months in and out of hospital. I'd say roughly about between 25 and 30 times trying to get this dosage sorted. And again, to say that my mental health dipped in that period would be an understatement because there's no other way of saying it, I became suicidal. For me, every thought on my mind was not only do I not want to be here, but mainly the way I rationalised it was I didn't deserve to be here. My wife deserves someone to love her, to cherish her, to treat her like the brilliant woman that she is. I wasn't doing that. And my kids deserve someone to love them, to play with them, to teach them right from wrong and just to be a good dad. And again, I wasn't doing that at all. So I thought the best thing for my family and for me to be honest with you, would be for me not to be here.

So it wasn't a case of, I didn't really think that I wanted to die, but in all honesty, I just didn't really think that I wanted to live anymore. That might sound weird to say, but I just, I couldn't cope with the pain that I was feeling and I couldn't cope with the pain that I could see on my wife and kids face all the time. So, I went downstairs one morning, I just had enough. I got a pint of water, a box of tablets and a bottle of Oramorph, liquid morphine. I took the tablets in the water upstairs, I started to swallow all the tablets because I couldn't cope with it anymore. I realised I forgot the morphine, so as I get up to get the morphine, I've got photographs of my wife, me and my family going all the way down my hallway and down the stairs. I started to look at these photographs and I, throughout my depression and throughout the era of suicidal thoughts, I've gone past these photographs, and thought nothing of it, but for some reason, now I'm not religious at all, but I thank God to this day that I really started to look at these photographs and it's like, I just thought to myself, what am I doing here? I think I'm doing my wife and kids a favour by ending my life when the reality is I'm going to ruin my wife's life, my son's life, my family's and God knows how many others. So I went to the bathroom as quick as I could. I put my fingers down my throat to get as much medication out as I could. Obviously rang for an ambulance and everything. And then from that point I was under the care of the crisis team at the mental health clinic for the best part of eight months, I think something like that. And my time there was, it was difficult, but you know what? It ended up being very rewarding. That's where I was introduced to CBT. And what really helped me was managing to change my thoughts because I honestly thought at the time I was a burden to my family. My wife hated me, my kids hated me when the reality is they didn't, they loved me. And it was me managing to change my thought patterns that really helped me get through this. In all honesty, I struggled with it for a little bit, the CBT, because it is difficult, but the more and more I put my mind to it, the better and better I felt to the point where, at the moment I'm in the best place mentally I think I've ever been. And that's down to me opening up and talking more. Because obviously I had counselling as well, but also through the CBT, to the point where I'd say, I think was it three, three years ago now, I was diagnosed with a form of leukaemia and what could have been the hardest 12 months of my life having chemotherapy. I wouldn't say it became a doddle because it wasn't a doddle, but it became a lot easier, and that was through, obviously, the techniques that I've picked up in the past. Because in the past I would've thought to myself, God, why me again? I've had these back problems, why me? And the reality is, loads of people go through chemotherapy, and loads of people survive it. I spun it in a total positive mindset from it. As I sit here now, I probably, I can be honest with you and say I enjoy what I do more now than what I did before when I ever played rugby, and I thought it was my dream to play rugby, where I'd say now I'm living it where I'm helping others and talking about my problems.

Helen: Ian, thank you so much for sharing that with us, and I'm aware that there's some hard-hitting stuff in there. And I really appreciate how open you've been about sharing your story and for me hearing you tell us about that, you reached rock bottom and, sort of, you found something that kept you with us, which I'm really grateful for, and I'm sure the people who care about you are incredibly grateful that something stopped you from doing that, and hearing about how you had the right therapy and you faced more challenges again, that anybody would find incredibly difficult to manage but your approach to it, the way that you've dealt with it, has been more positive because of what you learned about maybe challenging some of the ways that you were thinking, learning different ways of approaching things. And I wonder if I can ask you, I mean, I'm a CBT therapist and I know that it isn't just about positive thinking. I just wonder if you could tell us a bit more about how you and the person you were working with went about, I don't know, learning how to think about things differently. What happened there?

Ian: Well, the best thing that helped me was doing a thought diary and, actually checking what I was thinking about and then changing it. That did really help me because the thoughts that I was coming up with at first, it just, as I wrote them down and when I came to the conclusions, it just wasn't rational. It just, why is everyone looking at me? Why do I think people are judging me? And, they weren't, but it's what was going on in my head. I was actually thinking that, so to be able to talk about this with my specialist and obviously writing things down, which I still have now, and I still look at them now and I still do write some diaries sometimes. So, that would be the mainstay of what helped me definitely.

Helen: And I imagine after everything that you'd gone through up to that point, there must have been things about having the CBT that were also quite difficult. Can you tell us about the stuff that you perhaps didn't want to do or the stuff that sort of wish you hadn't had to do.

Ian: Most definitely that would be the homework. Because I've had counselling beforehand and obviously that's face to face and just talking. But coming home and then doing it at home because like at the time, because obviously you're not in a positive mind space, I was hoping to get like an instant result, if that makes sense, like just to be able to go and see my specialist a couple of times and all of a sudden, I'll be okay. And it's just not that simple, you really do have to put the work in and a lot of it is homework and writing down your thoughts and then looking at them again and then thinking well, is that right? Am I thinking about that right way? Could there be another way of thinking about that? And at first, like I said, I struggled with it. I really did. It's like, God, I don't want to do this. But the more and more I did it, the more and more it really did help me. And that, so that would be the hardest thing I did, but also probably the best thing I did as well, because that really did help me change the way of thinking.

Helen: So how did you get from whatever was happening there to getting involved with Phil here and getting involved with State of Mind Sport?

Ian: Well that was a chance meeting, to be honest with you. I went to a grand final, that's, I say this about 9 or 10 years ago, watching a game of rugby and then I was about to get in the car, I saw a friend of mine, so I started talking to him and Phil was stood next to him. So as I'm talking to my friend, my wife started to talk to Phil and it turned out that Phil is a Warrington fan, I was an ex- Warrington player. So, I started to talk to Phil, and Phil had heard about my issues. So, he invited me to come along to a meeting that to the lads were putting on and then see if I fancied talking. At first, I went to the meeting, I thought the meeting was fantastic, it really opened my eyes but then obviously my first couple of talks I really struggled with because, opening up and talking about the problems, which I've never done before, it, it really did get to me. I'd become very emotional, I'd cry and then I'd come home, and I'd feel like an adrenaline dump and I feel shattered for a couple of days, it was really hard. But the more and more I did it, the better and better it felt to the point where I really look forward to doing them now.

Helen: And that's for me, it's taken a lot of courage to do that. I mean, I'm hearing about you being at the top of your game, literally being a star in rugby, and the journey that you'd gone through to then start talking to people about what that had been really like for you. And I'm just wondering if I can come to Phil about what it was like then for you meeting Ian and getting him involved in all this?

Phil: Oh man. Well, for me, see, I told you I love sport, you see? So I've watched Warrington all through my life. I'd seen Knotty play for points and loads of times. So I knew all about his playing career, that he kicks some fantastic goals. And he talks a little bit about that when he speaks as well around some of the thought processes around that. So for me it was great. To meet Danielle is, he's a good lady who, he rightly praised immensely earlier on was great because I was thinking, ah, I was thinking. I remember going to a match at Bradford once and at half time they had some former players who had injuries such as Ian. Ian was one of those players walking round. It was a Warrington against Bradford game, and I was thinking wouldn't it be great to get Knotty to speak? But obviously I didn't know him. I've never met him sort of thing. So to bump into his wife at the grand final, you can't miss an opportunity like that to ask, say well do you think he'd be interested in having a meeting? Because I don't know anything about him really other than that. And she was going oh man, he'd love to do that, he was saying that he didn't really have a focus, wasn't obviously, because he of injury, he wasn't working and stuff. So I was thinking, because I've taught alongside many people who lived the experience. I was just hoping, well I know he's got a good story because he used to play rugby. He's had a bad injury, so I'm assuming he will have found that difficult for all the things you said from the being at the top and then not being able to play. So yeah, it's great for me. So I'm a bit like a kid really. So when we did those first sessions many years ago for all those players, my excitement was getting a signed in sheet with all the autographs of the players. Now that's sad, but, and I still got them in me loft, so obviously meeting Knotty is great for me. I'm meeting heroes and being privileged and humbled by hearing Knotty's story. I've heard Ian speak many times in front of many audiences. And also finding it difficult when he first started. But now he can hold an audience very well. And as you heard, the power of the story that he tells. So, for me, he was great rugby league player, but he is also a great presenter. Now so for me that's fantastic. So I feel privileged to have met Knotty and been able to work alongside him really.

Helen: Yeah, that's brilliant. So if somebody was coming to a mental fitness session, they might hear somebody tell their story like Ian's just told us. What else might they expect?

Phil: Okay. So I suppose the way we plan it is, so thinking about blokes and how blokes respond to different health interventions or don't, should I say. So involving players was a crucial element. So obviously someone who's a former top player, like Knotty, talking about his vulnerabilities and also how he overcame those vulnerabilities, gives you a great buy-in and engagement from blokes in an audience. Because they're seeing a bloke who plays the sport, they play a really tough sport. But being able to talk about that is an immense, again, privilege and humbling experience for me. But also, we also try to entertain people. There's always a difficult balance, I guess, or a tricky balance. You don't want to make light of any subject, however, blokes like to have a laugh when they're in any situation, so you have to be aware of that and do that in an appropriate sort of way. Really trying to do it in a stigma free, so in a rugby club or a sports club, so a nonclinical environment usually will engage blokes more.

So I think, I mentioned, a story when we first began in State of Mind when we had that round of fixtures, myself and, Jimmy, who Knotty knew at the Grand Final, was with me that day, before Knotty was involved. And we were just beside the ground. We had a free ticket. It was great. We had a marquee on the terrace. We'd only just started, people didn't know what State of Mind was. And this guy came up with this lady and said, I don't know what State of Mind is, but this is my friend and his son died recently and he's been talking about joining him on social media. So I had a chat with him about 15 minutes before the game kicked off, about support that was around in the local area or stuff that we could point into if he wanted to, so he just walks off. So I'm thinking, oh, right crikey, I hope that went okay. And then at the end of the game he came back and, on his own, but not with his friend this time. And he just said, oh, thanks for talking to me. Before, he said, this was going to be my last game of rugby league. I was going to take me on life tonight, but I don't think I will now. And then he buzzed off again. But I suppose that gave me the insight of, in places where blokes are and giving him some, an outlet maybe have a conversation. And that was a very simple conversation. And, but also something that obviously you do all the time as a therapist and when you are working in mental health. The great thing was we went back a couple of years later, same ground, different team playing against his local team. He came back with his, with his other son and his grandchild, or his grandson came up, gave me a massive hug and said, oh, I feeling emotional talking about this and he just said, oh, thank you so much for your time that day. He said. I don't know whether I'd still be here, I wouldn't be a granddad, that type of thing. And again, that just sort of ramps home the importance of Knotty telling his story. Just you've no idea who's going to hear that story and make a change based on that. Seeing someone else who can do something that's helped them, whether it's CBT or accessing support. Brilliant. And that's the point of doing what we do and that's what keeps us motivated to keep doing what we do.

Yeah, so you'll have a laugh. It's in a stigma free location. Again, little sort of brief interventions that you do as well as part of that. So there's one about alcohol where we'll have a picture of Homer Simpson and I'll do a very brief alcohol screen for people, just four questions, yes or no. And then it's just getting people to think about a situation and then move it on. You don't have to do a therapy with them, you just get them to think a little bit. And hopefully that might make them think, maybe I do need some support here. And that's all perhaps you can do in a simple, in a particular session. But we had a couple of people who've, or students and stuff who've done like, research or dissertations around what we do, been to see some of the sessions and interviewed audience members afterwards, and they say the fact that the sessions are relatable. So you can be clinical, I could be clinical and be dull as anything for half an hour. However, when you are, when you mix clinical information and Knottys powerful story, you've got a bit of a winning combination in my experience. And that prompts people to change a little bit. And just as all therapists will know, their personal interaction with somebody on a one-to-one basis can have such an important influence on the outcome. Having those sort of positive role models in front of you in somewhere that you are very comfortable being and you're not on your own, there's loads of other blokes going, And then what great feedback we get from clubs is that, blokes are talking about it next week in training, job done. You've got people to actually talk about and think and then, so we've not been an embarrassing subject to talk about, but something that they can think on, maybe go and talk to other significant others, whether it's family or whichever friends, but raising the conversation to think like, yeah actually I can talk about this. and it's quite okay and normal to do so whatever normal is, and then you can apply this to playing rugby league or whatever sport you play, you get mentally fitter, and you'll play better and get better results. There you go. Simple really.

Helen: Simple, maybe. Absolutely Phil, and maybe not always easy, but I'm really noticing that those sometimes brief conversations and being in situations where you are going to be somewhere anyway, and that message that it's okay to talk about it, and yeah there's some very heavy stuff in there sometimes, but also having a laugh with other people, while learning something about mental fitness is really positive. And again, I've already said this, but saving lives by doing something that brings that message in places where it's not always heard. And I know that, from what we were talking about before we started the recording, that you've expanded out beyond Rugby League. I'm not a rugby league player and honestly, it's a very long time since I went to see a rugby match of any kind. Tell us a bit more about how this message and this style of helping people to learn more about getting mentally fit, how's that spreading? How are you getting involved in wider things?

Phil: Okay a couple of things really. Been over to Ireland and Northern Ireland. And State of Mind has an organization or a parallel organization there. In the National Ruby League, Australia and New Zealand and Papua New Guinea, they utilise State of Mind, as a means to deliver the same messages across communities in Australia. And the Australian Rugby League team who are currently playing in the Pacific Championships, they have State of Mind on their sleeves, which is like ridiculous really in terms of having conversations and reading a paper on a Monday morning. But I just think lots of other sports, it doesn't really matter what sport you play so, for example, currently we're doing a project with two open age football teams in a local economically deprived area where suicide rates are high. The council asked us if we could have some input. Me and Phil Vievers, another one of our presenters, a former rugby league player and head coach went to, speak to players. They dragged them away from training, so I can't believe that they came. So we had a room full of these lads and they told them about what we want to do, want to try and improve their mental fitness and their mental toughness to play football in the third division of the Warrington and District League. So we're not talking like Premier League game by any stretch, right? So last Saturday, Bold Miners FC, give a quick plug there, they won't believe that they're getting a plug in this location. However, played a local Derby against Redgate FC. Now this was potentially going to be a very feisty experience at this level of a local derby where lots of players knew each other, had moved from different, from each other's teams from time to time Anyway, so met with the coach, the manager before, the head coach before, and he said, oh, why don't you come in the dressing room and have a chat with the lads before. So I just told him a little bit more about what we wanted to do, we sent them a survey that they'd responded to, so they said 80% of them wanted to improve the mental fitness. And I found myself doing an impromptu controlled breathing session for five minutes in the dressing room, about 20 minutes before they went out to, to do their physical warmup before they played. So I'm here and they're all just sat there in a dressing room, in through the nose, out through the mouth, that type of thing, thinking, wow, this is surreal that I'm doing this. But they went out, won six nil. So then now they think I'm great, they're quite happy for me to come back and do more stuff with them, which is great, clearly has nothing to do with me. We thought they played really well. However, that's the potential that you can do. So that's about being in a place where you can do something specific. I sent them another survey, said, well, which bits of these elements of mental fitness do you want to focus on? Managing stress and anxiety, emotional control, well some of the players needed that, a bit of anger management as well, but that's another thing. But they were keen to sort of address it and, help them to be better footballers. But obviously I know that's going to also include, being able to better control stress and anxiety or refer people on. So they all have my email address now, so if anyone's struggling mental health wise, they can contact me, have a chat, and I can signpost them to whether it's NHS Talking Therapies or CBT therapy in different locations. Or mental health services like, Ian spoke about. And I think every time we've been in different sport, it doesn't matter where we've been, we've been to gay league football, hurling, rugby union, rugby league, cricket, football, it doesn't really matter where you are. It doesn't matter what gender, you might have a different emphasis for the women's teams that we address, but again, you can get into that location and hopefully make a difference. And that's the key, just as every therapist will do whenever they engage for that first one-to-one assessment and try and build that initial rapport. That's what it's about. It's a simple opportunity to do

Helen: Thank you so much, Phil. I'm going to ask Ian, people out there listening, some of them may have quite a lot of familiarity with mental health or mental fitness, some might really not or be worried about engaging with it. If you had one key thing that you'd want everybody out there in the general public to know or to bear in mind, what would you say is most important from your point of view?

Ian: No matter how small you think your problems are, because everyone goes through life, at some point you have issues, you have problems and so no matter how small your problems are you need to speak your about straight away, get them off your chest as soon as you can. Especially with men, because we tend to dwell on things and we don't want to talk about our problems, but it's the worst thing you can do because it's a vicious cycle and it just gets worse and worse. So for me. Definitely it'd be to talk about your problems as soon as you can. Like I said, it doesn't matter what your issues are. It could be money problems, relationship issues, it could be anything with school bullying or social media, anything like that. You need to get things off your chest as soon as you can. It's hard and it's very brave to talk about your problems, but for me, we need to get past the being brave, and it needs to be the norm that we can all talk about our problems, and we can all just speak to our friends, just open up and talk no matter what the issue is. So that would definitely be my main thing to, to get across is to open up and speak out and offload.

Helen: That's an absolutely fantastic message, Ian. Thank you so much. And what we will do, alongside this episode is we'll put some links on the show page to make sure that people can find out more, link to the work that you are doing and other projects or other sources of help to make sure that, anyone listening who wants to find out more can do that.

Phil, have you got any final thoughts that you would like everyone out there to know?

Phil: Yeah, I suppose so. Thinking from a therapy point of view really, I think. so sometimes we're limited in where we're located, I guess, and thinking about a new 10-year plan from the labour government about health after the last 10 year plan about a few years ago. But ultimately, a prevention's going to be a big part of that, I think, and perhaps sometimes being able to adapt your practice maybe where you're located. For example, embracing different technologies like immersive technologies where you could do lots of different things to compliment the therapy work that you're doing. The other thing for me as well, again, sorry, I'll just plug this a little bit, but, Mind and Sport England nationally have a draft version that's going to be published next year, which is around safe and effective practice for organisations who provide physical activity, movement, or sports. So those people who work in those locations can feel comfortable enough or confident to signpost people, whether it's to NHS Talking Therapy, CBT, or wherever it is. So for us, it's, we are part of trying to endorse that and utilise all those principles within State of Mind and encourages many other physical organisations or charities or small organisation to try and reassure therapists about if you refer to state of mind or anywhere else, or a swimming group or a fishing group or whichever. But the people who are involved in those groups, are, look at this guidance and can, and feel comfortable and confident enough to refer people to. they're fantastic therapists that are around and, access that support. So if people are talking as Knotty mentioned, then, to get them to the right, the best place to try and find that, and therapy has a massively positive effect on so many people. So that'd be my thing. Just trying to adapt and think about how you deal with some of those things.

Helen: And it really brings to mind for me that when you broaden it out to any kind of sport and activity and making sure that we are making things accessible to anybody from any background, I know that we've spoken mostly about, men in sports where perhaps traditionally the idea of being manly isn't to talk about your feelings and actually how much bravery and courage it takes, but how beneficial it is. But that really does apply across the board. I mean, you've mentioned it doesn't matter what gender and any other background that people come from, there will be a way of accessing the right kind of help. And the more that we can do to make things available in the communities where people actually go anyway, much more likely for people to be able to get the right help if they need support, sooner more geared to their particular needs.

And I'm delighted to hear from you two because I mean, I'm a therapist and we talk quite a bit about men who don't talk about their feelings. And you two are a great example coming from, I don't know if I could use the word quite macho kind of sport, talking in such a way that's really showing that talking about it. However hard it is really worth it and can be done by people who might not normally do that.

Ian, can I just ask you if there's anything else that you would like to say before we finish this episode, is there anything that you would like to share with our listeners?

Ian: Yes, there is actually, it's no matter what therapy you kind of diagnosed to go down or what someone advises for you, to stick at it. Because I've had counselling a couple of times, obviously CBT, mindfulness, and for me, you've got to stick at it because I think every single one of them at one point, I thought, Oh my God, I don't want to do this anymore, this isn't working, but the more and more you do stick at it, the better it gets and it will help, 100%. That's my opinion anyway. I honestly think that no matter what the therapy is, if you put enough work into it, you'll get the help that you need.

Helen: Thank you, Ian. Any final thoughts? Phil?

Phil: Yeah, just to add to that really Knotty that, any therapist working with anyone who does any sport. If they've ever done any training, they'll know about repetition and trying to be as good at kicking a ball, passing a ball, whatever it might be. So to continue to that repetition of controlled breathing or mindfulness pays off. So as you say it's a good sort of way to encourage someone to continue when you put it in the terms of physical fitness and training. So it's exactly the same, just different ball games, so to speak.

Helen: Ian and Phil, thank you so much. It's been a great opportunity to speak with you today.

Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at [email protected], that's [email protected]. You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested.

If you've enjoyed listening to this podcast, you might find our sister podcasts Let's talk about CBT- Practice Matters and Let's Talk about CBT- Research Matters well worth a listen.

In this special episode celebrating World CBT Day 2025, we explore this year's theme: CBT: A Solid Return on Investment. Host Helen Macdonald, Senior Clinical Advisor at BABCP, is joined by a range of voices reflecting on the impact, value, and future of CBT.

We hear from:

• Dr. Adrian Whittington, National Clinical Lead for Psychological Professions at NHS England, about the rollout and outcomes of NHS Talking Therapies.
• Dr. Stirling Moorey, BABCP President, on the historical development of CBT and its increasing relevance and recognition over the decades.
• Nic, a former CBT client, who shares how therapy helped him manage anxiety linked to a long-term health condition.
• Dr. Saiqa Naz, past president of BABCP, who discusses her personal journey into CBT and her commitment to inclusion, diversity, and working with underrepresented communities

This episode offers a rich blend of lived experience, clinical insight, and future vision, showing how CBT continues to be a wise investment for individuals, services, and society as a whole.

Further information and links:

Visit BABCP to learn more about CBT

Find support via NHS Talking Therapies

Discover more about World CBT Day

Find our sister podcasts and all our other episodes in our podcast hub here: https://babcp.com/Podcasts

Have feedback? Email us at [email protected]

Follow us on Instagram & Bluesky: @BABCPpodcasts

Credits:

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This podcast was produced by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies.

Welcome to this special episode of Let's Talk about CBT celebrating World CBT Day. World. CBT Day takes place every year on the 7th of April, and this year's theme is CBT: A Solid Return on Investment. In this episode, we're exploring just what that means- I will be speaking with Adrian Whittington, who's the National Clinical Lead for Psychological Professions at NHS England and with Stirling Moorey, who's our current BABCP President about how CBT has developed over time and the importance of continued investment in it.

We'll also hear a personal story from Nic, who is a former client of Stirling's, who shares how CBT helped him manage anxiety and improve his quality of life. Finally, I sit down with Saiqa Naz who is past president of BABCP to talk about her journey into CBT from starting out in the Improving Access to Psychological Therapies services, to completing a clinical psychology doctorate, and how she embodies the idea of CBT being a real return on investment.

We hope you enjoy this episode and the range of voices reflecting on the impact and value of CBT. Let's get started! Here's my conversation with Adrian and Stirling….

Adrian, would you introduce yourself please?

Adrian: Yes. Hi. I am Adrian Whittington. I'm National Clinical Lead for Psychological Professions at NHS England, which means within England I'm the professional lead for psychologists, psychological therapists, and psychological practitioners.

Helen: Thank you, Stirling, please introduce yourself.

Stirling: Hi, I'm Stirling Moorey. I am currently the president of the BABCP and I'm a retired psychiatrist and really have been around in the CBT world since 1979. So, Adrian is speaking about CBT today and in the UK particularly and I'll just give a bit of a view of what it's been like to be in the CBT world for this length of time.

Helen: Thank you very much. And so Stirling, if we come to you first, that's a long career- you must have seen a lot of developments over the years. Tell us a bit about what you've seen and how things have developed.

Stirling: Indeed, I mean, so right at the very beginning when I was a medical student, cognitive therapy was just being invented. And so we had BT, Behaviour Therapy, but not the CBT that we have today. And so it was quite sort of revolutionary. The behaviour therapists look down their nose a little bit at it, the psychoanalytic therapists very much looked down their nose, and I remember at one point talking to a psychoanalyst who told me that being a CBT therapist was a bit like playing a tin whistle compared to being a concert violinist. I think things have changed since then. So, over the years, what's happened is that really from the work of pioneers like Isaac Marks in behaviour therapy, Aaron Beck in cognitive therapy, for the first time psychotherapists started to actually address what evidence do we have that this works? And using randomised control trials. And this has been really powerful. It was revolutionary at the time because people thought you couldn't manualise therapy but Beck and others managed to do that. I think that's been the legacy of that, is that the services that are recognised to be really effective and are spread out across the UK that Adrian will talk about, have resulted from us gathering evidence that CBT works. The other thing that's happened is that really up until the early 2000s, we were using CBT in a lot of contexts in the UK, evidence accumulating that it was effective for anxiety disorders, depression, but other things like eating disorders, psychosis, long-term conditions, various things but they were all being delivered within a hodgepodge of services really. And I remember when the IAPT services that Adrian will be talking about, were about to be developed, my chief executive in my trust said this is amazing, it's like moving cognitive therapy from being a cottage industry into therapy mills as he called them. So, we have therapy mills across the UK, which are proving very effective in helping people with anxiety and depression. And it was that revolutionary input of David Clarke and Lord Layard who said, actually, we can work this out as a way to deliver therapy effectively and efficiently, not just in these services here and there, but across the whole country. So there's been so much change and now CBT is there for everyone.

I suppose just finally thinking about what its impact in public consciousness has been, although people maybe have heard of it and maybe witnessed people who've received it, there've been some subtle changes, I think in our perspective on the world that have been influenced by CBT. I think people from the behavioural side now are recognising that a lot of our behaviour is learned in our everyday life. We have habits and people notice they have bad habits and go to podcasts to try and get them to rid them of their bad habits. And people are really aware of cognitive bias- it's there in the media all the time, that recognition that our thinking is not always that rational and straight, for good or ill. And then the third thing is there's a new wave of CBT that's come along that's called the third wave of CBT is really looking at how we can look in and just be aware and notice our thought processes. And so the whole field of mindfulness is very popular these days. So CBT, I think even if people aren't aware of what CBT is as a therapy, it has perfused our consciousness.

Helen: Thank you very much, Stirling. That sounds like a whole symphony orchestra, not just a tin whistle from what you've been saying during your career. And thank you because that perspective of many years in the field and how things have developed, it leads us nicely to speaking with Adrian about, you mentioned IAPT, which stood for Improving Access to Psychological Therapies. I'm going to hand over to Adrian to ask him a bit about that project, how it came about and what happened.

Adrian: Absolutely. Thanks Helen. Well, of course I'm a relative newcomer to the field having been trained as a psychologist 30 years ago and done my additional CBT training, I think 19 years ago, including under Stirling's tutelage as one of my training supervisors. So, it's great to join this session today with Stirling. So, NHS Talking Therapies as it is now was called Improving Access to Psychological Therapies is really something we're very proud of and feel as a sort of world leading program in implementing psychological therapies at scale. As Stirling's mentioned, David Clark and Lord Richard Layard were instrumental in founding the service and arguing successfully for its initial funding and have really been sort of fundamental to its success ever since. It's received investment every year, under every government since 2008 in the UK and it is just an England service so it's important to also remember there's other parts of the UK that don't have the same sort of service at the moment. It really makes a public promise, which is that it will deliver NICE guided psychological treatments. So NICE are our evidence-based, practice guidelines in, in the UK and, sort of established by independent panels of experts for each type of condition. So it makes a public promise, it will only deliver NICE recommended treatments, psychological treatments, that the therapists that deliver them will be fully trained and properly supervised and that it will publicly reveal its outcome data, anonymised, of course, but for the whole country so that we can see at a national scale, but also locally, how the service is performing, and the service can learn and the best performers can show what they're doing that's being so successful, to produce the best outcomes and other services can, can seek to learn from that and implement some of the same strategies.

So we now have a sort of situation where for a number of years, the service has met its objective of 50% of those who coming into the service, are recovering completely from anxiety or depression and about two thirds, improving reliably, during the course of treatment. But it didn't start there, of course, in the early days of talking therapies, as it was then, we would be sort of more around the 30% recovery mark, and it really is through the sort of publication of outcomes and the ability of the service to learn and improve as it goes. That we've reached the 50% objective, and I think we can go further. I'll just mention something about the sort of return on investment point, 'cause I know that's the sort of important theme for today. The latest modelling that we have from London School of Economics shows that a course of talking therapies pays for itself within two years. So the benefits that are generated for the economy are such that within two years post-treatment, the course has paid for itself. We've also got some very exciting evidence coming out of other parts of the world, so there's a Norwegian study recently using, looking at service that is very close in, in sort of style and operation to NHS Talking Therapies that suggests that over a six year period, the benefits economically of investing in a course of talking therapies are fivefold. So in other words, the economy gets out five times more than it puts in over a six year period. So I think that the indications are very clear that the return on investment is there, and there's of course a lot further that we could go. There's a lot more that we could do and perhaps we'll have an opportunity to talk about that.

Helen: Well, yes, and thank you Adrian. And what I heard you say there is not only is the CBT itself, and as Stirling was saying, the CBT itself is evidence-based, we know that it works. And what you've just been saying is about the way that we offer that to people, the way that people can have access to that is also important. It's not just that the therapy itself works, but the fact that we're measuring outcomes and working all the time to improve outcomes. So the whole system, not just the individual on the receiving end, is really important here. And I just wondered for people listening who are perhaps not familiar with sort of measuring outcomes and things, 50% doesn't sound like an awful lot- and you did say that we might be able to improve on that. I just wondered if you could say with treatment before we had CBT widely available in England and what kind of outcomes were people looking at or why is 50% good when we'd be kind of hoping for a hundred?

Adrian: Of course, and of course we hope that every individual who uses the service will recover. But it's not always possible to achieve full recovery within a course of treatment. And this is of course true of physical health treatments as well. But what has happened through the innovation of NHS Talking Therapies is that we now know exactly what's being achieved. And we didn't in fact know this at scale before. So we knew through research trials, which are of course a slightly rarefied version of treatment as usual, where there are sort of very high quality aspects being sort of added in; the state-of-the-art supervision, making sure the therapists are fully compliant with the treatment being delivered as expected. And we know that in those trials it was possible to achieve upwards of 50% recovery rate. So, actually for depression. I think the more real world type of trials was around 50%, but we know it's possible to get much higher than that with some of the anxiety disorders, with some of the specific CBT treatments for those. So, I think we can go further. We thought 50% was pretty stretching, I think when the service was launched. And of course it's taken a while to get there, but we have now stabilised at 50 and so I think it is actually time to push on and see if we can push that further.

Helen: And can I ask Stirling, do you have any thoughts about this?

Stirling: Yeah, so sort of sharing again, my long, long in the tooth sort of view on this. So when I went to the Centre for Cognitive Therapy in 1979, they'd just published the first trial of CBT for depression. And, at that time, medication was the gold standard, and they were told there's no way in which you're going to be able to meet the level of recovery that we get with medication. But that level of recovery is only 50-60%, at the best. And of course that trial showed that it did, that the recovery rate was equivalent or if anything slightly better than the gold standard of medication. And so I think, it would be wonderful, wouldn't it, if we could get a hundred percent of people better. But, in the real world there are so many factors that will influence that. And even in the best designed clinical trials where you get the best medication delivery and adherence, or the best psychotherapy for depression, we're only talking as Adrian says, about 50 to 60%. So if we're getting something equivalent to that out there in the real world in the talking therapies, I think we're doing pretty well.

Helen: And I think it's really important to hear that we are doing the best we can with what works and investing in treatments that really do make a difference, the best that we can do. So going on from there, Stirling, can I ask you how you see the future? I mean, how do you see things going forward and what would you like to see?

Stirling: Well, I think, there's been this tremendous investment in talking therapies for common mental health conditions, which were in the past were sort of looked and that has, sort of, as Adrian was saying produced tremendous results. What we need is to be looking at evidence-based therapies in secondary mental health care where we know that, for instance, CBT for psychosis is a very helpful treatment alongside the usual drug treatment and support. And in eating disorders and, in various areas. So looking at how we might be able to bring in some of the lessons learned from the Talking Therapies program, so that these areas can have both greater investment, which I think is really important and a way of actually delivering evidence-based treatment and evaluating it. And I think there are some interesting developments that, again, Adrian may be able to talk about in that area. So I would like that to happen and the other thing is that for some disorders, CBT is very clearly the most effective treatment. For others, we have a range of evidence-based therapies, and I think that is what's quite nice about the Talking Therapies approach is it isn't limited to one. It's saying if something is effective and we can actually find a way of delivering it effectively, then that can be in the mix too.

Helen: Thank you very much. Well, I think Stirling has invited you to talk about future developments there, Adrian, what are your thoughts?

Adrian: Absolutely. Well, of course, the NHS talking therapy service for anxiety and depression mustn't stand still. So, it's currently seeing about 670,000 patients per year. We know though that's only actually a very small proportion of people who experience anxiety and depression. So there's a lot further we can go on reaching people who could benefit, and that's really important that we continue to do that. And the service also, despite its huge success isn't perfect. We know that there's wait times that are longer than we would like for people to start treatment. So although, people are sort of reaching the sort of assessment point pretty rapidly and having that first contact pretty rapidly, there can be waits that are longer than we would like for treatment to start. So, for that reason, we've been successful in securing additional investment in the service over the next five years that will help us reach more people and reach them faster. And it will do that particularly by increasing the number of high intensity therapists in the service, so those are the people delivering psychotherapy rather than the guided self-help, including CBT therapists. So that's a really important investment that we want to see through, to maximise the benefits, seeing more people for treatment and enhancing as well our recovery rates. We think we can get the recovery rates up. But as Stirling said, there's obviously a whole lot of other potential groups who could benefit from talking therapies or psychological therapies that currently don't often receive a service. And we just wouldn't accept this in other areas of medicine, that, in cancer care, you wouldn't accept that radiotherapy isn't available and so people will just have to make do with chemotherapy. In this case, there's a very clear moral argument for us rolling out the success of psychological therapies to those other conditions, so psychosis, bipolar disorder, experiences that are sometimes classified as personality disorder, eating disorders, key examples. And we do have ambitions to further rollout access to those therapies for those conditions. We've done quite a lot over the last few years to train additional therapists in existing services, but we know that the method of delivery there is a bit challenging because there's so much other pressure on those services so it's hard for people to protect time just to deliver therapies. So really in the next phase of this, what we would like to see is, services that whose main focus is delivering the therapy, working very closely with hand in hand with sort of more traditional community mental health services because of course, for these groups, it might be necessary in many cases for there to be a sort of multidisciplinary approach, other team members involved. It will be a bit different to the talking therapies approach for anxiety and depression. So we're very keen to push that forward and we're working to sort of further the cause of that additional investment. We're not quite there yet.

Helen: Thank you, and it must be really heartening for people listening to hear that the intention is to make sure that as many people as possible who can benefit from those treatments that work are going to have access to it. You did just mention there that services are under pressure and it does make me think that we talk sometimes you, you hear things in the media about services being under a lot of pressure. Is there anything that we can say from a CBT perspective about, looking after the staff or, anything else that we can do to make sure that the people delivering the services do as well as they can.

Adrian: Well, I suppose, it may seem obvious, but sometimes we forget that unless you have well staff, you can't have staff who can truly help patients. And so it is really important that we get this right and that we make sure that there's a sort of, psychologically safe environment within which teams are working. And of course that doesn't mean stress-free environment, but it does mean an environment where the sort of inevitable pressure is dealt with in a constructive way. People are able to speak up to improve things, et cetera. And that's the sense in which I mean psychological safety. It's teams where people can work constructively together, even when the going gets tough.

Helen: Thank you. I don't know if you've got anything to add about that. Stirling, I know that staff wellbeing is a subject dear to your heart.

Stirling: Yes, indeed. I mean, it's one of the things that I want if, if a president of the BABCP can make any difference at all. it's, the hope is that perhaps, we can start to look at staff wellbeing, and maybe on, on a number of levels, that sometimes the attention to burnout has been focused very much on the individual and making them more resilient. And that's important. But we know that actually the factors that are perhaps more important in burnout are more systemic, they're more things to do with the pressure of face-to-face and the system, the service in which the person's working. So I'd really be keen to start looking at what services do that job well, where are the ones where that retain their staff, where staff are satisfied, where they feel able, as Adrian says, to speak up and how do we roll that out? How do we make services that perhaps are not doing quite so well aware of that, because it has a knock on effect everywhere. And particularly the key thing is as you say, if you don't have well therapists, then they can't be so helpful to their patients.

Helen: Thank you. and I know that we haven't necessarily mentioned this overtly while we've been speaking, but my understanding is that services that make sure they're really paying attention to things like diversity in their staff team and making sure that they properly promote access for people from all sorts of different backgrounds are likely to do better. And I don't know if you wanted to say anything specifically about that.

Adrian: Yeah, I mean, it's a really important point, that you raise about dealing appropriately with equality, diversity, and inclusion, and it's something that we know from the data and talking therapies, where we've got further to go. I think. ofcourse, we want to achieve and offer the same sorts of outcomes for people of all backgrounds, and all different protected characteristics who make use of the service. That hasn't always been the case and it still isn't always the case. And so that needs to change. We need that to be a sort of relentless focus. And I think actually, having, some staff teams where everyone feels welcome, included and free from harassment and bullying is vitally important to creating those outcomes for patients. But I suppose one thing that I do want to reflect on is that through the sort of gathering and publication of data, we've been able to do exactly what was referring to earlier in this sort of domain, which is learn from the services that are doing really a lot better with diversity and try to spread that learning. And, we still see disparities and we want to iron those out. But the fact that you see disparities and that some services are able to achieve just as good results or better results, for example, working with ethnic minority patients compared to white patients, suggests that is possible and we need to find out what they're doing and make sure that learning spreads. And that's what we've been trying to do. And sort of, if you look at this data at national scale, we have seen really significant improvements in that sort of equality of outcome, but a lot further to go and still some really troubling hotspots where we would like to iron out inequalities.

Stirling: I agree. We've got a long way to go. I suppose from my perspective, having been teaching since the 1980s, what's changed is in the faces that I see in front of me in our CBT courses, is they're no longer exclusively white middle class people. And I think that the talking therapies initiative has really worked very hard to make the workforce more diverse. And I see that in the people that I'm teaching, but we still have a long way to go, particularly in serving diverse communities.

Helen: Well, it's been really interesting to speak with you both about this and some really interesting developments over the years and interesting views of what's going to happen in the future and exciting things that are going to happen in the future. Just wondered whether you have a key message that you would like people to hear or, one specific experience that highlights that theme about CBT being a solid return on investment. I'm going to ask Adrian first and then go to Stirling. So what are your thoughts, Adrian?

Adrian: I mean, in terms of a key experience, the key experience that I've had is working in the services and seeing people recover and lives be transformed. And that's actually the return on investment that's most important. But if I have one message that's more to those who might be decision makers, in governments for example, it would be investing in talking therapy through a range of different conditions, helps to grow your economy and it reduces use of other healthcare services.

Helen: Thank you very much, Adrian. Stirling?

Stirling: I'd echo that. Really, that's exactly what I was going to say. That CBT can be helpful both on the very much the personal level, which is what's the most important thing, but also economically, there's an argument there. I think just backing that up, so we want to speak to people who might be funding these services in the UK or elsewhere, but also, I think I'd like to maybe speak to some of those people who haven't had CBT or have heard certain things about it. There are a lot of myths about this approach, that it's sort of ultra rational, that it doesn't address feelings, all sorts of things. And I hope that, we've started today perhaps a bit of a conversation about how it can be more, it is more, nuanced than that. And it's about, like any talking therapy, helping real people. And I'll be interviewing a client who's received some CBT who will speak from that very personal viewpoint, how it can change lives and maybe a good return on investment.

Helen: Thank you very much. I'm really grateful to you both and we'll put some links to more information, in the show notes that go with this recording but it just leaves it with me to say thank you very much indeed, Adrian, and thank you Stirling. Really appreciate you speaking with me today.

Coming up now, Stirling is speaking with a former client, Nic

Stirling: Hello, I'm Stirling Moorey. I'm president of BABCP and a cognitive behaviour therapist and on world CBT Day where we're thinking about CBT as a good return on investment, the most important aspect of all of this is the clinical impact is what this does to help people who are coming to terms with problems in all sorts of areas of life. And I'm very pleased today to have with me a client who I've worked with, Nic Allen, who's going to tell us a little bit about his experience of CBT. So welcome Nick.

Nic: Hi there. Thank you.

Stirling: Hi. so maybe if we kick off by you telling us a little bit about what brought you to consider having a course of therapy and why CBT.

Nic: Yeah. So, I think my experience with anxiety related conditions had been going on for a couple of years. And initially I don't think I was entirely aware that I was suffering from an anxiety related condition. So to provide a little bit of background on myself, I. I have a, inherited heart condition, hypertrophic cardiomyopathy, which has led to like a few lifestyle changes with my life, but generally I've been fit and healthy. And in my early thirties I started to experience some kind of changes in symptoms in my general life, which I think in hindsight probably were related to anxiety more so than anything else. They culminated in panic attacks, so kind of sporadic panic attacks, but several, like a year, maybe once every few months, as well as some kind of baseline anxiety that I was living with day to day. And ultimately what it was that led me to seeking help for CBT was, I tried a couple of different things, I'd gone down the route of speaking to cardiologists and assuming that maybe some of my symptoms were cardiac related. I tried a few kind of like mindfulness type things but ultimately it got to the point where the anxiety was getting in the way of my everyday life. So it was getting in the way of being able to do certain kind of like medical procedures to look after myself and just generally getting in the way of things like holidays and work and things like that. And then via recommendation from a family friend, got in touch with yourself and then, yeah, took it from there.

Stirling: Yeah. Thank you. And so the anxiety was beginning to have quite an impact on your everyday life. Was it?

Nic: Yeah, absolutely. And I think it wasn't entirely clear at the time, and I think in hindsight it's become more clear how much that was having an impact. So it was, the interplay between the anxiety and living with a heart condition meant that, I think I was hypersensitive to any kind of symptoms of physical discomfort, which meant that I was living quite like a limited life. So anytime I felt vulnerable or fragile, whether it's cardiac related or not, I was changing my lifestyle. I was not going out, I was not leaving the house, I was not traveling on certain forms of transport or going to busy places, it was really going in the way of everyday life. And then, yeah, the worst-case scenarios were panic attacks, which meant things like having to leave restaurants in the middle of a meal, all sorts of things like that.

Stirling: So in addition to the panics, your life was sort of understandably becoming more restrictive because if you're fearful that there might be something seriously wrong with your heart, it makes sense not to take risks really.

Nic: Yeah, absolutely. And there was also the kind of, the interplay with physical symptoms of anxiety. So, specifically for myself, I think I felt, kind of impacts on digestion and specifically indigestion and heartburn. And obviously the interplay between the feeling of heartburn and a discomfort in my chest and having a heart condition meant that I was quickly getting into these kind of, these like vicious cycles where it was self-perpetuating. And that was both unpleasant in the immediate term, the physical sensations, but also help to like perpetuate the anxiety.

Stirling: So you've begun to talk a little bit about how perhaps a cognitive behavioural model helped you to understand what was going on. So maybe if we move on to what happened in, in treatment and, maybe starting with what in CBT we call the formulation, which is finding a way of making sense of people's symptoms. So tell us a little bit more about what you learned there.

Nic: Yeah, this was really interesting. This was one of the first things we did together and was one of the kind of first tangible resources I had to help process these thoughts. The formulation, I guess for anyone who's not familiar, and my experience of it was a diagram which sketched out my thoughts. So thoughts that would go through my my brain when I was feeling anxious, the physical sensations that I would then experience as a result of this. So that would be things like heart racing and sweaty palms. Linking that back to a trigger which would trigger all of these things. And then the safety behaviours that I would take when I experience these thoughts and it's kind of hard to visualise, but all of these are connected with different areas indicating how they interact with each other. And I think having this formulation, something that I could look at, visualise, memorise, started to help me make sense of what was going on when I was experiencing these things because, prior to that, it was very hard to get my head around it. I didn't understand the theory, but what I could understand was something was definitely wrong because I was feeling physical symptoms and I was feeling discomfort and pain and fear to the point where in these worst moments, it felt life threatening. It felt like I was about to collapse and die. So to not be able to understand where that's coming from and how all of these things interact with each other meant that I found it very hard to process, and the formulation was the first step towards being able to process this.

Stirling: Yeah. Yeah. Great. And help to guide us a little bit in the work we did together. Yeah. So what were the things that you found most helpful about the therapy?

Nic: Where to begin and so many things. Honestly, I don't know where to begin because take taking a step back, it's been absolutely life changing. It's helped me process these kind of experiences and these, these feelings and basically the mental health issues. I was struggling in a way that I didn't think was possible, I thought it was something that I was probably stuck with or it was just a side effect of life. So at a high level, it's been huge. I think if we want to talk specifics, maybe going from like early on that even the formulation. Initially that started to explain how I could be getting physical symptoms like a racing heart, and then those symptoms potentially not being cardiac related, they're not being related to having hypertrophic cardiomyopathy, potentially they're related to anxiety. And trying to understand like how that all works together, where the anxiety might come from, it started to give me almost a path to understand that, ah, maybe this isn't just, I've got this inherited heart condition which means I'm destined to be ill for the rest of my life. And then, yeah, it's almost like by beginning to understand what might be going wrong, that then I felt empowered to be able to tackle it and tackle it together with yourself.

Stirling: Great. And you've mentioned this idea of safety behaviours, which is things that we do when we're anxious to try and keep ourselves safe in various ways. So it'd be interesting to unpack those a little bit. We mentioned earlier how your life was getting more restricted and you were avoiding certain things. we did some experiments to overcome some of that avoidance, didn't we? How did, how did that play out?

Nic: Yeah, this was a really interesting part of CBT for me to learn, I guess, both for the process and then actually try it out myself, the concept of experiments and it was really powerful for me. So some of the safety behaviours, just to list a couple of ones, were things like holding my partner's hand, seeking reassurance from even my partner or phoning my sister, potentially doing like little things like drinking a sugary drink or something like that. All of these things, which I thought in the moment were things that were keeping me safe and helping me. And I think by working through CBT with yourself, Stirling we were able to, I guess, like rationally analyse whether they actually were keeping me safe, was holding my partner's hand going to prevent me from having a cardiac arrest and rationally, obviously it is not going to. So by understanding that it gave me a chance to process what I was doing, and then that allowed us to formulate these experiments which we could run. So when I was feeling anxious, when I was potentially getting into a situation where these safety behaviours would appeal to me, I could proactively test not doing the safety behaviour, which was a little scary to begin with but I was able to do it, especially in a kind of gradual way. And then we could see the results and see whether anything got better or worse and see whether the safety behaviours were actually helping. And, unsurprisingly, they weren't helping. But it was one thing to know, it is another thing to prove it to myself via experiments.

Stirling: Yeah, absolutely. And, you've mentioned also how it's tricky when you have a physical condition to disentangle some of the sensations that you're getting from what might be anxiety related or might be normal sensations. Would you tell us a little bit more about how you managed to do that over the course of the therapy?

Nic: Yeah, this was really interesting, and this is something that early on in the therapy I was worried I wouldn't be able to get kind of conclusive evidence on like, how would I ever know something isn't my heart condition? How would I know it definitely is anxiety? And I think a couple of things. I think we established that one- I may never get a hundred percent certainty on this stuff that I will have to live with some element of uncertainty, but that's also true for almost everybody, if not everyone, so that became easier to accept. The other was just observations of these experiments, both kind of proactive experiments and kind of accidental natural experiments. So if ever I was in a situation where either I deliberately avoided the safety behaviour and then saw that the physical sensations of say heart racing, hands getting sweaty, didn't happen. That's more evidence for the fact that there probably was an anxiety spiral that was what was causing a or panic spiral that was what was causing the symptoms. And I think by building up this bank of evidence, I guess a natural experiment would be an example of where potentially I was in an anxiety inducing situation, but didn't realise it. I was distracted by something, something unusual had happened and I was distracted by something in the background, a TV being on in a situation when typically I would get anxious and then realising afterwards, oh, that was unusual. Like typically I would've got anxious there, but because I was watching TV I didn't get anxious, which again is more great evidence for the fact that it's probably not a heart condition, because a heart condition wouldn't respond to that. It probably is an anxiety condition that is causing this stuff.

And yeah, by building this bank of evidence week on week, it just got to the point where it just made sense that it was anxiety and I was not able even to convince myself. I just truly believed that it was that, and then almost because I believed that, it became easier to keep testing it and keep pushing the envelope further and further with more difficult experiments to the point where it felt almost like I was training myself. It was almost like going to the gym, but for my mind, kind of building up this resilience to these situations. And the stronger I got the more I reinforced that those conditions pro the root of it probably was anxiety.

Stirling: One of the things that you mentioned, a little bit earlier was. getting reassurance from your partner and and so on. And, it might be helpful to people who are perhaps partners and friends of people with anxiety problems who are going through CBT to hear a bit about how she helped.

Nic: Yeah, absolutely. So, my partner Isabel has been incredibly helpful throughout all of this, both in terms of encouraging me to get help and also supporting me when we're doing this. In terms of what maybe potentially advice to people who are in similar situations. One I would suggest, if you are taking course of CBT, inviting your partner along to come to a session. So we did a session together myself, Isabel, and Stirling, that was incredibly useful. In terms of kind of small, practical tips that help for me, I think, an important step forward was when Isabel and I discussed the, I guess, what to do in a situation where anxiety is setting in. So that would be I think prior to this, whilst I would give into safety behaviours, people around me would also give into safety behaviours and it almost like facilitate these safety behaviours. So Isabelle would be holding my hand and would be reassuring me. Whereas once we've established this formulation and I've shared that with her, she was able to tell me, kind of coach me through it. So say like, okay, if an anxiety situation is arising, then to lean into the anxiety, remember what we've discussed in therapy, try and like ride out the wave of it, remember that it will pass. But also be reassuring in a kind of, in a useful way, which would be something along the lines of acknowledging the situation is real, acknowledging that it is this, it is uncomfortable, but that you can handle it and work your way through it rather than, so instead of it being a safety behaviour, kind of being a bit more of a coach.

Stirling: Great. Thank you so much for sharing those experiences and talking about them so clearly. Anything else that you'd like to say and particularly anything that you would say to people who might be considering whether CBT would be helpful for them?

Nic: Yeah, I think. I think for me, I was probably sceptical before starting this whole process, and then I'd say midway through, I'd say it was possibly after four sessions, there was, it felt like there was a big breakthrough and suddenly things started to get so much better. And towards the end of the sessions I was, I completely changed my opinion, almost to the point that I started to feel like we should be teaching this in schools, some of these skills. I felt like it was something that I just wish I'd known years ago. In terms of like my decision to do it, that decisions I made when I filled out the initial form to get in touch. I think honestly it was one of the best decisions I made in my life, particularly when it comes to like return on investment for it. So in terms of things I've done for myself, that was probably the most impactful thing that I've ever spent money on. I was fortunate to get some support from my workplace, I know it can be expensive, or it can seem expensive. The way I was trying to think about it, it was comparing it to save the price of something like a holiday and maybe having to kind of forgo a particular holiday and instead do this. And in terms of like return on what I've got from that, this has changed my life more so than a holiday would. I do still enjoy going on holiday, of course.

Stirling: Yeah. Thank you. And just to say to people that the other part of this podcast, we were talking about CBT available on the NHS and the Talking Therapy Services are also there to provide help with anxiety disorders and depression. So thanks very much indeed, Nick. Thanks so much for coming on and sharing your experiences today.

Nic: No. Thank you so much for having me.

Helen: And coming up now I'm speaking with Saiqa Naz, who is past president of BABCP

Helen: Saiqa, would you like to introduce yourself?

Saiqa: Hello, I am Saiqa Naz. I am past president of BABCP, so I was president until November 2024. I'm a clinical psychologist and also a CBT therapist and I work in a learning disabilities service.

Helen: Thank you, and one of the reasons why I said you were a solid return on investment is that you were part of a big government project in England, which involved investing very heavily in CBT in what was called the Improving Access to Psychological Therapies Project, which is now called NHS Talking therapies for anxiety and depression. Can you tell us a bit about your personal journey as part of that?

Saiqa: Yeah, so I actually studied in Sheffield, completed my undergraduate, and then I went back to Rochdale, which is my hometown. Beautiful Rochdale, a small town north of Manchester for those people who have not heard. But I struggled. I struggled to find any paid work related to psychology. I struggled to find voluntary work related to psychology, and the transport links were not that great which meant I couldn't leave, come and go, quite easily. So I was in this small town struggling to find any form of experience, and eventually found a little job as a support worker and then I had another job to, to earn a bit more income. So yeah, I was doing like two jobs concurrently. And then the IAPT initiative came along and I was offered a job as a low intensity practitioner or a psychological wellbeing practitioner and then I moved back to Sheffield. So that's how I came into the NHS.

Helen: Okay, so perhaps if you say a little bit more about what training as a psychological well wellbeing practitioner did for you, and then a bit more about your career after that, cause you're not still working in that role.

Saiqa: No, I'm not working in that role, but I'm still using those interventions. I think everybody should learn those interventions, if I'm honest with you. And I think that role gave me a nice introduction to the NHS supervision, you know, learning difference between clinical supervision and line management supervision. I was quite heavily involved in developing groups, the stress, delivering stress management course or managing lower mood. So I really developed my skillset in a range of ways, you know, one-to-one therapy, group therapy, did supervision, developing projects, started to do more outreach work around ethnic minority communities, started to do a bit of thinking around those groups. And that work still stays with me, I don't think I've ever really left it behind.

Helen: So even at that early stage in your career in the NHS, you were thinking about the value of developing yourself as a diverse individual, if you'll forgive me saying so. And we know that was one of the things that the IAPT Project bought, brought in was a more diverse workforce, which perhaps intending to be more representative the communities that people come from.

Saiqa: Absolutely. And so many years later it still is representative of the communities. And I think that is the beauty of the initiative is that I wasn't an afterthought- thanks David and Lord Layard. But I think when they were thinking about it, they obviously thought about us in their thinking in those early stages. And actually when I applied for the job, I can't remember exactly what it said, but it did allude to having knowledge of a different community or knowing a different language. And actually part of my interview was in Urdu at that time 'cause I was tested and I don't think we see that. I think some of that has been lost somewhere actually 'cause those early days where the money was there, the thinking was there, the will was there we've managed to produce a quite a diverse workforce.

Helen: Okay. and that's one of the things that I'm hearing from what you're saying is that you, your particular skills and your own background were particularly valuable and the investment of resources in training people from different backgrounds and who are really embedded in the communities that they served was genuine in enhancing and enriching what we could offer. And being taught CBT skills, which are evidence-based and most likely to help people with the common mental health problems that you were working with in that role. What about when you then went on to do further training? Because you haven't really stopped. Tell us more.

Saiqa: No. Then I went on to do my CBT training. I did that in Manchester and actually moved back to my hometown. And, I felt like I was giving back to my communities and that not just people who looked like me, I think just the town as a whole. There's some quite deprived areas, so there's four boroughs, and I had a day in each of those boroughs, so I felt like I was learning about the town, but I was also able to give back to the town. So I'm quite passionate about it. Yeah, it was tricky getting those videos in to pass. I had one attempt left and my friend said, you know, jump through the hoops. I took a generalized anxiety disorder and PTSD as my training cases and my supervisor John Storey is looking at me. He said, you're spinning a lot of plates Saiqa. And I said, oh, that's because I'm comfortable with depression and so I thought I'll bring something different in. And then when it came to doing the videos, it was, I took some really tough cases in, and they weren't quite meeting the criteria of passing the videos. And I had one attempt left, or I may never been sat here talking to you, Helen, but managed to get through.

Helen: And I think you'll be really speaking to the experience of some of the CBT therapists that are sitting here listening to what you're saying. The challenge of doing the CBT training can be one of the most difficult things that people attempt. So given that you did succeed, and here you are sitting talking with me, is there anything that you would say really helped you to get through those challenges that really did I don't know, improve your access as a clinician to being able to provide this service.

Saiqa: Yeah, I think while I was training, there was a group of us and maybe called the Specials because we'd meet for breakfast in the coffee shop, get there a bit early, and then we'd always be the ones that submitting our work just on the deadline or do the night before? Yeah, the all-nighters. So we were the little group

Helen: The last-minute deadline group.

Saiqa: The last minute deadline group, absolutely. So we did the training, but we ended up forming this lifelong sisterhood of friendship, which I really value, and they're really important and really big part of my support network. I think even continuing my journey. So you get a lot from the training that I think is really valuable and the camaraderie because everyone's going, oh, I'm going to fail if I get thrown off, if I don't pass this video, or I'm not meeting the CTSR…

Helen: So what I'm hearing is that actually you invest a lot of yourself in the training but it's worth it. And those connections with the other people who are in the same boat really helps to get you through.

Saiqa: Absolutely. And you know, you're more confident as a clinician when you come through because people have been watching your videos. You have to quickly get over then, oh, that angle on my face doesn't look right, and why did I do that? Oh, why was that looking, you know, why did I pull that face?

You just need to get over those anxieties if you want to get through it. That's what I'll say to anybody who's in on the course now or thinking about it. And, but as a consequence, because lots of people have had to look at your work and input it into it, and you can refine your skills. I think when you do have those stats later on, you can say, it's not just coming from me, people have looked at my work and actually, it's okay. It's not that bad.

Helen: Yeah, and actually everybody else other than you as the trainee on the camera, my experience is that actually focusing on the client is what gets you through that and trying not to focus too much on whether you've got the right angle or whether your hair looks funny in that outfit.

Saiqa: And am I good enough to be here? Do you know if you're from an underrepresented group, the imposter does come with you. I think you don't lose it. It's there and you don't want to reveal yourself, but. I don't, maybe it's, as I'm getting older, I'm like, yeah, this is just who I'm am.

Helen: I do think it's really important though to acknowledge that the training is hugely demanding, and then if you do come from a minoritised group, you've got additional challenges, and often intersectional challenges. However, you're sitting here talking to me and your career advanced even further after being qualified as a CBT therapist. Tell me what made you decide to train in another profession, even though you were already fully qualified and experienced as a CBT therapist.

Saiqa: Yeah, it's a good question. I think when I first started, when I was doing my undergraduate, I wasn't so aware of CBT and I think we probably could get better at bringing CBT into colleges and undergraduate courses because when I was thinking what am I going to do with my degree, CBT I don't think came up in my research. But then I was on the CBT path because that was the opportunity given to me and I went on the CBT path but I think part of it was, I was aware that it has its limitations. So I'm working people with complex trauma, with interpersonal difficulties and I think I was thinking, oh, then other ways of working with people apart from CBT and maybe I just need to have the humility to go okay, park the CBT for a while, do the training. But I also wanted the training to give me opportunities and open the other doors that, again, traditional CBT therapists are not provided with around leadership or managing services. So I think I was thinking longer term career, it'll give me opportunities, but I wanted to do research as well. So there's multiple reasons why I did it, but I have to say, every single service I went to in placement, there was some form of CBT there. And I've come out of that training even bigger fan of CBT if I'm honest with you, I'm like, yeah, evidence based. Okay, what are we doing? Not what am I doing, what's the evidence saying that we should be doing for this person? So that level of humility, I think that approach brings is really important.

Helen: Yeah. Thank you. So I know that you work clinically now with people who have learning disabilities. Can you tell us, it's one of the areas that we hear about perhaps a bit less in CBT sometimes. Can you tell us a bit about investing in working with people who do have learning disabilities?

Saiqa: Oh, you know, I'm quite big on inclusion and equality and interrogating systems that exclude people. I think I can't keep my mouth shut. But I think as clinicians, it's all of our responsibilities and roles and when we notice who's not in the room, that we then speak. I went to learning disabilities and I've been shocked at the level of underinvestment. And to me, it almost feels like they're the forgotten group. If I'm honest, like I think nationally they've been overlooked and forgotten. And also in our services, you know, some people who have let's call it milder learning disabilities, can access mainstream services. We've got to make room for those people, you know? So I think, I'm trying to think about adapting CBT in that context. And that's what I'm focusing on at the moment is, but again, you know, not digressing too much because don't want to do too much of a drift. And it's not CBT. But what I really want us to do as a workforce is really think collectively about people with learning difficulties and also learning disabilities because they're not in the room. They don't have the social care in place or the care needs in place to enable them to access conferences or sit at tables. So I think we need to be advocates for them and then create space and room for them to come and sit with us.

Helen: Thank you. So I'm hearing that you are absolutely a living example of CBT being a solid return in investment in terms of just your own journey through your career and how you've invested of yourself and you've been able to take advantage of the investment in training in CBT but also your own focus on inclusion, making sure that we are more representative, that we do more to make sure that underrepresented groups do genuinely have that access and the opportunity to have better evidence-based interventions to help improve quality of life and so on. Is it too much to ask you where you see yourself in five years' time?

Saiqa: Oh gosh, sat on the beach, like retired. No, I think, do you know when we talk about being a solid return on investment, a lot of this inclusion work, Helen, it's been done outside in our own time, you know, evenings, weekends, annual leave, holidays my family going what you doing Saiqa, we are at the airport! You know. Right. And I think what really want to see is some of this work embedded into systems, infrastructure because ultimately it's still a nine to five job, isn't it? And I hold their inclusion values. Yeah. I'm trying to convince myself it's a nine to five job but yeah, I think I'll still be involved somehow. I think maybe a little bit more around research because again, people like myself are actually, I don't know, somebody from my background in leading projects and research, to be fair know millions of pounds are invested, Actually, maybe that's where I might be in research and hold onto my clinical work. Yeah.

Helen: Saiqa, thank you so much for talking with me today. It's an absolute pleasure to be speaking with you.

Saiqa: Thanks for having me, Helen.

In this episode of Let's Talk About CBT, Helen Macdonald speaks with James from the charity Gambling with Lives about the serious impact of gambling addiction, its links to mental health, and the role of CBT in recovery.

What We Cover in This Episode:

🔹 How gambling has changed – From a backstreet niche to an industry making billions through addictive products. 🔹 Gambling addiction and mental health – How gambling harms go beyond financial loss and can lead to depression, anxiety, and even suicide. 🔹 The neuroscience of gambling – How gambling rewires the brain, making it difficult to stop. 🔹 Recognising the warning signs – What to look for in yourself or a loved one. 🔹 The role of CBT in recovery – How cognitive behavioural therapy is a key treatment approach in NHS gambling addiction services. 🔹 Breaking the stigma – Why gambling addiction is not just about personal responsibility and we need to talk about how it can harm people and the amount of gambling advertising that is out there. 🔹 Getting help – Resources for those affected, including training for healthcare professionals.

Resources & Links:

Find out more about Gambling with Lives: gamblingwithlives.org Visit Chapter One for training and resources: chapter-one.org NHS gambling support services: NHS gambling support If you or someone you know needs urgent help, reach out to Samaritans at 116 123 (UK) or visit samaritans.org

Find our sister podcasts and all our other episodes in our podcast hub here: https://babcp.com/Podcasts

Have feedback? Email us at [email protected]

Follow us on Instagram & Bluesky: @BABCPpodcasts

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This episode was edited by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies

Welcome to today's episode. I'm really pleased to have James with me today. He's from an organisation called Gambling with Lives, and I will ask him first to introduce himself. Hello, James.

James: Hi Helen, thank you for having me on. I'm James. I live in Stockport, originally from Norfolk, hence I haven't got a Northern accent, but I'm here today representing the charity Gambling with Lives. The charity was set up by bereaved families who'd lost loved ones to gambling related suicide and I now oversee our prevention work, which includes education, training, information, and resources. And a lot of that stems from my own lived experience of a 12-year gambling addiction, which started as a young person, and which I'm sure we'll touch on today.

Helen: Thank you, James. And so I'm very aware that a charity that's been very much grounded in the experiences of bereaved families, there's going to be some difficult things to talk about here. And just to say for our listeners, there will be links to where to find help and support on the show page and as well as anything that we talk about during today's episode. So can I ask you just to tell us a little bit more about gambling? What is it? You know, how people might get themselves into trouble with it, maybe?

James: Yeah, it's a big question. And the first answer that comes to my head is that gambling is not what it was. I think a lot of people have a perception of what gambling is, and that's a weekly bet at the horses or going to the bingo on a Thursday night, or the football pools. Gambling has absolutely transformed over the last 10, 20, 30 years. And it all really started from a point in 2005 when the Gambling Act was created by the Labour government at the time, which changed gambling from being this thing that was, you know, quite hidden, quite behind closed doors, wasn't promoted, was quite hard to go and do, wasn't that easy or available or accessible, and that Gambling Act changed that completely and allowed for relentless advertising, sponsorship, marketing, and allowed for bookmakers in the high street to have really addictive electronic machines in their premises. And they were things like the fixed odds betting terminals, which were roulette machines, which at the time were called the crack cocaine of gambling because they were that addictive. And that was not what gambling was. I remember when I was a child, in our town, I'm from a quite a sleepy, small town in Norfolk. And the bookies in our town used to be this like really dingy, horrible place to be honest behind in a back alley that I used to walk past it and think I'm never going in there, that is a place not for me. It's for old men, smoke coming out the doors, did not have any interest in that. But then when I was 16, which was a couple of years after this Gambling Act, it changed into a massive Ladbrokes in the middle of the high street, you could see through there, you could see the machines and you could see all the advertised on the outside of the windows.

And that's what's happened to gambling. And the impact on society is huge. We now know that 2. 5 percent of the adult population are experiencing so called "problem gambling". And just to note on that terminology, it's not a term that we like to use, but this is what the statistics say. And we don't like to use it because we don't like to put the problem with the person. There are many reasons why people experience gambling harms, which is what I'll come on to later. But that figure alone. So that's the very sharp end of gambling harms, but then you've got many more impacted by somebody else's gambling. You've got widespread harms happening to young people. So, a really important point here is that these harms aren't just financial. Again, I think there's a perception that gambling addiction is a financial problem, and the harm is felt through debt and long-term financial worries. Actually, this is a mental health condition. This is a diagnosable mental health condition. Gambling disorder is in the DSM manual since 2013, and it's a mental health harm first and foremost. And that then causes anxiety, depression, and suicidal thoughts as well, which again, we'll come on to based on the work we do at Gambling with Lives.

Helen: Thank you, James. So, what I've just heard you describe there, that it's gone from being a bit of a backstreet, rather unattractive niche thing, to being sort of very attractive and perhaps more widely, I don't know, more people participate in it. And you mentioned gambling machines and I'm also aware that people can gamble on the internet as well. They don't have to go out to do it necessarily. And I'm also aware that you used words like addiction, which most people would associate with substances, perhaps alcohol or drugs or something. And I wonder if you could say a bit more about, perhaps the difference between what I might have thought of as a harmless flutter and something that's harmful.

James: Yeah, another good question and potentially asking the wrong person because I, obviously I experienced a gambling addiction myself, but I'll try to answer based on my own experiences. And on your first point, actually, probably the thing I forgot to say, which is most important is that the biggest change for gambling is, as you say, the fact that all of these products that are now available on our phones, in our pocket. At the time when the legislation was written, there was concerns about super casinos in places like Blackpool and on the coastal towns of England. And actually what's happened is we all now have a super casino, but it's in our pocket and anyone can access it over the age of 18. There's very little safeguards and protections on there. And that's where the harm is felt most on online gambling. And that's sort of the answer to the second question as well is that gambling is not just one product, and some products are more harmful, risky and addictive than others. And that's not to say you cannot be harmed by, as an example, buying a lottery ticket. Because if you've only got 5 pounds to last you for food that week and you spend 5 pounds on a lottery ticket, you are experiencing gambling harms.

But evidence shows and experiences from people who have been there and been harmed are that the quickest, more attractive, the things that are designed to be addictive products like online slot games, online casino games, online bingo as well. These are the things that are really causing the harm and causing addiction. And the difference is the indication someone is experiencing gambling harm is how often someone is spending on those products and how much money someone is spending on those products and how quick all of those things are, those products. That's why people can get harmed quite quickly. Back in the day, again, you used to have to go somewhere to place a bet on, and you maybe did that once, twice a week. Now, because of how quickly you can do that, that creation of addiction is so much quicker and instant, and it can happen really quickly. I can give you examples of times where I spent five, six, seven hours just in bed spinning online roulette tables on online casinos. And that time I, it didn't feel like five, six, seven hours. It felt like I was just trapped in this zone. And that's because it's deliberately designed that way. So what happens is, and this is very medical and I'm not a scientist or a medical person, but this is a physiological change in the brain. So when you play these really fast paced products, these intense products like slots, like casino games, your pathways in your brain are rewired and it becomes a dopamine driven urge to do this thing again and again. And what's really worrying and something for your listeners to look out for, is if this happens to a young person before the age of 25, where their brain isn't fully developed and if they experience a big win and they get an explosion of dopamine in the brain from that win, that can be a real big indicator that they're going to experience gambling harm and even gambling addiction.

So I would say that and the other thing that I would just say to answer the question is, there is no national guidance on a safe level of gambling. So I'm hesitant to say what that is, but there are clearly signs, indications, symptoms that someone may be experiencing gambling harm, such as feeling the need to check devices a lot, not being motivated by relationships or by career, lying about how much time and money is being spent gambling, and then of course, feeling suicidal or feeling like the world would be better off without you. There are some, but there are an exhaustive list of, of indications someone might be experiencing harm.

Helen: I mean, this sounds really worrying, James. You've said probably around two and a half percent of the population may be experiencing gambling harms, and that doesn't count the people around the person who may be affected by their changes in how they interact, as well as things like, I don't know, would have an impact on household finances, for example, or occupation, things like that. And yet what we see in the media seems to be more about how to place bets and how to gamble rather than what the potential risks might be.

James: Yeah, there's very little public health messaging about the risks of gambling. From my own experiences, if I take you through the journey of my life, really, as a child, not at any point was I taught or warned about the risks of gambling. You know, I was warned about drugs, warned about wearing a seatbelt, warned about sexual predators, was never ever told that gambling came with a risk to my mental health. And then when I started to gamble at the ages of like 18 to 25, there was no preventative health messaging, through campaigns or through advertising that told you that this is a risk to your mental health that you're probably likely to lose your money but there is places to go for help and support. That didn't exist. All we got, my generation, were messages like, When the fun stops, stop. Which was a ludicrous message but was the main one for years and years which just, you know, really put the onus of responsibility on an individual to use addictive products responsibly, which of course is a contradiction in terms.

And even now there has been some progress, but there isn't messaging out there on the whole that really says the things that I've just said. Not many people know that this is a thing that impacts the pathways in the brain. Not many people know that this is an industry that makes 14 billion pounds every year and it makes most of that money from the most addictive products and from the people that are experiencing harm. And most people don't know where to go for help, support or treatment. We do a lot of prevention work and every time we're in a room with young people or with professionals, we ask them at the start of the session, do you know where to go if you're worried about someone you know because of gambling harms? And it's between like 80 and 90 percent of respondents to that question is a no, and that is really worrying. So it's not just that people aren't being warned, people aren't being protected from this either. And so there is a hell of a lot to do to ensure people don't experience harm in the first place. But if they do, they are, they're cared for.

Helen: Thank you, James. And I'll want to come back to talking more about that as well. I mean, I think, one of the things standing here as a cognitive behavioural psychotherapist, I was really curious about what you were saying about how addictive these products are, about the dopamine rush that people experience, and actually physiological changes in the pathways of the brain which we know happen if you do something repeatedly, and gambling is one of those situations.

And I remember very early in my learning about gambling, from a cognitive and behavioural point of view, one of the things that we talk about is the power of rewards. And you mentioned a big win, which may happen sometimes, even though, as you pointed out, overall, people would tend to lose money almost certainly if they gamble regularly. But the idea is that if you get a reward in an unpredictable way, especially if it's a really good one, we're much more likely to carry on doing that behaviour. The technical term for that would be intermittent reinforcement and when I'm talking about how CBT works, gambling is an example that I use because of that every now and again, you'll win something but what it does is it tends to keep going. Is that a reasonable understanding of, you know, how it's so addictive- are the things that I'm missing?

James: No, that's a much better explanation than I would give. I think it's true and the gamble industry knows that. It employs some of the best psychologists in the world to design these products because they know what makes brains tick and what makes people coming back to the products. And, you know, in my experiences, I used to know that on the whole, I would lose money. And I used to know that on the whole, it didn't matter how many times I tried to stop that I couldn't and yet I couldn't stop myself going back to using these products and I didn't understand why. And it's only coming into recovery and doing the work that I do now and being taught this and being told this and finding out myself what actually happened to my brain, that gave me agency to realise that I was being tricked, I was being conned by gambling companies. It's all an illusion, these products are designed to fool you, designed to think that you have an illusion of control. They're designed to make you think that you've got a chance of winning in the long run, but the truth is the algorithm is against you and the house always wins. And again, going back to messaging that people need to hear, I think to be more hopeful and positive. That kind of messaging can be absolutely crucial to unlocking something in people's brains and giving them that freedom and agency and license to not just rewire their brain for good reasons, but to rebuild their life.

And I, you know, I have a little mantra now that because of this knowledge that I have and because I know how the products are designed and I know how the industry operates, and I know the psychological tricks they used on me, they truly do not deserve another penny of my money or another second of my time. And that is such a big motivating factor for my recovery, and it keeps me going and I'm adamant until the day I die, I will not give them any of those things.

Helen: And I just want to check with you, when you're talking about these things, I'm thinking there might be listeners out there who perhaps every now and again enjoy a day out at the races with their friends, or perhaps when there's a big football match or something like that, that they want to put a bit of a bet on. Is that the same kind of risk for certain people or, you know, if somebody was vulnerable, would that lead to harm in the same way as the internet and the machines in the betting shop?

James: Yeah, again, I think all forms of gambling do carry a risk and some are more risky than others, and we're much I am genuinely and our charity is to not anti-gambling, we don't want to stop people recreationally gambling or go into events like that where gambling may be involved. But I would urge caution in that so often people's experiences of gambling harm and gambling addiction do start with what is perceived to be the more harmless or innocent forms of gambling, such as a bet on sports or a night at the bingo. And that's what happened with me. My first ever bet was a five pound football bet on a football match in a bookmakers. And you know, that, that led to years of devastation. And what the industry does is it spends lots of money on getting to these audiences in these sorts of venues, in these sorts of environments and in these sorts of sports to, to lure young people especially into then the more addictive forms of gambling, because that's where the profit is.

Yes, they do make profit from football betting and from horse racing, of course, but most of their money now, most of their profit comes from the quicker, more addictive products. And that's the business model, to get people through one avenue to the next. And of course, that's not to say that everybody that goes to the horse racing or put bets on the football will become addicted. But the truth is, again, is that the industry wants people to spend lots of money on their sites. That's their business model. And the longer you are on those sites, and the more money you are spending, of course, the more profit they are guaranteeing in the long run. So again, it's just being aware of how quickly this can happen and being aware of the ways the industry targets people.

Helen: And I mean, you've said, you know, just how quickly this can have an impact on people, how much it can suck you in to spending a lot of time and all the money and so on. How would somebody get from being in that position, and this is probably quite difficult to speak about, but where people are actually dying by suicide in relation to having gambling difficulties, how does it get to that situation?

James: Yeah. And I can answer from my own experiences partly, but I can also answer from the facts from the position of our beneficiaries, which are families who have lost loved ones to gambling related suicide. And I'll just start by saying that for those families, and I didn't meet the people that died, but I've met their families, and they all say the same thing, that these were just every day, normal, bright, happy, young people with their life ahead of them with no real vulnerabilities, no preexisting conditions, good upbringings, and gambling was the thing that changed them, that robbed them of their future. And I can really resonate with that. When I first came across the charity and I listened to the mums talk about their sons that had died. I did honestly think that could have been my mum quite easily. And that is because I feel like I know what it was like to get to that point. And what it is, it's not about losing substantial amounts of money. And of course, when that does happen, it can feel absolutely catastrophic. But what it is that sense of never being free of this. And, you know, I used to think I would always be addicted to gambling. I genuinely remember thinking I would spend my life addicted to gambling. This was just the, who I was, just the way I was. And that was such a horrible mindset to be in because it made me very pessimistic, nihilistic, didn't really care about myself, didn't care about my well-being, didn't do anything for myself, didn't look after myself, and because I had no control over what I was doing, that feeling of not being in control of your actions, you sort of think, well if I'm not in control of myself, what is the point? Because agency and control and freedom is sort of all we have and they're the fundamentals of how we live so to be robbed of those things, I can see so easily why people get to that point and think I'll never be free of this and I have lost all control over my life and there is no hope. And there is now, thanks to the work of bereaved families, there is now national recognition that gambling can be the dominant factor in a suicide, without which the suicide would not have occurred. And, sadly, it's somewhere between 117 to 496 people every year in England alone take their life because of gambling.

And, you know, we're there to support the families who come to us and thank God we are. But this is something that is happening far too often, and we're getting far too many families who need us. And again, where is the message that by engaging with these products, there can be a serious risk to your life. And it's, you know, it's not a drastic thing to say that gambling can kill. And the point of disclosure, the point of, sometimes what's referred to as rock bottom, but the point of when someone says, I can't do this anymore, I can't be like this anymore. That is where the suicide risk is greatest. And so, we as professionals, as people that come into contact with people experiencing harm, always have to be mindful of the suicide risk and do everything we can to use the right language to, to support someone as adequately as we can. Because a common feature and experience of those that are no longer with us was that they try to access services. They try to stop, they try to have the conversation with people, but there wasn't that understanding about how serious this is. I think going back to my first answer on today was people thought that this is just gambling. It's just betting. It's just, you know, he just can't stop a few bets at the weekend. This is not, this is a serious health issue that drives people to that, that moment.

Helen: And that's absolutely shocking statistics there, James, talking about the sheer number of people that are being lost to suicide, related to gambling and you're spending time with the families of people who've already gone. You said that you haven't met those people. You've met the people who've been affected by their loss. And you described what I would think of symptoms that sound very much like depression. You know, that sense of hopelessness, I'm never going to get any control over my life. I've tried everything and I've run out of ideas and all of those things. If somebody came to me and described that and didn't say that they were betting, I would think this person was really quite depressed. And you also said you weren't looking after yourself and your relationships weren't going well. And again, those would be things where I would expect a healthcare professional to be concerned about someone's mental health and think about depression. Is there anything that people like me, healthcare professionals, should really take care to check to know whether there's a gambling element to how someone's feeling?

James: Yeah, and it's interesting you mentioned depression because I think it's one of the most common harms felt from gambling. And I, again, from my own experiences, I used to think when I was addicted to gambling that I was just a depressed person who gambled. Having now been nearly seven years in recovery, I realise that I was a person who gambled and that caused depression and those feelings, because I wasn't like that before gambling and I haven't been like that after gambling. So it's something about gambling specifically, I think that makes people feel depressed. And similarly, with anxiety as well.

And in terms of what healthcare professionals can do, a real basic ask from us would be just to ask the question, and that is something that's not traditionally happened, but this is a new and emerging field so there's no judgment at all on any healthcare professional. But begin to ask the question and you can ask it in an empathetic way. You can ask it in an unjudgmental way, and it could just be as simple as, are you worried about your gambling or someone, you know, if you're worried about an affected other, and that could unlock something. It might be the first time someone's been asked that question. And if the answer is yes, then it's really absolutely crucial to determine what type of gambling they are gambling on, because as we know, if it's a weekly bet at the football or if it's some of the less harmful products like buying a lottery ticket or taking part in the, you know, the village fate raffle, we can probably assume there is a less risk of addiction and all the harms that I've talked about. But if they say, I've just been using an online roulette machine for four hours. Okay, alarm bells would need to be start ringing because we know how powerful those products are and the impact that has on the brain. It would then be to determine how often they're gambling, how long they're spending when they gamble, and asking them about their support networks around them.

And I kind of feel like here, I need to give a bit of a shameless plug to the work we do through Chapter One, is that there's no expectation for healthcare professionals that are listening to this to be experts in gambling because there hasn't been adequate information and training, but our program through chapter One is there for you. We are here to help. We are here to train you to be able to have these conversations, to have the information and the knowledge that you need. So if someone says, I can't stop gambling, it's not that you just know what to say next, but you know, why that person is experiencing that and what we can do to help them, stop and rebuild their life.

Helen: And I probably want to ask you a bit more about that, James, if I can come back to that. I think it's really important for our listeners in general, particularly the ones who are healthcare professionals, but also everybody out there to understand more about that. And I wonder, on the way to that, whether we could talk a little bit. You said that one of the things that you've done is talk to people working in NHS gambling services, and particularly people who do CBT. Can you tell us a bit about what it's like to talk to people doing CBT when it comes to gambling and gambling harms?

James: Sure. So, I didn't get any treatment or any support other than the self-exclusion tools that you can put on yourself and just support from my mum and from family and close friends. And that was because when I stopped gambling in 2018, I think there was just one specialist gambling addiction clinic in the country, possibly two. But not one that was local to me and not one that was accessible to me. I'm now pleased to say that there are 15 specialist clinics across the country that cover every single area of England. Same cannot be said for Scotland and Wales and Northern Ireland, unfortunately yet. But there is wider support out there, other than the NHS services.

Having met with all but one of these NHS clinics now, they all take a nearly identical approach and that is CBT first and foremost for someone that's experiencing gambling harm. And I've spoke to the clinicians at these organisations extensively and we've worked with them to learn how best to tailor our materials and to work together. And honestly, I'm not just saying this, I leave those conversations feeling like these are truly people who understand what happened to me, what happened to my brain and have the answers to rewire it and to change the behaviour for the better. And I left feeling like I would send anybody I knew that's experiencing gambling harms into their service tomorrow, because they would be in the safest possible hands and that's kind of what we're doing with our work now is we want to be that support and treatment pathway into these services because we know how effective CBT is. We think, and I say that because I'm not actually sure on the best international evidence, but we think this is the best form of treatment for people experiencing gambling harms. And this is what these services offer. So our job is to get many more people into those services because currently only one in 200 people who may benefit from treatment for gambling harms are accessing it. So there is clearly a massive gap and a massive job to do to get more people into those services.

Helen: Again, you're giving us some fairly shocking statistics there about the sheer number of people with the difficulties, the people who are losing their lives and the families affected by it, and the number of people who are accessing help. And I'm just thinking about the work that you do in Chapter 1. Did you say that training is one of the key things that you offer?

James: Yeah, so Chapter One provides information and support for everyone affected by gambling, including training for professionals. So, it's designed to give information to everybody about the causes and effects of gambling harms and how to support someone if you're worried. But a big focus of the work has been helping professionals perform very brief interventions and also helping them understand where specialist support and treatment is. And we have a training program for frontline professionals, which has been rolled out across Greater Manchester, in Yorkshire, and in Nottingham to really good results. And we're about to have an e-learning platform as well, which professionals will be able to access towards the end of 2025. And we just hope that it makes it easier because we are totally aware of how time pressured people are, how stretched people are, the fact that, you know, health professionals have to be experts in lots and lots of different fields and we want to lighten the load on that and make it easier for people because we know this stuff, we know gambling, everything has been informed by lived experience and by gambling addiction clinicians and those messages, that information, those resources are all accessible, on the Chapter One website, which is chapter-one.org. And there's actually a dedicated professionals hub on the website as well, where it's got additional resources, stuff that you can print off and start using tomorrow to put up into the places where you work, takeaway resources, posters, flyers, and that will be a really good starting point. But I would highly recommend trying to book on to some training to learn more about what we do and how you can help.

Helen: Sounds like a fantastic resource and we'll make sure we put that link on our show page so that everybody can follow that up and have a look. Thank you. So, I mean, it sounds like you've done a huge amount of excellent work, and you've also said there's probably a lot to do. How do you see the future? I mean, what do you want to see, you know, in, in the next few years? What would you want to see happen?

James: Yeah, well, I kind of have a vision of how to prevent gambling harm and to save people dying because of gambling related suicide. And it's a number of things and you have to bear with me here, but I think it has to start with better legislation of gambling laws to make gambling much safer in the first place and better regulation of those laws by the regulator, so the industry is accountable and those laws are enforceable.

But beyond that, look, I think every young person, in every school should have a curriculum mandated lesson on the risks of gambling. And that lesson has to talk about the risks to mental health and the addictive nature of gambling and the industry business model and the practices they use to draw us all in. I think that everybody in the public deserves public health information and messaging about why this happens to people and how best to support someone if you're worried. I think that every professional should have access to training. I think that every professional who works with children and young people should be empowered to have resources to deliver preventative education to the young people they work with.

And I think there should be much, much better joined up services so there's no wrong door for people experiencing gambling harms. If someone comes to a service and says, I'm worried about gambling or I can't stop gambling. Everybody should know at the very least where to point that person in the right direction. It's no good fobbing people off with generic mental health support advice. This is a unique and diagnosable mental health condition that deserves recognition for that reason alone. And everybody should know that there are now specialist NHS clinics that can provide support.

So that's the vision. And I don't think we're a million miles away from that happening. The political context is that we're about to get a statutory levy on the gambling industry, which will be roughly 1 percent of their profits that will be given to independent prevention, research and treatment. So that is a really positive step, and it will ensure that there is more treatment, better access to treatment. The truth is again, on the prevention side of things, probably 30 million pounds of that will be spent on prevention activities. But if we think about how much money the gambling industry spends on advertising which is 1. 5 billion pounds every year. Well, we're using a 30-million-pound budget to try and compete with 1.5 billion pounds of advertising, telling everybody that gambling is safe, harmless fun. So there's, the balance is still not there. So I would advocate for more investment in prevention and all the things that I said to make sure people know about the risks and how to get help much earlier.

Helen: Thank you. And I really would say hearing what you're saying about the extent of the difficulty, and that people are starting to talk about it more. you have the ear of the government, perhaps in a way that hasn't been the case in the past and things are perhaps moving in the right direction. And it really comes across how passionate you are about making a difference here. One of the things that I did wonder about, going back to one of the things that you said right at the beginning about this sort of dirty backstreet betting shop thing and, how the presentation of it all has changed and it's kind of shiny and attractive. I still wonder though if there's anybody listening out there who's thinking about, well, maybe this is something that is affecting me, but feeling embarrassed or ashamed or hasn't got a social support network that would hear them if they said I've got a difficulty. Have you got anything that you'd say to them?

James: Yeah, I would say, try to self-reflect on gambling and your relationship with it. So ask yourself, what is gambling costing me, not just financially, but including the money, but time. What is potentially gambling benefiting me and literally write those things out. And I can almost guarantee that the list of things that will be costing you will be greater than the things that you are getting benefit from. I would encourage you to really question whether you can engage with sport without having to put a bet on. That was a huge point for me is that the idea of watching sport, especially football, without putting money on it used to be an awful feeling. I couldn't bear it. And so ask yourself that. Has that become such a part of your routine that you always put a bet on when you watch the football? Do you find yourself gambling when you intended not to, how many days do you honestly think you can go without gambling? Ask yourselves those questions as a starting point. And I'm not going to tell you the answers to those because I don't think it's our job to, to tell people that I think self-reflection is really important.

And that's, you know, that's something that I did for my recovery was write down all the things that gambling had done to me. And every time that I felt, oh actually, maybe a bet on the football this weekend might be fine. Cause I'm over it now. I literally got that list out on paper and would go through it and go, oh yeah, I remember now this is what it costs me. This is what it did to me. And I'm not going to go into that.

And the other thing that I'll say as well is it try and give yourself as much information about gambling as possible. So again, look at Chapter One, go on the website and look at the information on there about how gambling products are designed, what the industry business model does, the whole myth of safe and responsible gambling initiatives, that kind of information might make you see gambling in a different light.

And I'll give you one personal anecdote actually recently that has helped me, is that I've started to look into and read about ultra processed food. And it's really opened my eyes about the tactics and the mechanics and the playbook of the junk food, fast food industry. And it's really put me off it. It's made me think, actually, I don't want to eat this stuff because I now know what's in it. I now know how the industry operates and lobbies similar to what happened with me with gambling. So I'm always a big advocate for information. Giving people information is absolutely key. So go find it.

Helen: It sounds as if, there's anything from just asking yourself some questions and educating yourself, just checking who's benefiting here, all of those kind of questions, but also places that you could go to learn more and places you can find help. And it sounds for you as if that comes in the context of a more generally healthy lifestyle as well, that you live these days.

James: Yeah, if you ask my wife, she may disagree, but I still eat unhealthy food. I still have a drink. I'm no angel, but I am now much more aware of how a whole range of industries actually, do everything they can to keep us as customers, especially the gambling industry, but, you know, I feel like we're all quite attached to our phones and to social media. And that's really difficult and it's deliberate. And that's the thing that really gets me is the deliberate nature of all this and going back to gambling, that is, you know, there is a deliberate side of this. It's to generate profit at the expense of widespread social harm. And that's the thing that, you know, you mentioned passion. That's the thing that gives me the passion to know that I can counter that information by going to tell people the truth and my personal experiences are what keeps me going, drives me on, but also knowing that I have the opportunity to tell people that and tell people the truth, yeah, is good for me and I'm hoping it will be good for many others.

Helen: Thank you. So if you had one key message out of all of those things that we've been talking about today, where you want people out there to know, especially if they've got a worry about a loved one or a worry about themselves. What's the one key thing that you really want people to remember from our conversation today?

James: The first thing that came to my mind, it's really difficult because there's lots of things I'd like to say, but I'll stick with the one. And the first thing that came to my mind is, please don't think this is all your own fault, and please don't think it's all the fault of the person that you care about or you love. And that's really difficult, especially for that latter category of people because you may be experiencing harms and none of this is definitely your fault because you've not even gambled, and you may be experiencing harms through a loved one. But there is a reason this happens. Nobody wants to be addicted to gambling. Nobody wants to experience gambling harms. And of course, yes, people do have agency, and people are responsible for their recovery and for seeking help and for staying recovered and abstinent. But from my perspective, I will never take responsibility for being given an addiction at 16 years old and never, ever take responsibility for throughout 12 years of addiction, never being asked by a gambling company if I was okay, or if I could afford to lose the money that I was losing. And so, to summarise, try to remove this blame that people feel because that is another reason why people get to that point of feeling that they've let everybody down and it's all their own fault. So challenging that narrative is absolutely fundamental for us and for me.

Helen: Thank you, James. And I just want to check whether there's anything that you would want to ask me or anything else that you'd like to say before we finish today.

James: I just like to say thank you for the opportunity to speak to anyone that's listening and thank you for dedicating time to this topic. I know it's not a topic that is always high up the agenda, until it needs to be. And that's the sad truth that gambling harms are often identified way too late, or at crisis point, or at death. And hopefully, by just spending a bit of time listening to this and looking up Chapter One, you may avoid those situations. So just to thank you for me. And if anyone wants any more information on these, anything from me, you can get in touch with me through, my email address, which is, [email protected]

Helen: Thank you so much, James. Thank you.

James: Thanks.

Helen: Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at [email protected], that's [email protected]. You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested.

If you've enjoyed listening to this podcast, you might find our sister podcasts Let's talk about CBT- Practice Matters and Let's Talk about CBT- Research Matters well worth a listen.

In this episode, Helen talks with Lizzie, a beauty content creator and disability advocate, and Bex, a CBT therapist, about Lizzie's journey navigating living with long term health conditions, trauma and the transformative impact of Cognitive Behavioural Therapy (CBT).

Lizzie shares her experiences living with Crohn's disease, POTS (Postural Orthostatic Tachycardia Syndrome), and hypermobility spectrum disorder, alongside the emotional challenges of managing these conditions. She discusses her initial scepticism about therapy and how CBT helped her address anxiety, PTSD, and prioritising her own well-being.

Bex offers insights into the therapeutic process, addressing common misconceptions about CBT, and highlights the importance of building trust and tailoring therapy to individual needs. Together, they discuss the interaction between physical and mental health and strategies for balancing driven lifestyles with well-being.

Useful links:

Explore Lizzie's content on Instagram and TikTok (@slaywithsparkle).

Listen to our sister podcasts: Let's Talk About CBT - Practice Matters and Let's Talk About CBT - Research Matters: https://babcp.com/Podcasts

Find us on Instagram: https://www.instagram.com/babcppodcasts/

Learn more about CBT www.babcp.com

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This episode was edited by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies

What we've got for you today is a conversation with Lizzie and Bex. Lizzie's going to talk about her experiences of having CBT and living with a number of conditions that she'll tell us more about in the episode. We're going to talk to Bex, who is a CBT therapist, and she's going to talk with us about working with Lizzie as well.

Welcome to you both. Lizzie, would you like to introduce yourself?

Lizzie: Hello! Thank you so much for having me. So as Helen's just said, my name is Lizzie. I am also a beauty content creator known as @slaywithsparkle on Instagram and TikTok and a little bit of YouTube and I'm also a speaker that talks about disability awareness. And I try and raise awareness about the health conditions I've got and general sort of disability awareness and activism about that.

Helen: Thank you Lizzie, and welcome. Thank you for coming to talk to us today. And Bex, would you like to tell our listeners about you?

Bex: Hi. Yes, I'm Bex. I'm a CBT therapist and worked with Lizzie a little time ago, when I worked in a physical health service for IAPT at the time. And I currently work more with trauma in Sheffield both in the NHS and privately.

Helen Thank you, Bex. And maybe I should just say, when you said IAPT, we're now talking about NHS Talking Therapies.

Bex: That's right. Yes. Thank you for providing the update.

Helen: So Lizzie, can I ask you a bit about what was happening for you? What was going on that meant you ended up having CBT?

Lizzie: So for me, I really had quite a negative opinion about any sort of talking therapy and had very much been brought up with the idea that if you have some sort of mental health problem, you should be able to solve it yourself. And if you just think positively and carry on, then everything should be fine.

Because of my health conditions, so I will just mention just briefly so people are aware what my health conditions are just for context. So I have, Crohn's disease, which I was diagnosed with when I was 21 and then later about 9- 10 years later, I was diagnosed with hypermobile spectrum disorder and also POTS, which is a condition that affects my blood pressure and heart rate. And when I had a first flare of Crohn's disease. I'd obviously had it a long time without realising, but when I first flared with Crohn's disease, I really struggled with the concept of having a physical health condition that I couldn't push through. So with my Crohn's, I ended up ignoring a lot of the doctor's advice because I had this idea that I should be able to cure myself. I really pushed myself to look at alternative therapies. And then, because of that, I ended up ignoring what the doctor said and becoming a lot more ill. Unfortunately, because of a combination of the Crohn's having been misdiagnosed for a long time as IBS, and then because of all of those sorts of ideas about that I should be able to cure myself, my Crohn's did get so bad that I ended up having to go to hospital and have emergency surgery on my bowel. Years later, so about two or three years later, I started having real panic attacks, which I'd never had before. I was anxious all the time and I couldn't sleep. I would sometimes wake up in the middle of the night at like 4am and get the urge to clean the entire house and was sometimes just up in the middle of the night pacing up and down. And my partner at the time said to me, you know, this is not normal. Something's going on. You really need to think about getting some help for this. And I was devastated at that concept because I obviously had this idea that I should be able to fix myself. And so that was the sort of wakeup call that I had to go and get some help and I applied to IAPT at the time and had my first round of CBT. Since then I've had three rounds of CBT and a course of EMDR as well but yeah, that was the first thing that sort of led me to CBT.

Helen: Thank you, Lizzie. And it just strikes me what a difficult combination of things you experienced that not only were you having a number of quite complicated and long-lasting physical symptoms, also the experiences you'd had when you were younger meant that it was really difficult to seek help for the panic attacks and the anxiety and so on. Can I ask you just to say, in case anybody's not familiar with the terms, can you just say a little bit about what the symptoms of Crohn's disease are?

Lizzie: Yes, absolutely. So Crohn's disease is different for everybody. For me, I really struggled with pain and one of the biggest symptoms that I had was pain. I also struggle with diarrhoea. It's not the most glamorous disease. It's quite embarrassing sometimes. Some people have a lot of nausea and vomiting. For me, that's not been as much of a problem. To me, the biggest problem has been pain. And it got so bad that when I was actually in my final year of university, I'd been told by the doctors repeatedly that it was IBS, and it was just stress related IBS and I just needed to make sure I watch what I eat, tried to up my fibre, which made me a lot more ill. And eventually it got to the point where I literally couldn't even drink water because my oesophagus was closing up. I was in absolute agony and I finally went back to the doctor and I was like, really, honestly, there's something seriously wrong here and then they finally sent me for the right tests and they found the Crohn's disease. The other big symptom with Crohn's disease as well is fatigue. So, most people actually say that fatigue is the most debilitating symptom of Crohn's disease. And for me, I mean, at the moment I am in a flare and I am sleeping 14 hours. And if I don't get that 14 hours, I cannot function and I need a full day in bed to recover.

Helen: And again, you've said about some of the symptoms being a little bit similar to IBS or Irritable Bowel Syndrome but having a really far reaching impact on every area of your life, really. You also mentioned that you had POTS, which can affect your blood pressure. And if I have this right, it's Postural Orthostatic Tachycardia Syndrome?

Lizzie: Yeah, so it affects your, for me, it affects my blood pressure. Not everybody has problems with their blood pressure all the time. But what happens is your heart isn't getting the right signals. And so you end up having a really high heart rate when you stood up and then that can lead to you passing out. It also leads to symptoms again, like nausea, fatigue and for me, it just feels horrible. Like, it's just that feeling of like sometimes the world's sort of closing in on you and when you're about to go you just feel really sick, really like something's pulling you to the floor. It's a very frustrating condition. I think out of all of them, Crohn's is the most dangerous and that one is the one that when that's flaring, I'm always a little bit nervous because mine is quite severe, but POTS is definitely the one that is the most infuriating. I've had to lie down in the middle of shops. I once had to lie on the floor in the middle of Poundland because I was passing out and honestly, it's just mortifying. It's really embarrassing.

Helen: And I'm noticing there as well, Lizzie, that you've just said that the Crohn's disease because of the symptoms of diarrhoea and you know that can be embarrassing. We all know that the impact of eating a lot of fibre, which you were advised to do can be, can lead to embarrassing symptoms and then the POTS as well, that having to lie down somewhere public, more embarrassment. And in addition to that, you also said that you have hypermobility syndrome. And again, can you just say a little bit about what that's like?

Lizzie: Yes, so for me, I have a late diagnosis of hypermobile spectrum disorder. There are a couple of things that are related, so similar, sorry. So there's hypermobile EDS and then there's also hypermobile spectrum disorder and they're very similar conditions. But the one that I have is hypermobile spectrum disorder and with that, it just basically means that my joints are too floppy. They extend past the natural point where they should extend because my collagen is built in a way that means it can stretch further than it should. So it was okay when I was younger. I used to be able to just do amazing, you know, bend my back really far back and look very bendy. And then as I got older, as the rest of my connective tissue ended up getting looser, as it naturally does when you get older, my joint started to get worse. I got more and more joint pain. I'd had joint pain my whole life, but it became a lot more severe. And it's now got to the point where I am not able to walk any distance with, any significant distance without a walking stick. And in order to go around, say, for example, like a supermarket, I need a wheelchair.

Helen: Thank you for explaining all that, Lizzie. Again, I'm listening to you and I'm hearing lots of things that could make it also really hard to manage your mental health. And I want to come back to you and talk to you a bit more about what it was like having the CBT.

Before we do that, can I just ask Bex what it was like for her when she first met you? Because we've heard a bit about your background and maybe what you were thinking before you first went to see her. So, Bex, what was it like meeting Lizzie for the first time?

Bex: So, you can't see Lizzie but Lizzie is a lovely, warm person. So that was obvious from the start and I guess I was, with any physical health problem, the thing we're trying to do at the start is to understand what someone's experiencing and making space for someone to kind of tell their story a little bit about what they've experienced and what they're finding difficult so that we can kind of map that out and work out how we could potentially help too by working on this together. I think when I first met Lizzie, we fumbled a little bit at that process. I don't know if you want to say a little bit more about that, Lizzie, and I think, you know, I was trying to explain how pain and mental health might interact, and I might've done that a bit clumsily.

Lizzie: I think, to be honest, I went in with this real prejudice, I guess, against mental health. So when I came to you, I had actually already had one round of CBT to start with, but I was really still coming from this place of prejudice against talking therapies and fear about whether I was going to be believed about my health conditions. The first round of CBT that I'd had, it was in a place I used to live down south, and it was very much focusing on the anxiety. And we talked about it being to do with the fact that I've been diagnosed with Crohn's disease and the fact that I'd had a lot of hospitalisations and the fact that I had emergency surgery, and also the fact that I'd been told that I might have a shorter life expectancy as well. And so it very much focused on the anxiety of dealing with those concepts. But underlying it all, I still had this fear of not being believed about my health conditions. I also, I will just share now, because it is relevant as well, that while I was in hospital for the emergency surgery, the night of that emergency surgery, I was physically abused by a doctor. He was a locum doctor that the hospital had employed just for, you know, a couple of nights. And he insisted on doing a physical investigation on me despite me asking him not to and then he purposefully inflicted pain on me and he enjoyed it, it was a really unpleasant, horrible experience and thankfully a nurse walked in as he was doing this and she got him to stop and he got reported and he no longer works in hospitals and that has all been dealt with.

But when I first went into CBT, I hadn't even thought about that as something to talk about because I felt like that was my fault. And I felt like that was my fault because I was in pain because I hadn't done a good enough job at curing my conditions. And so that narrative was in my head when I came to see Bex. And I already had this idea of like, I'm not good enough at curing myself, but I'm now getting to the point where I do need to believe that I've got these health conditions because I'm seeing physical evidence of it more and more. So I was sort of in this halfway point between trying to accept it, but also thinking, nobody else is going to believe this because I don't really believe it. And that's what I came to Bex with, which must not have been the easiest patient. And then at first we did have, I think there was a very slight miscommunication about the fact that CBT can help people with physical health conditions with pain. And I saw that as, oh she's saying it's all in my head and that if I just talk about this, then my pain is going to be completely cured, and they don't believe me that I'm in real pain. But then Bex was brilliant and stopped me and said, no, I really do believe you and you explained it. So, Bex, I'll go back to you because I think you explained it really well and it really helped me.

Bex: Well, I think I just said, I believe you and your pain is real. Can we just have that as a starting point and think about how what you've experienced has contributed to living with it and how some of those beliefs you have about yourself might make it harder and maybe they're the bits that therapy can support you with.

Helen: Thank you for that, Bex. We've just heard Lizzie talk about, not only having those health conditions and those beliefs, but also about being assaulted when she was supposed to be in a safe place. And you started to talk there about the interaction between the physical conditions and perhaps the emotional beliefs thinking. How did that then help you decide with Lizzie what to do next?

Bex: So we talked about it together to decide what to do next. And I guess part of that process was understanding kind of the emotional impacts of both the physical health conditions, you know sometimes there's understandable uncertainty, anxiety, maybe grief associated with those things and the adjustments that are necessary, but also the huge emotional impact of her trauma experience and how that contributed to the stress she was experiencing day by day.

And really it, originally, it's mapping that out and understanding it as much as we can to inform Lizzie making a choice about what she wants to prioritise. And, if I remember, we started with some work on physical health and understanding that, partly because of you already alluded to that kind of disbelief you had about your own kind of symptoms and in your own body and listening to that. So I think we did some work to start with on that before doing a kind of CBT for trauma approach that Lizzie was very much leading that decision.

Lizzie: Yes, I think the other thing that I remember as well is that I didn't, I don't think I opened up to you about the thing that happened with the doctor straight away. I feel like I went knowing that I had still got anxiety because of things that had happened in hospital and the Crohn's and everything generally and the fact that I was being diagnosed with POTS, I think that was what was going on as well. I was just about to be diagnosed with POTS, so this new diagnosis had sort of triggered a lot of anxiety because of what happened when I was diagnosed with Crohn's disease. It was sort of like coming back. But I don't think I actually mentioned the doctor to you straight away. I think that came out naturally when you sort of asked me to talk about what had happened and what were the things that I sort of was getting in terms of flashbacks because I was having PTSD flashbacks as well. Sorry, I forgot to mention that, and I think we pulled it out by having those conversations. So it was really important that you worked with me on it because that enabled you to be able to pull out this major thing that I probably didn't even see as a priority because I blamed myself for it. So I thought that was really useful.

Helen: And I'm hearing from what you're saying that combination between very difficult to manage physical symptoms and how those interacted with what you believed and how strong that was. And I think it's really interesting that sometimes people talk about long term health conditions, as if they were all in the mind and that being completely wrong. And coming to someone like Bex, who's got psychologist or psychotherapist or something like that in her title, being particularly difficult at the same time as for you, believing that it really was something that you had control over by the power of your mind or something like that, that somehow, if you only tried harder, you could change what was happening.

Lizzie: Yeah, absolutely. It was, I was terrified. Honestly, I was so confused about what was going on in my own brain. I felt like I needed to do something because I was getting flashbacks at that point. In any sort of moment where I wasn't actively doing something, I was getting flashbacks every 15 seconds, I think. Honestly, it was it was awful. I was getting certain colours were triggering things, and it was constant. It was exhausting and I knew there was something that I needed to do about it. I had my first round of CBT which was successful at helping me bring my anxiety down, so I had that sort of stepping stone, but I was still coming from this place of fear and doubt. And I think part of that is because I was told by the doctors when I was first diagnosed with Crohn's that I should have CBT. And I thought that was them saying that it was all in my head, but it was actually that they were prescribing it as a way of helping me cope with the pain, but the way it was communicated to me made it sound like they just thought, Oh, well, if you have CBT, then you'll be cured of Crohn's disease, which is not what they meant. And I now know that having spoken to people who work in the sector more, I now understand that.

But I think that a lot of people, when they are first told, oh, I think you should have CBT. They think, oh, this is just the doctor trying to fob me off, but it's not, it's them using their toolkit of things they've got available to them to try and help. It's just not necessarily communicated that well. And I think if it was communicated to me differently, back when I was first diagnosed with Crohn's, maybe I would have had CBT back then, and maybe I might have had a bit more support as I was going through the diagnosis. And some of that fear might have been mitigated a little bit back then.

Helen: I think that's really important for you to have explained that actually, that sense of, for people like myself and Bex, perhaps, to understand how to explain why what we've got to offer might be useful and not to make assumptions that someone that we're recommending for CBT will automatically know what we meant. So that's an important message. I think.

Once you did go to CBT, can you tell us a bit about what was actually helpful? What did you actually do or talk about? What was it that seemed to make a helpful difference?

Lizzie: So the first round of CBT that I had was very much focused on mindfulness and being able to be in the moment. I did have PTSD and my PTSD score was very high, my anxiety score was very high. I think my depression score was lower at that point, I'm not sure if I scored for depression at that point, but the main thing that I found helpful was being able to stay in the moment because I was constantly worrying about the future, worrying about death, worrying about what was going to happen if my Crohn's flared again, worried about what was going to happen if I had to stay in hospital again, and I was constantly writing all these stories for myself that weren't happening, and living in fear that I didn't need to be thinking about. So that really helped me just to be mindful and to focus on the moment. And when I first heard the term mindfulness, I was like, right, okay. Are we just going to be like sit in a circle and go "ohm" or something? And it wasn't that at all. It was very much using strategies that are very simple to just help my body and my mind realise that I am safe in this moment. And that for me was really helpful. And as somebody coming from a place of doubt, I think again, if that had been communicated to me before I'd gone into it, I think I probably would have been a lot more open, because I think even back then, my first therapist probably had a lot of resistance from me as well.

And then when I came to Bex, the main thing that I was struggling with then, I think was the PTSD flashbacks, but I think I also scored for anxiety and depression at that point. I was, again for context, I was a teacher still then, so I now have had to medically retire, unfortunately. But when I first saw Bex, I was still a teacher, and I was really pushing myself past the point that I should have been. I was exhausted. I was in pain all the time. I was determined to have a successful career, which I did have. Despite all of this, I did have a very successful career as a teacher, but the reason I had that successful career was because I pushed myself despite all this pain. And it was also a way for me to take my mind off the PTSD, because if I was busy, if I was constantly go, go, go, it meant I didn't have to think about it. So that was where I was at when I first came to Bex. And I think one of the things that she did was, like I said, pulled out the key things that were kind of coming up in flashbacks. And then we did a sort of narrative about the trauma, which was horrible. I'm not going to say it was really horrible, but it helped. So I think that's another thing to say, like, if you're having CBT and the therapist suggests something that is horrible, it's probably going to be good for you because yeah, so we had to basically go through the story of the most traumatic time of my life ever. Over and over again, and I was given homework of going home, reading it through this narrative of like everything that happened over and over again. And it was one of the hardest things I've ever done. Honestly, it was horrible. But by the end of it, I got to the point where I can now, you know, come on a podcast and tell you I was assaulted by a doctor. When I first saw Bex, I couldn't even say the words about anything that had happened. And the fact that I can now come on publicly and talk about this is, you know, that just shows how helpful CBT was for me, because I honestly, I would have never imagined talking to anybody about it. I didn't even tell my partner who I'd been with for, I think over 10 years at that point, I didn't even tell him until I'd gone through that process of CBT. Most of my friends and family had no idea.

Helen: Thank you, Lizzie. It strikes me from everything that you've just been telling me that between working on the post-traumatic stress disorder, the PTSD symptoms and working with Bex to do something that you really didn't want to do and actually deliberately, repeatedly going over it until you could talk about it until, like you say, you can come and talk publicly about it with us, which we're extremely grateful for, but also hearing how hard that is. And in a moment, I'm going to be asking Bex about what she does both to persuade you and other people to go through something that's that difficult, and how you make it manageable when clearly it's a horrible thing to go through. What I might also want to come back to you about as well is you really conveyed how driven you were about that wanting the career, keeping busy, pushing it. And I want to come back about the impact of that as well, if I may. But first, can I go to Bex and just talk about, Lizzie just told us that you've essentially asked her to do the worst thing and do it repeatedly.

Bex: Yes, we did. So yeah, it's intuitively the last thing you want to do when you've experienced, you know, something so, so awful and life threatening, that the last thing you want to do is talk about that. So, we do prepare for it, we do some sort of exercises to make sure that we have the tools to calm down if it's distressing, and we explain the theory for why we're doing that because these are kind of stuck, emotional responses and perspectives from being in a situation that was too much for your brain to process at that time. So we're making the space for it subsequently to understand what happened, connect to the feelings that were overwhelming at the time and sort of safely release them through this process. And as well as doing that, we also understand, you know, look at the beliefs that became stuck at that time. And we challenge those together to see if we can get some kind of perspective. So, for example, you were talking about the self-blame, that is so, so usual with trauma. And we looked at that from a different perspective now we had all the information, and I guess the way we encourage people to do that is very much making sure it's their choice, you know, nobody has to do this, but explaining what the benefits might be if we were to try doing this together and try doing it at the pace that you feel like you're able to tolerate and that you're in control of the process. And it's also important to have that story heard and understood by both of us in that process.

Helen: And can I just talk to you both about that experience of being really driven. And there was something about the way you described that, Lizzie, that part of that was trying not to be triggered or think about all the bad things that had been happening for you. But also that general style of pushing for a career, being really busy, being highly motivated and I just wondered how the two of you managed that aspect, you know, during your sessions or between them, perhaps more importantly.

Lizzie: I think one of the things I can remember was in the first session. So I explained that I was, you know, determined to still be a teacher and how I loved my job, which I did, and I still wish I could be a teacher, I'm not going to lie, I really did genuinely love being a teacher which is part of why I was so driven, because I actually did really enjoy it. But there was definitely that element of me trying to kind ignore everything. But one of the things that Bex did very early on, I think it was the first session, she just said, your homework is to do something fun. And honestly, the concept of doing something fun for myself at that point was unimaginable. And I found it really hard. I found it really hard to think about something to do just for fun for myself. And I think that was just a sign of how much I needed that help because I couldn't even think about what to do. And that really helped me to start to come out of this really, like, blinkered existence where I was thinking, go, go, go, go, go. And it just gradually, bit by bit, helped to pull me out of it. And I think you kept suggesting things like that. And then we talked about what was nice in my week and things like that. And it just helped bring me out of this sort of bubble that I was in.

Helen: And Bex, will you tell us a bit about how you were thinking about that as a CBT therapist? What's going through your mind when you're working with somebody like Lizzie, who's working really hard, but is almost stuck for finding something fun or rewarding to do? What's going through your mind as a therapist?

Bex: I didn't remember that actually, Lizzie, but I think, well, I guess I'm just noticing how driven and how exhausting it sounds to be kind of pushing so hard, despite feeling so ill. And I'm encouraging a new pattern of behaviour, I guess. I'm encouraging a different way of responding just to try it out. You know, with CBT, we're always just testing stuff, see what works, what doesn't, and so I guess I'm encouraging that early doors to get a bit of a buy into the concept, you know, are you're okay with this approach? And I do remember that we did throughout, we did do bits and pieces around understanding the consequences of working that hard or noticing, cause sometimes you might want to and it might be the right thing for you, but sometimes it might have more impact in ways that are less helpful and you might want to try out a different pattern. And I think we might've looked at working pattern and problem solving that or negotiating with work about trying different approaches and different working weeks to see what was more manageable and more sustainable.

Lizzie: Yeah, I remember doing that. And also remembering you helping me a lot with being able to actually have time off work before I was forced to by my body. So, I used to get to the point where I was completely exhausted or in such agony that I couldn't move. And that would be the point when I'd phone in sick, but I think we did a lot of work looking at what my body was doing, thinking about, actually would it be helpful to have some time off before I get to that point rather than waiting until, you know, I need to end up in hospital or something, and giving myself permission to relax every now and then and prioritise my body and that really helped me.

Helen: There's something there about finding a balance, whether it's a work life balance or a fun and effort balance, or a, I don't know, resting and doing things balance, but there's something about finding a way of managing your activity and energy levels and ending up actually being able to do more rather than pushing it beyond what your body could manage and then having to take enforced rest at a time, which was already kind of too late in terms of the symptoms. So I'm hearing what you were working on together was about managing day to day life as well as other pieces of work that was specifically to do with resolving incidents or traumas that had happened in the past. So you were fitting a lot into therapy sessions. It sounds quite busy.

Lizzie: Yeah, it was, it was useful.

Helen: And I wonder, looking back on it, you've already told us that doing that repeatedly going over the traumatic event was one of the hardest things that you've had to do. Was there anything else that you found really challenging that you and Bex agreed on, but you found it really challenging?

Lizzie: I think probably what I've just been talking about, about having time off work, I think I was quite resistant to that. I think I was scared to have time off work and to prioritise my health. At that point I'd just been diagnosed with POTS, I'd had a long-term absence from work and was feeling really guilty about that. Obviously as a teacher there's an added level because you've got your students who don't necessarily understand why you're not there. I was a secondary school teacher, so I did actually talk to some of them about my health conditions a little bit just to give them context, but some of particularly the younger ones, the year seven students really struggled with where I'd gone and were worried about me. So I think I had a priority in my mind to be at work and Bex's priority was my wellbeing overall, as well as making sure I had this fulfilled career. And I think I was willing to sacrifice my physical health for my career, but didn't see the big picture of that actually if I do that constantly I'm not going to be able to do this job anymore anyway, which did end up being the case naturally because of the way my health progressed. But that wasn't because of me pushing it. That was just because it got to that point. And when I did have to come to that point where I needed to medically retire, the work we had done ended up setting me up for that. And, I'm not saying as well that my, you know, the work we did in CBT was it. I've had more CBT, I had another round of CBT in the pandemic. Afterwards, I needed to have some more support because obviously all of this stuff to do with the pandemic and I was shielded. So I was actually picked as one of the most vulnerable people in society. And that was scary and brought up all this confusion about, Oh, I'm really ill. Like they, they actually believe me, the government messaged me, they told me I'm ill, you know, it scared me. And then I've also had a round of EMDR as well, which was focused on childhood trauma as well, which actually did weave its way into the physical health and also why I am so driven in terms of what I want to achieve as well and in terms of accepting my health conditions. But I would say that CBT helped me get to the point where I'm at now, where I'm medically retired in one way. I still do my content creation work. I still work as a speaker, so I will work a couple of times a month doing talks, and I am able to do that in a way where I'm still driven to help people, and I'm still driven to get that out that message out to people, but I spend most of my time in bed and that's okay and I can do a bit of both and if something needs to go because my health needs to take priority, then it does.

Helen: I'm really curious to hear about that, the things that you still put into practice now from what you've learned from the CBT and giving yourself permission to rest so that you can do things that you care about, things that you value. Can you tell us more about the key things from what you've learned from CBT that you still use the most?

Lizzie: It's a combination of things really, I use things from all of the rounds of CBT I think I've had, from the first round I still use some of the mindfulness techniques, I struggled to use those when I was really depressed. I think I was most depressed during the pandemic. I think that really, you know, everybody struggled, I think, during the pandemic but my depression got really bad and those techniques didn't work so well. But, for example, if I'm in a hospital waiting room, I will use those mindfulness techniques to try and just remind myself I'm safe. It's not that I'm going to be admitted to hospital immediately. Sometimes that's like a genuine fear that I think they're going to kidnap me. But I use those mindfulness techniques still there.

I think with the second round of CBT, when we did the narrative therapy, I think that just genuinely changed me internally in terms of the way I think about those memories, and I've also learned to give myself permission to be kind to myself. And I think that is just something that it was like a switch that, that turned on when we did the sessions. I don't know when it happened, but that switch is still on most of the time. Sometimes it turns back off again, and sometimes I have to stop. And actually either talk to a friend and they have to talk to me about some things and I'll then parrot back to them the things that I learned in CBT or sometimes it's just me quietly thinking to myself and thinking, no, it is okay for me to have time off. It's important to prioritise my body. And I'm not saying I do that all the time. I definitely don't. I still struggle with, you know, anxiety. I still have suicidal thoughts sometimes it's horrible, but I'm able to cope with those in a way that allows me to function a lot, lot better.

Helen: Thank you, Lizzie. And, if it's okay, I do want to just pick up on that. You said that you still get suicidal thoughts sometimes. Can you tell us a little bit about how you make sure that you stay safe when that happens?

Lizzie: For me, I very much don't actually want to kill myself and I never have. It's never been that I have suicidal thoughts in that way. It's that I think it's more to do with the fact that I'm exhausted with the battle going on in my mind. I'm exhausted with having to fight the negative side of my thoughts that's telling me, you know, you're useless, you're ill, you might as well give up. Those sorts of thoughts come into my mind. And my friends actually nicknamed that voice, Karen. So I apologise to anybody called Karen. it's one of those things that's picked up on the internet, but we've just called her Karen and so it's just helps me sometimes to think, Oh no, that's Karen speaking. It's not me. And so I'll sometimes have those thoughts, but now I'm at the point where I can just disregard them and they'll come in and I'll go, that's horrible. And then I'll carry on and it'll go away. And sometimes I have darker moments, but it would never get to the point where I'd actually hurt myself because I've got people I can talk to, I've got the techniques I learned in CBT to draw back on. I also have things in my life that I care about and I want to live for, and I can remind myself of those. It is difficult having physical health conditions. When you're living in pain, you're in bed for days on end, months on end. I, you know, I've had periods where I have been in bed for months on end and people listening will have had the same and it's horrible but it's just about looking at those little tiny things in a day that make the day worth living still, even if it's just having a nice cup of tea. And I think for me, those are the things that keep me going, but it's not easy and I think that's the thing with CBT and any sort of talking therapy is I don't think it's about completely eliminating any, you know, any trace of you having mental health problems. It's not that. It's about training you to live with them in a different way. And for me, I feel much more safe in my life. I feel like I can cope with those thoughts, and I've accepted that is not a nice part of me but it's something that is natural for me because of the pain I live in and because of the difficult things I've gone through and I'm not going to act on them, but they just, it's just there.

Helen: Thank you, Lizzie. And I just want to come back to Bex about that as well. And just hear what Bex is thinking about what you've just said about carrying on living with difficult days, difficult weeks, difficult months and really difficult thoughts.

Bex: Yeah, I think you've shared the kind of toll it takes to live with the extreme pain and tiredness that come with your conditions and the uncertainty and the sort of natural kind of phenomena really of living with those experiences and how you kind of navigate those really well now in terms of accepting, in terms of acknowledging what you're experiencing, but also putting them in perspective and focusing on stuff that's really important to you. And you know, that might be small things if you're really unwell, but I know from working with you from both that time and more recently that you do so well at sharing how you're feeling, at reaching out to people that you have a really positive relationship with, that you're actively managing those things so well when it is difficult and that's really fantastic to see. And it's really helpful how open you are about those things for other people who feel like that it's really valuable, thank you, Lizzie.

I guess the other thing I would say that maybe we haven't mentioned is that I've observed over time as well is the way you interact with medical professionals now. I don't know if you want to say something about that, but there's been a real difference in terms of, I guess, assertiveness or handling those relationships really well. So I don't know if that's something you wanted to reflect on.

Lizzie: Yeah, definitely, I feel like it's important to mention that actually, but I also did want to just say that you mentioned that I've been really good at reaching out and opening up to friends. And I think that is another thing that I got from CBT actually, because like I said, I didn't tell a lot of people that I was close to about what happened in the hospital and I did used to be a lot more closed off when it came to talking about my health conditions and I think I just thought I was annoying people when I talked about it, and one of the things I learned with CBT was that the people who choose to be in my life care about me, and that's why they choose to be in my life. And so they want to help me. And I was reminded that obviously I want to do that for them. So obviously why wouldn't they do that for me? And so that helped me to reach out to people. And it's not necessarily that I can always reach out. I think that's an important thing to say as well. A lot of the time, my friends are the ones that reach out to me when I'm in a difficult position. I think that's really important because sometimes when you're in the darkest sort of places, you're really not able to even see that you need that help. But I think the important thing is that if somebody in your life reaches out to you and asks you how you are, you're honest with them. And I think that's the thing that changed for me is that I used to just be like, yeah, yeah, fine, carrying on, you know, stiff upper lip type attitude. And I think it's really important to be honest and be authentic with the people in your life.

The other thing that you mentioned as well was about the health professionals. So not my proudest moment, but I did actually once punch a nurse. Not like, you know, like a proper thump, but it was a reflex reaction because I was so anxious in hospital. So she was, I think she was taking my blood or giving me an injection. And I was so anxious that my reflex was to just thump her on the arm. I felt so guilty because I've never, I'm not like that at all. I mean, hopefully you both, you've both interacted with me and you know, I'm not the sort of person to go around beating people up. So she was very professional and she just carried on completely like unfazed and I was like, I'm so sorry, I can't believe I just did that. She was like, don't worry, it happens all the time. I was like, wow, she really shouldn't have to deal with that. But I used to be so anxious around medical professionals. I didn't trust them. With that nurse it was slightly different, but I genuinely didn't trust medical professionals. I still don't to a certain degree because I've been misdiagnosed a lot. I've had lots of conversations with doctors who don't know as much about the condition as I do. I've had conversations with doctors who haven't read my notes. You know, recently I went into an investigation, it was important that they knew that I was immunocompromised, and he was like, Oh, you're not immune. You're not on any immunosuppressants are you? And I was like, Oh, only the three that I'm on. Yeah. And you know, that happens a lot. But I have learned to be more assertive in those sorts of situations. And now I'm able to communicate in a way where I can get across what I need to get across without having a huge panic attack. Because what used to happen is I used to just get completely overwhelmed and then I had to leave the room, or I just bursts into tears. And it does still happen. Even recently I've had a couple of things that happen where I get really overwhelmed, but it's nowhere near the level that it used to be. And now I've got again, another toolkit where I know what to do before an appointment. At the start of the appointment, I explain to the medical professional, you know, these are the mental health conditions I've got, I'm making you aware because this might happen. If this does happen, this is what I would like you to do and it's usually just a case of I just want them to be quiet and let me just process for a couple of minutes and then I'm usually fine. And then after the appointment as well, I've also got some things that I do afterwards to make sure that I'm as okay as I can be, but it's again, still difficult. It's not like it's taken it away and it's still something that I will always find hard and I need support with. So a lot of the time I'll have somebody come with me to appointments because I've recognised that is a need for me. And it's something that I can't do by myself, but that is part of me dealing with it. That's part of me managing it. And I think that's something that I've learned because of doing CBT and doing therapy in general. And it's changed my life. And it's helped me to get the diagnosis and also the treatments that I need. So it's been really important for my physical health as well.

Helen: Thank you very much, Lizzie. I'm thinking one of the things I would like is for people listening to hear what are the most important things that you would like them to know. And I'm going to go to Bex first. If there are people out there who are having similar experiences, whether it's long-term health conditions, whether it's having panic attacks, whether they've experienced trauma, struggling to manage what's happening to them? What are the key things that you would want people to know from what we've been talking about today, Bex?

Bex: I guess the key thing I'd want someone to know that if you're really struggling with those things, that matters and that there is support available where we can work out, you know, maybe some things can't be changed, maybe some things have to be adjusted or two, but the things that are possible to make different, maybe some ways of responding that can support you with what you're experiencing.

With trauma, I guess I'd want people to know that there are treatments that work for trauma that can make a vast difference in terms of re-experiencing and levels of anxiety associated with that past event. And I'd want people to know that they're entitled to that support and it's available for them if they want it and if they're ready for it because it might not be the right time. And that's entirely their decision. And often, you know with physical health we see quite a lot of physical health problems with people who've had chronic stress for a very long time as well and that there's an interaction there, and that we're interested to understand more.

Helen: Thank you. And Lizzie, what would your kind of key messages be, would you say?

Lizzie: I think the biggest message I want to get across is that it's not a replacement for the treatment that you'd get for your physical health conditions. It's something that can complement it and help to make life easier for you, but it's not about being something that you do instead of another treatment. And I think if you ever are in a conversation with a doctor where they suggesting that, so they're suggesting they're going to stop investigating and just send you to talking therapy, I would say it's important to advocate for yourself and say, you know, that's fine, but what's the differential diagnosis here and what else can we do to investigate what else might be going on? Or, you know, I'm happy to try that, but I would also like a plan for if this doesn't help me, what can I do after that? I think that's really important. The other thing that I would say as well is, I would say to somebody, if you are thinking about the possibility that doing CBT or some sort of talking therapy might help you, the likelihood is it probably will, because I don't think people would be considering it unless they're in the position where they probably would benefit from it.

And the other thing I would say as well is I got very lucky with having Bex as my therapist, and I think if you have started some sort of therapy or you're going to start and you don't feel like you gel or mesh with the person that you are speaking with, I think it's important to try and see if you can maybe change to somebody else, or be open with that therapist. You know, with Bex, if I hadn't have been open with the fact that I was anxious about her saying, you know, about the connection between physical and mental health, we might never have gelled, you know, that might have really stopped the relationship from progressing. I could have just never turned up to the next session if I hadn't been open about it. So I think that's the other thing is if you're feeling like something's not right, be open, and I think the vast majority of therapists go into the profession because they are genuinely caring people. I think it naturally attracts those kind of people. So the likelihood is they probably will want to try and help you and if it doesn't feel right after that, then try and find somebody else and see if it can find something that fits.

Helen: Thank you so much. I'd just like to say how much I appreciate you both coming to speak with me today. Bex and Lizzie, I'm really grateful for your input. Thank you very much indeed.

Bex: And thank you so much for having us. It's been really lovely to reflect on that, the experience together, and it was a joy to work with Lizzie.

Lizzie: Thank you so much. And yeah, I'm so grateful for honestly, having been able to have the experience and the experiences that I've had. I'm very lucky to have had the support that I've had. So thank you Bex for that. And it's great to be able to talk about it and hopefully this might help some of the people as well. So I really hope that if anybody's listening, who needs some support out there that this helps a little bit.

Helen: Thank you. So, our listeners will find more information on our show page and, I'm just going to say one more thank you to you both. Thank you both.

Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at [email protected], that's [email protected]. You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested.

If you've enjoyed listening to this podcast, you might find our sister podcasts Let's talk about CBT- Practice Matters and Let's Talk about CBT- Research Matters well worth a listen.

In this episode of Let's Talk About CBT, Helen Macdonald speaks with Pete Moore, author and creator of The Pain Toolkit, about his journey of living with long-term pain. Pete shares his experiences of how he was able to move from being overwhelmed by pain to learning CBT techniques and strategies which helped him learn to manage it effectively, regain control, and even help others do the same.

Useful links:

The Pain Toolkit website

Live well with pain website

Listen to our sister podcasts: Let's Talk About CBT - Practice Matters and Let's Talk About CBT - Research Matters: https://babcp.com/Podcasts

Find us on Instagram: https://www.instagram.com/babcppodcasts/

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This episode was edited by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies

Today, I'm speaking with Pete Moore, who'll be sharing with us his journey living with long term pain. Many years ago, Pete took part in an inpatient pain management program, which among other things uses cognitive and behavioural techniques to learn how to manage long term symptoms of pain. Pete will tell us about his journey and where he is today in not only managing his own pain and staying active, but also how he helps other people to learn key ways of living successfully with long term pain. Pete, would you like to introduce yourself to our listeners?

Pete: Yes, well, hi everyone. My name's Pete Moore and I'm the author and originator of the Pain Toolkit. I just want to say, Helen, thanks very much for inviting me along to do this podcast and I'm really looking forward to having a chat with you.

Helen: That's great. Thank you very much, Pete. I think a good place to start would be if I ask you just to tell me a bit about how you ended up living with long term pain.

Pete: Yeah, it's, such a familiar story actually that of mine. Back then in the early nineties, I had back pain and such and I used to sort of manage it by taking over the counter medication, et cetera, or just having a rest. But I didn't really do a lot to help myself. I didn't really know what to do with it. I just, you know, it's like most people just get on with life. But I think it was about 92, back then I was a painter and decorator, and I was painting a house over in Windsor Castle. Anyway, I went home that night and the next day I couldn't get out of bed. I found out later on that I'd prolapsed some discs in my back, I think, two in the lower, and one in the middle. And I was pretty scared, really frightened, et cetera. And I found it difficult even going to the GP, really. And anyway, long story short, I was given medication and anti inflammatories but little was I to know that back then there was, you know, managing back pain or managing pain itself was like being put in something called the medical model. And I wasn't really given any guidance around what I could do for myself. It was just, "take these pills. If they haven't worked, come back and see me". So I wasn't quite on Christmas card terms with the GP, but, you know, I was around there every month or so. Anyway, I had to stop working et cetera. And for me, movement was more pain. So I stopped moving. I was sent to the physiotherapist, but back then I don't think that they was quite well up to speed with managing pain or back pain and I was given exercises to do and which say do 10 of these, 10 of these, 15 of those and, and as you know yourself, when you've got subacute pain, as I did, then, I've got up to five or six repetitions and the pain went up so much I thought this can't be right. So, to me, I learned that, back then the exercise equalled more pain. So I just stopped moving.

Helen: So I'm hearing you got lots of back pain. You did what most people would do, which is go and see your GP and you got prescribed medicines. And you said, medical models. So it's very much, you go and see somebody and they're going to prescribe some treatment and you expect to get better. But what you're telling me is that the medicines, the physiotherapy actually ended up probably not helping very much. And actually you were still struggling with the pain. And you also said that you were really scared as well.

Pete: I guess I couldn't see any future for myself really and I was getting depressed and I just, I had no plan, you know, that was it and at the time I was only I think in my mid-forties, something like that back then. And I thought what's my future? I couldn't see any future for myself, and I went through a pretty, pretty sticky time really, you know. People that used to call and say how you doing, or they would pop around, but it was the same old story and then even people stopped ringing me, stopped calling me because all I could talk about was my back pain really. And they probably got their own problems to deal with, you know? And I did look around for seeing people privately, you know, the osteopaths and chiropractors and all them sort of guys and, and all in all I spent, I did actually spend all my savings really and, I was a doctor shopper, I was a therapy shopper and looking for something to fix me, and little was I to know that I had to learn how to fix myself.

Helen: So I'm hearing it was having a huge impact on every area of your life. It changed, you know, sort of whether you could go to work. It was changing whether you could see your friends. It was changing how you felt about yourself and your mood went down. You felt angry, anxious, all of those things. So tell me how you started to change how you approach trying to manage this, and moved away from, what did you say? Being a therapy shopper?

Pete: Yeah, therapy shopper, doctor shopper, serial shopper, serial health care. I was just looking for someone to fix me because as a child, you know, you don't feel well. So you go to the doctors, the doctor gives you something or do something. And then after 10 days or so you feel better, and you get on with your life. But, when it comes to long term, this back pain, it wasn't. I had a couple of turning points, really. One was, I thought, well, I'm not getting anywhere with the healthcare professionals. So, I always remember a little saying I learned years ago that, if you want to learn something to teach it, and I thought, I need to be around people like me, you know? So, I started up a back pain support group and I was quite surprised. I was contacted a local newspaper and said I'm starting this up, can you publicise it for me? And, I was quite surprised, the hall I booked, it was only, I think it's supposed to hold about 20 people, but I think it was over 50 people showed up, like, you know.

They was all like me, you know, struggling, looking for answers and that's the thing we wasn't, none of us were getting answers. Anyway, someone told me about a woman in Norwich or Norfolk who'd been on a pain management program in London called Input and it really worked wonders with her. And so I contacted them asking if someone can come along to speak to the group about what they did, et cetera. Well that was, that was the turning point and a really nice lady called Amanda Williams. She was a clinical, she is a clinical psychologist. And she'd come along and spoke to the group about, you know, learning how to pace the activities, about graded activities, moving will actually help your pain, et cetera. Really positive, information. I thought this is, this is right up my street. This is for me. And so I applied to go on the course and sadly it was the NHS so I had to wait till, 96, but in between that time, I was really getting depressed as well. And, on the, I always remember the date as it's my birthday, 31st December 94. I got so down with my pain, I had some friends wanted to come and take me out for the night, being New Year's Eve and my birthday and stuff like that. And that day I had my full quota of medication. I said, I just can't go out like, you have to go on your own. And that night I did actually consider ending my life really, because I just couldn't see any future for myself, you know. I think the only thing that kept me going really was knowing that I was on a waiting list to go to the Input program. And the program gave me the, not only the tools and the skills, but it gave me the confidence to manage my pain myself.

Helen: So, what you were saying there, Pete, about reaching a point where really you almost lost hope. Even though you'd done everything you could and you'd started a support group even, and found other people with similar experiences, you were trying everything you could, and then you did find something that you've described as a turning point for you, but you still had to wait a long time for that. I mean, I'm very pleased that you're still with us and I'm particularly pleased that you've got this opportunity to tell our listeners about, you know, how you did reach that turning point and how it helped you. So please do tell us what happened when you went to the Input pain management program.

Pete: Well, it was an inpatient program. So, it was spread over two weeks I think the very, the first day, it was the best day for me because, Charles Pyler, who was the medical director at a time, he went around all the people in the group. There was 18 of us there, I think. And, and we were split into two groups of nine and, but he went around to everybody in the group asking them how long they'd lived with pain.

And I think for memory, it was nearly 400 years. You know, of the 18 people. But he said, he said something really profound and it still sticks with me. He said, "we believe your pain", because when you live with pain and you're seeing endless people and nothing seems to be working. You start thinking that people are not believing you, you know, that, perhaps you're imagining it and things like that. And, we're malingerers and stuff like that. When he, when Charles Pylor said that, I thought, yeah, I'm, I'm home finally, you know, I feel this is my place where I'm going to be my place of learning. And I embraced it because to me that was the last chance saloon. And it was all different there, so when we was given exercises to do, it wasn't, you know, do ten of these, do ten of these, you know, like the old days. It was like do this and then, cut it back by, you know, say, for example, you did, you know, get sitting up from a chair, you could do six, cut it back, you know, just do three, then add on one each day sort of thing like, you know, it was proper graded exercises.

So not only was the, with the, doing the exercises and stretching and stuff like that, but the other important thing I learned was about pacing. Now, to me, you know, we've all, everybody knows the term pacing, where you just pace yourself, you'll be alright. But what is pacing? That's the, that was the question, you know, we were asked, well what is pacing? And what I learned was pacing is taking a break before you think you need to. Because see what, what us people with pain or even, even long-term conditions, what we do is we use our pain or our symptoms as a guide. So let's say for example, you're walking, etc. And then when you, uh, when the pain starts or increases, you're thinking, oh, I better take a break now. And what I learned that, that wasn't pain management, that was the pain managing me. And through learning pacing or taking a break before I thought I needed to, actually allows me to actually do more throughout the day without increasing my pain or my symptoms. And I'm still doing it now, I'm still pacing myself. So that I, allows me to do, you know, do what I do, et cetera, and enjoy life.

Helen: Thank you Pete. So what I've just heard there is there was something really important about being believed, you know, that that was how you were greeted is that actually, yes, we believe your experience of pain. We believe you. And we don't think that you're making it up or exaggerating. We know that if you say it hurts, it hurts. We believe you. But there's also something really important about getting more active, managing how much activity and rest that you do, doing a bit less than you thought you could do actually overall helped you to do more in the end.

And there's something important about having other like-minded people around you, people with similar experiences. And while inpatient pain management programs, there still are some, there's also outpatient primary care pain management group settings now which weren't available in the nineties when this was your experience, but the principles are still very much the same about learning to get the balance right and, learning to live well with the pain rather than trying to make it go away, which hasn't worked generally.

Pete: As I said, back in the day, it was like, movement meant more pain. But what I learned through, you know- 'cause the thing is, once you leave the program, you've got to keep your exercises going and stuff like that. And that can be difficult as well as I found out. Whereas back then exercise was not my enemy, but not my best friend either. But little was I to know that keeping stretching and exercising and moving, et cetera, is my best buddy. I'm pleased to say that since about a year after the program, I think it was, it was 97, that was the last time I took any pain medication. So for me, I still do me stretching. I'll do me some yoga in the morning and then I'll go down the gym and then do some more strength and exercises and stuff like that. And, to me, doing exercises and stretching and whatnot, yoga, tai chi, that to me is the equivalent of taking meds you know, but without the side effects, of all the pain meds and whatnot. I think the most important thing of what I learned, what I have learned over the years was that the skills and the tools that I learned on the input program or the pain management program have been transferable. So when I hit 50, I started getting arthritis in my joints and my hands, knees and whatnot. So again, using the skills and tools from the Input program and, and in recent years when I was diagnosed with prostate cancer, again, I'm still able to dip into that knowledge fountain of self-management. Well, what can I do to help myself like, and, you know, even with the oncologist, like, you know, when I'm talking to them and I'm saying well, at least this is what I'm doing, they seem a bit shocked like, you know. But it's only because of what I learned back in 96 that their life skills that have been transferable for me over the years and as I've become an older person now. I'm 70 years old.

Helen: Well, congratulations, Pete.

Pete: It's a miracle, you know. I've got a 70 year old body, but you know, my brain's still ticking over in my thirties, like, you know.

Helen: Absolutely. And, and I think, what I'm hearing though, Pete, is that actually you're, you're doing better physically at the age of 70 than you were in your mid-forties when all this started to happen to you. And you've gone from, you know, really finding it difficult to move, being in a lot of pain, taking all the pain relief you could to learning how to stay active, do your exercises and lots of different types of exercise. And that it applies to any kind of long term pain. It's not just back pain. This, this applies to any kind of long-term pain and you've kept doing it over the years. So, so you've mentioned yoga and Tai Chi and going down the gym. Tell us what you do down the gym.

Pete: I was always a lot of what I call a gymophobic, really. My partner at the time Kim, she was a yoga teacher and she would encourage me to go to the gym like and I just thought all the good looking dudes go down there, like all that, you know, ones with big, big guns and lycra and whatnot. And, you know, for people that don't see me, I'm no Chippendale like, you know. But the thing is, I got into the gym and although I was exercising at home, but now I found out when I started going to the gym, the pain levels dropped off even more. I thought, whoa. And to me it was, meeting other dudes as well, meeting other people. And, for me, I go down the gym and I'm only a little bit of a routine. It's not a bonkers routine, but I go down there at six o'clock in the morning. I'm a bit of an early bird, but I do me yoga about 20 minutes, 30 minutes of yoga before go down there. Then, I'll do some weights, because of the treatment I'm having from, the cancer. I've got to strengthen my bones because it's a hormone treatment I'm having. So, I'm prone to osteoporosis, I think, I think it's called. So I have to strengthen my muscles. And, but then I'll go, there's like a bit of another level there, so I'm out of the way of people, but I'll go up there and I'll do again it's a bit more stretching, but I mainly do all my Tai Chi up there. They all laugh at me, because of all the weird movements I do, but I don't care, you know, I'm enjoying myself, and, you know, for people that, Oh, Tai Chi, I do come out there perspiring, like, you know, it can be a workout itself, but for me it helps me with a breathing. I've always had asthma as a child since I was a kid, so it helps me with a breathing, but relaxation. And every time I come away from the gym, you know what, I'm really, I'm really a chilled out dude. I really feel great. It's great, you know, great for my head. And it's funny enough, I, I ask people, so when I see a newbie down at the gym, I, I have a little chat and I say, why'd you come to the gym? And even the young dudes like, I'm quite surprised they say, I come here from my head and, how it's, how exercising helps their mental, health, et cetera.

The other thing I do as well, I'm lucky where I live, it's quite a nice area, so I'll go out for walks and stuff like that. I call them pacing walks, so, you know, I'm not walking for miles and miles and then, but for me, it's a nice way of relaxing as well.

Helen: Again, what I'm hearing there Pete is about the importance of getting the activity right and the range of activity between doing the yoga and stretching, Tai Chi. I should perhaps share that I also do Tai Chi, which helps me with my balance and helps with my joint pain as well. But you also do the strength training, you're looking after your bones and your muscles, with those exercises as well. And I was really curious to hear what you're saying that over the years, the way you think about it has changed an awful lot as well. how you think about what the pain means and what you do about it is different from what it was all those years ago before you encountered the Input program. And did the program actually do anything specific about thinking, or is that something that's happened over the years with experience?

Pete: I suppose there was a lot of things going on, because pain does mix up your thinking. Your medication is changing your thinking, you know, especially on the, the strong stuff like the strong opioids and whatnot. So you get fuzzy thinking and so, if you're lucky enough to get on a pain management program or, you know, being outpatient or an inpatient, when you get to those sort of places, you are one mixed up person cause there's so much going on. Your thinking is all over shop, you know. So those two weeks went like a rocket anyway, but it's the keeping up when you go. I was lucky enough that I went back to the back pain support group that I was running at the time. And, I know, I know then, that I, that was how I started getting into doing other things like, putting a mini pain management program together.

But for me, it's, I think for a lot of people, when I was talking to Paul, I don't know if you know, Paul Watson used to be, like a physiotherapist, I think up at Leicester and he was, he was in the area a few weeks ago and he's a bell ringer now, amongst other things, and I was chatting with him and we were talking about this, about when people leave the program and he said before people leave the program, they have to have a sense of purpose. And that really struck a chord with me, really, because I don't think people, it's like, well, you've done the course, off you go sort of thing, yeah, and what is their purpose?

What is their, what are they going back to? And that's the importance of setting goals and action plans and stuff like that. So I was lucky I went back to the support group and so I was keeping myself busy in that way. That was my purpose. But I think a lot of people drop back into the old ways of, you know, they're thinking because they've had that, that, that period of time, whether it's, over spread over two weeks, three weeks or whatever, or longer, but what happens after that? I think that's where people can fall back into their old ways and I think if you're a healthcare professional listening to this, it's about before, before people leave you, it's about, they have to ask, well, what is their short, medium goals, long term goals. What is our purpose? What are we going to be doing for the rest of our life sort of thing, you know, obviously a day at a time.

Helen: So one of the key messages we want our listeners to take away with them from hearing what you're saying is what do you want in the long term? What, what are your goals and what's the plan that's going to help you meet those goals? And I know that, people who work. you know, sort of with people in a similar situation may well be used to doing a thing called a relapse prevention plan or a long-term wellness and recovery plan or something like that. And you've told us about, you keep your activity levels up, you pace yourself, you do have a sense of purpose. You've got things that are meaningful, that matter to you in your life. And that's really important. So there's something about having that, you know, what's important to you and being clear about what you're going to do. So, what would you say to people, because I mean, however well you manage it, there's going to be bad days, aren't there? There's going to be, you know, you'll get a flare up or, or a severe increase at some point, however well you do. What would you say about that?

Pete: Well, setbacks are normal. It's as simple as that. we're overdoers, you know, people with pain, in fact, people with long term conditions, we're overdoers. Hey, listen, we want to keep up with everybody else like, you know. And we don't want to stand out from the crowd and, and so what it tends to do, we, we overdo things, we overextend ourselves and the chances are that, it's going to increase our pain or our symptoms, et cetera. So it's important to have a setback plan. Think of it, think of your setback plan like a spare tire on a car. So you're in your car, you get a puncture, if you can change the wheel yourself you do it, if you can't, you wait for the breakdown. But the thing is then you put your spare, spare tire on, spare wheel, and off you go, carry on with your journey. And it's the same thing with us lot, you know, we need it. We need a setback plan because we're overdoers. I'm still an overdoer. I have to police myself that way. I'm not overcooking myself. I can get carried away, especially when I'm working in the garden, etc. So, it's when we do, when we do have a setback, pain increases, it's like, well, what's our plan? You know, so, so I can get back in the driving seat as soon as possible.

Helen: Okay. So, so setback planning is about. Yeah, you might need to slow down. You might need to take a step back a bit, but you don't stop. You don't go back to square one and you get back on to your plan, you know, sort of after a short space of time where you perhaps had to rein it in a little bit. But you still get on with your plan. You still move towards your goals.

Pete: Yeah I'll always suggest to people that they just cut everything down by half and then gradually like pace it up again, carry on keeping active, do you still do as you're stretching, think about how you're stretching, say, so if you're holding a stretch you got used to you holding stretch for 10 seconds, perhaps just hold it for five seconds.

I always think chop everything in half like, you know, it's like pacing, you know, like. People say to me, well, you know, taking a break before you think you need to, well, when's, well, when's that? When you set a baseline, let's say you can walk 100 metres and then the pain starts, well take a break at 50. Chop everything in half because everybody knows what half of something is. That's the same thing with a setback plan. Just chop out all your activities that came down by half and then slowly increase it. At a pace that suits you. Take your time because at the end of the day, we don't want to lose our confidence again, because, you know, people in pain, we, where we were can do people end up being can't do people. So it's about keep being a can do person, but do it in a pain self-management way.

Helen: Thank you, Pete. So being a can-do person, Pete, you put together the pain toolkit. So tell us about that. How did that come about and what's involved in it?

Pete: Well the Pain Toolkit had come around just by, just pure chance really. After I'd come off the pain management program, I thought there wasn't anything in my area. So I thought, well, okay, well I'll do one myself then. So I put together a six-week course for the people in the support group.

In fact, it was lucky really, because by then I bumped into another lady called Maggie Hayward. She'd been on a pain management program in Surrey, I think, a few years earlier. And, she was, like me, she was so impressed with it and she put together a video for all the pain, all the stretches and exercises from a pain management program. So the, the program that we put together was called Fighting Back, and we used the stretching and exercises from the video so the people bought the video and they could do those at home, but the physio that we hired showed them, made sure they were doing it the correct way, et cetera.

So, after that, the, I don't know word got around really. Someone had contacted me about some, a German company wanted, I think it was a, it was a, a pharma company and they, they wanted to hear from a patient apparently. None of these managers had ever heard from a pain patient. So I went, they invited me over to Germany to, to do a talk which I did to their managers. I don't think they were that interested, but I, I was wild, you know, I mean, I've never been out of the country sort of thing, with back pain, et cetera, you know, so it was a bit of adventure and a bit of apprehension as well.

But then someone else in, in the company had heard about my trip there and, they were putting together like a website for healthcare professionals to learn about pain management. They asked me to write a module for it called managing pain from the patient's perspective, and so I put together, I wrote this module about managing paint, but while I was writing it, remember I was a painter and decorator, so what tools did I need to be a painter and decorator, and I thought people who paint, we need some tools as well, you know. So I started writing together, put together some tools, I think there was about, initially there was eight, and then I was showing it to healthcare professionals I knew and stuff, and they said we need to include this, that, and the other, and what not, and then all of a sudden The Pain Toolkit come around and by then I'd started working in the NHS on something called the Expert Patients Program. I was a trainer and I was at a meeting in Cambridge, and there was a lady there called Angela Hawley. She was in charge of long-term conditions at the Department of Health. And I just took, took a chance on her. So I went up to her at the end, I said, she was doing a talk there about long term conditions. And I just said, oh, hello, you don't know me, but I'm Pete and I've written this. She said, oh, yeah, I've seen, I've heard about this. This is really great. Where can I get some copies from? I said, I can't afford to print it. And, she said, I would do that for you. So I said, how many do you need? I said, oh, 5, 000. That'll probably keep you going for a year. She said, okay. Anyway, it went so bananas like that in the first year, a hundred thousand copies had been sent out. Healthcare professionals were using it with their patients like as a guide and to get them started in self-management.

And I think the second year they printed off another 100, 000 and I think the last year was about 40k or something like that. So I was just, you know, one of these things in the right place at the right time. Then I got invited back to Germany again, because this, a guy called Reinhard Sitzel, he'd heard about me and he'd heard about The Pain Toolkit, and he was interested in hearing more about it, so I went back to Germany and had a chat with him, and it turns out we were really good buddies, and he got his daughter to translate into German, he then sent it off to his buddy in Switzerland, so to get it printed off. But as you know, in Switzerland, they just can't print things off in German. It had to go into, French and Italian. So now there's a German, English, da, da, da, you know, and then anyway, long story, short, over the years that company has been, it's all been translated into different languages, Spanish, Norwegian, Russian, Portuguese. I can't remember all of them. I think even the Aussies, the Australians, they did a couple of versions, a Chinese version and a Greek version like, you know, so it's just, it just went a bit wild really like.

But it's just a very simple booklet to help people get, get off the start line really, and the healthcare professionals like using it because it's like a little mini, like a mini workbook, so they give them the booklet to have a read through, then circle two or three of the tools you want help with right now and that's what they do. And then, so, see the patient's doing something, they've got to do something. So, they've read it, they've circled things off, they take it back to their healthcare worker, and then they work through it so when they feel confident with those two or three tools, they then choose another two or three.

I mean, it's not rocket science. It's just easy peasy lemon squeezy as I call it, you know.

Helen: Sounds amazing, Pete. It really does sound amazing that you've put together some practical tips for living well with pain, and now it's, it's gone well, global really if it's in Australia and all over Europe and everything. And you said that people circle the tools that they want to use. Can you give us a couple of examples of what the tools are?

Pete: You know, I'll tell you what I'll go through them with you if you like if that would be useful?

So Tool One is accept that you've got persistent pain and begin to move on. I think that's a, that's a tough one for a lot of people because, you know, to think that. that you accept that pain is going to be with you. I look at pain as being a bit of an unwanted passenger in your life, you know. And it's about accepting the fact that, as I had to accept it, that pain was going to be with me for a long period of time. As it's turned out, it'll probably be with me until towards the end of my life, but it's acceptance that, is going to be with you for so long, but it's not going to be…You see, I'm back in the driving seat, it'll be around with me, but it's not in charge anymore, you know, I'm the boss like, and I've got on with my life. So, but for a lot of people acceptance can be a tough one. So that's tool one.

Tool Two is about getting involved, building a support team. Now I've got to be honest with you, I've not actually met anyone yet who's actually been where most people are struggling with persistent pain and they sort it out on their own. We need that team and it's like I always think, think of yourself like a bit like a football coach. You choose people who you want in your team to get so that you can be a winning side, et cetera, you know?

So, and the same thing as well, back then, you know, I had to think about who do I want in my team? I needed someone on my side, so it needed a selection. Perhaps I need a few healthcare professionals that I could go to, obviously supportive input. I needed people, people around me as well, like friends and family, et cetera, to be there to support, so it's about, getting involved in the building, building a support team.

Tool three is about pacing. I always say to people, if you don't remember anything else about any of my presentations, remember about pacing because pacing allows you to do more throughout the day but without increasing your pain or your symptoms.

Tool four is about learning to prioritise and plan out your days because we're all over the shop. You know, we're very erratic, because you've got your medications going on. Doing all your thinking, perhaps you're being pulled in different directions back with family and work commitments and stuff like that. But if you learn to plan and prioritise what actually needs to be done, because again, see, we want to try and keep up with everybody else, but we need to have a little bit of a list. Now, tomorrow, I always say to people make your list the night before and then prioritise it. Well, what can I do and then pace it out throughout the day.

Tool five, setting goals and action plans. As I always say to people, if you don't know where you're going, it's unlikely you're going to get there. So, to me, setting goals and action plans is so important because you can look back and learn from what's gone on in the past, but now we're moving forward. I know I always say to people to get them in the hang of setting goals and action plans is, set yourself some fun goals just get you going like, so it could be that you meet a buddy for a coffee or go do something nice, you know, perhaps go to the seaside or something like that. So set your goal, but think about how are you going to achieve that goal like, you know, and when I'm teaching like, there's a little process I'll go through. It's a bit too long to go through it now. But it's a nice little process, about setting goals and action plans. But just keep it simple really. But have fun as well. You know, that's the main thing about self-managing pain is we need to put the F U N in it. Fun, have fun as well. Like, you know, I always call it buy yourself an ice cream from time to time.

Tool six is about being patient with yourself because we want to get there and we're in a hurry, you know, because we get a few winters under our belt and we get a bit frustrated, but we've got to be patient learning how to manage pain. You know, it took me a year to get off the meds like, you know, Dave, who I work with now, he's another self-manager, it took him the best part of two or three years to come off the meds like, you know, But we have to be patient with ourselves but sometimes we can be in too much of a hurry.

Tool seven is about learning relaxation skills I learnt back in the Input Program A relaxed muscle feels less pain than a tight one or a tense one. So, you know, if I've got to do any journeys now, I do a little, learn to do a little bit of meditation. I learned it from, that's what I learned off of, YouTube, really, of this, Tibetan monk. Because my brain's always ticking over, thoughts coming in, going out, going up and down. You know, I'm all over the shop sometimes. But, yeah, I learned from this little Tibetan monk about meditation, which is concentrating on breathing. You know, just breathing in, breathing out. And he said, that's meditation. I thought, mate, I can do that.

Tool Eight is about stretching, exercising. Again, the, the physios nowadays, they call it meaningful movement. The reason why they call it meaningful movement because when you say to someone, you need to learn such an exercise, if they like doing it and they choose to do it, they're more likely to keep it up.

Number nine, keep a track of your progress. That's not about a pain diary in such to where you're tracking how much pain you are in during that day because it's not for that's not really helpful, but it's about keeping a diary, it's sometimes just keep a track. I did actually put together something called, how am I today? It's like a little bit a like a report card for themselves. Like, you know, they can say, well, how am I doing? You know, am I doing a stretching? They can show it to their health care worker if they need it. Well, yeah, look, they look like you're struggling there, so perhaps we can work on that a little bit so tracking your process is important.

Tool 10, we talked about it already, have a step back plan.

Tool 11, going back to teamwork. But teamwork is so paramount it's why I've mentioned it twice in the twelve.

And the last one there is keeping it up and putting it into practice really. And the thing is, I've added in recent copies of The Pain Toolkit. I've actually had to learn about being resilient. We have to be resilient, we need to, uh, not toughen up, but we're on a long old journey here, like, and we need to think about it.

Helen: Absolutely. So if you were going to say one key message to people out there, maybe they're living with long term pain themselves, or they care about somebody who lives with long term pain, what would you say one key thing to those people out there?

Pete: Keep it simple.

Simple as that. Get some help, get some support. Yeah. So healthcare professionals, all healthcare professionals are taught something called a medical model. Okay. And sometimes they forget that we haven't, we wasn't sitting beside them in medical school. And, you know, they just overcomplicate things. It's nothing personal. Yeah. It's only observation. I watch them on social media. I think to myself, boy, mate, you know, why are you complicating this? Because when you breaks down pain management, self-management, it ain't got your science and, you know, when I was on the Input Program, and they were talking about the pacing, about taking a break before you think you need to, and I'm sitting here always saying to myself, well, that's common sense in it, but I wasn't doing it, you know, common sense to take a, take a rain check with all of us, you know?

Helen: That's a great key message, Pete. So really that message is for the healthcare professionals as well, who are supporting people, hopefully to self-manage their pain and moving away from a, a kind of medical approach, but particularly for the people who live with pain long term, simple, practical skills for managing that and planning ahead to manage it in the long term, actually ends up with you having fun, more quality of life than trying to fight it and use things that don't work. And, I mean, I'm, you know, you know, that I, I work in this area myself. And so, part of my work is doing exactly what you're talking about is helping people to manage living well with their pain and building that confidence and quality of life, despite having that ongoing pain. And with the Pain Toolkit and the other things that you've mentioned, we'll put links onto our show page so that people can follow that up and find out more if they'd like to. But at this point, I would like to say, thank you so much for talking to us here, Pete, it's been great to have this conversation with you, and to hear about how you've come from being really managed by the pain and overwhelmed by it to living such a good quality of life and helping other people to do that as well. Thank you.

Pete: Well, thank you. Thanks for inviting me on to do this podcast.

Helen: Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at [email protected], that's [email protected]. You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested.

If you've enjoyed listening to this podcast, you might find our sister podcasts Let's talk about CBT- Practice Matters and Let's Talk about CBT- Research Matters well worth a listen.

In this episode of Let's Talk About CBT, host Helen Macdonald speaks with Sarah, Sally, and Leanne about Sarah's experience of having Cognitive Behavioural Therapy (CBT) after giving birth. They explore how CBT helped Sarah regain control during a challenging postnatal period, addressing struggles such as insomnia, anxiety, and adjusting to new motherhood.

Sarah shares her journey of balancing therapy with the therapeutic benefits of movement and time spent in nature. CBT therapists Sally and Leanne discuss the powerful combination of therapy, physical activity, and connecting with nature for improving mental health.

Useful links:

NHS Choices- Insomnia-https://www.nhs.uk/conditions/insomnia/

NHS Guidance on feeling depressed after childbirth: https://www.nhs.uk/conditions/baby/support-and-services/feeling-depressed-after-childbirth/

MIND information on how nature can help mental health: https://www.mind.org.uk/information-support/tips-for-everyday-living/nature-and-mental-health/how-nature-benefits-mental-health/

For more on CBT the BABCP website is www.babcp.com

Accredited therapists can be found at www.cbtregisteruk.com

Listen to more episodes from Let's Talk About CBT here.

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This episode was produced and edited by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen MacDonald, your host. I'm the senior clinical advisor for the British Association for Behavioural and Cognitive Psychotherapies

Today I'm very pleased to have Sarah, Sally and Leanne here to talk with me about having CBT, in Sarah's case, when you've recently had a baby and also the value of getting more active and getting outside into nature and how that can help when you're also having CBT. Sarah, would you like to introduce yourself, please?

Sarah: Hi, I'm Sarah. I'm, 37 from Sheffield and like I said, just recently had a baby, and she's absolutely wonderful. She is a happy, loud little bundle of joy. I ended up having CBT though, because the experience of having the baby wasn't what I thought it was going to be, I think is the reason. And I, just went a little bit mad, so I got some help. Yeah, I'm normally a very happy, positive, active person. Lots of friends, very sociable, always like to be doing things, always like to be in control and have a plan. I like to know what I'm doing and what everyone else is doing. And all that changed a little bit and I didn't really know what to do about it. So yeah, got some therapy.

Helen: Thank you Sarah. So, we'll talk with you a bit more about what that was like. And first, Sally, would you like to just briefly say who you are?

Sally: Yeah, so I'm, my name's Sally. I am a Cognitive Behavioural Therapist, working both in the NHS and in, in private practice at the moment.

Helen: Thank you. And Leanne,

Leanne: Hi, I'm Leanne. and I'm a cognitive behavioural therapist as well. And I also work in the NHS and in private practice with Sally.

Helen: Thank you all very much. What we're going to do is ask Sarah to tell us a bit more about, when you use the term mad, perhaps I could ask you to say a little bit more about what was happening for you that made you look for some therapy.

Sarah: Wel the short answer to that is I developed insomnia about 12 weeks postnatally, didn't sleep for five days. Baby was sleeping better than most, you know, so it was equally frustrating because there was no real reason I didn't think that I should be awake. And sleep obviously is very important when you've had a baby. As I said, I like to be in control, like to prepare, like to know what's going on. So I did hypnobirthing, I prepared, I planned, I packed the biggest suitcase for this birth of this baby that I was really excited for and I thought I'd prepared mentally for every eventuality- what kind of birth, what would happen afterwards, but all very physical because they're the sorts of things that I could understand and imagine. And basically I ended up having an emergency C section, which in the moment I was fine with and I didn't think I was bothered by it, but the level of pain afterwards, that then again affected my level of control over looking after the baby. And the level of debilitation it created that I wasn't expecting- this is the key thing, I wasn't expecting it. That meant that I wasn't able to be me, really. I wasn't able to not least look after a baby, but get myself dressed, get myself showered, walk to the shop, drive a car, play netball, walk my dog. And I wasn't able to do any of that. I didn't appreciate that I was struggling with that, with accepting that. And because it went on for so long, and of course with this comes the baby blues that everyone talks about, but that's meant to only last apparently a couple of weeks. I, you know, you kind of just think, oh, well, I feel all this. I feel pain. I feel sad. I can't stop crying. But all that's meant to happen, all that's normal and it's sort of became the norm. So I was like, well, this is normal. This is how I'm going to feel forever.

At this point I didn't have insomnia. I just could not stop crying. And I mean, like I couldn't, I didn't talk to anyone for two days at one point, because I knew if I opened my mouth to say anything, I would start crying. Like literally anything, I would just start crying. What the clincher for me was when I spoke to a doctor, I thought they were going to say get out and about, do some therapy, which at the time, I'm going to be honest, I thought, I can't sleep. I need a fix now. What I now know is I was doing a lot of behaviours that over time culminated in my body going, you're not listening to me, you're not well. Right I need to do something physical so that you wake up and do something about it. And that was the insomnia. So, I went to the doctor fully expecting them to say, do some mindfulness, do this, do that. And at that point I was just, you need to fix this now. I need to sleep. I need drugs. And yes, that's what they gave me, but they did say you need to do CBT- but what they did say what the first thing the doctor said was, you need antidepressants. Now, as a nurse working in GP surgery for them to jump all the self-help stuff and go take these tablets was like, Oh, right. I'm not okay. and it gave me that like allowance to say, I need to take tablets. But I already had said to myself, but I want to do not just mindfulness and helpfulness for myself. I want to do structured CBT because that way it is something I'm doing to give me back my control and I've got a plan.

And because I already knew CBT was wonderful. Yeah, I didn't really understand what it was, how it worked, the structure of it. And I get that there's different types for different problems. but I knew that's what I wanted to do, once I had tablets to help me sleep and knew the antidepressants were going to work eventually, which did take a while. I was at least doing something myself that would help me forever. And I just thought, what have I got to lose? I need to do something. And until I started CBT, basically, I just felt like I was running around in circles in the dark. And the CBT gave me control and focus and, right, this is what we're doing going that way. Because until I started CBT, you know, I was Googling everything. Right, I'll try this. Right, I'll try that. And because it didn't work within 24 hours, I'd then try something else and try something else. Now it was making it worse, obviously. So, to have the CBT and have my therapist say, do this one thing for a whole week. I was like, all right, okay. That's quite a long time, but there's obviously a reason.

Helen: Sarah, thank you for telling us all about that. What I'm hearing is that you had a combination of massive changes in your life, which will happen when you've had a baby, all sorts of things about the kind of person that you are, kind of added to all your really careful and sensible preparations for having this baby and then really being taken by surprise almost by all the other impact that it had on you and taking a while really to look for help and to look for a very specific kind of help then. And I'm just wondering in the context of all that, what it was like when you first went to see Sally for therapy?

Sarah: Well, like I say, it was brilliant. It was like having someone turn the lights on and point me in the right direction and say, right, head that way and don't turn off and don't go any other direction. Just keep going that way. And it will eventually result in this. It's like if you go to the gym and you're running on the treadmill and you're thinking, well, is this going to achieve what I want it to achieve? And until it does start to, you've not got that positive reinforcement, to keep going. So quite often you stop, and that's what I was doing. I was trying one thing, trying the next, because I was so desperate for it to just go away, this insomnia. Which obviously at the time was one thing, but I understand now there was a whole other problem going on but the insomnia was what I needed fixing. I found CBT for insomnia, but Sally said, do you want to do a more generic anxiety control type approach and I said, yeah, because that's what if before this, you know, five, six years ago, little things would happen.

And I think, Oh, I should do CBT for that. So it's clearly the same thing. So yeah. Why don't we just tackle it as a whole? And that was definitely the best thing to do.

Helen: It sounds as if one of the things that was really helpful was looking at the bigger picture, as well as focusing on taking enough time to make changes. Okay. Can you tell us about the specific things that you did in therapy that you saw as particularly helpful.

Sarah: Yeah. Like you say, what was helpful was being given a timeline really, and a direction. Like I say, when you go to the gym, you're not sure if it's going to work, I had to just trust Sally that what was she was explaining to me was going to work. And of course, at the time I couldn't see how it was going to work, but at least someone I trusted was telling me it will this, just do this?

What was most helpful I could say was being told you've got to do the homework yourself. There's no point in being just told stuff. It was explained to me. And then what was helpful was then being told, go away and do this one thing for a whole week and then we'll review.

So it really just broke down my thoughts, behaviours, my thought processes that I was going at such a hundred miles an hour that I wasn't giving, even giving myself time to think or realise I was having, and essentially that's what CBT is, you know, making you stop, think and unpick your thoughts and your behaviours and then trying to change them accordingly. So yeah, that the homework was helpful. And then obviously reviewing that homework, which with, before I even got to the review, a week later, I was able to physically feel and see why I was being asked to do what I was being asked to do.

Helen: And I'm just thinking the analogy that you used there about being in the gym that you wouldn't necessarily expect to be super fit or running five miles the first time you got on the treadmill, but there was something that was tending to make you, you use the word desperate really to make a difference immediately. Because things needed to change. And during the therapy, was there anything that you found particularly challenging or something that either you and Sally talked about it, but you really didn't want to try it?

Sarah: Well, as the weeks moved on, obviously the challenges that the homework got harder because it asked you to delve further in and make the changes of what you've, you know, you've realized just to give an idea, essentially the first week, I was asked to literally rate my happiness per hour as to what I was doing. Sounds simple. It is simple, but very quickly I realised, well, this doesn't make me as happy. So why am I doing it? And then of course you stop doing it because you know, it doesn't make you happy. And then over time, there's less time that you're unhappy. The second week, it was a bit more detail, rate how anxious certain things make you., So that was all fine. But once it got to the weeks where it was highlight the things that you've found out make you anxious, now do them or don't do them. Or, you know, if there's something you're doing to make yourself feel better, but actually you've realised it doesn't really work, it actually has a negative effect later on, don't do it. And if there's something that you're avoiding, but you know probably will make you feel better- do it. So that's obviously that's the scary bit because you've literally facing the spider, if that's what your problem is. but again, like every other stage during the CBT, I found it really easy. The main thing was I trusted Sally and also had nothing to lose.

One of the things, the behaviours that we realized I was doing was seeking reassurance from people on hypothetical worries. So you Google, you ask your experienced mums, why is my baby this colour or not sleeping or eating or the poo looks like this? They can't answer that. And you're wanting them to reply, Oh, it's this. And of course they can't. So, or I'd say to my husband, am I going to sleep tonight? He doesn't know that. And by doing that, I would reinforce the anxiety. But yeah, that was an example of something I stopped myself doing. And within days I realized, Oh, there was that thing that normally I would have asked about or Googled. I didn't. And actually nothing bad happened and I forgot all about it.

Cause that was the worry was that it all comes back to sleep. If I didn't ask, would I then lie awake at night worrying I don't know what the answer is, but I didn't. So yeah, the hardest bit was actually stopping certain behaviours or starting certain behaviours. But actually I found it very easy once I had done because the positive reinforcement was there, you know, it worked.

Helen: Thank you, Sarah. And, in a couple of minutes, I'm going to bring Sally into the conversation to talk about her reflections on what you've just been saying. Overall though, what are the things that you're still using now from what happened in therapy? What are the things that you learned and how are things now compared with when you first went to see Sally.

Sarah: Well, things are great. I'm on antidepressants still. I'm going to see the doctor soon. Cause they want you to be on those for six months before you even think about coming off them. I feel myself now, so I feel confident to do that. Um, and because I'm healed, I'm back to being myself physically. I play netball, I walk the dog. I mean, I walked for four hours yesterday because of dog walking and pushing the pram around and played netball as well. So that helps, you know, being out and about physically, being in nature where I would normally be definitely helps my mood. The CBT a hundred percent has helped because there's been change again with the baby. So we've gone from breastfeeding to weaning, sleep changes, cause it's all about sleep, putting her in her own room, thinking when she's going to wake up, is she okay? Am I going to get back to sleep? Is there any point in me going to sleep? Cause she can be awake in this many hours. You know, that's a whole new challenge that I've had to deal with and there's been times that I've stopped and thought, Ooh. There's a thing I'm doing here and it's a behaviour that we recognised was what I was doing originally, which when I did it too much caused the problem. So, I've been able to really be more self-aware, basically, checking with myself and go, stop that. You don't need to do that. Everything will be fine. And guess what it is.

Helen: Well, that's really good to hear. And what I'm also hearing is that it's not just that therapy helped, is that you're still using the techniques that you learn in the therapy.

Sarah: I am. And also, I meant to say. This might not be the same for everybody, but it's quite important for myself because I'm not at work at the moment, you know, I'm a nurse. I've lost a sense of not purpose, but people come to me every day at work asking for help and support and advice. And I love to be able to do that and hear them say that's really helped, thank you. And since having the CBT, because it is something people are more happy to talk about nowadays, the amount of people I've spoken to that have said, Oh, I've done CBT or Oh, I'm thinking about, I've been told I should do CBT. Or none of that just I'm doing this behaviour and I'm not happy. I feel like I've been able to be a mini therapist to a few other people. I've been able to pass the torch a little bit because even though the problem they might be having is different to insomnia or anxiety, a lot of what Sally taught me was, I found, they were telling me things and I was thinking, well, I'll just say this thing that I do because it would work. And I've been able to relay what Sally said to so many people. And that's given me a lot of, joy because I've been able to help people. And they've said, Oh, right. Brilliant. You know, either they've gone to therapy because I've told them why they should because they didn't have anyone telling them that before, they've gone and then come back and gone, that was great.

Or they've said to me, Oh, I didn't think anybody else was on Sertraline. 80 percent of the country are on Sertraline. It's fine. And that gives them support. Or like I say, the little technique Sally taught me, I've said, do this. And then they've come back and gone, do you know that really helped. So that's been nice for me too.

Helen: Well, if there's somebody out there listening to this, who hasn't had that kind of conversation with you, or someone else who's recommended CBT or things that you can do to help in a situation like that. Is there anything that you would want to say about, CBT or looking after your mental health that anybody out there who hasn't encountered it before might need to know or want to hear.

Sarah: It's free, most of the time. It's something that will help you for the rest of your life. Unlike, you know, a course of antibiotics. it's something that gives you control. It doesn't hurt, there's no injections. It's brilliant. Talk to people, I think is the key thing, not least your doctor, because obviously that's a private conversation. But again, as working in a GP surgery, I know that majority of health issues that come through the door, there's always an in for therapy. There's always a little bit of whatever they've come in with. Do you know what therapy could help that? It should be the crux of everything. You know whenever a patient comes to see me, I can't think of many situations where I don't say, do you know what would help? Drinking more water. I feel like it's just as important as that in terms of you can't fix something up here if you don't get your foundation and your foundation is nourishment and happiness and the therapy made me happier because I had more control, and was less anxious and more relaxed and, you know, just chill. So I think just talk to people, not least your GP, if you don't want to talk to someone personally.

Helen: From my point of view, that's a great message, Sarah. Thank you so much for sharing that with us. And what I'm going to do now is I'm going to ask Sally, just to talk a little bit, I could see, I know our listeners can't see our faces, but I could see Sally smiling when you were saying some of the things that she told you to do. And I'd be really interested to hear Sally's reflections on her therapy with you and how you work together.

Sally: Yeah, absolutely. It was brilliant working with Sarah and I think it's really nice to see where she's at now and also the fact that she's still using a lot of those tools that she learned and that she put into practice and, I think one of the things that was really good is that Sarah was ready. She was ready to engage. She wanted to do, you know, she wanted to do all of the things. She wanted to practice everything. She was ready there with the notebook, every session kind of, you know, making notes, taking it all in. And that's brilliant because that's what you need in CBT is really just to come with an open mind and just think about things in a different way. So that was really good. And I think as well, one of the things we discussed before we started the therapy was, time away from the baby. So this was Sarah's time, you know, this was an hour a week where, Sarah's husband or mum would look after the baby and this would be Sarah's hour where it's just about Sarah and it's just about this therapy and the CBT and so it was really important that she had that time and that space with no distractions. And so that I think that worked really well. We did some face to face and some remote via Teams sessions together. And I think one of the, one of the sort of challenges initially, as Sarah's mentioned before, Sarah's problem was that she couldn't sleep, that's what Sarah came with, it was a sleep problem. And it took us a little bit of time to sort of think about that together and unpick it together and go, actually, do we think it might be a symptom of a bigger picture, something else that's going on. And so we talked a bit over time and agreed as Sarah mentioned that actually it probably feels like more of a generalized anxiety and worry problem that was going on that was then impacting on the sleep. We spent quite a bit of time just exploring that and we did some fun experiments and things as the sessions went on, which is probably what I was smiling along to because I know it's not always easy for clients to, to sort of do those things and want to drop things like reassurance seeking. It's a safety net. And it's hard to drop that sometimes.

Helen: Thanks, Sally. You've just said two things there that I would really like to explore a little bit more. You said fun experiments and reassurance seeking. So can you explain what you mean by those please?

Sally: Of course. So, suppose I say fun because experiments are quite fun, aren't they sometimes. I know it's not easy to push yourself out of your comfort zone but I think we, me and Sarah had a bit of a laugh about some of the things that, you know, in the session, once we'd sort of sat down together and said, okay, so you're asking all of these other mums, for example, you know, what would they do in this situation, or like Sarah mentioned, what does it mean that my baby is this colour or that this is here and, you know, as we sort of broke it down together we could sort of see that, oh, actually, yeah, that they don't know. They're not going to be able to tell me this. My husband doesn't know if I'm going to be able to sleep tonight or not. So I'm asking this, but actually it's not getting me anywhere. So I suppose we almost got to a point where we could sort of see the funny side to those questions. And actually that helped, I think a little bit with then, right. How do we drop these things? How do we experiment with them? How do we move forward? And that really started to increase Sarah's confidence. And I could see that from session to session, you know, she wasn't asking other people, she was just allowing herself to rely on her own thoughts and her own experiences. And that worked really well for her.

Helen: So there's something quite important about testing things out, finding out for yourself really having the experience of what it's like to do something differently and check whether that works in your particular situation.

There was another phrase that Sarah used as well, which was positive reinforcement. I think we should just mention that's about essentially what reward you get or what is it that happens that makes you more likely to do something again. And that's what positive reinforcement means. It's just something that happens after we've done something that makes it more likely we'll do it again. And, to me, it sounds like one example of that was making it fun, testing these things out and actually getting something rewarding out of it was part of that journey.

Sally: Yeah, absolutely. I think that's a big part of it.

Helen: And one of the things that made me smile when you were speaking, Sarah, was when you were talking about what Sally told you to do. And what things you ended up trying out for homework and those sorts of things, the way Sally's talked about it was deciding together, discussing it. I'd be really interested to hear a bit more about do you get told what to do in CBT or is it more you end up in a position where you've decided to do it?

Sarah: No, you don't get told what to do. Of course. It's all very, like Sally says, you talk about it and then together decide what might be the best experiments is a good word. Cause everyone's different. Obviously, my exact path of how we got from A to B probably might not work for somebody else. Like Sally says, I came with a notebook, wrote everything down, did homework, because that works for me. No, she didn't tell me what to do. And what was funny as well was Sally's very good at just sitting back and letting you talk, which works because I talk a lot. So she sits back and she's very good at just sort of nudging you to realisations on your own, because if someone tells you that you think something or that you should do something, it doesn't really mean much. If you think it through yourself, because someone's supported you towards that thought process, you believe it more. It makes more sense. And you're like, ah, you know, the cogs go a bit slower, but then you get there. And so over the weeks I would be reflecting on what I'd been doing for Sally, myself, but with the homework. And she'd just go, and so do you think, and what do you reckon? And then I'd go off on another blah, blah, blah, and come back to a realisation that, and she'd have this sort of pleasing grin on her face, of yes that's where I was hoping you'd get to, but you need to get there yourself, obviously. And I was just like, really proud of myself, but also proud of, chuffed for her that it was going in the right direction, it was working.

Helen: It's good to hear that you are proud and also it's good for me here listening to you both talk about this because we do talk in CBT about guided discovery and that's exactly what you've just described to us is that idea that it's you that's looking at what's happening And the therapist is perhaps asking you some well-placed questions, but it is about you and what you need and your process and drawing your conclusions from what you've discovered. It's good to hear you talking about that experience. And I'm just thinking about, at the beginning, we did mention that getting active, getting out into nature and things to do with moving more were an important part of the therapy and I'd really like to bring Leanne in as well to talk about how getting active, getting out into nature might be an important part of that therapy journey.

Leanne: Oh, lovely, yeah it's something that Sally and I do a lot in our CBT because we recognize that the cognitive behavioural therapy has a really strong evidence base. There's a lot of research that says that it works and it's useful for lots of common mental health problems. But we also know that there's a really strong evidence base for exercise. Exercise is known to be one of the best antidepressants. And there's research as well that says that being in nature has a massive mood boosting effect. And if you pull all those three things together, then surely the outcome can only be brilliant if you've got lots and lots of really good evidence to say that, you know, any one of these variables on its own is going to help you, but let's combine the three. So, so we are huge advocates of including that in the work that we do as much as possible for lots and lots of different reasons, but you know, that sits underneath it all. It can be so good for mood. And also from our own experience I know I feel better when I've blown the cobwebs off, or we've got outside, or I felt the wind on my face, or I've been in nature. I've just moved a little bit. So from personal experience, both Sally and I can say it works.

Helen: That's really good to hear, Leanne. And I'm just thinking, I can hear the enthusiasm in your voice and certainly we do know about that effect on wellbeing on getting out in the fresh air, moving more, and how important that is. And without taking away from how important that is, Sarah was talking about she just had major surgery. A caesarean section is actually quite a big operation. She's also got a tiny baby, so at least in the immediate short term, it would have been really difficult for her to move much or get out in the fresh air very much. And it might be the case not only for people who've recently had a baby, even without the surgery, it can have quite a big impact on your body but also perhaps for people with other challenges to getting out and about and moving and I'm just wondering, how can people still benefit from combining getting more active with things that might help say anxiety and depression when they do have challenges about getting out and about?

Leanne: I think the first thing that comes to mind is to get medical guidance to kind of find out from somebody who knows your body as well as you do about what's appropriate and what's doable, before you start leaping into exercise or doing anything. And I think it's about trying to find ways just to move a little bit, whether that's, you know, stretching or things like chairobics or chair yoga, those kinds of things can be things that people do at home when they have limitations or pain or, you know, anything like that, but within the realms of, I suppose you've got to pace it within your capabilities and what's appropriate for you.

But things like connecting with nature. I was looking into this prior to was talking today and things like birdwatching and looking out of the window or doing a little bit of gardening or tending to window boxes and those kinds of things can give you the same powerful effects of connecting with nature and a bit of activity too. It's not about, I suppose when we think about exercise and we think about movement, we often think about the Olympics and we think about marathon runners and we think about going to the gym and lifting really heavy weights over your head. And it doesn't have to be like that. It can be small things often and Sally and I were talking about this before about, the NHS recommendations and we worked out that it's about 20 minutes a day of movement that's helpful. And also, if you add 20 minutes a day in nature so you do 20 minutes moving around in nature every day, that's going to have a huge effect. So if you can find a way to, to do a little bit, a little walk, a little stretch, look out the window, even watch a nature documentary, that has a massive effect on your mood as well, because it's connecting with nature but in a different way, you don't have to leave the house for that. How does that answer your question Helen?

Helen: It does thank you, Leanne. And I'm really pleased to hear you say that it doesn't have to involve buying expensive equipment or joining the gym. You don't have to live on the edges of a beautiful park or something like that. It's something that you can do whatever your living circumstances are. There's all sorts of creative ways that you can incorporate this as part of recovering, improving depression and anxiety and your mental health more generally. And I wonder whether, Sarah has any comments about that, Sarah, because you did mention how important that was to you even before you had your baby, and of course there would have been quite a big change to what was available to you immediately after you had her. Just wondered what your responses to what Leanne's just been saying about that.

Sarah: Yeah, I mean, like I said at the very beginning, my expectations of getting back to being myself were not met. And so the big things were, I actually made a list for and showed Sally of things that I'd written down saying, and I entitled it Getting Back To Me. And it was in order of, I just want to be able to make tea for my husband, walk the dog with the baby. These are all things that I just thought I'm never going to be. I don't understand how I'm going to be able to do these. And every time I did them, I was like, oh look, I'm doing that. You know, playing netball and the big one was paddle boarding, and I did it the other week and I was like, oh yeah paddle boarding. Like Leanne says, when it was very important for me as someone who's very active and I'm outdoors with the dog in the countryside all the time to get back to that. And like Leanne says though, it doesn't have to be going for a run. You know, my level of, well, what do I want to achieve was forced to be lowered, if you like, that's the wrong word, changed and because what I hadn't realized on top of taking the dog for a walk was whilst I'm there, I'm listening to the water. I'm listening to the birds. I'm feeling, I'm smelling, I'm all these things. And I didn't realise all that had been took away from me. And so that was adding to how miserable I was. And, like Leanne says, it doesn't have to be right. I need to be able to go for a run. It can just be find yourself back in something that makes you feel happy. And I think one of the techniques I wanted to just mention as well, that Sally taught me, when Leanne mentioned about you doing 20 minutes a day of being in nature or exercising, so that you make sure that you really are doing that to its fullest and you're not, you know, birdwatching whilst washing the dishes or thinking about what you need to make for tea. She taught me a five, four, three, two, one mindfulness technique, which basically is whilst you're tending to your bird box or whatever you're doing, think of five things that you can see. Four things you can hear, three things you can smell, two things you can feel, a one thing you can taste or something like that. And not only does that focus your mind for that minute on those things. It's really nice to think, Oh, I didn't know I could hear that I'm tuning into it. And then you do it again, five minutes later or as much as you want or, and it stops the thought processes that are negative as well, because you're focusing on that, but it just makes sure that when you're in the nature bit you are really soaking it all in as much as possible.

Helen: Thank you for that, Sarah. And I'm just thinking, we've had a really interesting conversation about your experience of therapy, Sarah, Sally's and Leanne's thoughts about what they're doing in therapy and what. seems to help people to benefit from it. I was wondering if I could ask each of you in turn, what's your most important message that you'd want people out there to know? So, Sally, what do you think is one key thing that you would want people out there to know?

Sally: I would say that mental health difficulties are common and it's not something that you have to sort of put up with or that you're stuck with, I suppose, for the long term, often there are a lot of quite often very simple techniques that you can practice and try and learn either with or without therapy, that can just really help to manage those, either the feelings of low mood or those anxiety feelings as well so, it doesn't have to be a major change. There's a lot out there and a lot of cost-effective things as well that you can get involved with that can just really help to boost your mood.

Helen: Thank you, Sally. Leanne.

Leanne: Oh, it's such a good question. I think what I'd really like people to think about is thinking about mental health, the way we think about fitness and physical health and spending time each day doing something that nourishes and nurtures mental fitness, let's call it. In the same way that we might, you know, drink some water, like Sarah said, take our vitamins and have something to eat and try and have good sleep, but moving in the direction of thinking about our mental fitness being on the agenda all the time so that I suppose it normalises asking for help and talking about things and looking after yourself and, and good wellbeing all round. Because I think people often really struggle, don't talk about it and then come for therapy when they've been on their own with it for a very long time.

Helen: Thank you very much, Leanne. And Sarah, what do you think you would want people out there to know, one key thing that you'd like to say?

Sarah: Probably that if you think something's not quite right or something really isn't right and you just don't, you're not sure what, you don't have to know, you don't have to be able to go to a doctor and say I've got this problem, can you fix it please? Doctors are just as, they're well trained to know when someone needs referring for therapy.

So yes, that's who you need to probably go to first in a professional manner but if you just go and say, okay, this is how I feel, blah, blah, blah. They'll pick up and know, actually, you would benefit from therapy because it sounds like this might be happening or going on and then you get referred to someone obviously who's even more specialised, a therapist, and they can sit back and listen to you just offload and say, these are the things that's happening, I'm not happy because of this, that and the other, and they'll go, right, It could be this, shall we try that?

And so, yeah, you don't have to have all the answers, I think, is my key thing. but you need to ask for them,

Helen: Fantastic. Thank you so much. All three of you have been excellent at telling us about your experience and knowledge, and I'd just like to express how grateful I am for all three of you talking with me today. Thank you.

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