The British Association for Behavioural and Cognitive Psychotherapies, the lead organisation for cognitive behavioural therapy (CBT) in the UK and Ireland, is 50 years old this year. In this episode Dr Lucy Maddox explores how CBT has changed over the last 50 years. Lucy speaks to founding members Isaac Marks, Howard Lomas and Ivy Blackburn, previous President David Clark, outgoing President Andrew Beck and incoming President Saiqa Naz about changes through the years and possible future directions for CBT.

Transcript 

Dr Lucy Maddox:        Hello, my name is Dr Lucy Maddox and this is Let’s Talk about CBT, the podcast brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP. This episode is a bit unusual, it’s the 50th anniversary of the British Association for Behavioural and Cognitive Psychotherapies this year. And I thought this would be a nice opportunity to explore some of the history of cognitive behavioural therapy, especially the last 50 years.

                                    Some of the roots of CBT can actually be traced way back. Epictetus, an ancient Greek Stoic philosopher wrote that man is disturbed not by things, but by the views he takes of them. This is pretty close to one of the main ideas of cognitive behavioural therapy, that it’s the meaning that we give to events, rather than the events themselves which is important. But actually, cognitive behavioural therapy started off without the C. To find out more, I made a few phone calls.

Isaac Marks:               Hello, Isaac Marks here.

Dr Lucy Maddox:        Isaac Marks was one of the founding members of BABCP and a key figure in the development of behavioural therapy in Britain. I asked him if he could remember what CBT was like 50 years ago.

Isaac Marks:               Originally it was just BT and a few years later the cognitive was added. At the time, the main psychotherapy was dynamic psychotherapy, sort of Freudian and Jungian. But just a handful of us in Groote Schuur Hospital psychiatric department, that’s in Cape Town, developed an interest in brief psychotherapy. And I was advised if I was really interested in it and I was thinking of taking it up as a sub profession, that I should come to the Maudsley in London.

Dr Lucy Maddox:        Isaac and his wife moved to London from South Africa and Isaac studied psychiatry at the Maudsley Hospital in Camberwell.

What was it about CBT that had interested you so much?

Isaac Marks:               Because it was a brief psychotherapy, much briefer than the analytic psychodynamic psychotherapy. We were short of therapists and there wasn’t that much money to pay for extended therapy, just a few sessions. Six or eight sessions something like that could achieve all what one needed to. They had quite a lot of article studies.

Dr Lucy Maddox:        And I guess that’s still true today, that those are some of the real standout features of it, aren’t they? That it is a briefer intervention than some other longer-term therapies and that it’s got a really high quality evidence base.

Isaac Marks:               I think that’s probably true, yes.

Howard Lomas:          There was a group that met at the Middlesex Hospital every month. And that was set up by the likes of Vic Meyer, Isaac Marks, Derek Jayhugh.

Dr Lucy Maddox:        That’s Howard Lomas, another founding member of BABCP remembering how the organisation got set up 50 years ago from lots of different interest groups coming together.

Howard Lomas:          These various groups that got together and said, “Why don’t we have a national organisation?” So that was formed back in 1972.

Dr Lucy Maddox:        Howard’s professional background was different to Isaac’s psychiatry training, but he found behaviour therapy just as useful.

Howard Lomas:          I’d originally trained well in social work, but I was a childcare officer with Lancashire County Council.

Dr Lucy Maddox:        And how were you using CBT or behaviour therapy in your practice?

Howard Lomas:          Well, as a general approach to everything, thinking of everything in terms of learning theory. How do we learn to do what we do and maintain it with children? Things like non-attendance at school and other problems, behavioural problems with children and then later problems with adults.

But I suppose when I moved to Bury in 1973, I was very much involved in resettlement of people with learning disability from the huge hospitals that we had up here in the north. We’d three hospitals within sight of each other, each with more than 2,000 patients.

Dr Lucy Maddox:        Wow.

Howard Lomas:          They’re all closed now long since, but yeah, the start of that whole closure programme of trying to get people out into the community. You learn normal behaviour by being in a normal environment, which people in institutions clearly aren’t and weren’t. So it’s trying to create that ordinary valued environment for people. And simply doing that would teach them ordinary behaviours, valued behaviours. It was evidence-based, it was also very effective.

                                    It looked at behaviour for what it was rather than what might be inferred. I suppose I saw psychology as more of a science (laughs). I’m still in touch with some of the people that are resettled from way back. People who had been completely written off as there’s no way they could ever live in their own home are now thriving, absolutely.

Dr Lucy Maddox:        Now, Howard’s and Isaac’s memories of CBT 50 years ago highlight that an important route of CBT is behavioural learning theory. This includes ideas of classical conditioning, where in a famous experiment which you’ve probably heard of, Pavlov, taught his dogs to salivate in response to the bell that he rang for their dinner rather than the dinner itself. And operant conditioning, where animals and humans learn to do more or less of a behaviour based on the consequences which happen in response to that behaviour.

Howard Lomas:          Half a dozen of us sitting with Skinner, chatting for three hours. So that was quite influential (laughs).

Dr Lucy Maddox:        Skinner was another of the early behaviourists, and Howard has memories of being lectured by Skinner at Keele University. The formation of BABCP was important for therapists at the time because behavioural therapy back then was quite a niche field.

Howard Lomas:          It was publicly very unpopular indeed. Behaviour therapy was known very much as behaviour modification, which has got an involuntary feel about it, even the name that it was being thrust upon people. And even at that time, aversion therapy was being used for trying to change homosexuality in people, aversion therapy then. Which is quite topical now with the whole debate on conversion therapy.

Dr Lucy Maddox:        Absolutely. We’ve signed up to the memorandum of understanding against conversion therapy.

Howard Lomas:          The aversive is horrible. And there was a big scandal at I think it was Napsbury Hospital about their clinical programme, which was allegedly based on behaviour modification, more aversive techniques. So there was a big scandal and that led to a major government inquiry, and they asked for anyone to offer, submit evidence on the whole question of behaviour modification, which BABP did. And that then formed the basis of our guidelines for good practice.

Dr Lucy Maddox:        Just a note, if you’re listening to this as a cognitive behavioural therapist, please do read the memorandum of understanding against conversion therapy online at www.babcp.com.  It makes it clear why we’re opposed to conversion therapy in any form. I’ll put the link in the show notes, too. Like Isaac, Howard remembered that shift from behaviour therapy to cognitive behavioural therapy.

Howard Lomas:          Well, I was always against adding the C. I was always taught that behaviour has three components to it: motor behaviour, cognitive behaviour, and affective behaviour. So behaviour included cognitive, so why did you have to have it as a separate thing? Although in those early days I used to get told off if I spoke about thoughts and feelings.

Dr Lucy Maddox:        Did you?

Howard Lomas:          Yeah, because you can’t see them. You can’t measure them.

Dr Lucy Maddox:        Yeah, interesting, although there’s still a lot of measurement, isn’t there? But maybe it’s like you say what we think we can measure has maybe changed.

Howard Lomas:          That’s right, yeah. Yeah, I think the measurement and the evidence is so important.

Ivy Blackburn:             We actually changed the name when we started it was called the British Association for Behaviour Psychotherapy. So at one of the conferences we passed a motion and added the C.

Dr Lucy Maddox:        That’s Ivy Blackburn, another founding member of BABCP.

Ivy Blackburn:             At that point well, I was a qualified clinical psychologist. I’d just finished my PhD, I trained in Edinburgh. And I was working in a research set up, an MRC unit called the Brain Metabolism Unit.

Dr Lucy Maddox:        And so, CBT at that time was quite a new thing?

Ivy Blackburn:             Very, very new. I actually had just discovered Beck as it was, while I was going the research for my PhD, which was in depression. And I used to correspond with him and he used to send me his early papers and things like that.

Dr Lucy Maddox:        Ivy’s talking there about Aaron Beck, also sometimes known as Tim Beck. Also sometimes called the father of CBT.

Ivy Blackburn:             With Aaron Beck I always signed I M Blackburn. And the story he used to tell at conferences was he always thought I M Blackburn was an old Scottish man. (Laughs) So once he came to Edinburgh, he was on a sabbatical, and we were sitting at I think it was a case conference. He was sitting next to my boss, who was somebody called Dr Ashcroft, and I was sitting next to him.

                                    He turned to Ashcroft and said, “Could you show where I M Blackburn is?” Dr Ashcroft said, “You’re sitting next to her.” Yeah. So that’s how it all started, you know, we were a small group in those days, very small group.

Dr Lucy Maddox:        Do you remember what you were excited about by CBT at that time?

Ivy Blackburn:             I thought the research that Beck was doing about the factors in depression, about the role of thoughts I thought that was very interesting. The unit where I was working one of their things was working with treatment resistant depression. And they used to go through, the research was a series of drugs. You start with Drug A. If Drug A doesn’t work, you go to B, to C to D.

By the time they’d got to E and had nothing else to do I said, “I’ll take them.” And that’s how I started. I just thought it was very meaningful to me. They loved it, people talked to them and they could talk about what mattered to them, and they actually got better. Not long after that we decided to do the famous first ever trial in cognitive therapy for depression. That was published in 1981.

Oxford started at the same time, they also had started, John Tisdale and his group, a treatment trial. So ours came out in 1981 and theirs came out in 1984, I think. So we were actually the two centres, Edinburgh and Oxford. But cognitive therapy has developed so much. There’s all sorts of offshoots, I don’t know very much about. But another big person who did his PhD with me, big one at the moment who’s still active I think is Paul Gilbert. He was one of my PhD students.

Dr Lucy Maddox:        Was he? Wow, yes. Because of course he founded compassionate mind therapy, yeah.

Ivy Blackburn:             That’s it.

Dr Lucy Maddox:        If you want to hear more about compassion focused therapy, you can check out the earlier podcast with Paul Gilbert. And in fact, if you’re interested in any of the different flavours of CBT which are now around, series one is a really good place to start. We go through lots of different types of CBT there and we hear from therapists and also people who’ve had those different types of CBT. Am I right in thinking as well you were a chair of BABCP?

Ivy Blackburn:             That I was a what?

Dr Lucy Maddox:        A chair? Like a president of the organisation, is that right?

Ivy Blackburn:             Yes, I was. I was president, yes.

Dr Lucy Maddox:        Yes, and were you the first woman president?

Ivy Blackburn:             Yes. And I am of mixed race, so that was a bit of first as well. I went to Newcastle from Edinburgh in 1993. I think it was 1993.

Dr Lucy Maddox:        And what was your experience like of being president?

Ivy Blackburn:             As I say, we were so small in those days, you know, we had these little cosy conferences. We met in Newcastle every month. I was very, very well supported by Paul Salkovskis so he sort of guided me through. It was easy and of course some of those people are still there.

Dr Lucy Maddox:        Yeah, you’re the big names.

Ivy Blackburn:             (Laughs) We are, we are the oldies. Have I enjoyed it? Yes. Yes, I have enjoyed this work very, very much, yeah.

Dr Lucy Maddox:        What have you enjoyed about it?

Ivy Blackburn:             My work was very diversified because I was obviously also an academic so I did research, I did teaching, I organised a course. But I always carried on with my clinical work and I think that’s what I enjoyed the most, clinical work. This is what’s rewarding, isn’t it?

Dr Lucy Maddox:        For sure. Yeah, absolutely.

David Clark:                It was an exciting time. And people talked about it as a cognitive revolution. And I think it was a revolution.

Dr Lucy Maddox:        That’s David Clark. He’s based at the Oxford Centre for Cognitive therapy, which Ivy was talking about. We also met David in the very first episode of this podcast. He joined the BABCP in the late 70s, when the dominant approach was still behaviour therapy. But as we heard from Ivy Blackburn, there was a crosspollination of ideas from the United States, where Aaron Beck was working on cognitive therapy for depression.

The idea that the way we perceive the world and our future can affect how we feel about it is now rather taken for granted. But at the time it was quite a radical idea.

David Clark:                We suddenly started looking at a whole range of different potential therapy manoeuvres. There are thousands of ways you can change people’s beliefs and it was really exciting.

Dr Lucy Maddox:        The interlock between beliefs, behaviours, memory and attention was really the basis of cognitive behavioural therapy as we now know it, with the model of thoughts, feelings, behaviours and bodily sensations, which is a fundamental part of most explanations of CBT today. Another root which CBT grew out of was rational emotive behaviour therapy, which Albert Ellis pioneered in the 50s and which also included thoughts, behaviours and emotions in its way of thinking about problems.

In the late 80s and 90s, CBT as we now know it, grew out of all of these roots, behaviourism, rational emotive behaviour therapy, and influenced by the work of Aaron Beck and the bringing together of all of these different ideas. Through the 80s and 90s, lots of disorder specific psychological models were created, to try to tackle specific problems. For example, models for panic disorder, obsessive compulsive disorder, posttraumatic stress disorder, and other problems were developed and really changed the treatment for those difficulties.

David Clark:                And then, of course people start spotting ah, yeah, but some of the maintenance processes that had been invoked in a disorder specific model are also applying in other disorders. safety behaviour which Paul Salkovskis of course really pioneered is a good example of that. And also changes in attention, ways in which memory processes can go wrong. And so, you start moving into this way of thinking which is a bit more transdiagnostic.

Dr Lucy Maddox:        Yeah, lovely, so actually it’s kind of gone from a very transdiagnostic one treatment fits all at the very start to then getting much more specific and nuanced. To then zooming out again to a bit more of a broader picture again.

David Clark:                Yeah. And I think this is the sort of healthy dialectic that you experience when a field is moving forward.

Dr Lucy Maddox:        And I suppose that’s one thing that I feel like CBT I mean, other therapies too perhaps, but CBT in particular it feels like it really is a learning therapy, where it’s very good at creating an evidence base. And then holding that evidence base up to the light and saying, “Hang on, what could we be doing better here?” And it does feel like it’s continually evolving perhaps because of how well evidenced it is.

David Clark:                I think that’s right. I think it’s always had a very close link to the evidence base. But I think other therapies are going in a similar way, and I think this is really all to the good.

Dr Lucy Maddox:        What do you think of the? Because the sort of family of CBTs if you like, I think of them as a family, there different therapies that have developed I guess a little bit more recently which still draw on cognitive and behavioural principles. But maybe sort of run with a different strand of it each time. So I suppose I’m thinking about APT and DBT and compassion focused therapies. How do you see those fitting?

David Clark:                I’m just an empiricist, so I think what I think of them depends on what the outcome data is (laughs) with the particular conditions that they’re involved with. But when you get an approach which seems to be doing well and maybe improving on something else, then one always has to look at it. One of my friends, close friends through much of my career was Tim Beck who sadly died last year.

                                    But he was a very jokey person in many ways. But one of the points that he would sometimes make when someone said to him, “Well, what’s cognitive therapy?” He would say, “Well, anything that works.” And of course, it was a joke in a sense, but it was also serious because he was always watching for what other people did in other therapy approaches to see if they’d got something which cracks open beliefs in a way that he hadn’t seen before.

                                    And if so, it miraculously got incorporated into cognitive therapy. It’s really important that we as therapists always keep our eyes open to these things. One of the big developments more recently in the field has been to think well, how can we bring these advances to the public so that really large numbers of people benefit?

Dr Lucy Maddox:        Yeah, and of course improving access to psychological therapies has been a massive part of that.

David Clark:                Yes. It’s been a great honour to work with so many wonderful people who put in such hard effort to lobby for that. And then, to create the services and crucially, to make them work so effectively that successive governments across the whole political spectrum have cherished and expanded the programme.

At the moment it is the only aspect of our mental health services where outcomes are recorded on everyone and are published. In my worst nightmares I would not have dreamt that we’d still have almost every other area of mental health provision in the dark ages in terms of public transparency. And also in terms of learning.

Dr Lucy Maddox:        As David said there, a national improving access to psychological therapies programme in England doesn’t only include CBT. But it has been instrumental in increasing access to CBT as well as other evidence-based therapies within England. It’s also been responsible for creating a whole generation of low intensity therapists, who deliver CBT as part of a stepped care model.

Where briefer interventions, often in the form of guided self-help, are offered for less severe presenting problems. Now we move a little later in the history of CBT. I got in touch with the outgoing president of BABCP, Andrew Beck, and asked him how he first came across CBT. He told me about his first experience of the BABCP conference as a trainee clinical psychologist back in 1997.

Andrew Beck:             I managed to get a free ticket to it by DJing at the social party afterwards.

Dr Lucy Maddox:        Did you?

Andrew Beck:             Yeah, I did, I DJed at that and got a load of Rod Holland’s photographs from past conferences and made a sort of slideshow of them, which we showed, while I was DJing and it was great. But I really felt like I’d come home because there was such a wide variety of people there. It was people from all different professional backgrounds, all coming together and talking about the real practical aspects of working in mental health.

                                    Yeah, it was a real eye opener for me. Being around people who you feel share the same concerns, the same interests, who want things to be better in the same kind of way that you do is great. You feel like you’re part of a community then, don’t you? And being part of that community sustains you in what you’re doing in a really nice way.

Dr Lucy Maddox:        What was it about CBT that you liked?

Andrew Beck:             It was pragmatic, and I think there was something about it that was very much about being in the room with someone and helping them to get past the things that were stopping them getting on in life. And it was that really present focused aspect of it that appealed to me. That I felt like as a cognitive behaviour therapist, you were going to help someone find something to take home with them and do differently to improve things. And I think that was what really clicked for me, to be honest, Lucy.

                                    I came in 25 years ago, at a point where CBT had begun to be thought about as a therapy in a very coherent way. A lot of the models that we use now and are familiar with, were all really well established. And it was easy to imagine that it had always been like that. But of course, talking to some of the people who were around in those formative years, it’s been really interesting to hear that history of how the therapy has developed.

                                    And I’m told that there was a raging argument about whether these ideas about behaviour therapy and those ideas about cognitions could be brought together in one therapeutic organisation. And how that might look. Because they were quite distinct camps at times, really, with quite different ideas about what therapy ought to be like. And whether these very disparate ideas could sit well together in one organisation and what that organisation ought to be called.

But of course, by 25 years ago attending conference, what we now think about as second wave CBT felt very formed, actually. And what’s happened in the 25 years since is the third wave therapies have developed their evidence base, developed their theoretical foundations and have really grown in popularity. And there’s a whole group now of therapies that are considered to be part of the family of cognitive behaviour therapies but are the kind of next wave.

Dr Lucy Maddox:        So Andrew talks there about first wave CBT, which was really just behavioural therapy. Second wave CBT, where the thoughts got added. And third wave CBT, which is the larger family of therapies we now think of. As I said before, if you want more information on the different sorts of CBT, check out the podcast in series one. As we heard from Howard earlier, not everything about the past history of CBT is rosy by any means. Is there anything that you’re glad that we’ve left behind in terms of how CBT has changed in the last 50 years?

Andrew Beck:             Yeah, I am, actually. There’s a few things I think are real problems in the history of our therapy. And probably the one that stands out the most is the role of behaviour therapy predominantly in conversion therapy for people that are LGBT identities. And if you look back at conference proceedings from BABCP conferences 30, 40 years ago this was something that was seen as unproblematic.

That there was an idea that people who were unhappy with their sexual identity could have their sexual identity changed through behaviour therapy. And looking back now that was appalling and actually for many people at the time it would have been seen as appalling, too. So it’s not just one of those things that with the benefit of hindsight doesn’t look great, actually it didn’t look great at the time, I think for a lot of people.

And if you were a gay member of our organisation and came to conference and saw that as part of the conference proceedings, that would have been a really alienating process, really. And I think the other thing is because CBT has often been aligned with diagnostic frameworks over the course of CBT’s history, really see now and understood now as being quite unhelpful.

And the one that most stands out for me, I think is borderline personality disorder, which is a way of describing people who generally experienced extraordinarily abusive and invalidating environments growing up, who have developed all sorts of strategies to manage those difficult environments. But who have been understood by services as having a problematic or disordered personality. And I think broadly speaking, the world of mental health is moving away from that as a diagnostic category.

Dr Lucy Maddox:        Andrew is the outgoing president of BABCP, and he’s just about to hand over to Saiqa Naz, which is the last person I spoke to. Her perspective on CBT comes from her training as first a low intensity therapist, then a high intensity therapist and now as a trainee clinical psychologist.

Saiqa Naz:                  I really enjoyed my training, there was a core group of us. We had a routine, we’d go to Costa and have a coffee beforehand. So for me, I remember that (laughs), the social aspect of it. I think that really makes a difference to a training experience, just having that network of support around you. We’re actually celebrating our 10 years of friendship this year. So I’ve been in CBT for 10 years now this year, so it’s nice to be part of BABCP and hopefully be part of its future as well.

                                    And I’m mindful I’m probably a bit different to the other presidents in terms I might be a bit younger, or not a professor. But hopefully bring something different to the organisation. Yeah, I think when I trained as a low intensity CBT it was in the early days of the IAPT programme. So just really interesting to see something so huge being rolled out nationally. And how it was being developed locally, so I trained in Sheffield and we were based in GP surgeries.

                                    And I really liked that model, working a little bit more closely with other healthcare professionals, GPs. I’ve still held onto the skills that I learnt as a low intensity CBT practitioner, when I trained as a CBT therapist. So it lent itself really well to training as a CBT therapist. And again, I think both are valuable in their own right.

The step care model is really important if you’re thinking about long waiting lists and people having access to treatment sooner rather than later. So I think in that sense, the low intensity CBT role has really revolutionised mental health and how services are delivered today.

Dr Lucy Maddox:        David and Andrew both had similar respect for the low intensity role and how it’s changed access to CBT.

David Clark:                We now have people with a wide range of backgrounds, non-medical backgrounds, who are delivering evidence-based therapies and are considered on an equal basis and are considered to be real experts. So that sort of democratisation of mental health provision has been obviously an incredibly good thing.

Andrew Beck:             We’re really lucky in BABCP in that we’ve got a bunch of great low intensity members who are involved on board level, at committees. And I think that’s going to be a big part of who we are as an organisation.

Dr Lucy Maddox:        Saiqa and Andrew were also two of the authors of the IAPT positive practice guide for working with Black, Asian and minority ethnic service users, which is available at www.babcp.com and also in the show notes. Saiqa had some ideas about what would help this to be rolled out more fully.

Saiqa Naz:                  I think there’s quite a few things that will help. So people like Andrew and myself can take a step back and that’s having representation in those senior leadership roles, decision making roles. What we see is that IAPT has opened the doors for people from underrepresented groups, so working class backgrounds, BAME backgrounds, men, people with disabilities.

                                    But what we need to see is those people in more senior leadership roles. And personally I would like to see ringfenced funding now, to help the implementation of the guide. Otherwise, I think the system will keep relying on goodwill and it could be a bit exhausting.

Dr Lucy Maddox:        What about the future of CBT? We don’t know how it will change in the next 50 years. But everyone I interviewed had some ideas.

Saiqa Naz:                  I think for me looking forward I want us to learn more about our CBT heritage. We were just talking about it at the beginning, thinking about who are we inheriting the knowledge from? Where has it come from? Because it will help us to connect with CBT and also think about what’s the legacy of CBT long after we’re gone what we’re leaving behind for the next generation.

                                    And also, how are we going to support the development in a way we are privileged here with the amount of resources that we do get in mental health and the level of training. But how can we pass it on to more lower middle income countries? Taking CBT to communities I think is really important because sometimes I think an organisation can become too insular and just be focused on the inward and on itself. But having that one foot in, one foot out is really helpful.

Dr Lucy Maddox:        Andrew agreed that involving people with lived experience of having had CBT is really important when we think about the future development of the therapy and how it might evolve over the next 50 years.

Andrew Beck:             It enables us to think a little bit more about barriers to engaging in therapy, what we need to do differently to bring people in, what we need to do once people are in therapy. And it’s been a really lovely development, I think in CBT to think more about that. We really don’t know, we’re very much at the edges of thinking about how our therapies might develop over the next 25 and 50 years.

So it’s a really exciting time. We need to keep pushing and refining our ideas to improve. But the other one for me is about access and outcomes for diverse populations. CBT needs adaptation and therapists need to be able to take into account cultural contexts in order to do that because the large datasets that we’ve got show that for many communities their outcomes are not as good.

Now, part of that I think is because those communities experience particular social and economic hardship and marginalisation, and therapy can’t fix that. But part of it is because therapists just need to get better at thinking about difference in the way we work. So I think that’s going to be an exciting project over the coming years. And we’re just at the start of that, really.

Ivy Blackburn:             I think it will be still there with a lot of development, side developments, as we see at the moment, like compassionate and all sorts. Different branches. But I don’t see it disappearing to be replaced, developing as it should be. The beginning was very, very quick developing from depression it quickly went to anxiety. And then, Paul and David went into panic disorder, all this. One after the other, different methods.

David Clark:                I just hope that the speed of progress in the next 50 years is at least as fast as we’ve had in the last 50. And we get to a situation where helping people learn how to deal with setbacks in their life and deal with mental health problems becomes much more routine in society. I assume we’re going to have much more digital. I’m sure AI is going to help with a number of things.

But I’m also sure that the absolutely basic qualities that are in therapy about having someone who really cares what’s going on with you, being warm and empathic and really wanting to understand the world from your perspective will remain dominant and really important.

Isaac Marks:               Well, I imagine that new methods will continue to be developed from time to time by people in different countries. And as far as I can see, it’s the sort of approach that I think is likely to continue for the foreseeable future.

Dr Lucy Maddox:        I hope that’s given you a bit of a flavour of how CBT has grown and developed, especially in the last 50 years from its behavioural roots to the diverse and flourishing therapy that it is today. Do check out the other episodes of the podcast to hear from people who have actually had the therapy to hear in their own words what it’s been like for different problems and with different types of CBT. Meanwhile from me, that’s goodbye. Take good care and enjoy your summer wherever you are.

END OF AUDIO

Shownotes

Photo by Ryan Gagnon from Unsplash

Music by Gabriel Stebbing

Produced for BABCP by Lucy Maddox

For more on BABCP check out www.babcp.com

The Memorandum of Understanding Against Conversion Therapy can be found online here: https://babcp.com/Therapists/BAME-Positive-Practice-Guide

The IAPT Positive Practice Guide for BAME Service Users can be found here: https://babcp.com/Therapists/Memorandum-Against-Conversion-Therapy

For more on different types of CBT check out series 1.

 

In this bonus episode of Let's Talk About CBT, hear Dr Lucy Maddox interview Dr Tom Ward and Angie about SlowMo: digitally supported face-to-face CBT for paranoia combined with a mobile app for use in daily life.

Transcript

Dr Lucy Maddox:        Hello and welcome to Let’s Talk about CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not, and how it can be useful. In this episode, I’ll be finding out about an exciting new blended therapy, SlowMo, for people who are experiencing paranoia.

This digitally supported therapy has been developed over 10 years with a team of people including designers from the Royal College of Art in London, a team of people who have experienced paranoia. And a team of clinical researchers, including Professor Philippa Garety, Dr Amy Hardy and Dr Tom Ward.

The design of this intervention really prioritised the experience of people using the therapy in what’s called a design led approach. To understand more I video called Tom Ward, research clinical psychologist based in Kings College London, and I had a phone call with Angie, who’s experienced using the therapy. Here’s Angie’s story.

Angie:                          I mean, I’ve had psychosis for many years. About 20 years ago I was really poorly, I was in and out of hospital. Going back about 20 years ago they kept giving me different diagnoses and I expect everybody else had the same thing. Anyway, then I met a psychiatrist and I was with him for over 20 years until he retired. And he really helped me a lot, I was actually diagnosed with schizophrenia.

Part of me was really scared and another part of me was sort of relieved that I knew that I was dealing with. I get voices, sometimes I see or feel things that aren’t really there. But part of my diagnosis is I also get very depressed. And when I get very depressed, that’s when the voices are at their worst because I haven’t got the strength to sort of fight them off, if you like.

If I’m having a good day, then I can use the skills I’ve learnt in the past to not listen to the voices and to have a reasonably good day. If I’m having a bad day and it’s a duvet day, then that’s when I really suffer with the voices. Unless you can actually accept that you have this issue, and you actually accept that you need the help, it doesn’t matter what they do to help you, you’re just not going to take it on board.

Dr Lucy Maddox:        Angie wanted some help, specifically with paranoid thoughts she was experiencing about people looking at her or laughing at her. She found out about the SlowMo trial and applied to be a part of it. And ended up being one of the very first people to try the therapy. Tom led on the delivery of therapy in the trial.

Dr Tom Ward:              I’ve worked and have worked for the last couple of years trying to develop and test digital interventions for people experiencing psychosis. So I’ve been involved in developing interventions that help people who are experiencing distressing voices. And been involved in work in a therapy called avatar therapy and more recently I’ve been working with colleagues to develop an intervention designed to help people who are experiencing fear of harm from others, which we would sometimes refer to as paranoia.

Dr Lucy Maddox:        In case listeners wonder what avatar therapy is could you just briefly say what that is?

Dr Tom Ward:              So in avatar therapy, digital technology is used with the person to create a representation of the distressing voice that they hear. So we work with the person to create an avatar which has an image which matches the image the person has of their distressing voice. And which comes to sound like the voice that they hear. And we use this avatar direct in dialogue.

Very much with the rationale that many people who are experiencing distressing voices have relationships with their voice where they feel disempowered and lacking power and control. And we try to use the work with avatars and the dialogue with avatars to provide an opportunity for the person to reclaim power and control. And so we’re very much working directly with the experience in quite a potentially powerful way for people.

Dr Lucy Maddox:        Could you tell me about the current project you’re working on, so SlowMo?

Dr Tom Ward:              Yeah, so the first thing to say is that SlowMo stands for slow down for a moment. And so, it’s a therapy which is a targeted therapy for people who are experiencing paranoia. And it’s based in the idea that’s been popularised by Daniel Kahneman and other people that human thinking can be sort of thought about in terms of two different types of thinking. There’s fast thinking where we approach situations and we go with our first impression.

We go with our intuition and gut feeling and we don’t take time to think it through. And slow thinking is more around taking a step back from situations and weighing things up and considering different ways of looking at situations. So one of the things to say is that fast thinking is part of human nature, we all do it and in many different times in our lives.

But what we know from research into the experiences of people with psychosis is that people who worry about harm from other people, people who have significant paranoia can often be very likely to engage in this fast thinking. And find it difficult to feel safe in situations and to slow down and consider what else might be going on in the situation.

So the therapy is designed to help people build an awareness of this fast thinking which is a part of human nature but can be particularly difficult if we’re feeling unsafe. And it’s designed to support people to be able to slow down and feel safer in their lives. And managing situations so they can really engage and enjoy their lives in a way that perhaps in the past has been difficult.

Dr Lucy Maddox:        Fast thinking I guess that’s something like you were saying that we all can get into a bit.

Dr Tom Ward:              The first message that we try to get across within the therapy is that fast thinking is part of human nature, it’s natural. And there are times when thinking fast is actually very helpful for people, sometimes we need to react to situations, and we need to recognise where we are unsafe and there’s danger.

But in the context of when people are feeling unsafe throughout so much of their life, and in situations where perhaps the danger isn’t quite as much as the fear suggests it is, fast thinking can leave people feeling unsafe in situations where it might start to be a barrier to people living their lives.

And slow thinking is something that we’re all capable of, but all human beings find it difficult and people experiencing psychosis and worrying can find this difficult as well. But we’re really trying to find ways to support people to do that, to feel safe in their lives.

Dr Lucy Maddox:        And how does the therapy work? What does it look like?

Dr Tom Ward:              We would describe it as a blended digital therapy. And it’s important to explain what that means. The blending aspect of this is that we try to take the best of face-to-face therapy and the building of a relationship with someone. But we try to improve the therapy through using, through blending digital technology into what we do.

                                    So the therapy involves eight face-to-face sessions, but each of these sessions is supported by an easy to use website effectively, an interactive website. So within a session, you’d be talking to the person or the person would be talking with the therapist but also interacting with a touchscreen laptop. And this provides information, it provides interactive ways that the person can build a picture of their own worries about other people or situations.

                                    And really visualise what’s happening in a way that in psychological therapy we talk about a formulation. A formulation, an understanding of somebody’s difficulties. But the digital technology in SlowMo is trying to really bring the person into that process of understanding what’s going on and making it very engaging and interactive and visual and memorable for the person.

                                    In order to try to support the person to make changes in their daily life, there’s also a mobile app that comes alongside the therapy, which is very much aimed at taking what the person has learnt in the therapy and applying it into their daily life.

Dr Lucy Maddox:        Here’s Angie on what she remembers this digitally supported therapy being like.

Angie:                          You could choose pretty much where you wanted to do the therapy, you could have it at home, or you could have it in a café or somewhere else where you felt comfortable. So I did it in a café, a local café, with a lady called Alison. And what it consists of the clinician, Alison, she had a laptop. My heart sank originally because I thought oh no, I’m no good on computers. And I explained to her that I wasn’t very good on a computer.

And she was so lovely, so patient, she said, “I can do most of it for you.” So that was fine. What the therapy was it did what it says on the tin, really. It taught you to slow your mind down, and to break things up into little pieces, like for instance I used to be terrified of getting on the bus because I thought people were talking about me and laughing at me.

Dr Lucy Maddox:        That’s a horrible feeling.

Angie:                          Yeah, yeah. And this sort of therapy taught me to break it up. To say myself, “Well, hang on a minute, these people aren’t looking at you. They’re talking to their friends, they’re on their phone.” Just take it easy. And it’s a very simple idea but it works because although you know in your heart of hearts that that is the way to do it, when you’re actually in the situation, you forget. You just panic and to learn these skills was really good.

Dr Lucy Maddox:        I asked Tom to describe what the digital component of the treatment looks like.

Dr Tom Ward:              The website allows a person to build a picture of their worries. And these are using thought bubbles effectively, but really engaging well presented thought bubbles. And the idea of these is that they’re personalised and tailored for the person. So within a session, the person will be describing their worries but also creating these worry bubbles on the website. And the idea of fast thinking and slow thinking is represented by the way in which these bubbles spin.

                                    So when we’re talking about building an awareness of fast thinking, the person is actually able to control how fast their worry bubbles are spinning. And when we’re talking about maybe ways of slowing down the person can see visually how the worry is slowing down. So they build a picture of their worries and also importantly are building a kind of access to safer or more positive thoughts.

                                    And these are visualised as again bubbles the person creates, which can be made into different colours, depending on the person’s preference and can be linked into the worries and can be used on the mobile app outside of sessions. As somebody who’s worked in more traditional face-to-face CBT therapy, having these in the session and the person in control and interacting is a really significant thing to have in the session, really enhances the experience.

Dr Lucy Maddox:        I like the idea of the different colours and the different movement. Can you make the bubbles bigger and smaller as well?

Dr Tom Ward:              Absolutely. As you would have in a more traditional CBT session, at the beginning of a session, the person’s asked about how their week has gone, how much of the worry has been on your mind, how distressing has it been. And ratings are done on the touchscreen app, so the person is able to rate and see the change in the bubble. So if it’s been a week where it’s been a little bit less distressing, the person changes the slider and there’s that visual change as well that the person can see.

                                    And also, through the course of the therapy, we talk about different ways to slow down. And people develop their own strategies for slowing down in the situations that they’re struggling with. And the idea of the mobile app is that these strategies that the person might be able to think of in the session. They can be very difficult to think about when you’re actually in a situation where you’re worried if you’re on a bus or on a tube.

                                    So the idea is that these tips, these colourful tips can be brought into the mobile app. And the person can be just one or two touches away from something which they’ve created themselves and they know can help them in that situation.

Dr Lucy Maddox:        Angie used the app when she was out and about.

Angie:                          They gave you a phone with an app on it. You put in all your fears, like getting on the bus or being in a crowd, and then you put in what they called your support bubbles. They came up on screen in little bubbles and it had what you used to cope with these voices and delusions. And you could look on your phone, and it would come up.

Like for instance if I was in a crowd and I wanted to get away, you’d go onto your phone. And it would say things like just remember no one’s looking. Just slow down. And you could use this phone on the bus because nobody knew you weren’t just using a normal smartphone.

Dr Lucy Maddox:        Yeah, absolutely. That sounds really, really useful to have it on you all the time.

Angie:                          It was very useful, very useful. And yeah, nobody looks at anybody now, everybody’s got a phone, so nobody thinks that you’re doing anything different.

Dr Lucy Maddox:        It’s so true, it’s more unusual not to have a phone actually now, isn’t it?

Angie:                          (Laughs) It is. Yeah.

Dr Lucy Maddox:        Tom thought those blended approach meant that there was more chance that people could carry on learning from therapy into their day-to-day life.

Dr Tom Ward:              Having worked with people for many years, my experience is that really important things can be discussed during a therapy session and really meaningful understanding can emerge. And yet, that can actually be difficult to remember or to use when you need it, when the person needs it, which is in the flow of their life. So that’s really what the digital technology is allowing us to try to do here in SlowMo.

Dr Lucy Maddox:        And were the sessions weekly and how long were they for?

Dr Tom Ward:              It involved eight sessions conducted weekly. On average they’d range between 60 and 75 minutes across the trial. Given that it’s not simply talking one to one, face-to-face talking for 50, 60 minutes. Given that there’s interaction with the website, where people are listening to the experiences of other people with similar experiences it struck me that actually people were able to engage for slightly longer than we might expect within a more traditional approach.

And also, the other thing that we were very keen to do is where the person was willing, we wanted to take the therapy out into situations where the person was most worried. So this meant taking the phone out with the person to try their slowing down strategies in situations they were fearing.

Dr Lucy Maddox:        Yeah, that’s really interesting what you said about people being able to tolerate slightly longer makes me think about sometimes how having difficult conversations can be easier if you’re not having to look at each other all the time. So like if you’re driving or something, sometimes you can have a more in depth conversation. And I was just wondering if you thought that tolerance of slightly longer was to do with the conversation being triangulated through something else as well or whether it was for another reason?

Dr Tom Ward:              I absolutely agree with that. I think prior to having delivered the therapy I had some worries or reflections about what would it be like to not have a one-to-one discussion where you’re going back and forth in that way? Because that’s what I’d known, and I wondered whether it might be clunky in some way to have the structure of the website and the material and how that would work in the process of a session.

                                    I wondered how that was going to go. And how it went is exactly how you’ve described it. That the fact that the attention was triangulated, and the person could click and listen to people who had experiences that they may connect with or they might not connect with. And that could be used as a springboard back into a discussion around how the person’s situation was similar or different.

That really did seem to facilitate a really therapeutic process, which to me had some significant benefits over the classic mode of delivery of cognitive interventions. It naturally lent itself towards collaboration because the person was actually controlling the touchscreen and clicking on things. And true collaboration in that way was facilitated. One of the sessions towards the end talks about how our past experiences of relationships can affect how we worry about things in the here and now.

And that can bring up some of the experiences of the people that we’ve worked with involve experiences of trauma and bullying and discrimination are very painful experiences, which can be really painful and difficult to discuss in sessions. And the fact that they were able to hear the experiences of other people and choose the extent to which they wanted to discuss their own experiences. It felt to me that the power was very much with the person in the session and the triangulation really helped in that respect.

Dr Lucy Maddox:        And eight sessions is kind of not that long actually, I was thinking. What happens in those sessions? Is there quite a similar content that they tend to follow? Or is it a bit flexible?

Dr Tom Ward:              So partly the answer to that question is that it’s targeted and structured. And the evidence from the trial was that therapy was delivered very much as planned. And there are issues within psychological interventions, particularly in the context of psychosis where there’s so much complexity to the situation that it can be hard to retain the clear focus across longer periods of work.

                                    Very much what we were able to do here is provide an engaging way for somebody to really understand and make changes in one very specific area which proved helpful. Having said that, what we’ve also found and we might talk about the findings in a bit more detail. We’ve found that the improvements that we saw in the trial were not limited to the people’s experience of paranoia.

                                    But we actually saw more general improvements in wellbeing, quality of life and the person’s self concept and positive sense of themselves. And that showed that as well as targeting fast and slow thinking, we were able to work with this flexibility to be able to bring in other aspects that might have been relevant for the person. And we know within the context of psychosis how the person sees themselves and self esteem can be so critical. So we were able to target other areas as well within our main focus also.

Angie:                          I’ve suffered with psychosis for many years and I found this probably one of the most helpful tools that I’ve been offered.

Dr Lucy Maddox:        What do you think made the difference? What do you think made it more helpful?

Angie:                          Probably I was in the right frame of mind. I think it’s important that you accept that you do need some help. So I think that made a difference. Also, it was such a simple idea that you could grasp. And they’d show you little pictures of things. For instance there was a picture of a man with a wallet in his hand, and he was running.

And you had to say what you thought was happening, just to show how your thoughts can be different. I said that it looked like he might have pinched it and was running away. And she said, “Yes, that’s one option.” Or she said that he could have found it and was chasing after the person that had lost it. So it was just a way of learning how to think, to rethink it.

Dr Lucy Maddox:        So like opening up just the possibility of there being other explanations for something?

Angie:                          Exactly. Yes, exactly.

Dr Lucy Maddox:        Sometimes people can experience worried or paranoid thoughts about the internet. And I was curious to know how that fed into the design of the app. Here’s Tom.

Dr Tom Ward:              It was something that we were considering at the beginning of the trial as something that was potentially something that people might worry about. And one of the ways in which the phone was set up is such that it was possible to use it without connecting it to the internet. So it was possible to have the phone just as a sort of a standalone resource that wouldn’t be connected to the internet and wouldn’t be synchronised with the session. Given that people might potentially have concerns about information that they were adding to a phone being transferred across.

                                    But in effect in the trial, actually people didn’t commonly express those concerns and liked the fact that what they were doing with the phone was actually linked into the session, and it was automatically bringing that into the session. So the concerns around the technology and the surveillance were actually not as significant across the trial as perhaps one might think at the beginning. It was quite interesting to see how naturally people were engaging with the technology in the session.

Dr Lucy Maddox:        That’s really interesting and I bet it took so much thinking through at the start to think through all of these potential problems.

Dr Tom Ward:              Absolutely, and part of the blending of therapy so that you have face-to-face therapy which is augmented by digital therapies you have an opportunity to develop a therapeutic relationship. To develop trust, which is so crucial when we’re working with anybody but particularly people who’ve experienced worries about other people and paranoia. So in a sense that relationship is facilitating the person engaging with technology, because there is an element of trust, hopefully in the person that they’re seeing.

Dr Lucy Maddox:        Sounds like it was a nice experience for you as a therapist as well.

Dr Tom Ward:              Absolutely. It’s a nice experience to feel that it’s a really clear and collaborative thing that we’re doing with the person. And it’s thought and designed in a way to make it engaging and easy to use and enjoyable. Yeah, that was a real pleasure to be delivering a therapy that people were engaging with in that way. I sometimes feel you sometimes hear people talk about discussions about whether people are, the idea of socialising people to a psychological model.

                                    Or you even hear sometimes people say, “Perhaps somebody is not psychologically minded.” And you still hear that. And it always really surprises me because it implies somehow that we have the great therapies already and the issue is really the person is not really getting it or able to get it.

                                    Whereas the reality is that we need to develop and provide psychological interventions that meet the needs of a diverse range of people. And actually, in a room face-to-face talking for 50 minutes can be really helpful for lots of people, but it’s not for everybody. And so, I felt really privileged that in collaboration with others like Dr Amy Hardy who really led on this, that we were able to deliver something that really seemed to meet the needs of a really diverse range of people. And so that felt really good to do that.

Dr Lucy Maddox:        I was just thinking the only time it would be less accessible I guess is if someone doesn’t have so much access to the internet or to digital technologies. Is that a kind of barrier that’s come up at all or have you mostly found that people tend to have access?

Dr Tom Ward:              This is a really important question because it’s about the extent to which some of the people that we work with may be excluded digitally. As you say, maybe don’t have access to wifi, don’t have access to smartphones. Within the trial, we are looking to develop an intervention that works for everybody, regardless of their prior experience or confidence with technology.

                                    We had quite a few people in the trial that would come having not had any access to smartphones, using digital technology or laptops. And one of the interesting things that we’re looking at is just that actually this is an intervention that was engaging for people regardless of their other experiences of digital technology.

                                    But what we actually did within the therapy is that we provided the phone, the app that was loaded onto a smartphone. So that it meant that people could use that and take that away and could have access to that. And it didn’t need to be connected to wifi at all during the week, it was something that the person could take away, and engage with and use.

And when they came back into the session, it would be synchronised with the website so that anything that they’d added they might have noticed the worry or created a helpful positive thought. It would all be synchronised so that it was held within the website. So no learning was lost, it was facilitating in that way.

Dr Lucy Maddox:        I asked Angie what had changed for her in her life since SlowMo.

Angie:                          Before I couldn’t always get on the bus, that was a tricky one. I didn’t like going into crowds, I’d stay home quite a bit. Then I did the SlowMo and the SlowMo made a real difference because it taught me how to think in a positive way and not in a negative way. And it meant that I could actually sit on a bus and not have to get off at a stop because I was feeling conscious of people looking at me. I could go out and meet friends. It really made a difference.

Dr Lucy Maddox:        That’s so good. A trial of the effects of SlowMo has recently been published. So what did you find?

Dr Tom Ward:              So what we found is that this was an intervention that was designed to help people who were experiencing worries about harm from others or experiencing paranoia. And what we found was that people who received the therapy did show reduced levels of worries about harm from others or paranoia at our follow up periods. So it was effective in what it was designed to do.

                                    One of the other things that we were trying to do here is that it’s designed as a targeted intervention. So we wanted to know is it effective in helping people reduce paranoia? And if it is, does it work in the way in which it’s been designed to work? And that means does it help people to slow down their fast thinking? And is that part of what helps them reduce paranoia?

                                    And so what we found is that people that had the intervention were showing significant reductions in paranoia at the follow ups, compared to people who had standardised treatment as usual. And we also found that it did work in the way that we’d anticipated, it seemed to work by allowing people to slow down their thinking and worry less. So that was really, really encouraging evidence of the effectiveness of the intervention.

                                    And as I’ve mentioned before, the significant changes were not limited to the paranoia measures that we had. We also found really important changes in areas such as quality of life, wellbeing and positive beliefs about the self, really. These are outcomes that are really valued by service users. If you think about what people want from psychological interventions and therapies, people would often say, “I want my life to be better. I want to be enjoying myself. I want to be able to go out and work.”

                                    So we were really, really happy to see that not only was SlowMo effective in reducing paranoia in the way that we expected it to. We were also seeing broader improvements in those important areas as well, so that was really good to see.

Dr Lucy Maddox:        That’s fantastic. And really great that it’s actually effective in reducing paranoia as well as reducing those other outcomes to do with quality of life and how people feel. That’s really exciting.

Dr Tom Ward:              Absolutely. Other things that we were interested in that I’d mentioned before. We wanted to see the extent to which we were successful in designing an intervention that was engaging and accessible and liked by people. And so we’re really encouraged by the evidence that we’ve got that this was something that people engaged with.

Actually, delivering psychological therapy in the context of people who experience paranoia and may have difficulties building trusting relationships it can be challenging. And drop out from therapy is something that is a significant issue in our field. And so, from the perspective of someone who was responsible for the therapy across the trial, I was so happy to see that we managed to have 80% of the people in the trial who were allocated to receive the therapy completed all of the planned sessions.

And in the context of the field that we work in, this was something that we’re really happy with and speaks to an intervention that people engaged with. And we’re going to be looking at also measures of enjoyment that we’ve also collected. And they’re also showing signs that people found this an enjoyable and engaging experience. So excited about those areas of the outcomes as well as the main outcomes on paranoia and other areas.

Dr Lucy Maddox:        That’s great, great results. And really promising, I guess, for using this approach in the future for other sorts of interventions as well, using this design led approach.

Dr Tom Ward:              Some of the things that we do take from what we’ve learnt is that yeah, this approach to human centred design and this engagement with thinking about making our interventions more appealing to people. This is really something that people are beginning to think about, but we need to take very seriously. Yeah, we need to start to make interventions look and feel the way people want them to.

                                    And that’s something important. And the other thing is about the blending of digital therapy with face-to-face therapy. I think some people understandably worry when they hear about digital therapy. And they worry that maybe we’ll lose something important. That most psychologists and clinicians will think about therapeutic relationship and how central that is.

                                    And I think people worry sometimes that digital technology might end up lead us away from that important truth. But what we’re trying to do with the blending of digital technology is to take what we do well in face-to-face therapy and just make it better. And make it more effective, make it more engaging and make it work for people in their lives, because that’s where the important change should be occurring.

Dr Lucy Maddox:        I asked Angie if there was anything else she wanted to say about the therapy.

Angie:                          I’d just like to say that if you’re offered a therapy, then it’s worth having a go. If you feel that you’re in the right place in your head, and you’re offered some sort of therapy, it’s a good idea to embrace it and use all the help that you can. Because like me, many years ago I used to think I could cope with it and the voices would go away, and I’d be okay.

                                    But if you don’t take up opportunities when you feel like it, then you’ll miss out and people are there to help you. And you’ve got to try and understand that. And also, with the SlowMo, you’ve got the beauty of the technology with the laptop, but you’ve still got the clinician working with you. So you’ve still got a person that you can talk to. So that’s my advice to try. I know it’s not always easy but try and take up things that you’re offered and don’t be frightened to ask, if there’s anything.

Dr Lucy Maddox:        Yeah, that’s really, really helpful advice. And actually, you asked, didn’t you? And then you got on the trial, so that was really good.

Angie:                          That’s right, I had to keep on. But as I say, I got there, and it worked.

Dr Lucy Maddox:        Yeah, it’s great, good for you.

Angie:                          Thank you.

Dr Lucy Maddox:        Thank you to both my experts, Angie and Tom Ward. If you’d like more information on the SlowMo therapy, have a look at the show notes where you can find the website link. There’s a link in there as well to Angie talking on the One Show about the therapy. For more on CBT in general, and for our register of accredited therapists, check out www.babcp.com. And have a listen to our other podcast episodes for more on different types of CBT and the problems that it can help with. I hope you’ve enjoyed this bonus episode. I hope things are going well for you.

                                  END OF AUDIO

Show Notes

Websites For more about the research check out: http://slowmotherapy.co.uk

Angie talks about SlowMo on The One Show: https://youtu.be/lCI7LKFbyrw

For more on BABCP visit www.babcp.com

Articles These academic journal articles below are all produced by the SlowMo team to investigate the therapy.

Ward, T., Hardy, A., Holm, R., et al. (2022) SlowMo therapy, a new digital blended therapy for fear of harm from others: An account of therapy personalisation within a targeted intervention. Psychology And Psychotherapy: Theory, Research And Practice. DOI : 10.1111/papt.12377

Garety P, Ward T, Emsley R, et al. (2021) Effects of SlowMo, a Blended Digital Therapy Targeting Reasoning, on Paranoia Among People With Psychosis: A Randomized Clinical Trial. JAMA Psychiatry. 2021 Jul 1;78(7):714-725. doi: 10.1001/jamapsychiatry.2021.0326. PMID: 33825827; PMCID: PMC8027943.

Hardy A, Wojdecka A, West J, et al. (2018) How Inclusive, User-Centered Design Research Can Improve Psychological Therapies for Psychosis: Development of SlowMo. JMIR Ment Health ;5(4):e11222 doi: 10.2196/11222

Garety, P.A., Ward, T., Freeman, D. et al. (2017) SlowMo, a digital therapy targeting reasoning in paranoia, versus treatment as usual in the treatment of people who fear harm from others: study protocol for a randomised controlled trial. Trials 18, 510 . https://doi.org/10.1186/s13063-017-2242-7

Books Overcoming Paranoid and Suspicious Thoughts by Freeman, Freeman & Garety https://overcoming.co.uk/600/Overcoming-Paranoid-And-Suspicious-Thoughts---FreemanFreemanGarety

Children don't come with a manual, and parenting can be hard. What is evidence-based parenting training and how can it help? Dr Lucy Maddox interviews Sue Howson and Jane, about their experiences of delivering and receiving this intervention for parents of primary school aged children. 

 

Show Notes and Transcript

Sue and Jane both recommended this book:

The Incredible Years (R): Trouble Shooting Guide for Parents of Children Aged 3-8 Years

By Carolyn Webster-Stratton (Author)

Sue also recommended this book:

Helping the Noncompliant Child Family-Based Treatment for Oppositional Behaviour  Robert J. McMahon, Rex L.Forehand 2nd Edition Paperback (01 Sep 2005)  ISBN 978-1593852412

Websites

http://www.incredibleyears.com/

https://theministryofparenting.com/

https://www.nurturingmindsconsultancy.co.uk/

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

Accredited therapists can be found at www.cbtregisteruk.com

 

Courses

The courses where Sue works are available here, and there are similar courses around the country:

https://www.reading.ac.uk/charliewaller/cwi-iapt.aspx

 

Photo by Markus Spiske on Unsplash

This episode was edited by Eliza Lomas

Transcript

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

This episode is the last in the current series so we’ll be having a break for a bit, apart from a cheeky bonus episode, which is planned for a few months’ time so look out for that.

Today, I’m finding out about evidence-based parenting training. This is a type of intervention for the parents of primary school aged children. It draws on similar principles to cognitive behavioural therapy about links between thoughts, feelings, behaviours and bodily sensations and ideas from social learning theory. It also draws some ideas from child development such as attachment theory and parenting styles.

To understand more about all of this, I met with Sue Howson, parenting practitioner who works in child mental health services and Jane, a parent who has experienced the training herself.

Jane:  My name is Jane and I’ve got a little boy called Jack who is seven and he’s in Year 3.

Lucy:  And you’ve experienced evidence-based parenting training, is that right?

Jane:  Yeah, I have. It’s something called the Incredible Years. And there was a really nice lady called Sue and my school put us in touch to form a group to kind of help me manage Jack a little bit more at home.

Lucy:  So, your journey into it was that the school let you know about it?

Jane:  Yeah. Basically, I was having a few issues with Jack at home and I think it was kind of impacting on school as well. So, I was working with the special needs coordinator and she, obviously, had me, Jack and my family in mind as someone who might benefit from working a little bit with Sue.

 I was a bit nervous at first, you know, like professionals coming in, getting involved. But she was really nice and it was really beneficial.

Lucy: Is it okay to ask what sort of difficulties you were having at home, sort of what was going on?

Jane:  Yeah, I can tell you now because it’s all changed, it’s much better.

Lucy:  Oh good, that’s great to hear.

Jane:    I mean, Jack’s a lovely boy. He’s my eldest and he’s really nice and just a bit of a joy – he is now. But I think one of the main things that I was struggling with, with him, was kind of difficulties with falling asleep. In the evenings, he would always want me to fall asleep either next to him or in his bed and that was kind of impacting on our evening, mine and my husband’s quite a lot. And it was taking up a lot of time and I think evenings are quite hard because you’re so tired and you just want to go to bed.

So, that was one of the issues. And the no sleep was impacting on all aspects of our family life, really. I would just be really tired all the time and quite short, and end up shouting at Jack when I just wanted him to go to sleep and he wouldn’t. And shouting wasn’t ideal and doesn’t help but I’d just get frustrated, really and I think quite a lot of us were quite unhappy.

Lucy: That sounds super hard.

Jane: Yeah. I mean, he is seven but he’d kind of throw a massive wobbly if he didn’t get what he wanted, like, I don’t know, like an extra biscuit or chocolate finger or something from the cupboard, he would just kind of lose it. And that was really hard to deal with, particularly when you’re tired. I know you shouldn’t but you always kind of end up giving in a little bit, don’t you, because you just want the easy life. And you know that you shouldn’t but…

Sue: It’s really hard when you’re being shouted at or when you’re exhausted like that.

Jane: And I’d also feel like the path of least resistance, like sometimes it just easier to give in, even though I knew that I shouldn’t. So, I guess those are the main issues, really, kind of thinking about his behaviour.

And there were a few concerns from school in terms of his behaviour. Obviously, he was tired at school and maybe not doing as much as he could be schoolwork-wise. It was kind of impacting everything, really. So, that’s where Sue came in.

Sue: My name’s Sue Howson and I am a parenting practitioner and I’ve worked in CAMHS for many years, background in social work. I’ve been working with children and families for years and years and years. But I also have a role of teaching practitioners at the University of Reading.

Lucy: And do you teach practitioners about evidence-based parenting training?

Sue: Yeah, absolutely. So, I have trainees coming from various different parts of the country to Reading University where we teach two really strong evidence-based parenting interventions where the practitioners become super equipped to go out into the community and offer the support that the parents need.

Lucy: Fantastic. And this is all extremely topical because BABCP have recently launched the evidence-based parent training accreditation pathway.

Sue: Yes, which means that the parent training pathway is now on par with the CBT pathway, which is hugely exciting for all those people out there that are actually during parent training and offering parenting interventions. It’s a really great way to get those skills and practices recognised. So yes, I’m really excited by that too.

Lucy: Could you say a little bit about what evidence-based parent training is?

Sue:  It is a practice that is based in social learning theory and really focuses on the attachment relationships and building the relationships between parent and child and building on parental self-confidence and self-efficacy and trying to equip the parent and skill up the parent to notice particular behaviours in a child and them then feeling confident in applying a particular technique or a particular method in the moment which will make a difference to – fingers crossed – to the outcome of that little interaction between parent and child.

Lucy: When we’re talking about social learning theory, by that do you mean the way that we all learn from what we see around us?

Sue: Yeah. It’s learned from our environment and the things we see around us.

Lucy: So, it’s kind of providing parents and carers with a different model of how to do things.

Sue: Yes. So, perhaps in their upbringing, they were brought up with one particular style of parenting and parent training offers, perhaps, a selection of different ideas on how they may choose to interact with their child that’s different from the way that they were brought up.

Lucy: Which is very interesting, actually, isn’t it? Because, you know, it’s not something that’s taught in school, is it, parenting? So, it’s very much something that people do quite intuitively or in the way that they’ve been brought up or that their friends are doing it. So, there’s a lot of social influence involved, actually, isn’t there?

Sue:  A huge amount of social influence. And quite often, in homes, both parents don’t do it the same way. So, just because you do it one way, your partner might do it in a different way and you may never have even discussed that until you reach a point where you’re having challenges with your child.

So, you may end up having to think about things and being much more consistent. Especially with children with ADHD and autistic spectrum difficulties, the consistency element is really, really important.

Lucy:  I asked Jane what she’d expected from evidence-based parenting training.

Jane: Oh, I was a bit nervous and apprehensive to begin with because, you know, it’s bit embarrassing, isn’t it? You’re the one with the naughty kid that doesn’t do what they’re meant to.

Sue kind of made me feel super relaxed from the start. She’s really approachable and just like normal, like not too expert, not using all these words that I didn’t understand. And she was quite relaxed so that kind of made me feel quite relaxed and let me feel comfortable to ask questions, even though they might have been silly or they might seem obvious.

So, that was really nice in the beginning. I liked how she said things about the group rules, like intense confidentiality and respect and that made me feel like it was okay to share, really.

Lucy: That sounds really important.

Jane: Yeah. And I think one of the biggest things, obviously, apart from the actual strategies she gave me, was being able to meet other parents in a similar situation who had a child like mine. And we kind of set up a WhatsApp group after, which is really nice. Now Sue’s worked her magic, that kind of keeps us going. Like if you’re having a bad day, you can still speak to someone who knows.

Lucy:  I asked Sue to talk us through what evidence-based parenting training involves and she said there are two methods. The first is the group process, which Jane did. This is usually two hours a week minimum for 12 to 14 weeks on the Incredible Years programme together with parents who are experiencing similar difficulties.

Sue: The other offer would be an individual based programme, which we tend to offer for parents who find it hard to access the group. Or maybe they’ve tried a group before and it hasn’t necessarily worked. Or a parent that doesn’t feel quite ready or confident enough to go into a group so we would offer those parents a sort of one-to-one. Building a very similar model but the child is involved in those.

So, the group one is just for parents but the individual programme, the child comes along to those sessions as well.

Lucy: That’s great. And it’s lovely that it can be so flexible so it can be group or individual. That sounds really important.

Sue: Both have been able to go remote now. That’s been quite a spectacular shift and I think that It’s gone down quite well for parents because it means they don’t have to organise childcare in order to be able to attend groups and things. You know, practitioners have been able to offer them in the evenings, perhaps when kids are in bed or at school, when parents aren’t working. So yeah, it’s gone down really well.

Lucy: That’s fantastic. Yeah, that sounds really helpful. I was really curious about the sort of key skills and techniques that you teach in the evidence-based parent training. What are some of the topmost important skills do you think that get taught?

Sue:  The first quarter of the programme, I would suggest, is focused on building that relationship. And that’s largely done through child-led play, spending time together.

Jane: One of the things that we were asked to do was to set aside 15 minutes dedicated time each day to play with him. And I loved it and I felt like I learned loads about him in terms of some of the things he could do with play that I didn’t even know about because I was probably too busy doing the washing up, previously. Rather than me just getting frustrated and shouting. It really kind of built our relationship.

Lucy:  That sounds really fun, actually, yeah.

Jane:   Yeah, yeah, it’s nice to be a big kid rather than just be adult all the time.

Lucy: Back to Sue.

Sue: There’s a particular way of playing and it’s not just what you do, it’s the way that you do it. We particularly look at noticing what a child’s doing well.

If you’ve got a child who is inattentive, for example, it might be very helpful for the parent to notice when that child is paying attention and focusing. Quickly jump in with praise to encourage that child to do it again. So, that’s the bit of social learning that we’re building on there. So, the child is paying attention, the parent notices the child is paying attention. The parent says, well done to child, so child is more likely to pay attention in that way again.

Jane: Another thing that I learned was like the attention rule. So, it’s kind of drummed into us so what they always say is whichever behaviour you pay most attention to you will see more of and kind of flipping that on its head. So, thinking about what attention I was giving to Jack, whether it was positive or negative and trying to focus on the positives, really, which kind of gave me a little bit of perspective.

I just felt as though he was really difficult all the time, whereas, actually, if took a step back and focused, I realised that he wasn’t and there were lots of really good things that he was doing that I didn’t always necessarily notice.

Sue:  We also look at the ways of praising a child or rewarding a child. Quite often – and I’ve definitely been guilty of it myself – is putting a tag on a praise statement, for example. So, we might say, “Ooh, well done for tidying your bedroom. Why can’t you do that all of the time?” And that’s the tag. The tag there is, “Why can’t you do that all the time?” So, we’ve given with one had the praise, “Well done for tidying your bedroom.” But quite often as parents, we will take away the praise by adding that, “I wish you could do that all the time,” or, “Why can’t you be more like your brother?” Or we’ll add a something that actually negates the praise.

 So, parents, by week five, six are really becoming conscious of the language that they use and how impactful that can be. And this really works well with the group of kids that I’ve talked about already because they’re quite selective with their listening, perhaps or they don’t really hear it all. So, it’s very powerful for kids to make sure that they’re genuinely hearing praise.

 What else do we do? We then go on beyond praise and start thinking about our ability to remove that attention. So, we think about how we ignore a child. And quite often, parents will tell me, “Oh yeah, yeah, yeah, I ignore my children. I can ignore my children for five hours.”

We’re not talking about not being with a child or the child being occupied very happily doing something else. We’re actually talking about an active removal of a parental attention, which is then when the child complies again, then the parent comes back and uses their attention in a particular way to reinforce the positive behaviour.

Lucy:  When would a parent do that kind of taking the attention away? Would that be in response to something in particular?

Sue:  Yeah, ignoring a particular behaviour. And we suggest that those are the behaviours that are annoying type behaviours. So, we’re talking about whingeing and whining and grumbling and answering back and nagging, you know, “Mummy, can I have a biscuit? Can I have a biscuit? Can I have a biscuit?” The parent has said no and that potentially could escalate between parent and child, where the child says, “You are the worst parent in the world. I hate you. It’s not fair.” But the parent needs to be ignoring that the whole way through.

Kids are brilliant at this, absolutely brilliant, really clever at trying to get parental attention. So, they will up their behaviour. So, they may be saying, “Yeah, you’re the worst parent in the world. I don’t love you anymore. It’s not fair. Lucy down the road, she’s allowed to do this, that and the other.” Quite often, parents will snap at that point, therefore, no longer ignoring the negative behaviour that the child is presenting.

So, the skill is for the parent to be able to keep a lid on it until the child has run out of energy in their negative behaviour. And when the child comes back down, that’s when we want parents to reengage with the child and respond in a positive way to the quiet, calm, polite behaviour that you hope your child is now exhibiting.

Jane: Sue helped me, teaching me strategies to calm down, things like breathing techniques and stuff, obviously, for me and for him so that when he was on the verge of losing it, he could count to 10 or take some deep breaths. It wasn’t like I was just shutting the door and leaving him to lose his mind. And that really helps.

I understand ignore sounds awful but I think it’s about, it’s like what you do and how you do it, rather than ignoring and leaving him to it. Because that’s not very nice.

Sue: The idea of an ignore is only for the duration of the negative behaviour. So, if you think about the whingeing and whining for the biscuit, how long can a child continue to ask you for that biscuit? Five, 10 minutes, tops. You’re not leaving them in a room, you’re not walking out on them, you have just got to develop this sort of Teflon coating where you hear what they’re saying but you choose not to respond to it.

But it’s the parent’s removal of attention that’s key.

So, if a parent is actually leaving the room, then they’re not actively ignoring, they are doing something else. But an active ignore, which is what we’re talking about, the parent has to be very present because the moment the child has come back down that sort of angry curve, they come back down the other side. So, what you try to do if you wait for them to deescalate and then move on and get them involved in another task.

Lucy:  I’m just thinking it’s sometimes really difficult to do, isn’t it, just as you describe that kind of…

Sue:  Yeah.

Lucy:  …snap. Just as things are escalating, particularly in a public situation. Or I guess if you feel that you’re worried that the child’s upset as well, it’s hard, isn’t it?

Sue: Desperately hard, especially if you understand why your child is worried or you understand why your child is fearful, you know, if you’ve got an anxious child, for example. So, parents have to be able to work out which is a behaviour that they want to encourage or which is a behaviour that they want to see less of. And we spend a lot of time thinking about those things.

Parents will say they’re very good at ignoring children but they quite often forget to reengage at the other end. So, the active ignore is a big step.

Lucy:  I wanted to know from Jane how it felt to remove a tension in more difficult settings like in public.

Jane: Because I had – well, script is the wrong word – but like a thing to follow, it kind of built my confidence in being able to do it. I think once he kind of learned where the boundaries were at home, it kind of like resolved itself a little bit when we were out in public because he knew from the beginning that it wasn’t going to wash and he was just going to get ignored.

And flipping it on its head in terms of the negative tension, the positive tension, it just kind of got a bit easier because I felt a bit more confident and then I had the skills to cope.

Lucy:  Another important aspect which Sue talked about is how we think about the language that we use when we talk to children.

Sue: Quite often, we use a lot of negative commands, “Be careful.” It’s sort of an empty command, what does it actually mean? Whereas autistic spectrum children who probably need very, very clear communication, if they’re playing on a climbing frame, for example, “Be careful,” could be replaced with, “Hang onto the bars,” or, “Use both feet on the climbing frame,” really clear for children to know exactly what they should be doing.

And it’s amazing when you tune in to that and you start listening to your friends and your relatives and things, you do realise that in everyday English, we use a huge number of negative commands for children. You listen to teachers in schools and they’re saying, “Don’t wriggle, don’t poke him next to you, don’t do this, don’t do that.” But what we should be saying is, “Please do, please do this, please do that,” because children quite often only hear the last word that comes out of our mouth. So, if we said, “Don’t run,” the only word they hear is run.

Lucy:  Absolutely. And it’s also quite negative, isn’t it, if someone’s constantly telling you stuff not to do. I don’t know, it feels different in tone, doesn’t it to telling you stuff that they would like you to do.

Sue: And when you set them off, in the same CBT-type model, you set them off with homework and home practice and things to do, when they come back the following week, they often say, “Well, the atmosphere in my house completely changed because we were focusing on positives, not negatives.” And again, it begins to shift what you notice as well.

Jane:  It’s kind of a bit of a bugbear of mine and now I’ve realised it. Like, quite often, a lot of my friends and even my in-laws or my parents will say, “Oh, you’ve done really well, good boy, good boy.” And for me, it was like thinking about what that even was. Sue really helped me see the importance of being specific around the praise that you’re using. So, that kind of then links it to their behaviour rather than just being, “Oh yeah, that was really good.”

So, specific praise for me was really important. I saw a really big impact on Jack’s behaviour when I was able to use really specific praise with him to, kind of, you know, highlight the good stuff that he’d been doing, like putting his plate in the dishwasher or calming down after an ignore, you know. Like when he was able to use his breathing strategies and then come back and then when we started to play, I’ve said, “Well done for calming down,” or that kind of stuff. So, the specific praise, brilliant.

I think also, thinking about some of the phrases and the language that I use with him. So, if he’s really wanting something like, I don’t know, wanting loads of ice cream or something but he won’t eat his dinner, a little phrase like, “When you’ve eaten your dinner, then you can have your ice cream,” the when-then thing worked really well for me and made me think about the kind of words I was using and the impact that was having. Because, obviously, what I was doing before wasn’t helping.

And I guess the other big thing for me that helped was the use of rewards. So, it helped me think about a specific target for Jack in terms of how we could get him to stay in his own bed. We used like Batman stickers when he was able to do it.

Lucy:  That sounds nice.

Jane: And then when he did it consistently for like five nights, we then went ten pin bowling, which was lovely.

Sue:  Oh great.

Jane:   Yeah. Everything just became a lot more positive, really.

Lucy:  That sounds really powerful.

Jane:  It was, actually, yeah.

Lucy: Often, parents find that things like time out just aren’t necessary once praise and play and positive attention are in place.

Sue: Absolutely, absolutely. And I don’t know whether you’ve noticed that while I’ve been talking to you, I keep doing this, I keep forming a sort of pyramid with my hands. And the fundamentals of the parent training is really about building that broad base at the bottom, which includes play and attending to a child and listening and problem solving. These are all the building blocks of a really strong relationship. And we’ve got praise in there and we’ve got rewards in there.

And then as you move up the pyramid, you’ve got to start thinking about the other sort of techniques. We’ve got the children stuff at the bottom, you know, all the stuff that you can do with your children to build the relationship. And then you start thinking about the techniques that parents can apply to kind of modify behaviour. So, that’s when we start talking about ignoring or the language that we use, thinking about command statements and starting to put in boundaries.

And then as you get to the tippy top of the pyramid, you’re thinking about time out and the use of consequences.

But fingers crossed and a lot of periods experience this when they’re going through our programme, they start by saying, “I just want to hear about time out. I just want to hear about how to do it better.” We say, “Hey! No, no, no, we’re going to start at the bottom. We’re going to build that relationship.”

And by the time we get to the point where we want to tell them about time out, they actually find that they don’t need to use time out as much as they did at the beginning because they have so many other effective strategies on managing behaviour and noticing different behaviours before we get to the top, before we get to the point where we may need to put in a consequence or a time out.

Lucy: And the very, very end bit of that pyramid that you were describing, the time out is probably something that people kind of are really familiar with, actually, because it’s around because of programmes like Supernanny.

Sue:  Yeah, you’re right and people love it on Supernanny, because she spends a lot of time talking about “naughty steps,” doesn’t she?

Lucy:  There’s a lot of naughty steps in Supernanny. Is it the same in evidence-based parenting training or is it a bit different?

Sue:  It’s similar but it does hang onto that idea of differential attention. So, you can’t just put a child on a naughty step or a naughty spot – and we wouldn’t necessarily use that phrase – we would encourage a parent to be removing their attention on purpose for a period of time. And that time is linked to age, which is very much similar to the Supernanny model.

But one of the things that we would absolutely advocate is making sure that when the child has completed their moment of exclusion, the child comes back into the family activity in a calm state and they’re not expected to say sorry. They’re just expected to come back calm and quiet and you just move on with your activity.

A lot of parents don’t necessarily like hearing the bit about not saying sorry. One of the ways I try to describe it is if you’ve ever had an argument yourself, you don’t immediately calm down. You’re not always receptive to apologising or hearing somebody else’s view. So, by asking a child to apologise in that moment, you either get a, “Ugh, sorry!” which doesn’t mean anything anyway or you will get a reignition of the fire, of the flames of the heat of that moment.

So, it’s actually better to choose your moment to have that discussion, have that teaching element of your parental relationship when the child is calm or by modelling calm yourself or reminding them of what they do well, going back down that pyramid and through play. And the child will enjoy the attention they’re getting so much when they’re being played with in a particular and positive way versus the attention they get when they are simmering and smouldering. So, that’s the rationale.

Lucy: It also sounds less shaming because there’s something tricky, isn’t there, about when any of us have been told off, that rush of shame that you get to begin with. I guess your kind of avoiding like really going over that by getting a child to go over things and say sorry.

Sue: Yes, when they’ve thrown something at their brother and that’s why you’ve removed them from that scenario for a few minutes, they know that they shouldn’t have thrown that thing at their brother or they shouldn’t have kicked you or they shouldn’t have sworn at you.

So, that’s the sort of step on from the ignore and ignore is in the moment hoping that the child can deescalate, wind themselves back in. But if you feel like they have gone beyond that, so there are some behaviours that we completely see as being completely unacceptable and those are the sort of violent behaviours, then that’s when we would put them into the total removal of parental attention, the sort of time out type space.

And so, we do spend quite a bit of time thinking about parents’ thoughts and their physical emotion. So, we think about how cross they are when they’re ignoring or how wound up they are when they’re trying to do time out and we think about how they choose to behave, how they choose to respond to their child as a result of those thoughts and those feelings. So, we try to incorporate those three elements as best we can.

Lucy: I was curious to know whether Jane used any of the techniques from the top of the pyramid like time out with her son.

Jane: I don’t really feel as though we had to use it so much, I think mainly because of Jack’s age, he’s a bit bigger now. The ignore and the praise and the play and the positive attention and also building the relationship had the biggest impact.

And like Sue talked quite a lot about your pyramid being upside down beforehand or properly ignoring, you know, with any like real idea of how to do it or what I was doing. Or maybe trying to put him on the step and then he wouldn’t and then it just all goes wrong.

So, I was probably doing a lot of that at the beginning whilst trying to get through my day and not spending enough time with him and not doing the bottom stuff, which I think, obviously, is what for me has made the biggest difference.

Lucy: But you were doing the best you could, weren’t you, at the time?

Jane:   Yeah.

Lucy:  Super hard.

Jane:  I feel like they don’t come with a manual, do they? But that’s why the group kind of helped really. It gave me a bit of perspective like to stand back and think about things that are kind of happening on a day-to-day and what was going on for both of us, really. And also like a checklist in my head about what to do and when and that was amazing in terms of my confidence, really.

Lucy:  I asked Sue what changes she saw from the start of the programme to the end.

Sue: Yes, most parents want to come in and they really, really want to hear about these big time out, big guns approaches, potentially as a little bit of resistance to the idea of building a relationship. “Oh come on, come on, come on, let’s move on. I just want to hear about the big stuff. Why are we wasting our time on this little stuff? I just want to hear about the big stuff.”

But by week three or four, they really do begin to see shifts in the way their children are responding to them and the tone in the house about noticing the positives rather than just looking at the negatives. So, we really see shift early on.

 And like I say, by the end, fingers crossed, you would hope that parents are not needing… you know, they feel quite proud when we get to the sort of time out stage of the programme and they go, “Yeah, I get this but I don’t need it,” you know.

 So, we do see big, big, big shifts through parents. And one of the things I love and one of the reasons I just keep going with this is because I see that confidence building in parents. And we have parents coming back and saying, “Yeah, we only talked about getting my child to bed but I now realise that if I just apply the same ideas and the same principles, I can use that with, ooh, getting him into school or encouraging him to do his homework.”

So, there are all sorts. We are building skills which you then hope can be sort of expanded out and used in all sorts of settings.

Lucy:   And it’s called evidence-based parent training. What is the evidence base like for it?

Sue: The evidence base for both of the programmes that I’ve mentioned so helping the non-compliant child and in particular the Incredible Years, I mean, Incredible Years has had 25 years of research and has been developed over, I think it’s now delivered in 32 countries in 32 different languages to all sorts of different communities.

And it isn’t prescriptive. Parents come along and you work with parents’ individual goals. So, each individual in that group will be working towards their own goal in that group but they’ll have the support of the leaders plus their colleagues in that group who will help them reach that goal. So, it’s sort of tailor made, if you like, to fit individuals who are going through similar things but individuals within a group. Or in the individual programme it’s even more tailor made by definition, I suppose.

But yes, the shifts are huge and it doesn’t necessarily happen in two or three weeks. I think sometimes, parent training has been thought to be done to somebody. But you definitely have to have this sort of collaborative relationship, there’s no other word for it, but this joint working in order to reach the parents’ goals. So, I think that’s really important to get the outcomes that you want.

If I was just telling somebody to do this, you know, “Go home tonight and do this,” that wouldn’t necessarily have the impact of exploring how it’s going to work in your house. And thinking about the parent, well, they know their children the best, don’t they? So, you work with whatever the parent is bringing to you and thinking about how these principles will apply in that instance.

Lucy:   And what do you like about your role delivering evidence-based parenting training?

Sue:  I like the fact that parents become much more confident in their parenting skill. I love the fact that they come in a little bit like sort of timid mice and go out like roaring lions with the confidence that they’ve got by the end.

I think it changes the way they relate to their children, I think it changes the way they relate to each other as parents and I think it just changes atmospheres in households, which I think is really magical.

Lucy:  I asked Jane if there was anything she didn’t like about the sessions and she had no bad things to say. So, I asked her what she enjoyed about it.

Jane:   Learning about how to play properly, I think. With Jack, I’m not being like too directive. Like before I was like, “Jack, do this, do this, build your tower, build your train track like that, that’s wrong, dah, dah, dah,” and I didn’t realise how negative I was being.

So yeah, I guess the most enjoyable bit for me was having that dedicated time to spend with Jack playing and watching him play and kind of getting to know him a bit more. Playing and building our relationship really was my favourite.

Lucy:  And what sort of difference has it made?

Jane:   I just think everyone’s a lot happier at home, which is great. I’m not shouting as much. Jack’s a lot happier because he’s not being shouted at. And the whole house is just a lot calmer and a lot happier and everyone is a lot more positive towards each other and it just makes the atmosphere a lot nicer. There’s a lot less whingeing and moaning and whining from all of us and nagging. (Laughs)

And yeah, I feel like, because Jack’s now able to sleep in his own bed properly without me, it’s really had a positive impact on mine and my husband’s relationship because we actually get an evening together to watch Strictly Come Dancing or, I don’t know, something that’s not to do with the kids. So, that’s really helped.

And I think also because Jack’s now sleeping better and things are happier at home, school is better as well, he’s not so tired. So, he’s able to focus a bit more and get on with his schoolwork a bit more. So, that’s the kind of feedback I’ve had from school, which is nice.

Lucy:  It sounds like a really good result.

Jane:  Oh yeah, I loved it, yeah, I loved it. It changed my life, anyway. I’d recommend it to anyone.

And no matter how hard a problem seems, there will be someone else out there that’s got a problem like you. You’re not on your own and it’s okay to struggle. Pretty life changing, really.

Lucy:  If you’re listening and you want to know more about how to access this sort of support, you can explore your local services online and check out Incredible Years groups in particular. You can also ask your GP who may refer you to Child and Adolescent Mental Health Services.

 If you’ve got a child with a diagnosis with ADHD and you want this sort of support, you can ask, “Where can I access parent-based intervention?”

 Thank you so much to both of my experts, Sue Howson and Jane. If you’d like more information on evidence-based parenting training, have a look at the show notes. And for any parents juggling home school and work at the moment, my thoughts are with you and I really hope you’re doing okay.

For more on CBT in general and for a register of accredited therapists, check out BABCP.comand have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with. There are quite a few episodes to do with children, including Shirley Reynolds on values-based activities in the pandemic and Maria Loades on helping children with loneliness during Covid-19.

That’s all for now, take care.

END OF AUDIO

 

 

In this episode Dr Lucy Maddox speaks to Sharon and Dr Anne Garland, about CBT for depression. Hear how Sharon describes it, and how both group and individual therapy helped. 

 

 

Show Notes and Transcript

Books

Overcoming Depression by Paul Gilbert

Podcast Episodes

CBT for Perfectionism

Compassion Focussed Therapy

Websites

www.babcp.com

www.cbtregisteruk.com

Image by Kevin Mueller on Unsplash

Transcript

 

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

In this episode we’re thinking about CBT for depression. I spoke with Dr Anne Garland who spent 25 years working with people who experience depression and Sharon, who has experienced it herself.  

Both Anne and Sharon come from a nursing background. Anne now works at the Oxford Cognitive Therapy Centre as a consultant psychotherapist, but she used to work in Nottingham, which is where Sharon had CBT for depression. Here’s Sharon.  

How would you describe what depression is like?  

Sharon: When I was going to school, when I was a little girl, an infant, we would have to go over the fields because I lived in the country, and go down. I could hear the bell of the junior school but couldn’t find it because of the fog. I walked round and round, I was five, walked round and round and round in those fields trying to get to the bell where I knew I would be safe and being terrified on my own. And that’s how it feels actually. Darkness, cold, very frightening.  

Lucy: I asked Anne how depression gets diagnosed and she described a range of symptoms.  

Anne: In its acute phase it’s characterised by what would be considered a range of symptoms. So, tiredness, lethargy, lack of motivation, poor concentration, difficulty remembering. Some of the most debilitating symptoms are often disturbed sleep and absence of any sense of enjoyment or pleasure in life and that can be very distressing to people. People can be really plagued with suicidal thoughts and feelings of hopelessness that life is pointless.  

I think one of the most devastating things about depression as an illness is it robs people of their ability to do everyday things. So for example, getting up, getting dressed, getting washed, deciding what you want to wear can all be really impaired by the symptoms of depression. I try and help people to understand that the symptoms are real, they’re not imagined. Often people will tell me that they imagine these things or that they aren’t real and that it’s all in their mind.  

Their symptoms are real, they exist in the body and do exert a really detrimental effect on just your ability to do what most of us take for granted on a day-to-day basis.  

Lucy: And so it’s a lot more than sadness isn’t it? 

Anne: Absolutely. It can be very profound feelings of sadness but often that’s amplified by feelings of extreme guilt, of shame, anger and anxiety is another common feature of depression.  

Also, when people are very profoundly depressed they can actually just feel numb and feel nothing and that in itself can be very distressing because things that might normally move you to feel a real sense of connection. Say for example your children or your grandchildren, you may have no feelings whatsoever, and that in itself can be very alarming to people. 

Lucy: The way that depression and its treatment are thought about can vary depending on who you speak to. Just like with other sorts of mental health problems. More biological viewpoints prioritise thinking about brain changes that can occur with depression while more social perspectives prioritise thinking about the context that people are part of.  

Anne: As CBT tends to take a more pragmatic view of thinking about a connection between events in our environment, our reactions to those in terms of biology, thoughts, feelings and behaviour and how all of those things interact and that’s a very pragmatic way of thinking about things really. And I guess traditionally in CBT there’s the idea of making what is referred to as a psycho biosocial intervention. What that essentially means is that you can use medication plus psychological therapies – particularly CBT in this instance – and interventions that may influence your environment.  

If you do those things altogether then you’re more likely to get a better outcome, which is really what our service in Nottingham is predicated on that idea. That if you think about all of those aspects in a practical, pragmatic way, then that may maximise your chances of seeing an improvement in depression.  

And I think one of the challenges in depression, if you look at the research literature, is once you’ve had one episode of depression, you have a 25% chance of another. Once you’ve had two, a 50% chance. And once you’ve had three, a 95% chance of another episode. So the concept of recurrence becomes really important.  

A lot of the work we do with people who have more persistent treatment resistant depression is really trying to help the person develop strategies for managing the illness on a long term basis. So it’s very much about trying to manage your mood and how you structure your day and your life and activities and that type of thing. I can be a very complex illness to work with.  

Lucy: For Sharon, her first experience of depression was 20 years ago when depression suddenly had a huge effect on her and her life.  

Sharon: And at the time the word they used was ‘decompensated’. Like a little hamster in a wheel and I just couldn’t keep going anymore and everything fell apart. I ended up being admitted to a psychiatric hospital for a few weeks.  

Lucy: Ten years later, Sharon had another episode.  

Sharon: I just couldn’t manage everything, working full-time, single parent, no family support and it just all imploded, I just couldn’t manage, I became really depressed again.  

Lucy: This time she saw a psychiatrist who suggested she try CBT alongside medication. Although reluctant, she went ahead with it. At the time the therapy offered had little effect on her.  

Sharon: I can’t describe it, it juts was an academic exercise to me.  

Lucy: However, a few years later he doctor encouraged her to try CBT again.  

Sharon: Because I like to please, not upset anyone, I went along to it. And it was a group CBT and it was compassion-focused, compassionate-based CBT and it was over about 20-24 weeks, something like that. We met every week, this small group.  

Lucy: This time it was different, things started making sense for her.  

Sharon: We went through that limbic system, the old brain, the new brain, the threat, soothing, drive, and all this explanation which for me, was a very good fit. Because suddenly, it was like a revelation, “So it’s not just me being weak then.” Even though people had told me, I didn’t really believe it.  

So this information was important for me and from that we started to develop the discussions of, “Why do I think the way that I do?” Which was what the early CBT had done but somehow this meant more. It actually touched me. 

And being in that small group and hearing other people talking and the two therapists that were there guiding, compassionate responses and, “What would we say to this person?” enabled me to see actually far more clearly the relevance of what they were doing.  

Lucy: That sounds super helpful.  

Sharon: You could offer a compassionate response and you could see the effect it was having and when they said to me I found it very hard to take, I couldn’t accept anybody being kind or compassionate.  

Lucy: Sharon had a combination of group compassion-focused CBT which you can also hear more about in the episode on compassion-focused therapy, as well as individual CBT for depression. I asked Anne to talk us through how individual CBT for depression works.  

Anne: Well, CBT for depression has two aspects to it really. The first aspect is the idea of symptom relief and really the purpose of that aspect of the treatment is really to try and help people re-engage with activities.  

Say for example you feel too tired to get up out of bed, get washed and dressed and make your breakfast in the 30 minutes you normally would have done that, you might try and break that down into smaller tasks. So you might get out of bed and have a cup of tea. You then might get your breakfast and have another break and then you might get dressed.  

So this idea that if you make an allowance for your energy levels, your concentration and try and approach tasks by breaking them down into manageable chunks, that will start to get you active again. So that’s really the first step of symptom relief.  

The second aspect of symptom relief in depression is really trying to look at the role thoughts might play in the context of depressed mood. And what the research tells us in the cognitive science of depression is once mood becomes depressed, thinking becomes more negative in content. It also becomes more concrete and more over general, so it’s hard for us to be specific in our recall.  

And another important factor, a thing that occurs once mood becomes depressed is our memory more readily recalls past unpleasant painful memories and actively screens out positive or neutral memories. The reason why this is important is that our ability to solve problems is really based on being able to retrieve information from the past about how we did that.  

But once mood becomes depressed, you’re trying to do an everyday thing like say, I don’t know, mend a broken sink pipe, and you’re trying to do that, but because your mood is depressed and your concentration isn’t great, it’s harder to do. But also, all that’s coming back to you is all the times things have gone wrong, not the times when they’ve gone well. There’s a tendency when mood is depressed for thinking to be very all or nothing. Or you might predict that if you try something it won’t work and therefore you don’t do it. So it’s really about trying to work at that level as well.  

The second part to CBT is really what I would call a more psychological component which is really trying to look at some of what the theory might refer to as psychological vulnerability. So trying to look at some of our beliefs that might underpin our depressive episodes or might make it difficult for us to make progress.  

Lucy: Looking at the underlying beliefs was something Sharon remembers as being important for her.  

Sharon: So the group was great and from that I then moved into a yearlong one-to-one CBT. And that went into, right back to early life experiences, what sort of things have actually helped to develop you, it’s not your fault, these things happened to you, you were too young, you had no control. And a lot of forgiveness, which I’ve never been able to forgive myself even though I now accept I never did anything wrong. And I wouldn’t have been able to do that before.  

But the outcomes from that yearlong – it’s longer than a year because I became very unwell – but when we got to the end of it, we’d worked through looking at the rules that I live my life with and deconstructing them. Where have they come from? Do they stand up to scrutiny? What might be better rules to live with? All with this compassionate focus.  

And at the end of it, I’ve still got it now, I’ve got it with me now actually, it’s like a little credit card size piece of card, laminated cardboard with the rules on it, my new rules in case I need a little sort of quick fix of reminder of it. But they’re there, so it’s there all the time.   

Lucy: Would you be able to give an example of one?  

Sharon: I mean the major one, I was a perfectionist. I had to do everything right. And that’s because I used to get punished, I had a very traumatic, abusive childhood and was punished quite a lot, quite severely. And so I had to get everything right and it had to be right the first time and if I didn’t, I’d get really stressed and worried about it.  

In order to replace that now is, I like to do things to a high standard, but it’s okay when they don’t go to plan. Good enough is okay. So things just have to be good enough.  

Lucy: That’s great, it sounds a really nice modification because it’s not like you’re giving up on liking to do things to a high standard but you’re just being a bit kinder to yourself with that.  

Sharon: Yes, that’s right and to say good enough is okay, yeah.  

And the other thing, I’m very obedient, still. If somebody tells me to do something, I’m very likely to do it because I fear consequences. And so that was one that guided, was a very strong guiding thing. And then the other one, so once you’ve got that, it’s okay to be myself, I can let my own needs and feelings be known. I get along with others, but I don’t have to do what they say.  

Lucy: Lovely.  

Sharon: So they’re just a couple of examples for the way it changed from my rigid control of myself to get through life safely. It was all about safety with me, and security, being safe. To actually thinking, you don’t need to do that, it’s not necessary. You can relax and enjoy yourself and there are no consequences of any significance, to me personally.  

Lucy: Some of Sharon’s unhelpful rules for living came from difficult early experiences, although sometimes it’s less clear where these rules come from. You don’t have to know to be able to use CBT.  

It’s super helpful to have those examples because I think it can feel so abstract can’t it, when somebody is referred to therapy and they’re not really sure what it’s like. I just think it really helps to hear the exact experiences that somebody else has had.  

Sharon: Lots of things actually. You don’t realise, I found, you don’t actually realise you’re living by these rules. It sounds ridiculous (laughs), I didn’t realise until it was discussed in detail with me, gently probing and not going any further than I wanted to. But each time a bit further until actually it was out there. I kind of realised, that’s how I was thinking because it’s so tightly hidden.  

Lucy: I asked Anne if someone was a fly on the wall watching a session, what would they see going on?  

Anne: I guess they would see really, in terms of starting at the very beginning, trying to help the person to consider the links between events in their environment and then biological symptoms, thoughts, feelings and behaviour.  

Just to give you a very simple example of that, say you’ve been depressed for six months and your sleep is affected, it’s taken you until 3:00 in the morning to get to sleep and the alarm has gone off at 7:00, so you’ve woken up in bed. That would be your event in your environment. You feel exhausted and your head is like cotton wool. That would be biological symptoms. And importantly there, most of us when we’re deprived of sleep might feel that way but that becomes intensified in depression.  

You might have thoughts like, I can’t be bothered to get up, I feel really tired. You might notice that your mood is really low and so you might lay longer in bed. But also then you might have overslept, so you might then start to have critical thoughts like, you’re really useless, you can’t even get out of bed on time, you’re going to let people down at work, you’re going to be in trouble. You might then start feeling anxious and perhaps a bit guilty.  

So you’d really be trying to help people to see that sort of connection.  

The aim of antidepressants, if people use them, is really to try and help them to influence some of the biological symptoms of depression and lift mood slightly. So some people do recognise in taking an antidepressant that their mood lifts slightly, some of the symptoms are a bit better. They can do a bit more and therefore their thoughts are not necessarily as negative in content or they’re not as harsh with themselves.  

What we’re trying to do in CBT is add to the effects of that by tackling behaviour and thoughts. Usually one of the first homework assignments is to complete an activity schedule. An activity schedule is a diary with every day of the week broken down into hourly slots and what we ask the person to do is keep a record of what they’re doing on an hour-by-hour basis.  

We ask them to rate two things there. One is mastery, which is how well you engaged with the activity given how you were feeling. And given how you were feeling is really important because an important part of that initial rationale is making an allowance for the symptoms of depression which are real.  

And then the second rating is how much you enjoyed it. So it’s really important to check out if the person feels able to do that.  

On the basis on that you’d look for patterns and quite often what you’d see is a pattern between inactivity and low mood and that’s often a marker for rumination.  

Also you’d be trying to look for if there had been any activities that are giving the person any sense of pleasure and when you do the ratings, you rate it on a scale of nought to 10. So nought is low and 10 is the high end. And really anything over a four is quite good when your mood is depressed, so that’s what we’d be looking for.  

Then we might try and look at activities that the person used to do and enjoy but they’ve given up. Or activities that the person is avoiding and try and think about how we can re-engage with some of those.  

Lucy: Here’s Sharon on how her life has changed through doing activities that make her feel good.  

Sharon: I had a big fear of meeting up with people, so I wouldn’t go to anything social. I’ve been on my own since the relationship ended 20 years ago and I just won’t take the chance, I won’t risk it again. And all of these things I’ve relaxed now – not that I’m going out with anybody – but I am actually more willing. I meet people for coffee now and I’ll join up with a dog walk and things with other people. Whereas before I’d always make an excuse at the last minute and not go. And I stopped doing that.  

Anne: Another important factor in these early stages is really just trying to think also about the effects of not eating and not having a good sleep routine because those two things can really amplify biological symptoms.  

Trying to get people to eat regularly and again, with the sleep, trying to re-establish a sleep routine. Thinking about things like caffeine consumption and perhaps not drinking any caffeine after lunch. So very practical things to start with and then trying to begin to schedule pleasurable activities. And also, as I said before, breaking tasks down into manageable chunks. 

Lucy: It sounds like breaking stuff down, making it really small and manageable and scaling things back is really important. What other sorts of things might somebody see if they were observing a CBT session? 

Anne: I guess they would see us working together. It’s very much what’s referred to as a collaborative endeavour. The person receiving treatment, they bring their expertise and knowledge in how depression affects them on a day-to-day basis. And I bring my expertise and knowledge in terms of how to help people begin to tackle their depression.  

We’d also be writing lots of things down. Working towards goals as well, goal setting is a very important part of CBT. So the beginning of treatment you’d be thinking about what problems the person wanted to tackle and what would be the goals that would indicate you’d started to work on those problems.  

So it’s very much a participative activity, is CBT. So the person really needs to make an active commitment to try and work within the model. Now obviously depressive symptoms in themselves can make that a challenge because lack of motivation is a key symptom of depression.  

So again, in the early stages you might see the therapist working very hard to help the person to engage with treatment.  

Lucy: Negative automatic thoughts are those which occur to us automatically. So we don’t have control over thinking that way. And they tend to frame the experiences that we’re having in a way that makes us feel bad about ourselves, or what we’re doing, or about the world around us. They can have a really big impact on our mood and sometimes we don’t even notice that they’re happening.  

For people who experience depression, automatic negative thoughts such as ‘I can’t cope’, can often be problematic and persistent.  

How might CBT help people to manage those thoughts? 

Anne: Well, there’s a variety of methods that can be used. The first one is really just trying to help the person to recognise when they occur, so what are the triggers to them. And also how do they make them feel and what is the impact of that.  

And then you can try what’s called modifying or challenging automatic thoughts. So you can apply a series of questions to a thought, what is the evidence for the thought? What is the evidence against the thought? What is the alternative perspective? 

And this is a really useful strategy when you’re working with depression because people with depression apply rules to themselves that they wouldn’t apply to other people. So very typically I might ask the person, “Can you tell me the name of somebody whose opinion you respect?” And then I would say, “If you heard your friend Jane say that she was lazy, what would you say to her?” And then I might reverse that and say, “If Jane were here, what would Jane say to you?” 

What you’re trying to do is bring flexibility to the thought processes because in depression thinking processes are very rigid, they’re very all or nothing, so they don’t see the shades of grey and they’re very over general.  

You then also try to help them to think about what is the impact of thinking this way, or what can you do next? How can you test this out? Which is where the idea of behavioural experiments come from.  

Lucy: Behavioural experiments are planned activities to test the validity of a belief. They’re an information gathering exercise, so we test how accurate an individual belief is.  

For Sharon re-joining her group helped her test some of her beliefs about what the group members thought about her having left.  

Sharon: The group was a challenge because I don’t like being in a group with people. It’s an effort to keep smiling. But I learnt there that I didn’t need to. So I’d be stressed before I went there for quite a number of them and actually I just stopped going, just after halfway through because I just couldn’t cope with it. It was just too intense, it was too much.  

And so Catherine phoned me and persuaded me back and I said, “I can’t go in there, I can’t go in there,” and I walked out. I can’t go back in that room when I’ve walked out. And it was just gentle nudging and when I went in they were just, “Oh, hello,” nobody made a comment at all and I was astonished because I thought somebody was going to say, “Oh, back are you?” Not at all, and that was another illustration of my disordered thinking.  

So that was a tiring six months, but at the end of it I felt quite upbeat that I’d achieved something.  

The individual sessions for the year, they were always extremely positive. But I always came out of there feeling that it was a job well done, I’d achieved something. I never felt, “Ugh, I’m not coming back,” not once. It was excellent from start to finish.  

Lucy: I wanted to know from Sharon how she coped with negative thoughts and if she uses the techniques which Anne mentions.  

Sharon: I still use all those CBT techniques of the alternative way of looking… What’s another reason that this could be…? Is that really the way this is when you’re feeling down? Deconstruct it. What actually is it that’s a concern here? And are you actually…? Are you thinking about this clearly or could something else be happening? So I still use all of those techniques every day.  

Lucy: Do you? It’s really hard isn’t it when you’re having a worry or a thought about how things are in your own head that’s distressing. It feels real doesn’t it? We all feel that our reality is real. How do you manage to capture those thoughts and to sort of use those techniques? 

Sharon: I write it down. Things, when they start to swirl around my head and then I know from experience when I’m feeling well, this is just going to look nothing like the original issue unless you get it out of your head. And so I write it down and then I think, what’s actually… I deconstruct it and then put it back together again.  

Lucy: And when you’re coming out of it, did you notice yourself coming out of it? Did you notice things changing or was it after it’s gone that you kind of look back and see it differently?  

Sharon: Coming out of it, in some ways it’s a bit scary actually because you get used to being in that gloom and that dark. And it requires effort to re-engage and make contact with people and all the rest of it.  

It was a year ago that I finished; I’ve been well since then, yeah. So I felt smiley, I’ve had a few, we all have in the last year haven’t we, had a lot of low… Even thinking like that, thinking it’s not me not trying hard enough, I’m thinking why wouldn’t I feel like this? Everybody is feeling like this. So I consider that, when I think like that, I give myself a little mental pat on the shoulder for thinking, “Excellent thinking Sharon.” 

Lucy: I asked Anne what the evidence base was like for CBT for depression.  

Anne: Well, there’s a very strong evidence base that goes right back to the 70s and 80s really. Essentially, if you summarise, if you look at NICE guidance, what the research tells us is that CBT used alone is as effective as an antidepressant on its own. The two things in combination produce the best outcome. Particularly for people who have moderate to severe depression.  

For people who have more mild depression, you might actually just start with CBT and that can be highly effective.  

Lucy: The current NICE guidelines recommend CBT for depression and also a range of other treatments. I’ve put a link in the show notes for those guidelines.  

Anne: If you look at the evidence base for people with more persistent treatment resistant depression, there is evidence from two studies that I was involved in. One back in the 90s with Jan Scott and Eugene Paykel who were both professors of psychiatry who have now retired. And a more recent one that Richard Morris, Professor of Psychiatry in Nottingham and I conducted where we looked at using CBT in combination with pharmacology for people with more, either chronic depression or persistent treatment resistance. And there is a lot of evidence that it’s very effective in helping people manage the disorder rather than trying to get rid of it completely.  

Lucy: That’s really helpful for people to know isn’t it? I suppose not everything might totally resolve and it might be more a case of living with it effectively.  

Anne: Exactly, yeah.  

Lucy: Are there things you think people should know before they come for CBT? 

Anne: I think particularly just picking up on that last point as well, thinking about the impact of childhood trauma can have in terms of depressed mood. When we think about trauma we’re thinking about that in a broad context of it might be sexual and physical abuse, but much more commonly, it’s actual emotional abuse and neglect, childhood neglect, particularly in terms of how that impacts on what psychology would refer to as attachments. Our ability to make and maintain reciprocally beneficial relationships with other people.  

And there’s increasing amount of evidence to show that where attachments are disrupted, then that can have a profound effect in terms of adult depression. And I think that’s where a lot of the research is focusing now in terms of thinking about how you might develop more focused interventions in CBT terms.  

I think the other thing is that CBT is a very practical therapy. So there’s an idea that you participate, you will be asked to complete, what we refer to as ‘homework’, which isn’t a phrase many people like. So you’d be asked to work on your problems in between sessions.  

Initially it’s very here and now focused. So it’s really trying to think about what your problems are on a day-to-day basis in terms of how the depression affects you. And then later in therapy if necessary, we might go back to some childhood events. But generally speaking you only go backwards to the degree to which it tells you how that influences what goes on in the here and now.  

It’s also about doing, it’s not just about talking.  

Lucy: For Sharon, although she doesn’t feel depression has disappeared completely from her life, she’s found a way to cope and see her thoughts for what they are, thoughts, rather than acting on them. I wanted to know what she would say to anybody thinking of trying CBT for depression.  

Sharon: Go for it! Definitely! I think the thing is to be prepared; you’ve got to put some effort into it to get something out of it.  

Lucy: The experience that Sharon had of trying therapy more than once and finding it a better fit at a later date can happen to anyone, either because the therapist is a better fit, the type of approach works more or sometimes because the therapist has had more experience in a particular model of therapy.  

It’s always okay to raise it with a therapist if you feel like things aren’t working for you. It’s also important to be able to check out what training or experience the therapist has had with treating the problem that you’re going to see them for. One way to check this out is by seeing if they’re accredited with BABCP.  

Sharon: As I say, it was a revelation. In fact one of the biggest things was listening to people talking. You think, gosh, that’s how I think!  

Lucy: If you’d like more information on CBT for depression, have a look at the show notes. For more on CBT in general and for a register of accredited therapists, check out BABCP.com.  

Have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with.  

There’s one with Paul Gilbert, who Anne mentions and also Chris Winson, who speak about compassion-focused therapy for depression. And there’s loads more on other common problems that CBT can help with including anxiety.  

Thank you to both of my experts, Sharon and Dr Anne Garland.  

Thank you for listening and I hope you’re keeping well in these odd times we’re all living through. Until next time, take care.  

END OF AUDIO 

 

Anxiety is one of the most common mental health problems, but there's a good evidence-base for CBT as a helpful intervention. In this podcast, Dr Lucy Maddox speaks with Dr Blake Stobie and Claire Read, about what CBT for anxiety is like, and how anxious thoughts can be like the circle line. 

 

Show Notes and Transcript

Websites

BABCP

https://www.babcp.com

Accredited register of CBT therapists

https://www.cbtregisteruk.com

Anxiety UK

https://www.anxietyuk.org.uk

NICE guidelines on anxiety

https://www.nice.org.uk/guidance/qs53

Apps

Claire recommended the Thought Diary Pro app as being helpful to use in conjunction with therapy to complete thought records. 

https://www.good-thinking.uk/resources/thought-diary-pro/

Books

Claire recommended this workbook on Overcoming Low Self Esteem by Melanie Fennell https://www.amazon.co.uk/Overcoming-Low-Self-Esteem-Self-help-Course/dp/1845292375/ref=sr_1_2?dchild=1&keywords=self+esteem+workbook+melanie+fennell&qid=1605884391&s=books&sr=1-2

And this book by Helen Kennerley on Overcoming Anxiety is part of the same series

https://www.amazon.co.uk/Overcoming-Anxiety-Books-Prescription-Title/dp/1849018782/ref=sr_1_1?dchild=1&keywords=overcoming+anxiety&qid=1605884437&s=books&sr=1-1

Credits

Image used is by Robert Tudor from Unsplash

Podcast episode produced and edited by Lucy Maddox for BABCP

Transcript

 

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

In this episode we’re thinking about CBT for depression. I spoke with Dr Anne Garland who spent 25 years working with people who experience depression and Sharon, who has experienced it herself.  

Both Anne and Sharon come from a nursing background. Anne now works at the Oxford Cognitive Therapy Centre as a consultant psychotherapist, but she used to work in Nottingham, which is where Sharon had CBT for depression. Here’s Sharon.  

How would you describe what depression is like?  

Sharon: When I was going to school, when I was a little girl, an infant, we would have to go over the fields because I lived in the country, and go down. I could hear the bell of the junior school but couldn’t find it because of the fog. I walked round and round, I was five, walked round and round and round in those fields trying to get to the bell where I knew I would be safe and being terrified on my own. And that’s how it feels actually. Darkness, cold, very frightening.  

Lucy: I asked Anne how depression gets diagnosed and she described a range of symptoms.  

Anne: In its acute phase it’s characterised by what would be considered a range of symptoms. So, tiredness, lethargy, lack of motivation, poor concentration, difficulty remembering. Some of the most debilitating symptoms are often disturbed sleep and absence of any sense of enjoyment or pleasure in life and that can be very distressing to people. People can be really plagued with suicidal thoughts and feelings of hopelessness that life is pointless.  

I think one of the most devastating things about depression as an illness is it robs people of their ability to do everyday things. So for example, getting up, getting dressed, getting washed, deciding what you want to wear can all be really impaired by the symptoms of depression. I try and help people to understand that the symptoms are real, they’re not imagined. Often people will tell me that they imagine these things or that they aren’t real and that it’s all in their mind.  

Their symptoms are real, they exist in the body and do exert a really detrimental effect on just your ability to do what most of us take for granted on a day-to-day basis.  

Lucy: And so it’s a lot more than sadness isn’t it? 

Anne: Absolutely. It can be very profound feelings of sadness but often that’s amplified by feelings of extreme guilt, of shame, anger and anxiety is another common feature of depression.  

Also, when people are very profoundly depressed they can actually just feel numb and feel nothing and that in itself can be very distressing because things that might normally move you to feel a real sense of connection. Say for example your children or your grandchildren, you may have no feelings whatsoever, and that in itself can be very alarming to people. 

Lucy: The way that depression and its treatment are thought about can vary depending on who you speak to. Just like with other sorts of mental health problems. More biological viewpoints prioritise thinking about brain changes that can occur with depression while more social perspectives prioritise thinking about the context that people are part of.  

Anne: As CBT tends to take a more pragmatic view of thinking about a connection between events in our environment, our reactions to those in terms of biology, thoughts, feelings and behaviour and how all of those things interact and that’s a very pragmatic way of thinking about things really. And I guess traditionally in CBT there’s the idea of making what is referred to as a psycho biosocial intervention. What that essentially means is that you can use medication plus psychological therapies – particularly CBT in this instance – and interventions that may influence your environment.  

If you do those things altogether then you’re more likely to get a better outcome, which is really what our service in Nottingham is predicated on that idea. That if you think about all of those aspects in a practical, pragmatic way, then that may maximise your chances of seeing an improvement in depression.  

And I think one of the challenges in depression, if you look at the research literature, is once you’ve had one episode of depression, you have a 25% chance of another. Once you’ve had two, a 50% chance. And once you’ve had three, a 95% chance of another episode. So the concept of recurrence becomes really important.  

A lot of the work we do with people who have more persistent treatment resistant depression is really trying to help the person develop strategies for managing the illness on a long term basis. So it’s very much about trying to manage your mood and how you structure your day and your life and activities and that type of thing. I can be a very complex illness to work with.  

Lucy: For Sharon, her first experience of depression was 20 years ago when depression suddenly had a huge effect on her and her life.  

Sharon: And at the time the word they used was ‘decompensated’. Like a little hamster in a wheel and I just couldn’t keep going anymore and everything fell apart. I ended up being admitted to a psychiatric hospital for a few weeks.  

Lucy: Ten years later, Sharon had another episode.  

Sharon: I just couldn’t manage everything, working full-time, single parent, no family support and it just all imploded, I just couldn’t manage, I became really depressed again.  

Lucy: This time she saw a psychiatrist who suggested she try CBT alongside medication. Although reluctant, she went ahead with it. At the time the therapy offered had little effect on her.  

Sharon: I can’t describe it, it juts was an academic exercise to me.  

Lucy: However, a few years later he doctor encouraged her to try CBT again.  

Sharon: Because I like to please, not upset anyone, I went along to it. And it was a group CBT and it was compassion-focused, compassionate-based CBT and it was over about 20-24 weeks, something like that. We met every week, this small group.  

Lucy: This time it was different, things started making sense for her.  

Sharon: We went through that limbic system, the old brain, the new brain, the threat, soothing, drive, and all this explanation which for me, was a very good fit. Because suddenly, it was like a revelation, “So it’s not just me being weak then.” Even though people had told me, I didn’t really believe it.  

So this information was important for me and from that we started to develop the discussions of, “Why do I think the way that I do?” Which was what the early CBT had done but somehow this meant more. It actually touched me. 

And being in that small group and hearing other people talking and the two therapists that were there guiding, compassionate responses and, “What would we say to this person?” enabled me to see actually far more clearly the relevance of what they were doing.  

Lucy: That sounds super helpful.  

Sharon: You could offer a compassionate response and you could see the effect it was having and when they said to me I found it very hard to take, I couldn’t accept anybody being kind or compassionate.  

Lucy: Sharon had a combination of group compassion-focused CBT which you can also hear more about in the episode on compassion-focused therapy, as well as individual CBT for depression. I asked Anne to talk us through how individual CBT for depression works.  

Anne: Well, CBT for depression has two aspects to it really. The first aspect is the idea of symptom relief and really the purpose of that aspect of the treatment is really to try and help people re-engage with activities.  

Say for example you feel too tired to get up out of bed, get washed and dressed and make your breakfast in the 30 minutes you normally would have done that, you might try and break that down into smaller tasks. So you might get out of bed and have a cup of tea. You then might get your breakfast and have another break and then you might get dressed.  

So this idea that if you make an allowance for your energy levels, your concentration and try and approach tasks by breaking them down into manageable chunks, that will start to get you active again. So that’s really the first step of symptom relief.  

The second aspect of symptom relief in depression is really trying to look at the role thoughts might play in the context of depressed mood. And what the research tells us in the cognitive science of depression is once mood becomes depressed, thinking becomes more negative in content. It also becomes more concrete and more over general, so it’s hard for us to be specific in our recall.  

And another important factor, a thing that occurs once mood becomes depressed is our memory more readily recalls past unpleasant painful memories and actively screens out positive or neutral memories. The reason why this is important is that our ability to solve problems is really based on being able to retrieve information from the past about how we did that.  

But once mood becomes depressed, you’re trying to do an everyday thing like say, I don’t know, mend a broken sink pipe, and you’re trying to do that, but because your mood is depressed and your concentration isn’t great, it’s harder to do. But also, all that’s coming back to you is all the times things have gone wrong, not the times when they’ve gone well. There’s a tendency when mood is depressed for thinking to be very all or nothing. Or you might predict that if you try something it won’t work and therefore you don’t do it. So it’s really about trying to work at that level as well.  

The second part to CBT is really what I would call a more psychological component which is really trying to look at some of what the theory might refer to as psychological vulnerability. So trying to look at some of our beliefs that might underpin our depressive episodes or might make it difficult for us to make progress.  

Lucy: Looking at the underlying beliefs was something Sharon remembers as being important for her.  

Sharon: So the group was great and from that I then moved into a yearlong one-to-one CBT. And that went into, right back to early life experiences, what sort of things have actually helped to develop you, it’s not your fault, these things happened to you, you were too young, you had no control. And a lot of forgiveness, which I’ve never been able to forgive myself even though I now accept I never did anything wrong. And I wouldn’t have been able to do that before.  

But the outcomes from that yearlong – it’s longer than a year because I became very unwell – but when we got to the end of it, we’d worked through looking at the rules that I live my life with and deconstructing them. Where have they come from? Do they stand up to scrutiny? What might be better rules to live with? All with this compassionate focus.  

And at the end of it, I’ve still got it now, I’ve got it with me now actually, it’s like a little credit card size piece of card, laminated cardboard with the rules on it, my new rules in case I need a little sort of quick fix of reminder of it. But they’re there, so it’s there all the time.   

Lucy: Would you be able to give an example of one?  

Sharon: I mean the major one, I was a perfectionist. I had to do everything right. And that’s because I used to get punished, I had a very traumatic, abusive childhood and was punished quite a lot, quite severely. And so I had to get everything right and it had to be right the first time and if I didn’t, I’d get really stressed and worried about it.  

In order to replace that now is, I like to do things to a high standard, but it’s okay when they don’t go to plan. Good enough is okay. So things just have to be good enough.  

Lucy: That’s great, it sounds a really nice modification because it’s not like you’re giving up on liking to do things to a high standard but you’re just being a bit kinder to yourself with that.  

Sharon: Yes, that’s right and to say good enough is okay, yeah.  

And the other thing, I’m very obedient, still. If somebody tells me to do something, I’m very likely to do it because I fear consequences. And so that was one that guided, was a very strong guiding thing. And then the other one, so once you’ve got that, it’s okay to be myself, I can let my own needs and feelings be known. I get along with others, but I don’t have to do what they say.  

Lucy: Lovely.  

Sharon: So they’re just a couple of examples for the way it changed from my rigid control of myself to get through life safely. It was all about safety with me, and security, being safe. To actually thinking, you don’t need to do that, it’s not necessary. You can relax and enjoy yourself and there are no consequences of any significance, to me personally.  

Lucy: Some of Sharon’s unhelpful rules for living came from difficult early experiences, although sometimes it’s less clear where these rules come from. You don’t have to know to be able to use CBT.  

It’s super helpful to have those examples because I think it can feel so abstract can’t it, when somebody is referred to therapy and they’re not really sure what it’s like. I just think it really helps to hear the exact experiences that somebody else has had.  

Sharon: Lots of things actually. You don’t realise, I found, you don’t actually realise you’re living by these rules. It sounds ridiculous (laughs), I didn’t realise until it was discussed in detail with me, gently probing and not going any further than I wanted to. But each time a bit further until actually it was out there. I kind of realised, that’s how I was thinking because it’s so tightly hidden.  

Lucy: I asked Anne if someone was a fly on the wall watching a session, what would they see going on?  

Anne: I guess they would see really, in terms of starting at the very beginning, trying to help the person to consider the links between events in their environment and then biological symptoms, thoughts, feelings and behaviour.  

Just to give you a very simple example of that, say you’ve been depressed for six months and your sleep is affected, it’s taken you until 3:00 in the morning to get to sleep and the alarm has gone off at 7:00, so you’ve woken up in bed. That would be your event in your environment. You feel exhausted and your head is like cotton wool. That would be biological symptoms. And importantly there, most of us when we’re deprived of sleep might feel that way but that becomes intensified in depression.  

You might have thoughts like, I can’t be bothered to get up, I feel really tired. You might notice that your mood is really low and so you might lay longer in bed. But also then you might have overslept, so you might then start to have critical thoughts like, you’re really useless, you can’t even get out of bed on time, you’re going to let people down at work, you’re going to be in trouble. You might then start feeling anxious and perhaps a bit guilty.  

So you’d really be trying to help people to see that sort of connection.  

The aim of antidepressants, if people use them, is really to try and help them to influence some of the biological symptoms of depression and lift mood slightly. So some people do recognise in taking an antidepressant that their mood lifts slightly, some of the symptoms are a bit better. They can do a bit more and therefore their thoughts are not necessarily as negative in content or they’re not as harsh with themselves.  

What we’re trying to do in CBT is add to the effects of that by tackling behaviour and thoughts. Usually one of the first homework assignments is to complete an activity schedule. An activity schedule is a diary with every day of the week broken down into hourly slots and what we ask the person to do is keep a record of what they’re doing on an hour-by-hour basis.  

We ask them to rate two things there. One is mastery, which is how well you engaged with the activity given how you were feeling. And given how you were feeling is really important because an important part of that initial rationale is making an allowance for the symptoms of depression which are real.  

And then the second rating is how much you enjoyed it. So it’s really important to check out if the person feels able to do that.  

On the basis on that you’d look for patterns and quite often what you’d see is a pattern between inactivity and low mood and that’s often a marker for rumination.  

Also you’d be trying to look for if there had been any activities that are giving the person any sense of pleasure and when you do the ratings, you rate it on a scale of nought to 10. So nought is low and 10 is the high end. And really anything over a four is quite good when your mood is depressed, so that’s what we’d be looking for.  

Then we might try and look at activities that the person used to do and enjoy but they’ve given up. Or activities that the person is avoiding and try and think about how we can re-engage with some of those.  

Lucy: Here’s Sharon on how her life has changed through doing activities that make her feel good.  

Sharon: I had a big fear of meeting up with people, so I wouldn’t go to anything social. I’ve been on my own since the relationship ended 20 years ago and I just won’t take the chance, I won’t risk it again. And all of these things I’ve relaxed now – not that I’m going out with anybody – but I am actually more willing. I meet people for coffee now and I’ll join up with a dog walk and things with other people. Whereas before I’d always make an excuse at the last minute and not go. And I stopped doing that.  

Anne: Another important factor in these early stages is really just trying to think also about the effects of not eating and not having a good sleep routine because those two things can really amplify biological symptoms.  

Trying to get people to eat regularly and again, with the sleep, trying to re-establish a sleep routine. Thinking about things like caffeine consumption and perhaps not drinking any caffeine after lunch. So very practical things to start with and then trying to begin to schedule pleasurable activities. And also, as I said before, breaking tasks down into manageable chunks. 

Lucy: It sounds like breaking stuff down, making it really small and manageable and scaling things back is really important. What other sorts of things might somebody see if they were observing a CBT session? 

Anne: I guess they would see us working together. It’s very much what’s referred to as a collaborative endeavour. The person receiving treatment, they bring their expertise and knowledge in how depression affects them on a day-to-day basis. And I bring my expertise and knowledge in terms of how to help people begin to tackle their depression.  

We’d also be writing lots of things down. Working towards goals as well, goal setting is a very important part of CBT. So the beginning of treatment you’d be thinking about what problems the person wanted to tackle and what would be the goals that would indicate you’d started to work on those problems.  

So it’s very much a participative activity, is CBT. So the person really needs to make an active commitment to try and work within the model. Now obviously depressive symptoms in themselves can make that a challenge because lack of motivation is a key symptom of depression.  

So again, in the early stages you might see the therapist working very hard to help the person to engage with treatment.  

Lucy: Negative automatic thoughts are those which occur to us automatically. So we don’t have control over thinking that way. And they tend to frame the experiences that we’re having in a way that makes us feel bad about ourselves, or what we’re doing, or about the world around us. They can have a really big impact on our mood and sometimes we don’t even notice that they’re happening.  

For people who experience depression, automatic negative thoughts such as ‘I can’t cope’, can often be problematic and persistent.  

How might CBT help people to manage those thoughts? 

Anne: Well, there’s a variety of methods that can be used. The first one is really just trying to help the person to recognise when they occur, so what are the triggers to them. And also how do they make them feel and what is the impact of that.  

And then you can try what’s called modifying or challenging automatic thoughts. So you can apply a series of questions to a thought, what is the evidence for the thought? What is the evidence against the thought? What is the alternative perspective? 

And this is a really useful strategy when you’re working with depression because people with depression apply rules to themselves that they wouldn’t apply to other people. So very typically I might ask the person, “Can you tell me the name of somebody whose opinion you respect?” And then I would say, “If you heard your friend Jane say that she was lazy, what would you say to her?” And then I might reverse that and say, “If Jane were here, what would Jane say to you?” 

What you’re trying to do is bring flexibility to the thought processes because in depression thinking processes are very rigid, they’re very all or nothing, so they don’t see the shades of grey and they’re very over general.  

You then also try to help them to think about what is the impact of thinking this way, or what can you do next? How can you test this out? Which is where the idea of behavioural experiments come from.  

Lucy: Behavioural experiments are planned activities to test the validity of a belief. They’re an information gathering exercise, so we test how accurate an individual belief is.  

For Sharon re-joining her group helped her test some of her beliefs about what the group members thought about her having left.  

Sharon: The group was a challenge because I don’t like being in a group with people. It’s an effort to keep smiling. But I learnt there that I didn’t need to. So I’d be stressed before I went there for quite a number of them and actually I just stopped going, just after halfway through because I just couldn’t cope with it. It was just too intense, it was too much.  

And so Catherine phoned me and persuaded me back and I said, “I can’t go in there, I can’t go in there,” and I walked out. I can’t go back in that room when I’ve walked out. And it was just gentle nudging and when I went in they were just, “Oh, hello,” nobody made a comment at all and I was astonished because I thought somebody was going to say, “Oh, back are you?” Not at all, and that was another illustration of my disordered thinking.  

So that was a tiring six months, but at the end of it I felt quite upbeat that I’d achieved something.  

The individual sessions for the year, they were always extremely positive. But I always came out of there feeling that it was a job well done, I’d achieved something. I never felt, “Ugh, I’m not coming back,” not once. It was excellent from start to finish.  

Lucy: I wanted to know from Sharon how she coped with negative thoughts and if she uses the techniques which Anne mentions.  

Sharon: I still use all those CBT techniques of the alternative way of looking… What’s another reason that this could be…? Is that really the way this is when you’re feeling down? Deconstruct it. What actually is it that’s a concern here? And are you actually…? Are you thinking about this clearly or could something else be happening? So I still use all of those techniques every day.  

Lucy: Do you? It’s really hard isn’t it when you’re having a worry or a thought about how things are in your own head that’s distressing. It feels real doesn’t it? We all feel that our reality is real. How do you manage to capture those thoughts and to sort of use those techniques? 

Sharon: I write it down. Things, when they start to swirl around my head and then I know from experience when I’m feeling well, this is just going to look nothing like the original issue unless you get it out of your head. And so I write it down and then I think, what’s actually… I deconstruct it and then put it back together again.  

Lucy: And when you’re coming out of it, did you notice yourself coming out of it? Did you notice things changing or was it after it’s gone that you kind of look back and see it differently?  

Sharon: Coming out of it, in some ways it’s a bit scary actually because you get used to being in that gloom and that dark. And it requires effort to re-engage and make contact with people and all the rest of it.  

It was a year ago that I finished; I’ve been well since then, yeah. So I felt smiley, I’ve had a few, we all have in the last year haven’t we, had a lot of low… Even thinking like that, thinking it’s not me not trying hard enough, I’m thinking why wouldn’t I feel like this? Everybody is feeling like this. So I consider that, when I think like that, I give myself a little mental pat on the shoulder for thinking, “Excellent thinking Sharon.” 

Lucy: I asked Anne what the evidence base was like for CBT for depression.  

Anne: Well, there’s a very strong evidence base that goes right back to the 70s and 80s really. Essentially, if you summarise, if you look at NICE guidance, what the research tells us is that CBT used alone is as effective as an antidepressant on its own. The two things in combination produce the best outcome. Particularly for people who have moderate to severe depression.  

For people who have more mild depression, you might actually just start with CBT and that can be highly effective.  

Lucy: The current NICE guidelines recommend CBT for depression and also a range of other treatments. I’ve put a link in the show notes for those guidelines.  

Anne: If you look at the evidence base for people with more persistent treatment resistant depression, there is evidence from two studies that I was involved in. One back in the 90s with Jan Scott and Eugene Paykel who were both professors of psychiatry who have now retired. And a more recent one that Richard Morris, Professor of Psychiatry in Nottingham and I conducted where we looked at using CBT in combination with pharmacology for people with more, either chronic depression or persistent treatment resistance. And there is a lot of evidence that it’s very effective in helping people manage the disorder rather than trying to get rid of it completely.  

Lucy: That’s really helpful for people to know isn’t it? I suppose not everything might totally resolve and it might be more a case of living with it effectively.  

Anne: Exactly, yeah.  

Lucy: Are there things you think people should know before they come for CBT? 

Anne: I think particularly just picking up on that last point as well, thinking about the impact of childhood trauma can have in terms of depressed mood. When we think about trauma we’re thinking about that in a broad context of it might be sexual and physical abuse, but much more commonly, it’s actual emotional abuse and neglect, childhood neglect, particularly in terms of how that impacts on what psychology would refer to as attachments. Our ability to make and maintain reciprocally beneficial relationships with other people.  

And there’s increasing amount of evidence to show that where attachments are disrupted, then that can have a profound effect in terms of adult depression. And I think that’s where a lot of the research is focusing now in terms of thinking about how you might develop more focused interventions in CBT terms.  

I think the other thing is that CBT is a very practical therapy. So there’s an idea that you participate, you will be asked to complete, what we refer to as ‘homework’, which isn’t a phrase many people like. So you’d be asked to work on your problems in between sessions.  

Initially it’s very here and now focused. So it’s really trying to think about what your problems are on a day-to-day basis in terms of how the depression affects you. And then later in therapy if necessary, we might go back to some childhood events. But generally speaking you only go backwards to the degree to which it tells you how that influences what goes on in the here and now.  

It’s also about doing, it’s not just about talking.  

Lucy: For Sharon, although she doesn’t feel depression has disappeared completely from her life, she’s found a way to cope and see her thoughts for what they are, thoughts, rather than acting on them. I wanted to know what she would say to anybody thinking of trying CBT for depression.  

Sharon: Go for it! Definitely! I think the thing is to be prepared; you’ve got to put some effort into it to get something out of it.  

Lucy: The experience that Sharon had of trying therapy more than once and finding it a better fit at a later date can happen to anyone, either because the therapist is a better fit, the type of approach works more or sometimes because the therapist has had more experience in a particular model of therapy.  

It’s always okay to raise it with a therapist if you feel like things aren’t working for you. It’s also important to be able to check out what training or experience the therapist has had with treating the problem that you’re going to see them for. One way to check this out is by seeing if they’re accredited with BABCP.  

Sharon: As I say, it was a revelation. In fact one of the biggest things was listening to people talking. You think, gosh, that’s how I think!  

Lucy: If you’d like more information on CBT for depression, have a look at the show notes. For more on CBT in general and for a register of accredited therapists, check out BABCP.com.  

Have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with.  

There’s one with Paul Gilbert, who Anne mentions and also Chris Winson, who speak about compassion-focused therapy for depression. And there’s loads more on other common problems that CBT can help with including anxiety.  

Thank you to both of my experts, Sharon and Dr Anne Garland.  

Thank you for listening and I hope you’re keeping well in these odd times we’re all living through. Until next time, take care.  

 

END OF AUDIO 

 

We tend to think about therapy as something that is helpful for individuals, but what about when you want to address problems which affect you and a partner or spouse? In this episode, Dr Lucy Maddox speaks to Dan Kolubinski about cognitive behavioural couples therapy, and hears from Liz and Richard about what the experience was like for them. 

Show Notes and Transcript

Dan recommended the book Fighting For Your Marriage by Markman, Stanley & Blumberg

https://www.amazon.co.uk/Fighting-Your-Marriage-Best-seller-Preventing-dp-0470485914/dp/0470485914/ref=dp_ob_title_bk

Some journal articles on couples therapy are available free online here:

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

The podcast survey is here and takes 5 minutes: https://www.surveymonkey.co.uk/r/podcastLTACBT

The BABCP website is at www.babcp.com

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

Photo by Nick Fewings on Unsplash

 

Transcript

Lucy: Hello, and welcome to Let’s Talk About CBT. It’s great to have you listening.  

When we think about therapy, we often think of one-to-one conversations between one person and their therapist. But what about when the problems that we’re going for help with are related to how we’re getting on with a partner or a spouse? Cognitive behavioural couples therapy helps with these sorts of difficulties. To understand more about it I spoke to a married couple, Richard and Liz, and Dan Kolubinski, their therapist.  

Richard and Liz did this therapy privately, but couples therapy is also available on the NHS to help with some specific difficulties. We hear more about that from Dan later on. For now though let’s hear what Richard and Liz thought of their couples therapy in this interview which I recorded with them remotely.  

Richard: My name’s Richard. I’m 37 years old and I’ve been married to Liz for just over seven years now. I’m a postie at the moment, and kind of lived in Essex most of my life.  

Liz: It’s like a dating programme.  

Richard: It is, isn’t it? Yeah, a little bit. (laughs) 

Liz: So I’m Liz and I make cakes for a living, and write about mental health. So that’s us.  

Lucy: That’s great. So thanks so much for agreeing to speak with me about your experience of couples therapy, and specifically cognitive behavioural couples therapy. Would you mind telling me how you came across it and what made you think you might want to try it? 

Liz: Yeah. So I think it’s something that we’ve spoken about in the past. And we’ve both had therapy separately, and I think we’ve both had various different types of therapy. So Richard has had CBT before, I think we’ve both done psycho-dynamic counselling.  

So when we decided we were going to do it, we realised that for us it was more beneficial to almost do a crash course, as it were, together. So to do a whole weekend, rather than a little bit once a week. And that was how we discovered Dan, and were able to book in with him.  

Richard: Yeah, I think we both understand the value or had both experienced and understood the value of therapy individually. So it was kind of an easy step for us then to decide there could be a lot of value in doing this together.  

Lucy: That makes total sense. So you already had a bit of an understanding of what it might be like, or what it’s like on an individual level? 

Liz: Yeah, definitely. And actually very early on in our marriage we had some couples counselling, which I don’t think was actually as successful, and it was after that that we had separate counselling. And I think it was after we were both able to get ourselves into better positions, as it were, that that’s when we were able to come back together and experience some therapy together.  

Lucy: That’s really interesting. Do you think that helped you access the conversations together in a different way? 

Richard: Yes, I think it did. I think we both had an experience of therapy, of CBT and of other therapies, and the structure they would take or how they engaged you and enabled you to talk safely, and the prompts that might be used.  

When we did it together, it did make the conversations a bit freer, a bit more open. And I think we both felt it was a safe environment, which when we first had it I don’t think we did feel. And that made a big difference I think.  

Liz: Yeah. And I think as with any relationship, until you’ve got a level of happiness with yourself, it’s very difficult to have a relationship with somebody else that involves vulnerability or trust.  

And I don’t think we had that the first time we tried having counselling together. I think we were almost so reliant on our relationship to form who we were, that the first time around we put too much pressure on ourselves, on the relationship, and also on the counselling, and we expected some magic wand. Whereas now we’ve realised it actually does take a bit of work.  

Richard: Yeah.  

Liz: But obviously the pay-off is huge, so that’s brilliant.  

Lucy: That’s so nice. Sometimes you see adverts for couples counselling, or couples conversations, when people are thinking of getting married. Was that something that was around for you? 

Liz: (Laughs) Yeah, slightly ironically we started it and it was meant to be three sessions long, or four sessions long, and I think before the second or third session we had such a big argument that we never went back.  

So yeah, again it’s something that I think in hindsight there were warning bells that both of us were probably having our own inner struggles, as it were. And that we weren’t really able to reap the benefits of that pre-marriage counselling. But I would definitely recommend it to any friends who were getting married.  

Richard: Yeah, absolutely.  

Liz: I’d definitely recommend it, even if it’s just to get the conversation started.  

Lucy: Yeah, it’s interesting. So there are some conversations it feels like almost we don't quite have permission to have without somebody prompting it or some kind of structure around it.  

Liz: Yeah, definitely. And I think it takes a certain amount of emotional maturity to have conversations like that, or the difficult conversations, and not to take something personally or get defensive. And I think that that’s something as a society we don’t necessarily encourage people to have those conversations, or to be able to freely explore things without there being some element of self-worth dependent on it.  

Lucy: Liz and Richard went for therapy after experiencing a bit of a rocky patch in their relationship.  

What was it like going for the weekend? 

Richard: I think it was really beneficial. It’s certainly something that – hopefully we’ll never be in that similar circumstance again – but in a situation where we thought it was beneficial, doing it over… was it three nights? 

Liz: Yeah, three nights.  

Richard: Was really valuable, because it kept you in that space. So there were no distractions from, I don’t know, going to work, having to get back, get to the session.  

Then inevitably when you finish the session you get home and normal life kicks in straightaway. So whether it’s cooking dinner or having to get ready for the next day, that’s unavoidable. But in this situation we were really able to take ourselves away from normality and the routine, and really focus on it. And I think it had a great impact doing it that way.  

Liz: Definitely. And also I think that having – because the sessions each day I think ran from 10:00 till 1:00, and then 2:00 till 4:00. So having those extended sessions meant you could really get down to what was happening and really attack that. As opposed to when it’s say weekly, hour long sessions, having to almost get past the initial boundaries that you might have set up and break those down, and get into a place of being able to talk freely.  

Lucy: And were there other people there as well? Were there other couples there or was it just you? 

Liz: It was just us.  

Richard: Yeah.  

Lucy: And what was it like before you went? Was it frightening to think about going? 

Richard: I suppose for me it was a sense of that nervous excitement. So I didn’t quite know what was going to happen. I knew what I wanted from it. And it was the kind of knowledge that this was going to be good for us, at least for me.  

Liz: Definitely. And I think one of the first things, on our first evening there, we had the initial introduction session together. And Dan did say it was quite unusual to be dealing with a couple who were in such a good place. And that was quite nice actually, and we definitely subscribe to the idea that therapy isn’t just for when something goes wrong; it’s actually really useful to keep things right, as it were.  

And I think it was funny because the things we thought we were going to end up talking about over the weekend, actually it all came down largely to communication, which I think is often the case with couples. And learning how to communicate with each other.  

Lucy: Before we hear more about Richard’s and Liz’s experience, here’s Dan to give the bigger picture on this type of therapy.  

Dan: My name is Dr Dan Kolubinski, and I am the clinical director of Reconnect UK, which is a CBCT based intensive retreat programme.  

Lucy: And what’s your professional background? 

Dan: My master’s degree is in counselling psychology, and a PhD in psychology as well. And I’ve been a CBT therapist for about 15 years now.  

Lucy: Cognitive behavioural couples therapy might be something that people haven’t heard of before. Could you explain what it is? 

Dan: Well, as in CBT, in cognitive behavioural therapy, there are these two different aspects; there are cognitions and there are behaviours. The ideas are that if you change those two things you might change how a person feels. And with the couples aspect of it, it’s built on the same principles, but trying to treat a relationship rather than an identified client. It’s not just about one person, it’s about how the two of them as a unit are.  

So the primary focus is on the behaviour side of things. The idea is that if I can change what the couple are doing, that will change the way that they think about each other which will change the fundamental feelings of the relationship.  

And so that breaks down into a couple of different components. There’s on the one hand, ‘do nice things’; trying to bring up some of those caring behaviours. That if I know what my partner likes and how they feel cared for, we have to guide the couple sometimes to actually doing those things.  

And the other thing is around skill building. So we’ll have things particularly around communication; really breaking it down to some of the fundamentals of how we talk to one another to make sure the message that’s sent is the message that’s received.  

Lucy: Could you give some examples of the sorts of changes in the way that people talk to each other that you might encourage? 

Dan: There are a couple of one-liners that I like to use in the work that I do. And one of the big ones I think that comes up in communication is that it’s very important to listen in order to understand, rather than listen in order to respond.  

So most of the time when couples get into a conversation, even the positive ones but especially the negative ones, rather than hearing what the other person is saying, what we have a tendency to do is already think about what we’re going to say next. And so I’m not engaging with what my partner is saying, I’m already finding holes in their argument, I’m already stating my next case in my head.  

And so we really have to stop that process so that people can slow things down and really make sure that what’s coming across is what was meant to come across. So that idea of I need to button my lip, I need to put my world view on the shelf and I need to listen to what’s being said, in order to understand it.  

Lucy: That sounds super useful for all sorts of relationships actually.  

Dan: Absolutely, yeah. These are generalisable principles, I think. It’s when we’re dealing with a couple, that’s really the emphasis, but the same sorts of principles can be used for other family members, can be used for co-workers, can be used for neighbours. It’s all about just two people interacting with each other.  

Lucy: And so if a couple came to a therapist for cognitive behavioural couples therapy, what could they expect? 

Dan: They can expect somebody who’s there to try and understand their own point of view, but isn’t going to take their side. So the role of the therapist really is to try and guide those conversations, and shift away from accusations and misunderstandings.  

And to act almost as a bit of a mediator sometimes, in the very beginning. Eventually, like any good CBT therapist, our job is to try and make ourselves obsolete as quickly as possible. So it is about trying to skill them up to have those conversations. But in the beginning we can be there to try and translate; make sure that the message that's sent is the message that’s received.  

One thing that I meant to say, and I got a bit side-tracked, was one of the key principles is if I do something different then my partner might do something different. Usually what we’re doing is we’re waiting for our partner to do something different before I do something different.  

And there are some interesting things with that. Number one is I have to take the lead; if I put 55% to 60% of the responsibility for my relationship on my shoulders, and just expect 40% to 45% from my partner, then if both people are doing that then they probably stand a good chance. So I’m not doing a tit for tat, trying to keep score; I’m actually taking a little bit more of the initiative, willingly. And then if I do that, chances are I’m going to inspire that good in my partner and they’ll do that as well.  

But the other thing that comes up I think in a lot of sessions is that people have a tendency to do something that seems like a good idea at the time, but can be really destructive to a relationship, and that is we have a tendency to follow the golden rule. Now what I mean by that is that the golden rule, treat other people the way you want to be treated – and it sounds good, and generally I’m very supportive of it – but it actually ends up being really bad relationship advice. It becomes so much more important to treat the other person the way that they want to be treated.  

So if I’m doing all of the nice things for my partner that I would want her to do for me, they’re not going to land well. And I’m not going to get the credit for them, because I’m not speaking in her language, I’m speaking in mine.  

Lucy: So are the first few sessions trying to get that shared understanding with a couple, of what the problems are? 

Dan: Typically. The first few sessions are usually assessment-based. So an assessment would take a little bit longer in CBCT than it would with CBT. Because typically – and again, this is something that couples can expect – the first session would usually be with the couple themselves. Coming in, getting a sense of the history, where they are now, current state of play, what might bring them to therapy. And getting their story; what brought them up to this particular point. We go right back to the very beginning.  

And I think there it’s necessary not just to hear what the couple is saying, but also how the couple are saying it. There’s a fair amount of information in how people tell their own story. And then we can see if there still is some love there between the two of them; if they’re warm and fuzzy. It’s amazing when you ask a couple how did they meet, they both look at each other and they smile. That can be really quite telling, compared to those that just stare off into the distance as if they wished that day didn’t happen.  

But then we get into conversations with them as individuals. So there will be a couple of sessions where it is about tell me your story, tell me your side of things. We need to be able to understand both of them. And so that’s a part of the assessment as well.  

And then the final assessment session would be bringing it together. So as CBT therapists, we’ll draw this out in what we call a formulation, which is just this diagram that links our thoughts, our emotions and our behaviours, and our view of the world, to one another, to each other.  

Because I can see my partner’s behaviour, what I can’t see is what’s underneath that. What are their thoughts? How are they feeling in these moments when they do what they do that drives me crazy, and then how do I react, and then how does my reaction then impact my partner? So we’ll go through a session looking at that system, and the habits that have been formed.  

And then from there we’ll get into the communication side of things. I usually do. Starting off with the talking element of trying to understand each other. And at the same time, usually for homework between sessions, we would also expect a fair amount more of the positive behaviour, the caring behaviour. So that they’re actually do something differently; hitting the ground running and trying to demonstrate that they care about one another, which they typically aren’t doing by default.  

Lucy: Are there any other concrete examples from therapy of things you encourage people to do differently, that have caused a change in thinking? 

Dan: Yeah, I think generally speaking, there’s a common thing that I see with a lot of couples. When we get into the formulation diagram – and so as I said, it has this connection between what we’re thinking, what we’re feeling and what we’re doing. And it’s informed by this higher idea of how we see the world.  

And if I’m looking at my partner’s behaviour for example – and I’m doing that through my lens, I’m doing that through the way that I see the world – well that’s just going to be crazy town. It’s not going to make any sense to me whatsoever; “I don’t know why you’re being so unreasonable. Can’t you see that?” 

And then we start to slow things down and start to highlight the other person’s framework. And if I’m really open to that, that you see the world from a certain point of view, where we agree, we don’t have problems. The problems come from where we might be on a different page. And we’ve done that because we’ve had different experiences.  

And when couples start to really slow it down and listen to where those connections are being made, or how those experiences have shaped why they might see things the way that they might see things, it is amazing how the walls start to come down.  

Lucy: I bet that’s really rewarding.  

Dan: Absolutely, absolutely. But frustrating in equal measure, because it’s also one of those things that might be blatantly obvious to the therapist, but it’s not obvious to the couple.  

Lucy: Back to Richard and Liz. I wanted to know what practical techniques they’d learned that they could use day-to-day? 

Richard: Yeah, so I think one of the early ones we did at the weekend was just about active listening. And like Liz says, a lot of it was about communication. And so we did some exercises talking about aspects of our relationship, and ensuring each of us was being listened to properly. And so we did an element of one person would talk about how they were feeling and the other person would almost paraphrase, and repeat it back to them to try and ensure that they had taken in what they were saying and understood it.  

And the understanding bit was key, because initially there’s that aspect of right, I need to remember this and say back to her, so to your other half. But if you do that, and I’ll admit I did that initially, you get caught out so quickly because all you’re trying to do is to remember it to repeat, instead of actually taking it in. And so that was a really valuable exercise that we’ve tried to continue using day-to-day as much as we can.  

Liz: Yeah. And I think one thing that really stuck with me was we did an exercise about what’s the best case scenario to come out of this, how does that look, what will happen if that doesn’t happen? And so actually exploring possible consequences. And I found that really helpful. Because I think so often you can get caught up in the moment and being concerned with who’s in the right, who’s in the wrong, who hasn’t washed up, whatever. And actually lose sight of what it means and what could that niggle lead to, and is it important in the run of things? 

Yeah, it was very helpful to be able to step out and be given written exercises to help us step out of the now and consider what the future looks like together, and what we can do to make that happen.  

Lucy: How nice to be asked what the best case scenario is as well.  

Liz: Yes.  

Lucy: I don’t know about you, but I so often spend time worrying about the worst case scenario, so yeah.  

Liz: For me it always sticks in my mind now, that if something happens, I think is bringing this up, is fussing over this going to get me closer to that best case scenario? If it’s not, then can you let it go? And that’s quite helpful. Like I say, I do that all the time, I let so much stuff go now. (Laughs) 

Lucy: It’s super hard though this stuff though, isn’t it? It’s really hard.  

Liz: It is. And I think especially at the moment, I think that’s the thing. The idea of being able to step out of things is very helpful at the moment because emotions are running high, and so it can be difficult sometimes to know if what you are feeling is actually a direct consequence of something that has happened with your partner, or just made up of general stress about everything.  

Richard: The current situation.  

Liz: Yes, absolutely.  

Lucy: Are there other things that you think people should know, if they’re thinking of embarking on cognitive behavioural couples therapy? 

Liz: I’d say that it’s definitely an investment. Because it’s not the cheapest thing to do, especially if you’re doing a weekend of it. But the pay-off has been incredible. And this is why we were so eager to speak to you, because we do still get so much from it.  

So for example one thing we’d spoken about at the weekend was the idea of having time to check in with each other each week. And talk about how things are going and what our hopes are for the week ahead, and also hold each other accountable for things if we need to.  

And so now once a week we have what we call an MM, our Marriage Meeting. And every week we come to the meeting with two things that we’re grateful for, or that we’ve really appreciated that the other one has done in the week. And I love a spreadsheet, so we have a little form that we fill out that basically at the beginning says we will always come to these meetings positive and ready to engage.  

And that has been really lovely, and that’s something that I think has kind of become part of our week now, hasn’t it? 

Richard: It has. Very much so, yeah.  

Liz: It’s really lovely. And I mean I’d say physically things are much better as well. So obviously things… It seeps into other aspects of a relationship; when certain aspects are good other aspects are good.  

Richard: Sometimes it may only be 20 minutes or something like that. So it’s not something that will last for hours, but it’s just a really good way to check in with each other.  

Liz: Yeah. And initially we made sure we kind of sat down at a desk or on the sofas opposite each other. And now we have got to the stage, when the weather’s been nice, we might sit outside in the sun with a G&T and have it. Or we’ve had a couple where one of us is sat in the bath and the other one is sat there chatting. So we are now integrating it into our everyday life, but it’s a specific thing we make sure we do.  

Lucy: It’s interesting though the idea of the meeting, because it’s such an important area of our lives, and yet we don’t always put the same amount of effort into it that we might a job or other aspects of our life.  

Liz: Yeah, it’s funny you say about the job, because one thing that really struck me from that weekend, was when we spoke about relationships and roles in a relationship, and we said how essentially we have roles to play. So initially we audition for that role when we’re getting to know each other. And then it’s like okay, I’ve interviewed you for this job, you can be the role of my boyfriend or fiancé or husband, and we need to show up in those roles. And we need to give consideration to what we’ve agreed to be together in each other’s lives.  

And that I think was something that really hit home for me as well. And I think the meetings help us do that in a sense; we both show up to work each week.  

Richard: We do indeed.  

Liz: And it just resets that I think.  

Lucy: As I mentioned earlier, Richard and Liz did their therapy sessions over the course of one intensive weekend, and it was a private arrangement rather than an NHS service.  

Dan explained to me what other sorts of options are available.  

Dan: There are these two different streams I guess that would be useful to see what might be accessible via the NHS. I should say that within the NHS, the real criteria there is mainly around depression; I think some services will offer it for substance misuse as well. So it would be good to know what might be available and what the criteria would be in order to be able to access that.  

And so as a useful treatment for depression, usually you would have one, and then sometimes two people, who would meet the criteria for a mood disorder. And in couples therapy, the relationship and the depression can relate to each other; they can build on each other. And so by treating the relationship you can have a significant impact on depression. 

In private practice, which is where I think most couple therapists reside, there it would be accessing online directories, looking at Google, typing in things like CBCT, cognitive behavioural couples therapy, or just behavioural couple therapy.  

I should add that there are those therapists who actually don’t look at the thoughts as much, it’s more just the behaviours. And that is the fundamental core; it’s about doing things differently. So behavioural couple therapy would usually be something people would have on a website, if that’s what they’re offering.  

Lucy: Obviously it must be different for every couple, but roughly how long would a treatment take? 

Dan: It would be similar to a lot of individual CBT. It can be for some really low level; we want to prepare things, we don’t want to have the cracks form later, a little bit prevention. That can just be a few sessions; five, six or so of the actual treatment, once you get out of the assessment stage. That would be about three or four really, if they’re just doing prevention stuff.  

But typically a course of therapy would be about 10, 12, maybe upwards of about 15 sessions. Sometimes more, it could be upwards of 20, depending on how entrenched these old habits are.  

Lucy: And is that something you do get; people coming early on in a relationship to try to head-off bad habits? 

Dan: Absolutely. That’s something that certain religious organisations have been doing for quite a while. The Catholic church has always expected couples to go through a marriage preparation course. And there are fewer people who are seeking that religious intervention now, so they come to us. We have the same principles, and a lot of the same material. 

And so we see the divorce rate is 42%; that’s a pretty staggering number when you think about all of the unhappy married couples, it’s about a coin toss about whether or not any couple is going to make it and be happy. But there are things that we can do in order to make sure that we’re in the right 50%.  

Lucy: And what got you into doing this sort of therapy? 

Dan: I’ve always been fascinated by relationships. I was first inspired by Albert Ellis, as a first year psych student, and I knew this was the area I was going to work in. But then as I was going through my studies, I just became really fascinated with relationships.  

I’m one of the very fortunate ones, my parents are still together after 40 years – coming up on 50 years actually, very soon. And I just always appreciated their relationship, the way they interact with each other, the way they talk.  

And in conversations I’ve had with clients over the years, I do recognise that very rarely is there the one person who’s fully to blame. It’s usually a system thing. And I think what the world needs more of is just slowing things down and trying to listen to understand, rather than listening to respond.  

And so it’s a very different type of work than if you’re working with depression or anxiety, that’s very much around distress and trying to reduce distress. There’s distress in relationships, but it’s the system that’s the problem rather than there being an issue with mood or anxiety.  

Lucy: Do you ever feel sort of caught in the middle as the therapist? 

Dan: Sometimes. It’s really odd when a couple has been particularly conflictual, and been fighting a fair amount, and they want to feel heard. And they’re already under the impression that they’re the reasonable one, and if you can just fix my partner then we’ll be okay. Very rarely is that ever the case. But you do get dragged into that a little bit.  

That’s rare. Most couples, they come to see a couples therapist because they recognise that there’s a problem with how they’re interacting rather than, “Just try and fix my partner.” But it does happen.  

Lucy: It sounds like hard work, actually.  

Dan: It’s very much a game of mindfulness, I think, for a couples therapist. You always have to be on the ball and always in the moment. Especially with those couples who can trigger each other really quickly, and get caught in that vicious cycle of arguing, and they think they’re the right one and their partner’s the wrong one. And just blinking; you think you’re having a productive conversation and it can just set off.  

So we have to be far more active than we would do when treating individual clients, to make sure we’re interrupting that pattern, because it’s happening live. If I’m treating an individual, I might generate a panic attack, but one doesn’t generally spontaneously happen in a session, but in couples therapy, the fights do.  

Lucy: Do you think it has made you more able to listen in that kind of slowed down way that you talked about? 

Dan: Well, there are skills there to try and understand some of the fundamental premise that someone might be saying. And I think I recognise that just about every topic under the sun tends to be a lot more complicated than what some people tend to think.  

There are very few simple answers in this world, and I think that idea of being that mediator, from seeing a couple to diplomacy between nations, are all just aspects of the same spectrum. It’s just people feeling unheard and misunderstood, and sometimes closing their ears to the other side.  

Lucy: Couples therapy is in the NICE guidelines, which draw on different research studies to understand what the most effective therapies are for different sorts of problems. I asked Dan what the evidence base for this type of therapy is.  

Dan: It’s a bit of a tricky question to answer, for a couple of reasons. The short answer is, pretty good; not absolutely fantastic, there’s no guarantee I think for any couple. But it is better than nothing, and it is one of those very few evidence-based treatments that we have. There is a lot of couple work out there that doesn't have the evidence base, that behavioural couples therapy would do.  

And a lot of the time it really does depend on the couple. Again, one of the shocking statistics is that the average couple could very well wait around six years of having problems before they seek help. And as a result of that, it does linger and become and become a bit more complicated.  

And it’s the same thing with the relationship, and so those who are able to see the cracks beginning to form, they tend to fare a little bit better than the couple who have canyons that have come into their ways of communicating. But I think with an open mind, with an understanding, and with a willingness to be able to hear – which is usually the biggest obstacle – then a couple can do well with some good tools and the right direction.  

Lucy: One really tricky thing about evaluating the effectiveness of cognitive behavioural couples therapy is that unlike individual CBT, the aim isn’t always to make the relationship better. Pre and post scores on a relationship satisfaction measure aren’t always the best indicators.  

Sometimes couples use therapy to determine whether ending the relationship is the best option for them, which could still be a good outcome even if the scores don’t improve.  

I asked Richard and Liz what else had stayed with them since doing the therapy.  

Richard: For me I suppose it’s more the approach. So if people were interested in doing it, then the environment that you’re going into is one of the safest that you’ll have to talk about the really difficult stuff. So there’s no reason not to be as open as you can. And don’t hold back, because there’s no point, you won’t benefit from it. So I would just thoroughly recommend being as open and honest as you can, and you really will reap the benefits from it.  

I think it’s almost like that green light to be able to say maybe the things that you haven’t said before, or the things that you’ve been scared of saying. Because it might be that those things in the past have been a catalyst for an argument or some difficulties. Whereas in this space you’ve got someone who, if it does go that way, can bring it back, and also is there to help balance the conversations.  

And so once you’ve done it once in that environment, and realised the benefits, then just keep doing it, because it’s very, very powerful.  

Lucy: It sounds helpful for stepping out of patterns that we can all get into.  

Liz: Yeah. And I think also it was having someone there who is trained, and they have this incredible toolbox of things that they can give to you.  

And the range of things that we spoke about, I think there were some things that I think we didn’t realise we would speak about, which actually in hindsight, of course they were going to come up. And we dealt with things across the spectrum of a relationship, didn’t we? 

Richard: Yeah, we did. Yeah.  

Liz: And we were given tools not only to help us communicate there, at the time, but then also afterwards. And that has been really helpful for us as well. So we haven’t just been left to get on with it, and hope that everything works out okay.  

I think we’ve tried sometimes in the past to deal with things by Googling them and looking for articles. And you end up with all of these things that are suggestions as to how you can improve your relationship. But actually having a professional who takes the time to sit down to work out what’s best for the two of you is invaluable.  

Richard: I think it was almost like – and not to sound too cheesy – but we went there wanting to know how to dance, like how to do a Viennese waltz, and Dan was able to pull us back and say well, let’s just make sure you can hold hands properly, first.  

Liz: Yes. Yeah, exactly that. I still want to learn to Viennese waltz but…  

Richard: Yeah.  

Lucy: What was the hardest thing, do you think, about it? 

Liz: There were elements where we were talking about physical things in our relationship, that you have the schoolgirl kind of – you get embarrassed talking about things like that.  

But much like Rich said earlier, when he said just be honest about something, and when it doesn’t go wrong you’ll realise it’s a safe place to keep being honest. And I think that’s the thing. As soon as you start talking about something, and you realise the world hasn’t stopped turning, it’s then like that switch – again, as Rich said – that switch goes on and you actually realise this is okay, and this is normal.  

Richard: Yeah.  

Lucy: And what do you think the best thing has been to come out of it? 

Richard: It’s hard to answer that, because I just think it’s the way we are. So the developments in our relationship, the way we communicate. The closeness, like Liz says, physically and mentally, is better than it has been, I think. So okay those butterflies may have gone, but like Liz says, it has been replaced by just a stronger bond. 

Liz: A different type of butterflies.  

Richard: A different type of butterflies.  

Liz: Yeah, maybe.  

Richard: Do you know what I think is important; it encourages you to want to continue to do that. So you don't go there have a session or a number of sessions, and once you’re done, that’s it, you’re fixed. It doesn’t work like that. But it encourages you to develop yourselves and keep going with, like Liz says, with the tools you’ve been given.  

Lucy: But brave to be able to do that as well, because it’s challenging too.  

Liz: Yeah, absolutely. Because the path most trodden is the one you go back to, isn’t it? But yeah, just recognising I think those old behaviours is a victory in itself.  

Lucy: I asked Liz, Richard and Dan for their final thoughts for couples who are thinking about having this type of therapy.  

Liz: If anyone’s even thinking about it, take the leap, because the one thing you’ll wish is that you’d done it sooner. And the good thing is if you’re going to invest one day in it, you might as well invest sooner rather than later, because then you’ll have longer with the benefits of it. And it’s worth it.  

Dan: I’d definitely encourage it. And there is an element of don’t wait; don’t wait until it’s too late. There are those couples that I have seen where, in the session, five sessions in, one partner might say to another, “Look, had you offered to do this five months ago I would have been there, but I’ve lost it, and the fire’s out now.” And so this is a time limited situation sometimes. People do end up getting to a point where they’ve passed the point of no return and they just shut down.  

So a relationship, it’s a little bit like a fire. The flames tend to go out pretty quickly – the passion, the heat – and we have that in the first six months to two years, and then that starts to go. And that’s the case for any relationship. But you would expect the embers to be glowing, you would expect some sort of heat to still be generated from what’s left, from those coals.  

But there is a time when that starts to extinguish. Sometimes it’s as dramatic as a bucket of water being poured over it, sometimes it’s just time, and it burns itself out. And so the sooner tends to be the better. And that would be the main advice.  

Lucy: And just one last question, how do you know when to stop? 

Dan: (Laughs) That’s a great question. As I say, I think my job is to make myself obsolete as quickly as possible.  

And in your typical therapy, there’s a difference between treating relationship distress and treating substance misuse. With substance misuse there’s very manualised – today is session two, therefore we’re going to talk about this; this is session five, so therefore we’re going to talk about… They’re very rigid and strict in what they do, and it’s a very dedicated programme.  

For relationship distress, generally for the population where substances aren’t involved, it’s a little bit more open, shall we say. We deal with what’s going on at the time. And I have a loose structure in my head, where I want to deal with things like caring, communication, and conflict management. Those are the three things that I want to make sure the couple has. So they have a lot of positive going in, they have little negative coming out, and they’re able to use the tools to understand each other better. When they can do those three things then we start to wrap up.  

And it would be very similar to how do you know you’re done with depression. People feel a little bit more confident moving forward and don’t really need you as much; we can phase things out a bit. They’re managing their own conflicts.  

Most problems won’t go away; about two thirds of all conflict are what they refer to as unsolvable problems. When you pick a partner you pick a set of problems – that’s kind of how relationships work. But they can manage them better; they’re not sparking each other off. They’re not becoming emotive conversations, they’re becoming much more productive conversations around understanding and meaning. And then I’m not really required any more.  

Lucy: Thank you to all of my guests, Richard, Liz and Dan. If you’d like more information on CBT for couples, have a look at the show notes.  

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

That’s all for now. Thanks for listening and take good care.  

 

END OF AUDIO 

 

 

 

 

 

 

 

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

 

Show Notes and Transcript

BABCP website is at www.babcp.com

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

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

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

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

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

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

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

Information from Cruse about traumatic grief

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

The Good Grief Trust

https://www.thegoodgrieftrust.org

Image is by Cassie Boca on Unsplash

Transcript

 

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

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

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

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

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

Lucy: Gosh, so in a way good timing.  

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

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

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

Lucy: I’m so sorry.  

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

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

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

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

Lucy: It sounds like such a dark time.  

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

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

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

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

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

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

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

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

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

Lucy: Super, super hard. Yeah.  

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

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

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

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

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

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

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

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

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

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

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

Lucy: Like a kind of Messenger chat? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lucy: That sounds really important, yeah.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Graham: Yeah, absolutely.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lucy: That sounds really different, yeah.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

END OF AUDIO 

 

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

Show Notes and Transcript

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

Books

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

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

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

Websites

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

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

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

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

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

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

Articles

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

Podcast

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

 

Transcript

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

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

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

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

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

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

Lucy: And what did you find?  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

END OF AUDIO 

 

How does doing more of what matters help teenagers with low mood and depression? And what can we all learn from this, particularly at the moment? Prof Shirley Reynolds speaks to Dr Lucy Maddox.

 

Show Notes and Transcript

If you want to know more the following resources might be helpful.

Books

Shirley has written two books about depression in teenagers, one for teens and one for parents:

For parents: Teenage Depression:  CBT Guide for Parents https://www.amazon.co.uk/Teenage-Depression-CBT-Guide-Parents/dp/147211454X

For adolescents: Am I Depressed and What Can I Do About It? https://www.amazon.co.uk/Am-Depressed-What-Can-About/dp/1472114531/ref=pd_lpo_14_t_0/260-4076808-4951665?_encoding=UTF8&pd_rd_i=1472114531&pd_rd_r=bd1ea151-b4d3-40bc-99bc-583aa3824613&pd_rd_w=xtKq9&pd_rd_wg=CFBxI&pf_rd_p=7b8e3b03-1439-4489-abd4-4a138cf4eca6&pf_rd_r=MFANFKSAD9RE92R6XS65&psc=1&refRID=MFANFKSAD9RE92R6XS65

Websites

BABCP website www.babcp.com

Register of BABCP accredited therapists https://www.cbtregisteruk.com/

These resources about child and adolescent mental health might also be useful

Young Minds https://youngminds.org.uk/

MindEd https://www.minded.org.uk/

Association for Child and Adolescent Mental Health https://www.acamh.org/

Other resources

Shirley is running a course with Future Learn from 1st week in June about adolescent depression – aimed to help parents and professionals understand and help young people who struggle with low mood: https://www.mooc-list.com/course/understanding-depression-and-low-mood-young-people-futurelearn

Have you seen the BABCP animation about what CBT is? Only 1 minute long and available here: https://www.youtube.com/watch?v=ZRijYOJp5e0

Photo by Daria Tumanova on Unsplash

Podcast episode produced by Dr Lucy Maddox for BABCP

Transcript 

Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. This podcast is all about CBT, what it is, what it’s not and how it can be useful. Today I’m speaking to Professor Shirley Reynolds from the University of Reading about how doing more of what matters can help teenagers boost their mood, and how this might be particularly helpful for all of us to remember at the current time.  

Shirley: The thing I’m really mostly interested in is understanding more about adolescent depression in order to help us really develop better treatments and better ways of preventing young people from developing depression. So that we can really try and divert them away from a path that can lead into a lifetime of problems with low mood.  

Lucy: Fantastic. And at this time in particular when we’re all shutting doors a bit because of the pandemic and teenagers are shutting doors as well, what can your research tell us that might be helpful at this time in particular do you think? 

Shirley: I think there are some general points and some more specific points. I think the general point is that one of the things we know, not just from our own research but from many people’s research is that when you’re a teenager, most teenagers are going to be incredibly attached to and reliant on having relationships with their friends, their peers.  

The family becomes a bit less important, it’s not unimportant, but the importance of it becomes a little bit less and that’s replaced by a really, really strong focus on needing to be part of a social group. Being accepted by other people, contributing to things with your friends, being part of something bigger than yourself.  

And so what that tells us then is that a period like now when young people simply cannot have those relationships in the normal ways, that this is a potential point of really massive stress for them and distress for them. And we need to try and support them; to maintain any relationships they already have, in whatever way is possible.  

And what most parents are currently struggling with, but I think getting a handle on, is that currently that is going to be on a computer.  

It’s not just young people, we all need these things. This is a lifelong thing for most people, but it’s a particular importance at that critical development period when we’re teenagers.  

Lucy: So making sure that we’re supporting the young people in our lives to maintain contact with their friends in whatever way is possible.  

Shirley: In whatever way is possible, absolutely. And accepting and understanding that it’s frustrating and difficult and anxiety provoking and that that’s true for everybody, parents, children, and everybody else.  

There’s a degree to which we have to kind of let our normal expectations just be shifted around a bit and learn to live with that and be okay with that.  

Lucy: Actually, just you talking about teenagers in particular made me think about that tension that can happen sometimes between teenagers really wanting to be independent and maybe family really wanting to comfort teenagers during this time. And sometimes that can be a really tricky balance to walk, can’t it, if you’re a parent who wants to offer comfort and your teenager is saying, “No, leave me alone.” Is there anything, from your point of view, that you would say about that?  

Shirley: I think that’s absolutely right because the other task of being an adolescent or a teenager or growing up is to learn to be independent and to learn to do things on your own. And at the moment everybody is forced to spend 24/7 with their families and that exploration and getting out there and taking a bit of a risk and learning about yourself in the world is something, it’s very hard for teenagers to do at the moment. So they are going to need time to be separate and to be on their own.  

And it is fine for them to tell you to back off and it’s inevitable that people will feel a little bit pushed away and maybe left out or maybe tempers will be frayed and there’ll be a bit more irritability. But again, I think that’s one of those inevitable challenges that there’s no right answer for this.  

So I think that tension between needing support and also needing to be separate is really a massive struggle, especially for people who live in very small houses, don’t have outside space. So sharing bedrooms. I think trying to find a space for young people to call their own, for at least some of the time is going to be really important, if that’s at all possible.  

Lucy: Yeah, really helpful. And helpful to remember that in the midst of trying to homeschool and all the rest of it as well actually, that to be somebody’s teacher and mum and seeing them all the time is not possible. 

 And some of the research that you’ve done that I found really interesting has been about valued actions. I wondered if you could say a little bit more about what valued actions are? 

Shirley: Yeah, so this comes from the research we’ve done with teenagers with depression and low mood. What we see when somebody has depression or beginning to become depressed is that as we feel a little bit worse, what we tend to do – this is in normal life – is to take ourselves out of our normal social activities. So young people who have got problems with depression very often, nearly always, spend more time on their own than they would have previously.  

And as they do that, as they take themselves further out, they get less reward from life. So fewer of the things that would have just happened in their normal daily life, a smile from somebody or a shared joke or something that you notice outside of the house that just made you feel good about yourself, those things just are less available to you. They happen less because you take yourself out of what’s happening in life.  

 

As you withdraw what we see is you get less reward from life, or less of what we would call the ‘feel good factor’. And when you get less of the ‘feel good factor’, that makes you feel worse. And as you feel worse, you withdraw a little bit more and you get less reward and then you get less of the ‘feel good factor’.  

So you find that young people with depression and adults with depression get themselves into this very hard to escape from cycle, this vicious cycle.  

Lucy: Shirley’s research looks at ways of trying to break the cycle of low mood and doing less.  

Shirley: So, we want to break the cycle and the way we turn it around when we’re working with young people is we help them to do more of what matters. More of what matters are things that are important to them and we help them decide what matters to them by talking to them about their values.  

Lucy: Values are guiding principles in life, the things that show us the direction we want to go in. To work out what matters sometimes takes some real reflection on what it is that’s important to us.  

Shirley: Now, they’re really big questions, why am I here? What am I doing? What is the point of it all? They’re massive questions, but they’re brilliant questions and lots of teenagers are sort of playing around with them anyway. So if we can tap into that need to work out why I’m here and what I’m doing and what my values are, it becomes a really exciting, interesting conversation.  

Lucy: Shirley told me about three main areas that she tends to ask young people to think about. Values to do with themselves, like health or fun, values to do with things that matter, like education or politics and values to do with people that matter, like family and friends.  

Shirley: And then the idea is that once we’ve helped them think about what their values are, which we can do in a very structured way, we then help them to do a little bit more of what matters. These are the valued activities.  

So tiny little, small, easy to do activities that help them get a little bit more of that ‘feel good factor’.  

Lucy: By increasing time spent on things that matter, that vicious cycle Shirley talked about before can be reversed. 

Shirley: And as that reward comes back, we start to reverse the cycle. They feel a little bit less bad, so they’re able to do a little bit more and that makes them feel a little bit better. Then they can do a little bit more and so on.  

So we’re taking the cycle we had that was dragging them down and we’re turning it into a cycle that can help them build their life back up again.  

Lucy: Shirley encourages young people to think of a wide range of things that they can to help them move towards their values. Key is to make each step as easy as possible so young people feel a sense of achieving what they want, not failing. Also key is that the things really do matter to the young person.  

Shirley: Most kids are doing a whole load of stuff that other people make them do. Their lives are much more circumscribed than adults’ lives. They’re told what to do by other people. There are hundreds of things they can’t get out of. So you can be really busy doing loads of stuff, but if it doesn’t really matter, you don’t get that ‘feel good factor’.  

We find even 11 year olds and 12 year olds can begin to tell you about things that really matter to them. And these don’t have to be sophisticated or complicated or smart. The importance of the value is not in its cleverness, we just care that it kind of lights you up a bit.  

Lucy: Because what matters to each young person is specific to them, how the treatment looks is very individualised.  

Shirley: Everybody is following a similar recipe, but what they’ll be doing and how they’ll be doing it and how we’ll help them to do it will be completely different for every young person. The way we get them into the this, we get them to keep diaries really. And that is to help us see, and for them to see what they’re currently doing and what it usually shows us is that there’s almost no reward in their daily life. And so it helps us also find times in their days and their weeks when we can pack a bit of reward in, or we can swap one activity to another.  

So when we do it for ourselves and we write down our activities and then we write down our values, and we try and map across, we’ll nearly all find a huge gap between what we value and how we’re spending our time. We’re just saying, “Where’s the flex here in your life to put in more of what matters?”  

Lucy: Shirley’s research has found that people are less likely to drop out of therapy when the treatment focuses on what matters to them in this way. It also helps young people move on from feeling stuck in the here and now.  

Shirley: We don’t talk about the future in an explicit way, but when you talk to a 15 year old about what their values are, they’re nearly always going to connect with the future and where they want to go and what they see themselves as. And it allows them to kind of use a bit of, yeah, just a little bit of imagination about, “Oh, I don’t know…”  

And if they’ve never thought about what they want or what their values are, they go, “Oh, I don’t know.” It’s actually quite an interesting question, even if it’s something you’ve never thought about.  

I mean the other part of what we do is we try and get other people in the young person’s life to help them with those rewards because young people don’t have as much autonomy or as much money. They don’t have as many resources. They sometimes need practical help to get things done. Or they need encouragement, giving lifts or arranging things at home that are a little bit different to give a young person a bit more space.  

Or thinking about rewards that might be shared, like deciding on somebody’s favourite meal and then going out and doing the shopping together and then cooking together. That can be quite nice because it’s a kind of value about wanting to get on with my family but it might also be learning a skill.  

Lucy: I asked Shirley how we can use these same principles at the moment, even though young people, and adults too, are going to be unable to do all the things that they value at the moment.  

Shirley: I don’t think there are any fundamental differences. I just think we’re looking at a different range and a different kind of repertoire that we can use.  

Lucy: What Shirley said earlier about teenagers being so, so busy, but actually their time is all stuffed with things that other people want them to do made me wonder whether there’s a slight perspective shift that’s helpful for young people and for adults. From thinking about how much stuff we’re all doing to really thinking about how much of that stuff matters to us.  

Shirley: And I think if we thought more a little bit about well, what are the rewards I’m going to get from this, what am I going to take away from this that’s going to make me feel good, we might make different choices about how we’re going to spend our time. For me it’s all about the search for more positive experiences. It’s not about getting rid of bad experiences because we’re all going to have bad experiences, that’s just part and parcel of life. But if we’re filling a lot of our time with positive rewarding experiences, there is, by default, less of the time to have more negative experiences.  

Lucy: There’s maybe something here for all of us. At the moment when our usual schedules are for lots of us upside down, maybe it’s a chance to pay attention in a different way, to helping young people in our lives to be doing stuff that matters to them. And also to be thinking about this for ourselves.  

Shirley: Learning to savour things, paying attention to those positive things that sometimes we perhaps just let them go and they’ve gone before we’ve kind of properly enjoyed them. There’s a sort of opportunity to just notice a little bit more deliberately some of the more positive aspects. And that could be something like our first cup of tea in the morning. 

Lucy: Always the best one. 

Shirley: Exactly! Or the cat purring on your lap or I don’t know, silly things, tiny things and they’re different, some of them are shared, but many of them are very personal. It doesn’t matter what they are, it’s just capturing them somehow.  

I like my phone for that reason, I do a lot of photographs of things that make me feel good because then I kind of feel I’m carrying them in my pocket. I think it’s always about finding the thing that fits your preferences and your personal style. But I do think some sort of recording of what is happening in your life, especially when we’re living through a weird time like this, is likely to be useful.  

So that could be through writing. It could be through photos. It could be through just what you email your friends. But I think some way of kind of recording what you’re doing, where you’re at in your life and spending a bit of time just thinking about that becomes a very helpful habit to have. Because it can stop you falling down into those vicious cycles that when we don’t notice we’re falling into them, it can be much harder to climb back out later.  

I would just say, I think everyone needs to give themselves a bit of a break, and their kids. And we just all need to just, what’s that expression… Be kind.  

Lucy: Wise words there I think, being kind to ourselves and each other goes a long way.  

I hope you enjoyed that episode and can think about how both you and any young people in your lives can do more of what matters. It’s challenging at this time but there are still lots of possibilities.  

I’ve put some resources that Shirley recommended in the show notes and if you want to hear more about values in particular, check out the episode on acceptance and commitment therapy. We speak about values in that as well.  

That’s all for now, take care.  

 

END OF AUDIO 

 

 

We're all living through uncertain times at the moment. What does research from CBT tell us about what tends to help people tolerate uncertainty? Dr Lucy Maddox interviews Professor Mark Freeston about what might help.

 

Show Notes and Transcript

For more on BABCP our website is www.babcp.com

For Mark's research survey follow this link:

https://www.ncl.ac.uk/who-we-are/coronavirus/research/uncertainty/

A preprint of Mark's research paper on coronavirus and uncertainty is available here:

https://www.researchgate.net/publication/340653312_Towards_a_model_of_uncertainty_distress_in_the_context_of_Coronavirus_Covid-19

If you feel like you're struggling here are some resources:

https://www.nhs.uk/oneyou/every-mind-matters/

https://www.samaritans.org/

https://www.nhs.uk/conditions/stress-anxiety-depression/mental-health-helplines/

https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-services/how-to-access-mental-health-services/

The register of BABCP accredited CBT therapists is here: 

https://www.cbtregisteruk.com/

Photo by Katie Mourn on Unsplash

Episode edited and produced by Lucy Maddox

Music by Gabriel Stebbing

Transcript 

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

Today in another post-pandemic special episode I’m speaking remotely to Professor Mark Freeston from Newcastle University. Mark’s research is about how intolerance of uncertainty relates to anxiety and he spoke to me about how findings from this research can be relevant at this current, very uncertain time.  

Mark was clear that feelings of anxiety and distress in response to the current pandemic are totally normal.  

Mark: Anxiety problems that we see in mental health services have an element that is recognised to be excessive about them. But what we’re looking at at the moment, which is anxiety and distress in response to the coronavirus pandemic doesn’t necessarily have this excessive element about it. So it’s not a disorder, it’s just a lot of very anxious and distressed people.  

Lucy: How is your research particularly relevant at the moment?  

Mark: Since the early 90s, we’ve been looking at a thing called ‘intolerance of uncertainty’. This is particularly timely given the high level of uncertainty that’s going on. Some people find not knowing, the unknownness of things as particularly difficult to manage.  

Lucy: It’s quite an existential problem almost, isn’t it? It’s quite a human problem that we all might have at different moments.  

Mark: The evolutionary theory, so some very clever evolutionary psychologists and they say that everyone is probably born to be intolerant of uncertainty, but to greater or lesser degrees we become more able to tolerate uncertainty. So it’s not like a personality trait that is sort of stuck at the same level all your life. When different things happen your ability to tolerate the unknownness of things is likely to change, not necessarily on a day-to-day basis, but you may have periods of greater tolerance or intolerance of uncertainty.  

Lucy: Is it that intolerance of uncertainty which leads us to feel very anxious?  

Mark: Eventually, yes. The way we’ve been looking at it in our current research and we’ve been working on this for over a year, because we’ve been thinking about before the pandemic came along, we’d been thinking about caregivers of people with dementia or people living with chronic and fluctuating illnesses. And so we were thinking about a lot of different types of contexts where there’s both scary things happening and a lot of uncertainty going on at the same time.  

If you are intolerant of uncertainty and there is real uncertainty around, you are going to probably perceive the situation as being more uncertain than it is. So you start off not liking uncertainty, then when things are uncertain, not only do you not like it, but you see the situation as even more uncertain. And you probably also look at the things that might happen, particularly the bad things that might happen as more likely. It’s that combination we think, that makes people anxious.  

Lucy: And then at the moment, do the same things apply, might some of us feel more anxious in response to what’s going on with the pandemic than others?  

Mark: Yes, and obviously people who have got more at stake, so people who are at greater risk, also about financial things. It’s at multiple levels that there’s lots of uncertainty going on and some people find this more difficult than others.  

Lucy: Mark told me about some research which suggests that over the last 30 years we’ve all been finding uncertainty harder to tolerate.  

Mark: What we found is that intolerance of uncertainty scores have been going up since the 1990s.  

Lucy: Oh really?  

Mark: Yeah, so essentially year on year. One of my colleagues in Canada, Nick Carlton did a very nice study where they looked at all the published North American studies of similar types, examples, and then they looked at the extent to which people had mobile phones or high speed broadband.  

And so if you think from the early 90s through until the mid-2015s, then there’s been a massive increase in our degree of connectedness, the access of information. And so one of the ideas is that the more information that we have available, the less certain we are about things.  

Lucy: This research suggests that sometimes too much information can be unhelpful, can make us more uncertain.  

Mark categorised information about Coronavirus into three types. Information that we need to know, like the current rules that we’re all expected to follow. Information that might be interesting to know, like answers to responsible questions that are being asked about what’s happening. And then less helpful information which is unreliable or even malicious.  

Even the responsible questions might sometimes be problematic because they’re often unanswerable, so they might just generate more uncertainty.  

Mark: There’s a lot of people working on the assumption that the answer is out there if only I can find it. From the point of view I’ve been working from, we can’t information our way out of this, out of feeling uncertain.  

Lucy: We will likely all have had other times in our lives when things have felt uncertain and when it’s felt difficult to tolerate this.  

Mark: I was reflecting on my own life and I’ve emigrated three times in my life, okay? From the UK to New Zealand, from New Zealand to Quebec and Quebec back to the UK. And so obviously they tend to be very uncertain times because you don’t quite know what to expect.  

So things like emigration or becoming a parent for the first time or moving in with a partner for the first time. So it’s not just bad things, but these are just things where you don’t know what it’s going to be like because you haven’t done it before.  

Everyone has had experience of big changes, sometimes they’re chosen sometimes they’re imposed. And there’s only so much you can find out, the rest you have to wait and see and that’s an uncomfortable state to be in. But the belief that drives people to try and get more and more information is that the answer is there, but it probably isn’t. It would be nice to say that the information is there, but it’s not.  

Lucy: What do you know about, from your research, into intolerance of uncertainty that might help people at this time?  

Mark: I think there’s two main things to do at this time. I think one thing is people really thinking about their use of information and where they’re getting it from and is that being helpful or not. Those are the things you want to manage the intake.  

But there might be other types of information that might be worth finding out, that might put a bit more balance back into things. Are the birds still singing? What are some of the things that people are doing to help each other out?  

Rather than stories about all the things we don’t know, there’s plenty of stories about people who are actually getting on and doing things, groups of people getting organised. So being a bit more selective in what news you go looking for.  

Lucy: I really like that. The birds are still singing in Bristol, happily! (Laughs) 

Mark: They’re still singing here in Whitley Bay as well and as usual, as for every year, we’ve got a particularly noisy group of sparrows that have taken up residence and I’m pretty sure the starlings will be under the eaves and they’ll be making noise for the next few months. That bit hasn’t changed.  

Lucy: So managing information could be about restricting input of stuff that’s not so helpful, but also looking for information that balances the picture out a bit, it’s really nice.  

Mark: Yeah, certainly. And I guess that looking for information, that balances things out a bit leads onto the next point, which is the thing about intolerance of uncertainty is that we need the presence of safety rather than just the absence of threat. So if we don’t have the presence of safety, that’s when we feel uncomfortable and that’s when intolerance of uncertainty kicks in.  

So it’s not just that there’s no possibility of bad things happening, it’s about the presence of signs that things are okay in very small ways. Hence are the birds still singing? That’s an example.  

We know how disrupting the pandemic has been at all sorts of levels, but it’s very easy to focus on the big disruptions, right? So people cannot go out, they cannot socialise, they cannot go to school, but there’s probably lots of little disruptions that people don’t even notice as much. Small routines of everyday life.  

Lucy: One of the everyday routines that Mark has made sure to keep the same is his morning cup of coffee and a new small thing he’s noticed is that he started to eat Marmite again, which he hasn’t had since he was a boy.  

Mark: So I guess it was one of the signals of safety that would go back a long way. It’s these small routines that can help us feel safer, even when there’s a lot of uncertainty.  

Lucy: That’s really nice because that’s something we have some control over actually isn’t it?  

Mark: Yes.  

Lucy: Whether we can keep some of those small routines in place.  

Mark: Many, many, many people have been taken, if you like, out of their comfort zone. What are the different things that help us feel settled and safe? And then that means that if we can get those, our perception of uncertainty will go down, our perception of danger will go down a bit and we’ll be a little less distressed and anxious.  

Lucy: So two things there which might help at this time based on the research that Mark has done. Number one, thinking about which information we seek out and how often. And number two, thinking about how we signal to ourselves that we’re safe. Perhaps in quite small, but still significant ways.  

Mark: There’s other types of information that says the world is still as we know it and that’s sort of the link between feeling safe and information management. That’s where the two come together.  

Lucy: Although we’re all experiencing uncertainty at the moment, Mark acknowledged that some people may be finding things extra hard if they have personal experiences in their past which resonate with what’s happening at the moment in some way.  

Mark: There’ll be things happening, whether it’s due to isolation, whether it’s medical threat, whether it’s seeing one part of your life being disrupted. This is going to, I guess wake up or trigger things that you might not have thought about for a long time.  

So I think it’s being able to recognise that it isn’t just what’s going on outside in the world, it’s what’s going on inside your own mind as there’s a degree of match between some of the things that you’re being exposed to, that we’re all being exposed to, and things that we’ve lived through in the past.  

Lucy: If you feel like that’s the case for you at the moment, do please try to reach out and seek help, whether from friends and family or from professional sources of support.  

I’ve put some links in the show notes to some different resources and also to the BABCP register of accredited CBT therapists. Also in the show notes is a link to the survey that Mark has been sharing and a recent journal article that he’s written.  

If you liked this episode, there are loads more you can listen to at the Let’s Talk about CBT website, or wherever you get your podcast from. There’s a short episode featuring Jo Daniels about anxiety in relation to coronavirus and a new episode about CBT bipolar disorder too.  

If you have ideas for other episodes, feel free to get in touch at [email protected].  

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

 

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