INTRODUCTION
Cognitive Behavioural Therapy (CBT) techniques have been developed from extensive research. Studies indicate that treatments for psychological disorders based on CBT principles are as effective as medication in treating many psychological disorders and often more effective in effecting long-lasting change.
The principles of CBT are particularly effective for common mental health problems such as anxiety, depression, panic disorder, phobias, stress, eating disorders, obsessive-compulsive disorder, post-traumatic stress disorder, and difficulties with anger. They can also help if you have a low opinion of yourself, or can even be applied to physical health problems like pain or fatigue. Evidence suggests that CBT can be useful in helping to manage more severe mental health conditions like bipolar disorder and psychosis.
CBT works on the principle that our behaviour and emotions depend to a large degree on our perception of what we understand is happening. What we think and anticipate can greatly affect our reaction to events and people. Having understood what you are thinking and how to deal with your thoughts, it is possible to train yourself to respond in a different way. This new style of thinking and behaving can then lead to a potentially more satisfying way of life, becoming part of your normal lifestyle.
This page will place emphasis on the practical skills and techniques that have been developed using the principles of CBT. This will help the reader to make lasting changes in the way they think and behave in order to help with their mental health.
“Men are disturbed not by things but by the views which they take of them . . . when, therefore, we are hindered, or disturbed, or grieved, let us never blame anyone but ourselves: that is, our own judgments.” – Epictetus, Greek philosopher
Cognitive Behavioural Therapy: where did it come from?
Some readers may be familiar with the name of Pavlov, and his early experiments in the 1900s which looked at the way in which dogs can be ‘conditioned’ to salivate at the sound of a bell. What isn’t realised by many is that Pavlov was actually studying the digestive system of dogs and just happened to observe this “conditioned reflex”. However, he opened up a whole new field of study, allowing new insights into understanding the way in which animals learn. It was from there, and a transfer of knowledge which led to the field of behaviour therapy being born. It stemmed from applying the principles of learning theory to shaping the behaviour of first animals and eventually humans, looking at ways in which altering behaviour might help alleviate psychological “disorders”.
Dr Aaron Beck, originally a psychoanalyst, is generally credited with founding cognitive therapy in the 1970s. Working with depressed patients, he noticed they experienced a series of spontaneous negative thoughts, which he called automatic thoughts. He divided them into three categories: negative thoughts relating to the self, to the world, and to the future. Working to identify and challenge these thoughts enabled patients to re-evaluate them more realistically. The result was that patients felt better and showed positive changes in behaviour. They became able to think in a more balanced, realistic way; to feel better emotionally and to behave in a more functional manner.
The key concept of cognitive therapy concentrates on how we process information, organise it, store it, and relate new information to old. In cognitive therapy, the focus is on understanding the way in which humans think and applying these principles to the treatment of psychological disorders.
In the 1970s and 1980s furious debate raged over whether behaviour therapy or cognitive therapy held the key to understanding and overcoming psychological difficulties. Eventually, although there is no general agreement of exactly when, it became clear that this wasn’t a contest with a winner and a loser. People neither operate on purely behavioural principles, nor live their lives based purely on thinking. It is in this realisation that we find the roots of CBT.
In the early 1990s, an apocryphal tale about understanding the nature and treatment of a particular anxiety disorder was written. The author believed in its importance and was convinced that the research had international significance. But there was a conundrum: two world conferences appeared to address the same subject matter. One was the World Congress of Behaviour Therapy, the other the World Congress of Cognitive Therapy. The two were apparently miles apart, the conceptual separation reflected geographically, with one taking place in Canada, the other in Australia.
As a behavioural experiment, the author sent an identical abstract to both. Both conferences were delighted to accept the paper as truly representative of research in that field.
The following year, a historical first took place – the first World Congress of Behavioural and Cognitive Therapies.
Modern ‘Cognitive Behavioural Therapy’ applies principles of both schools of thought to the treatment of psychological distress. It looks at the way in which our thoughts, emotions, behaviours, and physical states, all interact to cause and maintain difficulties. Since we know all of these factors interact, it follows that altering any one of them will have an effect on the others. CBT focuses on the way we can change patterns of thinking and behaviour in order to feel better.
Now, more than 25 years later, we are moving into what is called the “third wave” of CBT. Instead of just ‘mind’ and ‘behaviour’, CBT is moving into domains previously addressed primarily by other traditions, in the hope and expectation of improving both understanding and outcomes. Third wave therapies include concepts such as mindfulness meditation, acceptance, values, and relationships. The emphasis in these newer ways of thinking is less on changing the content of thought; rather it is on changing our awareness of and relationship to those thoughts.
1. The ABC of CBT
Antecedents – Beliefs – Consequences
A = the Antecedent, trigger event, or occurrence which appears to lead to an emotional reaction.
B = our Beliefs, thoughts, interpretation, or evaluation of that event and its possible causes or meaning.
C = the Consequences of that way of viewing the event – our emotional or behavioural reaction to it.
Let’s imagine you are in bed at night, alone in the house and you hear a sudden noise downstairs. This is the antecedent, the triggering event – an A.
You might think you’d know immediately how you’d react or feel in this situation. But actually, our feelings and reactions depend entirely on how we interpret the A. Here’s some possibilities:
[1] You might think: ‘Oh gosh there have been several burglaries in this area recently, I bet it’s them’. This would be a belief, or thought – a B. It might follow that you’d feel scared or even angry. This would be a consequence, or reaction – a C. Your behavioural reaction (another C) might be to hide under the covers or to call the police.
[2] You might think: ‘That’s my son coming home late again and crashing around waking me up – third time this week – he’s always so thoughtless!’ – a very different B. In this case your reaction (C) might also be quite different. Now you might feel very angry and frustrated and your behavioural C might be to shout at him or try to impose some kind of sanction.
[3] But you might also think: ‘Ahh! That’s my lovely partner returning earlier than expected to surprise me because I was feeling a bit low today. How very sweet!’ Then your feelings (C) might be loving and positive and your behavioural reactions (more Cs) equally so!
So, in each of these scenarios the A is exactly the same. The Cs are all completely different. What makes the difference? The Bs, our beliefs! The way in which we think about the situation determines the way we feel about it and react to it.
Of course, in real life things are more complicated. Our beliefs are influenced by myriad factors including our upbringing, education, and past experiences. Behavioural and emotional Cs in one situation feed into the As and Bs of other situations, and so on. However, bearing in mind these same principles can help us understand and then make changes in many areas of difficulty.
This page will be illustrating how it’s our Bs (beliefs) that largely cause the stressful Cs (consequences), not necessarily the actual situation itself. If someone, for instance, isn’t stressed about meeting important deadlines, giving a presentation, or meeting new people, it’s because they believe they’ll cope well and therefore don’t predict any dire consequences. The fact that they’re not stressed in this way can then become a self-fulfilling prophecy, in that it will cause them to behave and react in positive ways which might actually make a successful outcome more likely. When we hold overly negative beliefs the opposite can happen.
A key part in the process of challenging negative beliefs is to question the commands which say you must, ought, should, or even have to achieve a particular outcome.
Where do these commands come from? Do they just pop automatically into your head, or are others telling you these things? If they’re from others, is there a reason you have to agree? Are others necessarily infallible? What would happen if you did fail? Would it really be that unbearably awful? Could you be exaggerating the outcome? And if it did happen, is there a way you could bear it, even if you didn’t like it? After all, there’s no law which says you have to like it. Challenge those previously unquestioned assumptions.
In becoming more aware of the beliefs that are driving your reactions and behaviours you can then make those beliefs more balanced, realistic, and flexible, less demanding, and no longer so absolute. When beliefs are modified you usually find that you feel emotionally and physically different. This actually enables you to evict catastrophising and its companion, procrastination, and get on with the task in hand. As a consequence, you will normally find yourself feeling much better than before.
Look at the question again from Epictetus during the introduction to this page. That’s amazingly accurate, which encapsulates the latest developments in CBT, despite it having been said over 2,000 years ago.
But identifying the Antecedents, and the Beliefs, and then actually challenging them, both in your mind and behaviour, like so many things, is much easier said than done.
It’s imperative to tell yourself that like any new skill, learning your ABC takes a while. It will take time before you know it by rote and can incorporate it automatically into your daily routine.
2. Managing anxiety
Understanding anxiety
The internet offers around 46.5 million answers to what anxiety is about. If you were to go through them all, at 5 minutes per website would take around 450 years of your time. Let’s look at the basic essentials:
. What it is
. Where it comes from
. What form it takes, and, most important of all…
. What you can do about it.
Anxiety is often described as a feeling of worry, fear, or trepidation. It is, however, much more than just a feeling. It encompasses feelings or emotions, thoughts, and bodily sensations.
Occasional anxiety is absolutely normal within our everyday experience. If you did not ever feel anxious, that would be something to worry about! Life presents us with challenges, which we are not always confident we can handle, so a degree of anxiety is natural. The challenges can be stressful events including actual danger that is happening in the real world, and/or they might be things our minds conjure up, such as what if a catastrophe did occur.
Feelings or emotions
When we experience severe anxiety, we usually feel terrified. While sometimes it is quite straightforward to identify what it is that we are scared of, at other times we just get an overwhelming feeling of panic. But whether you love or hate this feeling depends to a great extent on your personality and the context.
Some people actually seek and thrive on strong sensations, and for these people the more powerful they are, the better. Experiencing high anxiety can be pleasurable, even though that might sound peculiar. Think of amusement parks or extreme sports adventures. Certain people love the adrenaline rush these activities provide. The key is that usually the enjoyment is linked to it being a time, place, and activity that they have chosen. They would probably be less enthusiastic about something that was happening to them uninvited, unwanted, or out of their control.
Thoughts
We all usually try to make sense of our environment, and to understand what is happening to us. It can be frightening not to know what is happening, and to anticipate that whatever is going to happen next will be even worse. Anyone experiencing feelings of panic and terror is likely to try to figure out why it’s happening, and what it means. How we make sense of our world is what tells us whether it is safe or dangerous. Shakespeare neatly summed this up, writing in Hamlet, “there is nothing either good or bad, but thinking makes it so”.
So, the link between thoughts and emotions should be apparent – if you think something is really dangerous, you are likely to be seriously scared of it. People watching a horror movie are less likely to enjoy it if they then start looking out for aliens and monsters when they leave the cinema, while those who recognise it as being “only make believe” can safely enjoy the scariness in the confines of the cinema, knowing that in reality there are no such dangers.
Bodily sensations
It can be quite astonishing to discover how many different sensations can be triggered by anxiety and how many different parts of the body can be affected. You may get just a few of these or most of them. Some common sensations include your heart beating faster and harder, profuse sweating, you may tremble or have shaking arms and legs, blurred vision, you may feel as if everything is very unreal, feeling dizzy, lightheaded, or faint, and also have general aches and pains that may make you feel tense, restless, or unable to relax.
It is normal to experience anxiety when we feel we are in danger. Your body responds with the “triple F” reaction of Fight, Flight, or Freeze. It’s a very important automatic response – your body does it all by itself. The 3 Fs are linked to the survival of our species over the years. Take the example of disturbing a hungry wild animal. Depending on both you and the type of animal, you might try to fight it, to run away as fast as you can, or to keep still in the hope that the animal had poor eyesight and wouldn’t charge at you.
In situations you perceive as dangerous, you body produces a whole range of chemicals (including adrenaline) which trigger all of the physical symptoms described. These bodily changes are what have helped the human race to survive. The chemicals released cause physical changes which enable us to run far faster than otherwise, have greater strength, and generally have a better chance of defending ourselves and our loved ones. That’s great for an objective danger like a wild animal, but not particularly helpful when the perceived danger is more of a social one, like being afraid you will make a fool of yourself or a (most likely unfounded) fear of a physical catastrophe such as having a heart attack.
There are various and specific types of anxiety disorders. Each links to a range of thoughts about what is happening. So, for instance, if you suffer from panic attacks, you’ll probably fear that when you experience one something terrible will happen such as a heart attack, or that you’ll go hysterical and make a total fool of yourself. If your problem is obsessive-compulsive disorder, then your fear may be that if you don’t do things in the right order, or clean or check sufficiently, then something dreadful will befall you or those close to you. A key feature of post-traumatic stress disorder is that the person tries to avoid reminders of the trauma. They frequently think that if they’re reminded too sharply of what happened, they’ll start re-experiencing it, and that the feelings might be more than they can bear.
Anxiety becomes a problem when:
. It is out of proportion to the stressful situation
. It persists when a stressful situation has gone
. It appears for no apparent reason when there is no stressful situation.
CBT looks at how our thoughts, emotions, physical sensations, and behaviours, all interact to maintain our anxiety. When we perceive a “threat” of any kind – whether that is a fear of something that is happening right now or a worry about something that might happen in the future – our bodies and minds react in ways previously described. For example, physical sensations equate to the heart beating faster, muscle tension, or a churning stomach. Our emotions will lead us to feel nervous or scared, and our behaviour will relate to us dwelling on worries or seeking reassurance. Such habits are, however, most often unproductive, and simply serve to increase our anxiety without actually improving or changing our situation. Seeking out reassurance from people close to us, searching the internet, or consulting professionals, might make good sense if we do it once and it serves to calm our fear in a lasting way. But what tends to happen when people suffer from anxiety is that they will seek reassurance, feel better for a short time, but then keep needing more reassurance. This means that nothing changes, and they never develop more effective, lasting ways of managing their anxiety.
There are several types of anxiety disorder – general anxiety disorder (GAD), panic disorder, agoraphobia, obsessive-compulsive disorder (OCD), phobias, post-traumatic stress disorder (PTSD), social anxiety disorder, health anxiety, and stress reaction disorder. They all have some symptoms in common.
Listed below are the key areas which point to problems with anxiety:
. Having difficulty relaxing
. Feeling nervous, anxious, or edgy
. Easily annoyed or irritable
. Being restless and unable to settle
. Unable to stop or control worrying
. Worrying about practically everything
. Fearing something awful might happen.
If any of these frequently apply to you, it may be useful to see your GP and talk through what’s going on and what help is available.
What is an anxiety disorder?
Let’s look in more detail at the different types of anxiety disorders and the techniques CBT employs to help people deal with them. They all share many common elements. Some case studies will be offered in the mix.
. Generalised anxiety disorder (GAD)
Suffering from GAD means you’ll be feeling anxious, tense, and will worry most days, often about things other people consider quite minor. If you don’t tackle it, the problem can last years, severely interfering with quality of life. Generalised anxiety can frequently be something that people feel they have always experienced to an extent – “I’ve always been a bit of a worrier” – but which becomes more disabling during or following periods of increased or intense stress. Sometimes it can become more of a problem following distressing events such as bereavement, redundancy, or a relationship breakdown, and can start some considerable time after these events.
Women are more likely than men to be diagnosed with GAD, perhaps partly because women are more willing to see their doctor and admit to such feelings. You are more likely to experience GAD if you are aged 35–54, if you are divorced or separated, or if you are a single parent – but anyone can develop this problem.
Someone with GAD usually recognises their worries are excessive and inappropriate. Sometimes, though, they aren’t even aware of what it is they’re worried about – they just feel uncomfortable and can’t settle or relax. For a diagnosis of GAD, you’ll usually have three or more of the following symptoms:
. Restlessness
. Irritability
. Tiredness
. Physical tension
. Disturbed sleep
. Problems concentrating or feeling as if your mind just goes blank.
– Jane (GAD)
Jane is in her early thirties. Her young child has just started school. Jane’s back at work and wants to make a good impression on her new boss who was appointed during her maternity leave. She’s always been a bit of a perfectionist, but previously had time available to devote extra hours to meeting with her excessively high standards.
Now, with the additional demands of motherhood and work, she feels it is all too much. At work, she worries about not being as quick and efficient as colleagues who haven’t had a maternity break.
Jane experiences anxiety about how her child is coping, feeling she should be a full-time mum, but knowing her income is required to make ends meet.
There’s no peace at home – work-related thoughts intrude constantly, as do self-critical thoughts about her ability as a mother and a wife.
As for GAD symptoms, she has a full house! Constant worry and restlessness, sleep problems, physical feelings of tension, and various aches and pains.
. Post-traumatic stress disorder (PTSD)
When people experience a trauma, such as being involved in a car accident, or being attacked, it is very common for them to experience fear, recurrent and distressing thoughts and memories of the event, a sense of emotional numbness, a distance from those around them, and intense anxiety. They may also try to avoid any reminders of the event or its consequences.
These symptoms are all very normal and are part of a process of adjusting to and making sense of what has happened. Generally, these symptoms diminish in the few weeks following a trauma and most people recover well with time and the proper support.
For some people, however, these symptoms persist or even worsen over time, and it feels impossible for them to move on from what has happened. In some cases, symptoms can continue or even just suddenly begin months or even years after the trauma. This is post-traumatic stress disorder. Coping with very difficult life events and how CBT techniques are used will become a later feature on this page.
. Phobias
A phobia is a strong fear or dread which is out of proportion to the reality of the situation causing it. Coming near or actually in contact with the feared thing or situation causes anxiety, and just thinking of what you are phobic about is frightening and upsetting. You may sometimes be able to avoid the feared situation, but in many cases, this can mean restricting your life. Also, the more you avoid, the more you may want to avoid, and this can become more and more limiting over time.
There are many phobias of specific things or situations. Common examples include claustrophobia (fear of confined spaces or of being trapped), fears of specific animals, and fears of injections, vomiting, or choking. There are dozens of phobias, but the treatment for them all follows the same principles of graded exposure.
. Social phobia
Social phobia, or social anxiety disorder, is possibly the most common phobia. You become very anxious about what other people may think of you, or how they may judge you. You fear meeting people, or “performing” in front of others, especially strangers. You fear that you will act in an embarrassing way and that other people will think that you are stupid, inadequate, weak, foolish, or even crazy. You avoid such situations as much as possible. Psyching yourself up to go somewhere is really hard – you often leave invitations open to the last minute, so as not to have to commit yourself. If you do go to the feared situation, you are very often anxious and distressed, and may well leave early. As with all anxiety disorders, the key to overcoming social phobia is to use a combination of thought challenging and behavioural experiments.
. Panic disorder
People with panic disorder experience recurring panic attacks. A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without warning, and for no apparent reason.
The physical symptoms of anxiety during a panic attack can be severe and may include: a thumping heart, trembling, feeling short of breath, chest pains, feeling faint, numbness, or pins and needles. Each panic attack usually lasts 5–10 minutes but sometimes they come in waves for up to 2 hours. Panic attacks are incredibly frightening experiences and whilst they are happening people can really feel as if they are dying. This naturally leads to fear of fear – feeling scared that an attack will occur and that this time it will finally be the one where something terrible really does happen.
People often try to cope by avoidance, shying away from any situation in which they think an attack might happen or where they might not be able to escape from the panic. This can severely limit someone’s life and for some people is also associated with agoraphobia.-
. Agoraphobia
Agoraphobia in ancient Greek literally means “fear of the market place”. The term describes a fear of open spaces and frequently includes difficulties being in public places – shops, crowds, on public transport, crossing bridges, or even simply being away from home. It is usually difficult, if not impossible, to do these things alone, though some sufferers of agoraphobia may manage to go out and about if accompanied by someone they trust.
All the different situations which cause difficulties for people with agoraphobia are united by one underlying fear – that of being in a place where you are overwhelmed by panic, where no help is available, and where you’ll find it difficult if not impossible to escape to a safe place (usually to your home). When you are in a feared place you become very anxious and distressed and have an intense desire to escape. To avoid this anxiety and panic many people with agoraphobia stay inside their home for most or all of their time. Sadly, however, they can then experience panic attacks even in their home and so feel they have to have someone with them at all times.
Agoraphobia and panic disorder affect around 5 per cent of the population, affect women more than men, and most commonly occur between the ages of 25 and 35. Agoraphobia affects up to one third of people with panic disorder and occurs before the onset of an attack. The fear means that the person tries to avoid places where they are likely to have panic attacks, and, while avoidance can be successful to some degree in keeping panic attacks at bay, the restrictions on a person’s life usually just keep increasing, affecting both the person and those close to them.
– Case study – Billy (panic disorder with agoraphobia)
Billy is a 25-year-old office-worker. He commutes using public transport. He used to like the train journey. It gave him time to read the paper and relax a little before the start of a stressful day.
One day, however, the train was particularly crowded. It was very hot and the train’s air conditioning had failed. Billy started to feel very warm. He noticed that he was sweating and that his heart had started to race. His chest hurt and he felt shaky. He thought something must be very wrong. He was convinced he was having a heart attack. He got off the train at the next stop and called an ambulance. In A&E he was examined and told that there was nothing wrong with his heart. He had (had) a panic attack. He felt very relieved but shaken and frightened by what had happened. He had really felt like he was dying. He never wanted to feel like that again.
The next time he went on the train he was very anxious and again started to notice symptoms. Again, he focused on these and experienced the frightening feeling that he was dying. The sensations were very difficult to cope with and he was forced to get off the train and return home. Gradually, Billy found that his fear of the panic symptoms led to him avoiding more and more situations where he thought they might occur and where he was afraid that he would not be able to escape.
Over time, Billy’s avoidance became more and more entrenched. He did not believe he could withstand or manage the panic symptoms and so he would simply not do anything that he felt might trigger them. He gave up his employment and started to work from home. Slowly, his social life dwindled, and he went out less and less. As he avoided more situations, so his fear that a catastrophic attack would happen increased, and he felt increasingly unable to go out at all.
. Obsessive-compulsive disorder (OCD)
This condition consists of recurring obsessions, compulsions, or both.
Obsessions are recurring intrusive, uninvited, and unwanted thoughts, images or urges that cause you anxiety or disgust. Common obsessions are fears of being contaminated by dirt, germs, disease, or body fluids, and also fears of disasters. They can encompass worries about violence that will happen to you, or harm you might do to others despite it being against your will. Fears related to religious beliefs are also common.
Compulsions are thoughts or actions that you feel you must force yourself to have to do, and often that you feel you have to keep repeating, until you have got it “right”. Usually, a compulsion is a response the person makes to ease the anxiety caused by an obsession. A common example is repeated hand washing in response to obsessive fear of dirt or germs even though the environment may already be impeccably clean. An individual may disproportionately fear that they have dangerous germs on their hands from touching things and that these could be harmful to themselves or people around them. They may therefore feel a compulsion to very frequently wash or disinfect their hands in order to reduce this fear. Other examples of compulsions include repeated cleaning, checking, counting, touching, placing objects in particular positions, and also hoarding objects.
Professional help is often required, as it can initially be quite difficult for a person to discriminate between obsessional thoughts and actual danger.
People suffering from OCD often have an exaggerated sense of responsibility. They may feel it is their role to protect themselves from the dangers of the world, the threats of which they usually considerably overestimate. They may also feel they must ensure that harm does not come to others. Very often carrying out the ritual or compulsion still doesn’t solve the problem. They might experience intrusive thoughts about harm coming to others. So, for example, they may feel they have to move stones off pavements to avoid someone tripping up but then go on to worry that the new place they have moved them to could cause harm to someone else.
. Health anxiety
Some concern about your health can be useful, as it means you may try to lead a healthier lifestyle. People who have had health problems, in particular something like a heart attack or cancer, often decide to take them as a warning that unless they make certain changes, then something worse could happen next time. While that attitude can be very productive for some, others find they become increasingly obsessed with their health. Some people find this increased anxiety happens to them following the illness of someone they know, after an important life change or just out of the blue for no obvious reason at all.
Any minor symptom is blown out of all proportion. A minor sniffle equates to imminent death from a Covid variant, a mark on the skin means malignant cancer, tiredness is multiple sclerosis, while a headache equates to a brain tumour – which will, of course, be inoperable. People with health anxiety visit their doctor frequently and can end up having several investigations, tests, and visits to hospital specialists, which often come to nothing. They may also spend a large amount of time researching illness on the internet and in books. The worry and fear of illness can take over people’s lives and cause considerable misery.
– Mamta (health anxiety)
Mamta is a fit, healthy woman in her 50s. Tragically, one of her closest friends recently died of breast cancer. She had been a very healthy woman who took good care of herself, ate well, and exercised regularly. Her cancer came out of the blue. She went through many months of distressing treatment before dying at the age of 53. Mamta is naturally very upset by this loss and also frightened by the way in which her friend suddenly became ill.
She begins focusing on her own body and on anything she experiences which could be interpreted as a symptom of ill health. If she has a headache or a muscle twitch or notices an ache anywhere in her body she becomes totally preoccupied with this, worrying endlessly about what it might mean. Mamta looks symptoms up on the internet or asks others what they think is wrong with her. She visits her GP more frequently, asking for reassurance that what she sees as being symptoms aren’t signs of something more serious. Having seen the doctor, Mamta feels better for a short while but then starts worrying again. Her GP sends her for various tests because Mamta is worrying about symptoms which previously, she’d have ignored.
As Mamta’s anxiety and stress increase, she experiences more physical symptoms related to anxiety – frequent headaches, more fatigue, palpitations, and general aches and pains. These of course add to her worries and send her back to the GP and to other sources of reassurance. When assured that there’s nothing wrong, Mamta begins to doubt her doctor and starts exploring an ever-increasing range of different types of therapies.
How can CBT help with anxiety?
There are lots of tried and tested techniques which have been developed by CBT therapists to help people overcome anxiety disorders.
The methods which will follow can all be applied to a variety of the disorders which have been described above. Some will be more helpful in certain situations than others. A good starting point is to look at how you might deal with your thoughts and then to move on to examine some behavioural strategies which may be helpful to manage your anxiety.
. Thought balancing
This technique is key to cognitive therapy and involves looking at your anxious thoughts in a different way. You really can start to see that thoughts are just that, and do not necessarily represent facts. We can see thoughts as simply mental events. Yet, frequently we respond to them as if they were concrete facts rather than possibilities or ideas. Just because you think something bad will happen, is that guaranteed? Some thoughts will be true, some will not, and there will be a large grey area in between these two extremes.
To begin managing negative thoughts by examining the objective evidence for them and working on developing alternative balanced ways of viewing a situation, will ultimately prove to be more realistic and helpful.
Challenge your worries or anxious thoughts
When dealing specifically with anxious thoughts, worries, or predictions, it can be helpful to ask yourself some questions to help you gain a different, and potentially more helpful, perspective. As with all mental health conditions and disorders, it is a good idea to run a daily journal by entering your thoughts and emotions and what may have triggered you to act or behave in a certain way. Maintaining one can be a very useful record for both yourself and those who may be treating and caring for you. Write down the answers for each of your separate worries or thoughts:
. How important will this be in my life 5 years from now?
. What would my best friend say I should do about it?
. What would I advise my best friend to do if this was their problem?
. Am I assuming my way of seeing things is the only one possible?
. Am I jumping three events ahead when the first step hasn’t even happened yet?
. Am I overestimating the chances of disaster?
Now think of some of your own questions to challenge your worried, anxious thoughts, and write them down in your journal.
Challenge perfectionism
Do you always expect more of yourself than it is possible to achieve? Do you have much higher standards for judging yourself than for other people? If this is true, then you may be falling into self-defeating patterns that are maintaining your anxiety and making you very unhappy.
Watch out for “should”, “always”, and “must”, in the way you talk to yourself – these words are rarely helpful. Jane from the case study (above) frequently says to herself, “I should be doing this perfectly”, and “I must get all this right first time all by myself or I’ll look a right idiot!” These statements just make her feel miserable.
Try to stick to the rule “good enough is good enough”. You can still be good at things, but aiming for excellence rather than perfection is much more likely to get you results. You’re very unlikely to know anyone who is actually perfect in every way. So how come you expect yourself to be able to achieve this?
If you aim for excellence, you might be happy a lot of the time. If you aim for perfection, you will never be happy.
Examine your beliefs about worry
Lots of people find worry a problem because of the beliefs they hold about the process of worry. Some people have positive beliefs about worry such as:
. Worrying helps stops bad things happening and helps me stay safe
. Worrying helps me be more organised
. If I didn’t worry constantly, I’d always get things wrong.
At the same time, they may also have negative beliefs about worry such as:
. Worrying could drive me crazy
. Worrying could make me ill
. Worrying puts a strain on my heart.
With beliefs like these no wonder some people find it hard not to worry – and then feel very afraid when they can’t stop. You might like to think about your own worry beliefs. Construct a table within your journal with two columns, thus:
| Why worrying is useful to me | Why worrying is bad for me |
Now try to think them through logically. When we worry, we are actively trying to anticipate every bad thing that could possibly happen in order to (somehow) prevent it. But is this actually possible? Isn’t it true that sometimes unfortunate things just happen no matter how much we have thought about things beforehand? Can we really cause things to happen or not happen with our thoughts?
Most worry is unproductive. Time we spend on it doesn’t help us to be more organised or effective. The outcome of worry is usually just more stress, tension, and anxiety. Research shows that stress can affect us physically. However, there is very little evidence that stress and worry alone (in the absence of pre-existing medical problems) can actually cause lasting or catastrophic damage to us physically.
Use the worry decision tree
In the table, you’ve probably written down quite a few worries about your worrying. Are you now worrying what to do about it? Fear not, an exercise is at hand. Let’s deal with our worries by having a worry plan. When you notice yourself worrying, go through the following exercise.
Ask yourself: What am I worrying about? Write down each worry separately. Keep going until you have listed them all. Then for each separate worry go through the following diagram and algorithm.
Absorbing yourself in something else
It’s very easy for psychologists to tell you to “distract yourself” when you are worrying or in the middle of a panic attack – but very difficult to do this in practice. Frustration with this is very natural. Our minds are very busy places – they are designed that way. We experience countless thoughts in a day and emotionally charged ones like our worries can be very hard to ignore. However, what is known is that with practice and patience you can learn to move on rather than remain stuck with them. Telling yourself “Don’t think about it!” most certainly will not help. Be firm (but kind) with yourself and your busy mind.
Once you have run through the worry decision tree and have identified that you have done all you can, remind yourself that further worry will just be unproductive. Don’t berate yourself – just gently direct your attention elsewhere, on to something absorbing.
Choose an activity that will easily hold your attention and focus all of your senses on it. Maybe you will choose talking to a friend or family member, watching a TV programme, or doing some housework or physical exercise. Whatever it is, practise focusing all of your attention on it. Your mind will try to intrude on this with worries, but each time it does firmly remind it that this is not helpful and return your focus to what you are doing. You may have to do this a great many times at first and this can be frustrating. Don’t give up or tell yourself you can’t do it – that will only undermine your good work. Nobody gets this straight away. It will take a lot of practice but over time it will become easier to do.
Getting involved in alternative activity isn’t easy. Patience and practice are the key.
Relaxation
Believe it or not, being able to physically relax is quite a skill – one which unfortunately many people have never adequately learnt.
When we are busy rushing about from one task to another, day after day, we can very often find that we carry a lot of tension in our muscles. Do you ever find your shoulders, neck, or back, aching by the end of a long stressful day? Much of this may be due to muscle tension. When we are stressed, worried, or anxious, this tension increases and can result in aches and pains, headaches, and fatigue.
Spending some time learning to physically relax can be a worthwhile investment to help you to cope better with anxiety or stress. Like learning any skill, it takes practice. Deep muscle relaxation exercises should be repeated daily when you are learning. Setting some time aside each day to carry out these exercises will also help you to develop the good habit of prioritising a short time for daily relaxation. Once you know how to relax, keep up the habit. Finding a time each day to help yourself physically relax can make a big difference.
First, concentrate on your breathing with the aim of breathing slowly and calmly after a few minutes. You will then start to work through different muscle groups, teaching yourself first to tense, then to relax. You should breathe in whilst tensing and breathe out when you relax. It is best to start with the hands, followed by the arms, neck, face, chest, stomach, buttocks, and legs.
On each occasion, study the tension for a few seconds and then relax. Notice the difference between the tension and the relaxation. You might feel a slight tingling. This is the relaxation beginning to develop.
Each time you relax a group of muscles think how they feel when they are relaxed. Don’t try to relax, just let go of the tension. Allow your muscles to relax as much as they can.
Another very useful physical relaxation exercise is known as a safe place. This is a visualisation exercise which can take a lot of practice before you get the hang of it. People often think they are not good at visualisation, but with practice and patience most people can actually conjure up pictures in their minds. Research shows you don’t need vivid pictures for this to work. Faint and fuzzy ones that appear are equally as good.
Find a quiet space and sit or lie comfortably. Relax and concentrate on your breathing. Breathe in and out slowly and deeply from your stomach (around 10–12 breaths per minute) and just breathe naturally. Close your eyes and start to imagine yourself in a place that’s safe, warm, and peaceful. This could be anywhere such as a beach, a park in the summer, your bed, or even some exotic place. It can be real or imaginary. Focus on your senses: what can you see, hear, smell, taste, and touch, in this safe place? How do you feel while you are in this place? What’s around you?
Spend a few minutes exploring your safe place. Relax your muscles and let all the tension disappear while you are in your safe place. Again, your busy mind may try to distract you with other thoughts, worries, or images. Just gently let them go. Remind yourself that right now you are in your safe place – the other thoughts can be dealt with later. Practise turning down your thoughts – just like you turn down the volume on a radio. With practice, you’ll find that you can very usefully call up your safe place whenever you are stressed or anxious. Going to this place briefly in your mind can help you refocus, calm down, and then be able to move forward in a less stressed state of mind.
Break the panic cycle
Earlier on this page, it was described how thoughts and physical sensations interact to create a panic attack. The first step in dealing with panic attacks is to educate yourself about what causes them. Panic feels incredibly awful, and terrifying. It’s very hard to believe that something catastrophic isn’t happening to you. However, we know that panic is a self-limiting system. It cannot harm you. There is no evidence that anyone has ever died from having a panic attack without having an underlying health condition. Neither is their evidence anyone has ever “gone insane” from having a panic attack. Just because you are feeling very strong physical sensations does not mean the catastrophe you believe will happen is inevitable. The chances are it won’t happen at all.
For example, many people feel that when they have a panic attack they’ll pass out. But for you to pass out your blood pressure needs to drop suddenly. During a panic attack, your blood pressure actually increases (though generally not dangerously). The only exception to this is if you have a phobia of blood or injury, in which case seeing these things could make your blood pressure fall. It’s virtually impossible for most people to pass out during a panic attack.
Consider what your fears are when you panic:
. What is the worst thing that could happen?
. How likely is it that this will actually happen (rather than how much it feels like it will)?
. How likely would someone else consider it to be?
. If the worst did happen, how likely is it that you would not be able to cope with it (no matter how awful it was)?
Thinking in this way can be very helpful when trying to break a panic cycle. However, ultimately the only way you will prove to yourself that all this is true is by facing your fears and testing out this new way of looking at things. Graded exposure and behavioural experiments will help you do this.
Graded exposure
Exposure therapy is the way that CBT helps people to face up and to overcome their fears. It is used in various ways in treating all the anxiety disorders. There are fundamental principles that apply to them all.
[1] Develop a graded hierarchy. Write the numbers 1 to 10 along the side of a piece of paper. 1 represents activities that aren’t particularly scary – those you would be a little anxious about but could do by pushing yourself. 10 represents the activities that hold the most fear for you – the ones that make you say “No way! I could never do that!” Start by writing something down for the top and bottom of this scale. Then think of what might go in the middle – what activity would rate about 5? Continue until you’ve got 10 activities and have filled out the scale. Getting help from someone who knows you well can be invaluable for this exercise.
[2] Start working through your hierarchy from the bottom up.
You may ask someone close to you to accompany you if that helps to get you started, but then it is very important that you continue to practise on your own. Keep repeating each item until you begin to feel confident about it, and until you find that the scary outcome you feared, whatever it might be, doesn’t happen. At each stage make a note in your journal of what you learned and use that to help you progress to the next step on the hierarchy. Remember to congratulate yourself each step of the way, rather than saying “it’s easy for others so my achievements are no big deal”. But they are. These are big achievements for you.
[3] Stay in the situation until your anxiety falls.
At the beginning of each exposure task, rate your anxiety out of 10. It is likely to be very high at first. It is very important that you stay in the situation until your anxiety falls to at least half of what it was originally. This can be tough. However, if you “escape” too early you won’t learn how you can cope with your fear. Stay put – your anxiety will fall, and you will learn what you need to in order to progress to the next step.
A word about safety behaviours
Think about the following story:
A man was sitting outside, rhythmically clapping his hands. A boy approached him and asked, “Why are you clapping like that?” The man replied, “It keeps the tigers away”. The boy smirked and looked around, “But there aren’t any tigers!” And the man replied, “See? It works!”
We might ask why this story is amusing. The man really believes that his clapping is keeping tigers away. He believes this because while he does it there are no tigers. However, what he doesn’t know, but the boy does, is that there are no tigers in the first place. The only way for the man to discover this would be to stop clapping and test out his belief – but this is very scary to do if he really believes the clapping is keeping the tigers away. The clapping is what is referred to in CBT as a safety behaviour. People with anxiety frequently use safety behaviours to try to help them cope better. For example, they may:
. Carry a bottle of water when they are out in case they get hot and start to panic
. Sit close to the door on a train so that they can escape if something bad happens
. Try to control their breathing
. Use headphones to block out the sounds of other people talking (if those sounds increase their anxiety)
. Bury their head in a newspaper if they imagine people are looking at them.
All of these things may help them to tackle things they wouldn’t otherwise do. The problem is that, like the man clapping they continue to believe that the feared outcome – the “something bad” – would definitely have happened if they had not carried the water, used the headphones, sat by the door, controlled their breathing, and all the rest. In this way these behaviours prevent the person from really testing out if they can cope with their fear, and finding out if the thing they are afraid of really happens. So, the anxiety never really goes away.
While you are doing your exposure work, watch out for safety behaviours. If you need to use one to do the exposure at first, that’s fine. But remember it’s a safety behaviour. You need to drop it as soon as possible and carry out the exposure without using this crutch – only then will you really conquer your fear.
Behavioural experiments – stepping up the pace
Taking things a step beyond graded exposure, you can become a scientist, testing out your anxious thoughts and fears. A scientist designs experiments to test out theories and hypotheses about the way the world works. In CBT, the same approach is used.
Step 1
Think of a situation which you avoid because you are afraid something bad will happen. What is it you are afraid of? What is the worst thing that could happen? What is your most anxious prediction about what might happen if you were to put yourself in this situation? Write down this fear or prediction. Remember that your prediction should not simply be that you will get anxious in the situation – we already know that to be true. There would be no point in doing this experiment if the situation didn’t make you anxious. Your fear is likely to be more than that – what is it that you think will be the consequences of getting anxious? Losing control? Not coping? Falling apart? Becoming dangerously ill? Making a fool of yourself? What are you really terrified about will happen?
Step 2
Design an experiment to test out the prediction. What do you need to do? How would you measure whether the prediction is true or not? Write all this down. Rate out of 10 how much you believe your prediction will come true. Also think about what might be stopping you from carrying out your experiment – how could you overcome such obstacles to ensure you do complete it?
Step 3
Carry out the experiment. Remember to use whatever way you have decided on to measure what happens. Write down what happens.
Step 4
Okay. What did happen? Did you most feared prediction come true? What did you learn? Write all of this down – this can then help you to design your next experiment.
Returning to the case study – Billy (panic disorder with agoraphobia)
Remember Billy from above, in the panic and agoraphobia case study? Here is an experiment that Billy did to help test out his fears, and what he learned from it.
Step 1
Anxious prediction: If I go to the local shop, I’ll have a panic attack and I won’t cope with it. I’ll faint or lose control in some way and make a total fool of myself. I believe 80% that I’ll lose control if I get anxious.
Step 2
Experiment: To walk to the local shop and go inside. To spend a few minutes looking at the magazines. To stay for at least 5 minutes and then to come home.
. What might stop me? I might get overwhelmed with fear and not be able to go through with it.
. How can I overcome this? I’ll write down the rationale for this experiment and use it to remind me why I am doing this. Remembering this will help. I’ll get a friend to encourage me to leave the house. I’ll arrange to do something nice afterwards as a reward.
Step 3
What happened? I did it! It was really tough, and I did feel pretty bad. My heart raced and I felt very wobbly. I was exhausted afterwards. But I didn’t freak out or pass out and I don’t think anyone really noticed how awful I was feeling.
Step 4
What did I learn? Although I felt awful it was not as terrible as I first thought. People didn’t seem to notice my anxiety as much as I thought they would – perhaps it is not as obvious as I assumed. I do panic a bit, but I don’t lose control. I now believe only 40% that I will lose control if I get anxious.
. What next? I’m going to try this in different situations – test out what I fear.
Activity scheduling and planning
Very often we feel anxious and panicky because we have taken on too much or not planned our time effectively. Effective planning is a very important life skill which many of us need to work on.
When we have a lot on, we often get anxious, and the anxiety can paralyse us – stopping us from being able to tackle the many things we have to do. There are a few rules which we can follow to prevent us from getting overwhelmed and stuck in this way.
[1] Be more like a hummingbird than a butterfly
Watch a butterfly. It seems to flit from one place to the next, and when it stops you can’t really see it doing anything before it flits off again. When we are anxious, we tend to act like that butterfly – dashing from one task to the next, trying to do too much at once and ultimately not doing anything properly or completely. A hummingbird, on the other hand, stays in one spot, hovering despite the pull of gravity, drinking the nectar out of one flower before proceeding to the next. The rule is – however much you have to do, do one thing at a time, and focus on just that one thing until it is finished, and you can move on.
[2] Break things down into manageable steps
Have you ever looked at all you have to do and felt overwhelmed, not knowing where to start? It’s so tempting to abandon any attempt to start your task and just to bury your head in the sand. Instead, break tasks down into small steps. What’s the first thing you need to do? Then just do that first step without worrying about the next. Now move on to the next small step and before you know it you will have completed what felt like a mammoth task. If something feels too overwhelming, just do it using the 5-minute rule, a maximum of five minutes doing it. Don’t think any further ahead than that.
[3] Write out an activity plan
Each day, list out the tasks you intend to do. Ensure your choices are realistic (this will probably mean crossing out a few), then prioritise them. Which ones have absolutely to be done today? Which could wait a little? Decide what you want to do, when, and how much time you need for each task. Then add a bit of extra time for good measure. Draw up a timetable for the day. Build in “bio breaks” (coffee and tea, meals, and toilet stops), and even allow for brief daydreaming periods! Then follow your timetable. As you work your way through, visualise yourself as that hummingbird, hovering away steadily until the task is complete, then head for the next task.
[4] Problem solve
If you are not sure how to deal with a certain task, take some time to work it out instead of panicking. Are there any sources of support you could use? Who could help? There’s no shame in asking for help if you are stuck – how else would anyone learn anything? What would someone else say about this?
Write down the problem clearly. Now spend some time brainstorming all the possible solutions there might be. Really go for it – imagine as many as possible. Write them all down. Now go through each solution. Identify the pros and cons. Write them down. Give each solution a mark out of 10 after you have balanced the pros and cons. Then select the solution with the best scores. You could even get a friend to help you with this task. Not every problem will have an instant solution but breaking things down into small steps can often help us to see what we can do first or identify what information we need to gather to be able to come up with a solution.
Finally, test out the solution. Did it work? If not, why not? Go back to your problem solving with the new information and try something else.
Learning to say “no” can be very important. Do one thing at a time and try to avoid taking on too much in the first place.
Medication
There are certain medications available, both on prescription and over the counter, which can help anxiety in the short-term. Beta-blocker medicine can ease anxiety and some physical symptoms such as trembling. It can be helpful for certain situational anxiety, like a performer wanting to reduce symptoms of shakiness before a concert. Beta-blockers are not addictive, are not tranquillisers, and do not cause drowsiness or affect performance, so you can take them as required. Sometimes your GP might prescribe diazepam (a benzodiazepine) as a short course for 2–4 weeks, if the cause of the stress is likely to last a short time, and if the symptoms are particularly acute and severe. You are unlikely to be prescribed diazepam for longer given the potential problem of addiction.
However, a note of caution: there is good research evidence suggesting that using medication alone to deal with anxiety doesn’t prevent anxiety recurring in the future. Learning new ways to cope is usually very helpful, as the chances are the anxiety will return at times. There is also evidence that in certain cases using medication whilst undergoing CBT can in fact reduce the effectiveness of the therapy. The theory is that in order to learn to cope with anxiety and panic, you have to actually experience those feelings and develop ways to overcome them. Medication reduces the experience of anxiety in the short-term and so can prevent effective learning taking place. The only way to truly conquer anxiety is to learn strategies to manage it.
Let’s now put into practice some of the things on this page that have helped our three case studies:
Case study – Jane (GAD)
Jane starts to put into practice the idea that “good enough is good enough”. She keeps to her paid hours, and when she’s unclear how to prioritise her work (too much to do in the available time) she asks her boss, and is told what she can drop. To her amazement, she becomes much faster at her work, and nothing’s returned with identifiable errors. Her confidence increases, and within six months she’s offered a promotion. Jane discusses it with family and friends, concluding that her present level of stress is about right. She tells her manager that she’s keen to reassess the option in six months, and this is agreed.
At home, her sleep improves; she has more energy, and is less snappy with the family. When Jane has thoughts about not being good enough, she puts into practice thought balancing techniques, finding to her surprise that her self-esteem dramatically improves. The family start going on fortnightly outings, sometimes just to the local park, and all feel closer to each other. Jane and her partner also put time aside for themselves, as well as time together, and both are much happier with themselves and with their relationship.
Case study – Billy (panic disorder with agoraphobia)
As we have seen, Billy makes really good use of behavioural experiments to start testing out the fears he has about going out. He also reads about panic attacks and now understands more about the interaction between his thoughts, feelings, physical sensations, and behaviours. He finds that once he recognises what’s happening, it’s easier for him to control the panic. He still experiences it, but it gradually becomes less intense and he’s less frightened that he’ll completely lose control. He gradually starts to go out more and more. He decides with friends and asks them to support him to carry them through.
Billy designs behavioural experiments to get back into using public transport and travelling on his own by train. He notices the safety behaviours he’s using, such as sitting close to the door, and gradually reduces these so he really tests out whether the things he fears actually happen. He discovers that they don’t. He is now seeking work outside of his home again and is enjoying his social life.
Case study – Mamta (health anxiety)
Mamta understands the role that focusing on symptoms and seeking reassurance is having in maintaining her health anxiety. She enlists the help of her family and her GP to no longer provide her with reassurance but to encourage her to challenge her fears herself. She writes out a plan to cope when she notices what she regards as symptoms.
Mamta now weighs up the evidence that the apparent symptoms are actually just passing, normal sensations. She postpones thinking about them and gets involved in alternative activities, as well as using relaxation to move her mind away from them. Mamta uses thought balancing to help reduce her fear. She promises herself to only go to the doctor if something she regards as a symptom persists for longer than a week.
Gradually, Mamta begins to feel better. As her anxiety and physical tension decrease, she notices that in fact she experiences far fewer “symptoms”. She asks others about their physical sensations and is amazed to find that everyone occasionally experiences the things she was worrying about. The only difference is that they consider this to be normal. Mamta talks with her family about her grief over losing her friend. She still fears getting cancer, but slowly finds it no longer dominates her life and that she can get back to normal. However, Mamta regularly does a monthly breast check, and always goes for screening tests when invited by her GP.
Facing up to your fears can be one of the hardest things you’ll ever do.
Remember these words: The greatest victory of all is victory over oneself.
3. Dealing with depression
“Depression is a prison where you are both the suffering prisoner and the cruel jailer.” – Dorothy Rowe
“Depressed” is a word which we often use in everyday language to describe our mood when we feel low, out of sorts, or just generally not at our best. For those who experience debilitating depression, however, it’s very different indeed. If you are clinically depressed, the way in which you view and experience the world can change beyond recognition. Simple everyday tasks become like climbing Everest, and the smallest of setbacks can feel like the end of the world. People have described the experience of being depressed as “like wading through treacle” or like seeing the world through dark glasses, where colours become shades of grey. Winston Churchill described his depression as being like an “enormous black dog which followed him everywhere”, weighing him down.
Everyone feels low from time to time – it’s completely normal. Arguably part of what makes us human is the way in which we experience a range of emotions in response to life’s events. To feel sad in response to losses or disappointments or simply just to have a “bad day” is something which we all experience, and usually just accept. Generally, when we feel this way, we are able to identify roughly why we feel as we do. Usually the feeling passes reasonably quickly, or we do something to cheer ourselves up. It’s important not to label normal sadness as pathological in some way.
For some people, however, low mood persists for weeks, months, or even years, with very little relief. It may be accompanied by other distressing symptoms, such as changes in appetite and sleep patterns, fatigue, physical aches and pains, or feelings of worthlessness, helplessness, and alienation from those around. Studies suggest that 1 in 5 of us will experience depression at some point in our lives. The experience of depression often brings other difficult emotions like guilt, shame, or anger with it.
Symptoms of depression
. Prolonged depressed mood
. Thoughts of hopelessness and worthlessness
. Changes in appetite – eating too much or too little
. Changes in sleep pattern – sleeping too much or too little
. Tiredness and fatigue
. Physical aches and pains
. Restlessness or agitation
. Feeling physically down
. Thoughts of self-harm or even suicide
. Difficulties with concentration, memory, and attention.
Whilst these symptoms paint a pretty gloomy picture, there is some good news amongst all this gloom. We now recognise and understand depression far better than just a few years ago. The stigma surrounding this, and other mental health problems is slowly reducing. Sufferers often feel more able to talk about what they have experienced and to share their trials and their coping strategies. A recent campaign, “Time to Change”, highlighted the importance of challenging the stigma surrounding mental health problems like depression. It drew on the stories of high-profile people such as Stephen Fry, Alastair Campbell, and Ruby Wax, demonstrating that depression can and does happen to anyone. But the very best of news of all is that there are now many tried and tested treatments which have helped millions of people throughout the world. These include medication, talking therapies of many kind, complementary or alternative therapies, and community or social activities. CBT is one of the ways in which people with depression can be helped to get better, and evidence shows that it’s one of the most effective.
When a normal low mood becomes depression
If you experience a difficult life event, such as a bereavement or other loss, such as redundancy, it would be unusual not to experience some low mood. These feelings may last for some time, making it difficult to judge what might be considered “normal” for such a situation. Often what you need most is time, support, and care, from those close to you. Most people recover over time from such difficulties. However, for some people, events like these can trigger a more lasting and pervasive depression. Usually, you are considered depressed and perhaps needing help if you have had psychological and physical symptoms of depression on most days, over several weeks.
The following questions might help you think about whether or not you may be experiencing depression. Think about how you have felt over the past 2 weeks. Have you regularly experienced any of the following:
. Feeling very sad or irritable?
. A loss of interest in things that you previously enjoyed?
. Feelings of guilt or feeling bad about yourself?
. Being unable to concentrate, remember things, or make decisions?
. Changes in your weight or appetite?
. Changes in your sleep pattern?
. Fatigue or feeling drained of energy?
. A feeling of restlessness or decreased activity which has been noticed by other people?
. Feeling that your situation is hopeless or that you are worthless?
. Thoughts of death or suicide?
If you have been experiencing more than 5 of these symptoms on most days over the past 2 weeks, then you may well be depressed. If you think you are depressed it is a very good idea to talk to your doctor and explore the options for treatment.
It can be very frightening if you or someone close to you experiences thoughts of suicide or self-harm. We don’t often talk about these things, but they are much more common than you might think. During bad times, huge numbers of us may have thoughts like wishing we could just go to sleep and never wake up, or that we’d never been born. There is a huge difference between having these kinds of thoughts and actually devising a plan to harm yourself. If your thoughts start to turn to plans, it’s a good indication that professional medical help is needed. In a crisis, your GP or hospital A&E department are good starting points to find help. Research shows that depression is linked to chemical changes in the brain, making it very difficult for you to think in a clear, positive, or healthy way.
How CBT can help us to understand low mood and depression
Psychology often uses a flow chart diagram in displaying the “five areas model of CBT” which can help in understanding what’s happening to you when you’re depressed. For those unfamiliar with how to interpret a flow chart, I have provided a narrative instead.
The five areas model of CBT
Essentially, we start with a [1] trigger (such as loss of job), which will manifest into [2] thoughts (or interpretations) (such as “I’ll never find another job; “I’ll lose my home”; “They got rid of me because I’m completely useless”; Pictures self on the street, destitution). This then transpires into [3] emotions (such as being sad, depressed, or ashamed), resulting in [4] physical sensations (such as crying, tiredness, and lack of energy) and [5] behaviours (such as staying in bed, avoiding answering the telephone, and cancelling social engagements).
Case study – Linda
Linda is made redundant. The company is going through troubled times and Linda was the last to join so it’s easy for them to let her go. However, Linda has always experienced low self-esteem and worries about her competency at work. This dates back to experiences of being bullied at school. Losing her job brought back feelings of not being good enough, and she tells herself that the company’s been looking for any excuse to get rid of her.
She feels ashamed, choosing not to talk to friends and family about it because she’s sure they’ll agree with her thoughts, and judge her. This means she’s not hearing other points of view about her problems and finds it impossible to see any other interpretations of what’s happening.
Linda feels exhausted and drained of energy, stops going out and spends a lot of time in bed or alone, dwelling on negative thoughts. At first, avoiding people and social events brings some relief. She tells herself she needs the rest because she was so tired. However, over time, rather than the tiredness dissipating, Linda begins to feel less and less motivated, ever more lethargic and wearier, and her mood worsens.
What causes depression?
There is no single cause for depression. People do talk about depression as a “chemical imbalance” in the brain and research shows that certain brain chemicals change in people in a depressed mood. However, for most people the cause of depression is a complex mix of biological (chemical), psychological (thinking and feeling), and social (life) factors.
CBT suggests that early experiences and life events (such as trauma in childhood, early losses, bereavement, or bullying) can make us more vulnerable to developing depression later. This is because such experiences lead us to develop underlying negative beliefs about ourselves, other people, and the way the world works. Let’s look at how Linda’s depression may have developed.
Early experiences Bullied at school. Laughed at by other children. Not well supported by parents – told she was being “weak” and should just “ignore it”.
Negative beliefs I’m weak and cannot look after myself; I’m incompetent; Other people are likely to hurt me; The world is unfair.
Strategies for managing the negative beliefs She avoids getting close to people. She sets really high standards for herself and works harder to avoid people realising that she is incompetent.
Trigger for negative beliefs Losing her job. Linda’s underlying negative beliefs developed when she was quite young. However, up until now she’s coped by employing strategies to prevent what she viewed as her incompetence showing to other people. The problem came when losing her job triggered these negative beliefs and led to a series of negative interpretations of her situation. This then led into the vicious cycle of thoughts, emotions, physical feelings, and behaviours, which were examined above.
How CBT can help you to tackle depression or low mood
There are a number of things that you can do which can help you improve your mood, whether you are suffering from long-term depression or just having a period where you feel low.
At this point, though, it is really important to stress, that if things get too much to manage alone, then you should remember to ask for help. There is excellent help out there. Depression is incredibly common, and sufferers are not alone. Ask for help if your depression is severe, if you are finding it impossible to begin to feel better, or if you have thoughts of self-harm.
Step 1: Get active
Mood and movement – How would you rate your mood right now? On a scale of 0–10, where 0 is not low at all and 10 is the most depressed you have ever felt. Write your answer down. When we feel very low, we don’t want to do anything at all. Often, we find it hard to muster the energy to even get out of bed. However, if you’ve scored 1 or more, here’s the experiment: Go out for a 5-minute walk, right now, even if it’s raining! It’s only 5 minutes, so you won’t melt . . . or drown!
While you are walking, think about your posture. Keep your head up and your back straight. Look around. Notice your environment, including any people. What can you see, hear, and smell? Try making eye contact and smiling at anyone you see, even if you really don’t feel like it. If you find yourself caught up with negative thoughts like “I can’t do this” or “I’m so tired” try moving your attention back to everything around you. Walk briskly – faster than you feel like moving…
After 5 minutes rate your mood again. How is it now? How would it have been after those 5 minutes if you’d spent them sitting alone, brooding on your low mood? The chances are that you’ll have found your mood has improved a little, or at least not become lower, which is what might have happened had you not got moving.
When our mood is low, we naturally stop doing things we usually enjoy because we don’t feel like doing them. But the less we do, the less we feel like doing. Consequently, we feel worse. So we do less still, feel even worse – and down the vicious spiral we go.
This is a basic principle of CBT for low mood. We need to look at our patterns of activity, reinstating things we have stopped doing or are avoiding. Sometimes this can involve a lot of effort – we may no longer enjoy things which we used to get a lot from, and simple things might take far more energy than before.
Let’s revert back to our case study and look at what happens to Linda when her mood becomes low, and she stops doing things.
. Feeling down and tired makes Linda cancel meeting up with her friends. Initially she feels better because she isn’t risking being judged negatively.
. Over time, seeing less of her friends means Linda is increasingly isolated and more convinced of her negative beliefs.
. This leads to her feeling even more depressed as she spends more time alone, dwelling on her negative thoughts.
. Linda’s self-esteem drops even lower, which means she wants to do less.
. Linda’s depression worsens still, and she never challenges her negative beliefs.
You can see how Linda is clearly caught up in a negative spiral of thoughts and behaviours which maintain and worsen her low mood.
Using behavioural activation
So, one might ask, how do you go about breaking this downward spiral? The answer is quite simple – start doing more. This is very easy to say and can be very difficult to do. But, if you approach this in a gentle, structured way, you can gradually begin to reverse the spiral’s direction, travelling up instead of down. For a few days, try monitoring your activity and your mood. Use the mood scale of 0–10 you used earlier. Before we move on to the next exercise, hold on a moment…
You did go out for that 5-minute walk, didn’t you? If you didn’t, why not do it now before we proceed any further? The experiment’s designed to show you how you really can reverse the spiral – but it won’t work if you don’t do it.
Activity diary
Draw up an activity diary in your journal like this sample of Linda’s. For each period of the day, Linda rates her mood (where 0 is not depressed at all, and 5 is the worst she ever feels), her pleasure in the activity she is doing, and the sense of achievement she gains from the activity (again, where 0 is none, and 5 is the most she feels).
| Day: Monday | Activity | Rating |
| Morning | Got up, showered, dressed, breakfast | Mood 4/5 Pleasure 0/5 Achievement 1/5 |
| Lunch | Lunch and shopping with friend | Mood 1/5 Pleasure 4/5 Achievement 1/5 |
| Afternoon | Housework, washing | Mood 3/5 Pleasure 1/5 Achievement 4/5 |
| Early evening | Walked dog | Mood 2/5 Pleasure 3/5 Achievement 4/5 |
| Supper | Not hungry – had a snack | Mood 3/5 Pleasure 2/5 Achievement 0/5 |
| Late evening | Completed jigsaw puzzle | Mood 2/5 Pleasure 4/5 Achievement 5/5 |
Try keeping a diary like this yourself for a week. It might look like a lot of work, but this exercise can provide you with a lot of very useful information about your mood.
After a few days, look at your diary. What do you notice? Most people find that even when they are depressed their mood fluctuates at different times of the day and with different activities. We also know that activities that gives us pleasure or those that use our skills, giving us a sense of achievement, are important in helping us to maintain a better mood.
The next step is to start planning in activities. Use the diary sheet again. Each day plan what you are going to do. Make sure you build in some daily activities which give pleasure and a sense of achievement. These can be very small things – perhaps taking a bath, watching a favourite television programme, or completing one small task you’d been meaning to do for ages. Planning and writing down your structure for each day will help you to stick to it, allowing you to monitor your mood and to see how increasing your activity affects it.
The 5-minute rule
When we are feeling really low and lethargic, drained of energy, it can be so hard to get moving. To do anything feels impossible. We can often overwhelm ourselves by thinking about everything that we have to do at once. We then get anxious and often decide there is no point in even starting. Use a “5-minute rule”. Just do something for 5 minutes. Don’t focus beyond 5 minutes. Just coax yourself to do this very small thing – then congratulate yourself for doing so. Remember that even just 5 minutes is better than nothing, and when you are depressed, it can be the equivalent of an hour’s activity when your mood is good. At the end of 5 minutes, see how you feel.
Let’s see how behavioural activation helps Linda.
. Linda begins to monitor her activity and plans to speak to a friend by telephone.
. Making this call gives Linda a sense of achievement. She finds talking to her friend easier than she’d thought.
. Linda plans to meet her friend for coffee, and then suggests having lunch and going shopping.
. When the friend agrees, Linda feels just a little more positive.
. This makes Linda feel more in control and even more positive. It interrupts her negative thoughts.
. Linda starts realising that there are different ways of looking at her situation and that by doing more makes her feel better.
So, from this, we can see how Linda gradually begins to feel better by becoming more active. As this happens, her mood improves, and the downward spiral is reversed.
☑ Small, gradual changes in your activities can begin to boost your mood. Break things down into small steps – don’t expect too much of yourself too quickly.
Step 2: challenge negative thinking
Research tells us that when people are depressed their thinking style changes. Experiments comparing depressed thinking with usual thinking show that when depressed we tend to have a negative bias in how we evaluate the world. We see negative events and outcomes as our fault, while ignoring positive outcomes or crediting other people, or by chance, with making them happen. When depressed, it is as if we have put on dark glasses and can only see gloom. Negative thoughts in low mood tend to be automatic; we don’t even notice they are there. This isn’t really surprising, as the pessimistic nature of the thoughts is perfectly in tune with our low mood. So, everything fits together, meaning we’re often not aware of the thoughts, or able to challenge their accuracy. Instead, the first thing we’re aware of is that we feel low. To change this, first we need to get better at recognising these thoughts. Next time you feel low ask yourself: What was going through my mind just before this?
You’ll find if you start looking, the negative thoughts are there – you just have to recognise them.
Common types of biased thinking in depression
[1] Mental filter
“My boss said I hadn’t got that report right – I’m useless.”
When we are low, we tend to only notice and accentuate the things which fit with our negative view of ourselves, other people, or the world around us. We ignore the fact that our boss also said we had done really well in another project or that we were given an award for our work last year – we concentrate on the things that fit with our depressed view, blind to anything more balanced or positive. Conclusions based on only half the evidence wouldn’t stand up in court!
[2] Over-generalising
“I can never do anything right. No-one will ever love me.”
When we are depressed, we tend to make global statements about negative events, using words like “always” and “never” instead of “sometimes” or “right now”. Look out for these words. Then work on collecting all the evidence, not just the negative. Try to recognise that the way things are now is just how they are now. Things seldom stay the same, and we can’t predict the future. Nothing is ever always the same.
[3] Catastrophising
“I haven’t finished that project on time. My boss will be furious. I’ll lose my job! The mortgage won’t get paid. I’ll be homeless…”
When feeling low we often allow our thoughts to run away into the worst-case scenario before anything has actually happened. We then tell ourselves that such scenarios are inevitable. Try to take one thing at a time. The worst doesn’t always happen, and catastrophising makes our mood even lower. Instead, try to think about one thing at a time. You may be able to take measures to prevent the worst happening. Overwhelming yourself with catastrophes, however, means you are more likely to panic and so less likely to take effective action.
[4] Black-and-white thinking
“I am not perfect at work; therefore, I am a failure. My home is not completely spotless, so I’m a slob.”
When we think in “all or nothing” terms like this we feel inadequate or a failure. The problem with this is that not much in life is really “all or nothing”. Nobody can be perfect and if we always aim for this we will never be satisfied. Try aiming for a good job done, rather than perfection. In fact, for minor things like washing the car, experiment with the idea that “good enough is good enough”.
[5] Mind reading
“Rob didn’t phone. He thinks I’m an idiot. Mum didn’t say I looked nice. She thinks I’m fat and ugly.”
Try as we might, we can’t actually read other people’s thoughts. Sometimes we can be reasonably good at reading people, but when we are depressed our negative bias kicks in. We tend to assume we know people are thinking negative things. Any ideas why else Rob didn’t call? Maybe he was just busy and actually feels bad for not having had time to call, because he likes you. Perhaps her mother did think she looked good but was preoccupied, or just forgot to say so. Don’t jump to conclusions based on biased appraisals.
[6] Emotional reasoning
“I feel upset and anxious about work. That must mean something is really wrong. I am obviously doing very badly.”
Sometimes the way we feel about something isn’t the best guide to how it really is. Try looking at the facts instead of using your feelings as a guide. Ask someone else who isn’t experiencing this emotional reaction what they think. Weigh up the evidence separately from how something feels.
Do you recognise any of these thinking biases? They are very common ways of thinking when we get low in mood, distorting the way we see things, maintaining, prolonging, and deepening depression.
CBT sometimes gets accused of being “just positive thinking”. Actually, the way CBT views thoughts is that we should try to re-evaluate them, not necessarily making them “positive”. It is about finding a more realistic, balanced way of viewing and interpreting events. Rarely is any situation either all good or all bad. As Einstein wrote, “the world . . . is a product of our thinking; it cannot be changed without changing our thinking”.
Watch out for distortions in the way you are thinking. Ask yourself: Is there another way of seeing this? If I wasn’t so down right now, would I still see it like this?
☑ Find balanced alternatives to negative thoughts.
Let’s look at a simple example:
Look out the window, It’s pouring with rain.
An overly negative view would say: “It’s raining. It’s never going to stop. I’ll be stuck inside forever, and I’ll never get to do what I want to do outside.”
An overly positive view would say: “Another lovely day! I’ll rush out right now and do what I want to do.”
A realistic or balanced view would say: “It’s raining, that’s disappointing – but it might stop in a couple of hours. If it doesn’t, I can use an umbrella and still do some of the things I wanted.”
When you notice yourself feeling low, try to identify the negative automatic thoughts that are driving that mood. Write them down. You should attempt to answer the following questions by recording them in your journal:
. Is there another way of looking at this?
. How might I view this if I was feeling more positive?
. How might I view this in a week/month/years’ time?
. What would someone else say about this? How might my partner/sibling/friend view this?
. What is the evidence for this thought? Is my thinking distorted or biased in any way? Can I find evidence that contradicts this thought? What am I missing?
Asking these questions and providing a written answer in your journal of wellbeing will help you to evaluate your thoughts and to recognise that you may not be seeing things as clearly as you think.
Now, next to the thought you wrote down, list any alternative or balanced thoughts – different ways of looking at the situation which may not be as negative as your original thought.
Let’s look at how Linda from our case study balances her thoughts:
Negative thought – “Losing my job just proves how useless I am at everything.”
Alternative balanced thoughts – “Losing my job makes me feel useless. In fact, there have been other times my work was commended. My last boss considered me very good. This job ended because the company was in trouble. Maybe they really did let me go because I was last to join.”
You won’t need to write down your thoughts forever, but it is important to practise this as a new skill when you are low. Writing things down in this way helps to develop a new habit of automatically balancing your thoughts, but without practice you’ll never get the hang of it (despite what you may think).
Silencing the critic
Many people use self-criticism as a tool to spur themselves on. Learning to be tough on ourselves can sometimes help to motivate and get us going when we are flagging. That voice in your head that says, “come on, you can’t lie around all day, get up and walk the dog/clean the car”. We’re all familiar with this and can sometimes, in small doses, find it effective. The problem is that when you are low, this critic in your head turns into a bully who no longer has your best interests at heart and isn’t motivating but attacking. Because this bully is part of you, they know exactly what upsets and worries you most and can pounce on those things in a way that just depresses you further.
If you are trying to encourage a struggling friend to do well, which of the following approaches might work best?
“Come on. You can do this. So you’ve made mistakes – that’s normal. Focus on what you can do – I know you can get there if you just keep going.”
OR
“You idiot. How stupid are you? Look at all the mistakes you are making! You always get everything wrong. Go on, try again – give everyone a laugh.”
It seems obvious, doesn’t it? Even leaving aside the fact that the second approach is clearly nasty and unkind, which of the two approaches is likely to be more effective in getting the desired result? It should seem pretty clear that the first approach is more compassionate and more likely to help someone achieve what they are trying to than the second. Yet when we criticise ourselves inside our own heads, we’re taking the second approach, and beating ourselves up. No wonder we feel more discouraged and depressed.
People who are effective in what they are trying to do usually act as a friend to themselves. They are encouraging, supportive, and compassionate, to themselves in the same way we might choose to be a good friend.
Returning back to our case study, let’s look at how Linda might add compassion into her thought balancing:
Negative thought – “I’ll never get another job because I’m just useless. I didn’t even get shortlisted for that job I applied for last week. There’s no point in trying again. I’m just an idiot.”
Compassionate alternative balanced thoughts – “You can’t see into the future. Yes, you missed out on this one, but it probably had hundreds of applicants. Keep going. You’ve been successful in the past and so can be again.”
A helpful story: the poisoned parrot
Imagine you are given a parrot. This parrot is just a parrot. It doesn’t have any knowledge, wisdom, or insight – it’s birdbrained after all. It recites things “parrot fashion” without any understanding or comprehension. It’s a parrot.
However, this particular parrot is a poisoned parrot. It has been specifically trained to be unhelpful to you, continually commenting on you and your life in a way that constantly criticises you and puts you down.
For example, your bus gets stuck in a traffic jam, and you arrive at work 5 minutes late. The parrot sits there saying:
There you go again. Late! You just can’t manage to get there on time, can you? So stupid. If you’d left the house and got the earlier bus, you’d have arrived with loads of time to spare, and the boss would be happy. But you? No way. Just can’t do it. Useless. Waste of space. Absolutely pathetic!
How long would you put up with this abuse before throwing a towel over the cage or getting rid of the parrot?
Yet we often put up with the voice of this internal bully for far too long – decades, even. We hear that “parrot”, believe it, and naturally get upset. This then affects the way we live our lives, the way we behave towards others, what we think about others and the world, and how we think and feel about ourselves.
We can learn to apply an antidote: notice that parrot and cover the cage!
Say to yourself, “It’s just that parrot again. I don’t have to listen to it – it’s just a parrot!” Then go and do something else. Put your focus of attention on something other than the parrot. This parrot is poison though and won’t give up easily. You’ll need to keep using that antidote and be persistent! Eventually it will get tired of the towel, tired of you not responding. You’ll notice it less and less. It might give up its poison as your antidote overcomes it, or perhaps it will just fly off to wherever poisoned parrots go.
Self-bullying is not helpful to you. Try treating yourself as you would a friend. Encourage yourself and you’ll be more effective.
Thinking about thinking
Let’s think about the mind. How many thoughts do you think you have in one day? How often do things just pop into your mind that seem random, even strange? Our minds are very busy places, and not all thoughts deserve our attention. When we are depressed any negative thought that enters into our head tends to grab our attention – we believe it and assume it is true simply because it fits with how we feel. Sometimes this can happen without us even noticing it – negative thoughts follow negative thoughts, and our mood gets even lower. Training ourselves to become more aware of what is going on in our minds can show us that thoughts are just thoughts – not facts. As explained above, thoughts can be biased, wrong and unhelpful. With practice we can learn to separate the good from the bad and choose which to listen to.
Find out what works for you
This page offers ideas and guidance using a range of techniques. It is envisaged that the reader will be looking to find those that help them the most. Some people who suffer from depression only make limited progress with certain psychological therapies, and when such people are also averse to drugs, they can be in trouble. However, there are always through. Always seek medical attention if you feel you have been depressed consistently for more than two weeks.
Case study – Joe
Joe’s childhood was isolated after his mother lost her first child to diphtheria. Deprived of social contact and play, Joe was bullied at school and was said to be a “dreamer” in class. In his working life, he was introverted, tense, serious, and hypercritical of others. He was never happy with his place on the career ladder, although he was considered by others to be very successful. He suffered depression throughout his adult life and only made friends through sports teams and sports clubs. He was married for 20 years before separating from his wife.
Joe consulted several physiotherapists over two decades. While in therapy he learned to understand the possible causes of his depression, but his moods persisted. Indeed, at times they got worse and when he started having suicidal thoughts, he was referred to a psychiatrist. The various drugs prescribed all had side-effects Joe couldn’t tolerate and he felt he was back to square one.
Then Joe came across the Buddhist teachings on suffering and the causes of suffering. He learned to use mindfulness meditation to investigate the reality of his own distress. He started to think about the way in which his mind worked and began to recognise the negative thoughts that drove his depression. He found that as he did this, he became more able to question the validity of those thoughts and to change how he interpreted things around him. Joe also looked at his activities and lifestyle. He built in more time with people he cared about and tried out some new social activities.
Friends of Joe have witnessed great changes in his personality. He is confident that the dark moods are unlikely to overwhelm him in the future because he now uses the investigative tool of mindfulness meditation to determine the reality of any problem. The illusions and distortions created by his early childhood do still crop up, but he can now see them for what they are and not let them damage his health and relationships.
CBT recognises the value of mindfulness meditation, and it can become a very useful tool to aid therapy.
Summary – the dos and don’ts of being in a depressed mood
Do:
. Tell someone how you feel
. Get moving – do something active for 5 minutes
. Treat yourself as you would a friend
. Examine your thoughts for biases
. Remember thoughts are not facts.
Don’t:
. Beat yourself up
. Stay in bed
. Expect too much of yourself
. Listen to that parrot!
Coping with bad times
“People are like stained glass windows. They sparkle and shine when the sun is out. But when the darkness sets in their true beauty is revealed only if there is a light within.” – Elizabeth Kubler Ross
On this page, it has been described how CBT highlights the way distortions in our thoughts and beliefs about events in our life lead to emotional distress and/or patterns of unhelpful behaviour.
That aside, what does CBT say about situations where our so-called negative thoughts could be correct? Perhaps you’ve lost someone you love. It might be accurate to say, “I’ll never see that person again.” That’s no exaggeration, or other type of negative distortion – anyone, understandably, would be extremely upset. We all experience unpleasantness in our lives sometimes, but some people are faced with more, and tougher, things than others.
Dealing with depression and illness can be very difficult. One of the tools I have previously mentioned that should be used is a manually written journal. Here, again, it should be used to record any upsetting things you’ve experienced in the last five years. Construct a three-column table with headings of Date, Event, and Feelings, and enter the details in your journal.
Listed below are some events that within Western society have been shown to be potentially the most stressful. Have you experienced any of them? If any apply to you, you might like to include them when compiling your entries:
. Death of a spouse, partner, or close family member
. Prison sentence
. Death of a close friend
. Divorce/family break-up
. Relationship break-up
. Period of homelessness or housing problems
. Significant debt/financial problems
. Unemployment
. Serious illness of you or a family member
There might be others on your list. Do fill in the table and take the time and effort to carefully write down your feelings too. Try to be as accurate as possible.
If you have experienced one or several from the list above, research suggests you are more likely to experience both physical and mental health problems, and to find yourself less able to cope socially. The more you’ve experienced, the worse you are likely to feel.
Many variables do, however, dictate a person’s response to stress. Some people are more resilient and therefore cope better with stressful events than others. While certain factors like biological vulnerabilities, upbringing, or historical events, are beyond our control, there are many things we can do to improve our chances of coping more successfully with stressful events. Contrary to popular belief, some people aren’t just stronger than others. Our resilience and ability to manage stress changes throughout our lifetime, and normally “strong” people can at times find themselves feeling defeated by things which they coped well with at other times.
It’s helpful to think we have a limited capacity for stress, rather like a bucket which holds a finite amount of water. We all experience some stress in everyday life. Indeed, some stress is needed to motivate and energise us into action. However, if our stress bucket is consistently almost full, it won’t take very much for it to overflow, or for us to develop difficulties in coping. This is why sometimes a seemingly small problem coming on top of many other comparatively small problems can finally make us feel we’re falling apart. We’ve perhaps coped very successfully with everything until then, but that’s where it all ends in tears.
Research shows that many factors dictate how we are affected by negative life events, both big and small. Negative experiences can often work in different ways for different people at different times. Sometimes we learn from things and become more skilled through our experiences. At other times we can’t, and the identical negative experiences can have a much greater effect. If you find yourself less able to cope successfully with stress, there are probably many good reasons for this. It’s certainly not that you are just weak.
Key factors determining coping
. Meaning of the event
. Identification of your strengths and abilities
. Historical factors
. Personality traits.
Let’s look at these in a bit more detail.
The meaning we give to events can change both our reactions, and our ability to cope with them. For example, if we think we caused a problem by doing something wrong, our reaction will depend on whether or not we view our mistake as understandable. If we think the mistake was forgivable, we may be able to learn from it and make positive changes for the future. But if we judge ourselves as “bad” or flawed we may feel helpless to change and learn from the experience. One view means we can still feel good about ourselves, the other means we don’t.
If we think we have the strengths and abilities to cope with a situation, and that it is manageable, however awful it may be, then we’ll use strategies which are more likely to have a positive outcome. These are approach-related strategies like problem-solving, learning from difficult experiences, and using support from others.
But if we think we can’t cope, or that the problem is totally unmanageable, we’re more likely to use less successful strategies. These avoidance-related strategies include staying away from others, cutting down on the things we normally do, using drugs or alcohol to escape or pretending that the problem doesn’t exist, while vainly hoping it will simply disappear. Predictably, these strategies have been shown to be less successful.
Historical factors like upbringing, education, and early life experiences, are also important in coping with stress. If we’ve been taught that showing emotion means we’re weak, we may be angry with ourselves for what are normal reactions under the circumstances. So, for example, if we lose a very dear friend, we may cope less well as we berate ourselves for feeling very normal emotions such as sadness and grief. But if we’ve been taught that we should express and share our emotions, though our grief will still be as strong, it will be easier to manage and we’ll cope better with it.
Personality traits such as optimism or sociability may also make us more or less vulnerable to stress. Social support has been shown to be very important in how we manage after a stressful life event. People who have a natural propensity to be sociable, or form close relationships, therefore have an advantage here.
Many other factors have a role in how well you cope. These include your age, socio-economic status, or life-stage. Clearly some factors above are more within our control than others. The meaning you give to events and your prediction of how you’ll cope are essential to CBT.
As for the influence of historical factors and personality traits, the good news is that none of these are insurmountable. No matter what the situation, we can all learn to manage stress better, irrespective of our background, gender, age, or experience.
The definition of a stressful life event differs for everyone. Just because your particular stressor might not have been detailed here, this doesn’t make it any less difficult or challenging for you.
Golden rules for coping with stressful life events
There are several golden rules for coping with a stressful situation and looking after yourself during a difficult time.
[1] Take care of the basics – When bad things happen it’s tempting to curl up into a ball under the duvet and get out of your usual routines and habits. Taking care of your basic needs is even more important at these times. You may not feel like eating, and sleeping may seem impossible, but it’s vital you take care of yourself. Eat little and often rather than trying to force down normal meals, but make sure you do eat – emotional times can drain us of energy and our bodies need food, despite our minds insisting we’re not hungry and don’t want it. Try to rest even if your sleep is disturbed. Many people find that sleeping tablets used sensibly and for as short a time period as possible can be a useful way to get through the first few nights after something difficult has happened. If you are having problems sleeping, CBT can be very helpful for insomnia, but this will not be a major topic described on this site. Various forms of mindfulness such as mindful listening, looking, living, and resting, are proven CBT techniques for dealing with the condition.
[2] Keep (reasonably) busy – Going through the motions of our usual routines can actually be very helpful during difficult times. If you usually take the dog for a walk in the morning or pop out to the local shop for a newspaper in the afternoon, try continuing with these activities. We all have familiar tasks which can help keep us in touch with normal life and we do almost on autopilot. They can prove soothing at difficult times and can also remind us that our life is still going on and that we can still control at least some aspects of it. Sometimes we have to go through the motions in order to then move on with life.
Beware – sometimes people use work or other activities as a way of hiding from or avoiding their emotions. This can mean it takes longer to properly recover.
[3] Exercise – This could well be the last thing you feel like doing. However, there’s good evidence that physical exercise is important for managing low mood and stress. Even just a brisk walk round the block or in a local park may improve your mood just a little and will probably have a more positive effect than simply sitting and focusing on your problems. So, EXERCISE! Get moving! Force yourself to do anything physically active – just for 5 minutes. You must do it if you want CBT to help in your recovery.
[4] Allow yourself to feel sad
This may sound strange, but many people spend a lot of time fighting normal, natural reactions to what has happened to them. Losses and disappointments can bring grief. Feeling and expressing grief and sadness is neither weak nor pointless. It may even be the only way we can truly heal and move on. Everyone experiences and expresses emotions differently. No way is either right or wrong. However, when we struggle and fight against feeling painful emotions, usually we only make them worse.
Think of what you might do if you were trapped in quicksand. Your first instinct would be to struggle desperately to escape. But that’s just the opposite of what you should do. The more you flail around, the faster the sand will suck you down. Your best bet is to stop struggling, lie flat and slowly inch forward. It’s the same with painful emotions. Stop struggling and try to just tolerate the pain. Stay with it. Don’t fight the feelings – they’ll get stronger and try to drag you down. Remind yourself that what you are feeling is normal, natural, and understandable. Most importantly, remind yourself that, with time, you will heal, and the feelings will pass. That does not mean that your loss will ever be forgotten or even totally eradicated, but just that your feelings will become less intense and less painful over time. Some things will always hurt, but they will gradually have less effect on your ability to function – even if, while you are going through it, that time seems impossible to imagine, or a really long way off.
When you feel sad, just allow yourself to feel that way. Remember:
. You are feeling this way for a reason
. This is just how you feel right now
. There will be good days and bad days
. Feelings change and even grief comes and goes in intensity
. Make the most of the good days and on the bad days be good to yourself
. Do things that soothe and comfort you and be gentle with yourself
. Treat yourself the way you’d treat a close friend or a child who was in pain
. You will heal faster if you show yourself kindness
. Don’t scold yourself or tell yourself “you should be over it by now”
. Be your own best friend and do what is right for you.
It’s utterly useless demanding that you “pull yourself together”. If it were that simple, you’d have done it long ago – and there would be no need for therapies of this kind.
How to be gentle to yourself
Take a warm bath. Have a massage. Eat comfort food (bananas and chocolate can help – but only in moderation). Make time to talk to a friend. Watch a favourite film. Go for a walk in the countryside. Buy a new outfit.
You may have other ideas which haven’t been mentioned here.
It isn’t being suggested for a moment that any of these things will take your emotional pain away completely. However, they may help you to relax a little. Indulge yourself just enough to give yourself space to overcome the numbness and start to feel again.
[5] Watch out for distorted thinking
At the beginning of this section, it was stated how some negative thoughts we have at difficult times in our lives are inevitable and may actually be accurate. That doesn’t necessarily mean, though, they all are. We can still have distortions and misrepresentations in our thinking during such times. Notice the things that are going through your mind. How accurate are the assumptions you are making and the things you are saying to yourself right now? How helpful are they to you?
Case study – Jenny
Jenny is going through a divorce, having found out her husband has had a series of affairs. He has finally left her for a younger woman he met at work. Naturally, Jenny is very angry, sad, and distressed. Many thoughts go through her mind. Some of these thoughts, such as “he doesn’t love me anymore”, “he finds her more attractive than me” or “he wants to be with her more than with me” may well be true. Of course, they’ll hurt terribly. However, these thoughts are accompanied by many others which are less true and just deepen distress unnecessarily.
Finding some logical counterarguments to these examples of distortions in Jenny’s thinking is important for perspective. I’ve given some suggestions, and of course there can be a whole lot more. If you find yourself in a situation like this, it is good to write down your feelings in your wellbeing journal and offer counterarguments too.
. Distorted thought: “No one will ever love me or find me attractive again.” This might be countered by saying: “None of us can predict the future”.
. Distorted thought: “Every man will eventually leave for a younger woman – they’re all the same.” A counterargument might be: “Everyone is different”.
. Distorted thought: “I will never be happy again.” Countered by: “Painful feelings rarely last forever, even if they are excruciating at the time”.
Though the distortions may feel as true as Jenny’s initial thoughts, an outsider will readily see they are distortions of reality. These distortions or any others you have been having in any given situation need to be worked on by balancing them or by providing logical counterarguments.
However awful or painful your situation is, it may be that not all your negative thoughts or predictions are completely true. Work on catching yourself if you are trying to predict the future or jumping to conclusions based on your current situation. Don’t give yourself more pain by telling yourself that you can never move on or get over this.
Have you ever noticed how, in a city, it can be very hard, if not impossible, to see the stars in the night sky? This is because the light pollution generated by buildings, streetlights, and cars, prevents us from seeing the light of those stars. The wonderful thing is that the stars are still there. We just can’t see them. As soon as the lights are turned off or we go out into the countryside we see the stars again. It is a little like this with good things in our lives when we are in pain. We can’t see any positives. However, it is important to remind ourselves that they are still there somewhere. When our situation changes and the painful feelings dim even just a little, then the positives start emerging and become clearer again. None of this is about denying or avoiding the negatives. They are all too real. It is about recognising that nothing is ever either pure black or white.
[6] Cut down on self-criticism
Telling yourself that you are weak because you are “not coping” is not likely to be helpful. Read again the story of the poisoned parrot on this page (under the section, dealing with depression). Do you recognise this? Be a friend to yourself. You can be firm and encourage yourself to move forward – but at the right pace and in a supportive, kindly way. You will find that this is much more effective than beating yourself up for reacting in a very normal way, which you would probably understand and forgive very easily in others.
[7] Lean on others
We all need support in difficult times. It can be very hard to admit that we need help, or are not coping as well as we’d like. It can make us feel that we are weak or useless, and that people whose opinion we value think less of us. However, very often when we make the first move to ask for support, we can be pleasantly surprised. Usually, people are pleased to be asked to help. We all like to be needed or feel useful and sometimes helping someone else can make us feel better about things in our own lives. Give those around you a chance. Reach out and ask for help – even in small, practical ways. You’ll probably be surprised with the results.
Be wise in your choices – select people you think will be supportive and let them know what you need. If you can be brave enough to communicate your feelings and needs, the chances are those needs will be met. If help isn’t forthcoming, try to let go of any anger about this – you should have enough to deal with.
[8] Write it down
There is evidence that writing about negative events can help people to feel more positive and can even reduce the number of physical ailments they experience in the months after a difficult life event.
Try this exercise. Set yourself a short time every day over the next few days to write about your experiences, feelings, and reactions. You can write about the same thing every day if you wish or something different each day. Don’t think too closely about what you write or worry about punctuation, spelling, grammar, or even accuracy! Just write. Then get rid of that writing. Don’t re-read it. Throw it away, burn it, recycle it, rip it up – whatever works for you. This exercise is designed to help make sense of and process emotionally charged information, which then helps us to move on and be less affected by stress related to the experiences we have written about. It also might explain why diary and journal keeping has always been a very helpful and popular mechanism in dealing with stress related illnesses and disorders. You have a right to record anything in your journal, but the main factor in running and maintaining one is honesty. Keep your integrity.
When do normal reactions to stress become a mental health problem?
It’s a fact that sometimes adverse life events can trigger mental health problems such as anxiety or depression. It’s very difficult for professionals to say exactly where “normal” reactions stop and a mental health problem begins. For some people, adjustment to an adverse life event or loss takes a very long time – it may be months or even years before you feel better or able to fully move on with your life. In CBT it’s often recommended that people don’t get active during formal treatment in the first few months after a negative life event because distress – even depression and anxiety – is a very normal reaction itself to an abnormal event in a person’s life. However, it can also be true that some people, for whatever reason, get very stuck following a negative life event and find it impossible to move on or to rebuild their lives.
If you feel that this has happened to you, think first about whether you are perhaps expecting too much, too soon of yourself. Is it really that realistic to expect to be “over it” by now? If you do feel you may be depressed or anxious then the sections above (‘Managing anxiety’ and ‘Dealing with depression’) could help you find some ways to tackle this. Talk to people around you. Do they think you are depressed? Sometimes others can judge this much better than we can ourselves. Most importantly, if you feel that things are out of control and some of the CBT strategies suggested here aren’t working, despite time and practice, then ask for help. What does your GP think?
Post-Traumatic Stress Disorder (PTSD)
So far in this section, the topic has been about quite common, but difficult and stressful life events. These can feel traumatic, but the traumatic events which will be focused on now are in a different league. The kind of events which might lead to developing PTSD are ones people believe are life threatening either to themselves or to someone close to them, and that they are helpless to do anything about. Traumatic events, while rare, can happen to anyone. Reading newspaper stories can make one wonder how people cope with situations involving serious injury or death. PTSD arises when the normal responses to an abnormal event:
. Begin within 6 months of the event or period of trauma
. Carry on for more than 3 months after this time
. Start over 6 months after the trauma – this is called delayed onset PTSD.
People experiencing traumatic events feel intense fear, helplessness, or horror. Traumatic events are outside our normal experience. Divorce, bereavements (except those caused by traumatic events), loss of employment, chronic illness, and marital or domestic conflict, therefore don’t count as trauma even though, as we have seen, they may be triggers for extreme stress and even anxiety and depression.
PTSD has a very particular set of symptoms, different to those of mental health problems, although PTSD sufferers may also have elements of both depression and anxiety. Examples of common traumas that may lead to PTSD are road traffic accidents, attacks or assaults, combat situations, and being caught up in natural disasters, or acts of terrorism.
Commonly, after a traumatic event most people get some of the following reactions:
. Distressing thoughts, memories, images, dreams, or flashbacks of the trauma, which keep recurring – sometimes there are blank bits which the person can’t recall
. Avoidance: where possible, you try to avoid places, people, activities, thoughts, feelings, conversations, or anything else which might trigger memories or thoughts of the trauma
. Emotional numbness, detachment from others, difficulty having loving feelings
. Seeing the future as hopeless, pointless, and likely to be short-lived
. Losing interest in and stopping activities you used to enjoy
. Increased arousal – you are easily startled and don’t like bright lights or loud noise
. Problems sleeping, irritability, anger, difficulty concentrating, and increased vigilance.
These reactions may be normal at first and usually pass with time and the use of some good coping strategies. However, for some people, for reasons that aren’t yet fully understood, these symptoms don’t improve and may even worsen over time. If they aren’t improving, or are even worsening, you may find that some of the activities described later in this section useful. But if things get no better, or worsen, then it’s very important to seek professional medical help, either from your doctor, or a qualified mental health professional.
Why do flashbacks happen?
Scientists don’t know exactly why the brain re-experiences things in the way that it does following trauma. Psychologists believe, however, that it’s to do with the way in which the brain processes events and stores them as memories. Just imagine your memory is like the linen cupboard of a neat, organised housewife (or husband). Each item is first sorted, neatly folded, then put away in an ordered fashion. Sheets go with sheets in one pile, pillowcases are all together in another. When the door is shut, our memories stay locked up inside. When something happens and we choose to open the door, we can take out a memory and examine it or use it. Occasionally, things fall off the shelf and out the door at strange or inappropriate times, but generally we can pack things away again and it’s no big deal.
Now, imagine that along comes a huge, irregularly shaped duvet, which has to be put into the cupboard. It doesn’t fit. It won’t fold into a neat, organised shape, and no matter how our heroine (or hero) tries to pack it away, it just keeps falling back out, forcing the door open. This is what seems to happen with traumatic memories. Our brains initially seem to find it impossible to make sense of or properly process these types of memory – perhaps because they are so far out of our normal experiences and expectations of life. There’s no template to fit them in. It’s as if our brains need to keep re-experiencing the memory in order to try to process it – to pack it away. All the time it’s not processed in the usual way, we experience the event not as a normal memory from the past but as a new event – just as if it is happening right now.
There is some evidence that the part of the brain which is associated with traumatic memories is the same part connecting to our flight, fight, or freeze mechanism which was discussed previously on this page (see above: ‘Managing anxiety’). So, all our anxiety reactions are triggered each time this event pops up, unbidden, into our minds. Flashbacks can be terrifying, horrible experiences, but they may actually be our brain’s way of trying to heal itself. Fortunately, there are ways of lending your brain a helping hand to accomplish this.
What you should not do
Quite often, people use alcohol or even illicit drugs to try to relax, to help them sleep, and to stop thinking about the event. Unfortunately, this usually proves at best unsuccessful, and at worst, can increase your problems by adding alcohol or drug dependency to them.
What you should do
Let yourself accept the whole array of feelings that you are experiencing. Remind yourself that these are perfectly normal under the circumstances. They don’t mean you are “going crazy”, “being pathetic”, or any similarly unhelpful name-calling you are doing.
Now look at what you are doing differently compared to before the trauma. Are you over-cautious? If what you are doing really is excessively cautious compared to before, make a list of the things you are now avoiding and start facing them one at a time, perhaps trying the easiest first. If there is something outside of your home, or you are unwilling to leave after a certain time of the day, ask a friend or relative to accompany you in the first instance, but then gradually move on to doing it on your own, just as you did before. At first it can be very frightening but as you repeat the actions, and find that nothing awful happens, you’ll probably find your self-confidence steadily increasing.
It’s so important that you do re-evaluate the actual event, perhaps even talking it through with someone. Maybe there really is something to be learned. Work on discriminating between what is a reasoned, more cautious approach, from the probably quite extreme course of action being dictated by your anxiety alone. In a case, for example, where someone has suffered a burglary, you might decide to install a burglar alarm and use it for certain rooms even when you are at home. Or, if you’ve been involved in a car accident linked to driving in bad weather conditions, you might decide to do an advanced driving course.
Separating then from now
The way our minds store information after a trauma is often a bit jumbled up. At the time of the trauma, everything tends to happen really quickly, and each bit can get tangled up with the others. Quite often an innocuous smell, sound, or even piece of music, can take you back into the trauma, which then triggers a complete flashback of the whole event.
If you do experience this, then remind yourself kindly but firmly that (that) was then, but then is not now. Tell yourself where you are, for instance in a different car, and remind yourself of the date today, and the date of the trauma, to help you separate the then from the now. You can apply this technique to any trauma, and it is especially helpful if you are experiencing frequent flashbacks.
Coping with flashbacks
Tell yourself that when you’re having a flashback that this is OK and very normal in people who have experienced trauma.
Remind yourself that the worst is over – it happened in the past, but it is not happening now. Remember the adage: “that was then, and this is now”. The traumatised part of you is giving you these memories to use in your healing and, however terrible you feel, you survived the awfulness then, which means you can survive and get through what you are remembering now.
Call on the stronger part of you to tell the traumatised part that you are not alone, not in any danger now, and that you can get through this. Let your traumatised self know that it’s OK to remember and to feel what you feel, and that this will help you in your healing and getting over what happened to you. However hard it is for you your brain is attempting to heal itself the only way that it can.
There are some ways of grounding yourself by becoming more aware of the present:
. Stand up, stamp your feet, jump up and down, dance about, clap your hands, remind yourself where you are now
. Look around the room, notice the colours, the people, the shapes of things – make it more real
. Listen to and really notice the sounds around you like traffic, voices, machinery, or music
. Notice the sensations in your body, the boundary of your skin, your clothes, the chair, or floor supporting you
. Pinch yourself or ping an elastic band on your wrist – that feeling is in the now. The things you are re-experiencing were in the past.
Take care and look after your breathing. Breathe deeply down to your diaphragm; put your hand there (just above your navel) and breathe so that your hand gets pushed up and down. Imagine you have a balloon in your tummy, inflating as you breathe in and deflating as you breathe out. When we get scared or frightened, we breathe too quickly and shallowly, and our body begins to panic because we’re not getting enough oxygen. This causes dizziness, shakiness, and more panic. Breathing more slowly and deeply will stop the panic.
If you have lost a sense of where you end and the rest of the world begins, rub your arms and legs so you can feel the edges of your body, the boundary of you. Wrap yourself in a blanket and feel it around you.
Get support if you would like it. Let people close to you know about the flashbacks so they can help if you want them to. That might mean holding you, talking to you, and helping you to reconnect with the present, to remember you are safe and cared for now.
Flashbacks are powerful experiences which drain your energy. Take time to look after yourself when you have had a flashback. Try a warm, relaxing bath, have a nap, have something hot to drink, play some soothing music, or just take some quiet time for yourself. You deserve to be taken care of given all you’ve been through.
When you feel ready, write down all you can remember about the flashback in your wellbeing journal and focus on how you got through it. This will help you to remember information for your healing and to remind you that you did get through it (and so can again).
Remember, you are not crazy – flashbacks are normal and form part of the healing process.
Plan some activities
After a trauma, especially ones involving loss, everything can feel both overwhelming and yet at the same time pointless. It’s tempting to do very little. But the catch is, the less you do, the worse you feel and the more everything mounts up. So you feel still worse, do even less, watch the backlog grow and just don’t know where to start – and anyway, you think, what’s the point?
A way out of this hole is to start with a rough plan for each day – one thing to do in the morning, one in the afternoon, and something for the evening. Try to plan one week ahead, carry out what your plan tells you to do, and then plan the next whole week. Congratulate yourself for having done the things you achieve but work on not beating yourself up for what you didn’t do. Instead, break that activity down into smaller steps and put them onto next week’s schedule.
Move from audience to film director
Flashbacks can be horribly unpleasant, and even terrifying. One way to deal with them, as mentioned above, is the technique of separating then from now. Another solution is to discover that you have a level of control that you maybe thought was impossible. While you are unlikely to prevent flashbacks, when they do start, you can experiment with treating the scene as a film you are watching. Instead of becoming a passive member of the audience, take over the role of film director. Start modifying the flashback, treating it as if it were a film, rather than the real event. Tell yourself that though the event did happen, what is now going through your head is something your mind is picturing. Give yourself the option that you really don’t have to watch that particular picture again and let yourself instead work on developing a different ending. Some people change the distance from the event, so it becomes small and far away, others might take the aggressor and make them look ridiculous, for instance by imagining them in a clown-suit, wearing clown’s makeup, and walking along on their hands. Still others bring someone or something comforting into the event, so they feel they are receiving warmth and support.
The important thing with this technique, called imagery re-scripting, is that in no way are you denying that the actual event took place. What you are doing is being creative with your imagination. There is no reason why you have to keep reliving it as it was. You discover that, surprisingly, you do have a choice of what you watch inside your mind, and you can choose something that feels better in some way.
The silver lining
Finally, in this section, it is worth remembering that many people who have recovered from a traumatic or stressful life event have said that with hindsight, they now see it as an important wake up call. They then start making many changes to their world which they otherwise would not have done. In fact, as one practitioner put it “the individual is able to see him or herself as stronger, wiser, and with a new value to his or her life”. Some researchers call this post-traumatic growth and think that to achieve the optimum level of growth and learning in life a certain amount of adversity may be important or even essential. It can be very difficult to believe or recognise this when in the midst of a crisis, and this is not being insensitive or patronising. However, it’s worth remembering that this idea has been around in the writings of philosophers for a very long time. Nietzsche is quoted as saying, “What does not destroy me, makes me strong”.
Maintaining progress and reducing recurrences
As we head towards the end of this page, hopefully there will be quite a difference between how you view and feel about things now compared with when you started to read about CBT.
However, it’s an unfortunate fact that many of the perceptions and feelings that have been discussed here can return – at least for a short while. Difficult times will always happen. Research has found, for example, that if you’ve had more than one episode of depression then you are quite likely to experience depression again. So, the question now is…
What can you do about it?
Case study – Rachel
Rachel is in her early 30s, with two children under the age of five. She experiences depression after the birth of her youngest child, and successfully works through this using many of the strategies that have been described on this page. Rachel recognises her thinking is very negative and that she’s constantly berating herself for not being a sufficiently good mother. She realises that much of this stems from her long-standing fear of failure. Rachel identifies her negative thoughts, weighing up the evidence for them, instead of just assuming they’re true. So, instead of assuming she knows how things are in other families, she tests out some negative thoughts by observing what other new mothers do, and by asking some of them about their own experiences. Rachel also practises challenging the self-critical voice in her head, treating herself the way she’d treat a friend who was feeling down. She shares her feelings with her partner, asking him to help her more, which gives her some time for herself. Noticing that she’s stopped doing things she previously enjoyed, like seeing her friends and exercising, Rachel starts making time to see her closest friends and also enjoys an exercise class for mothers, which she can fit in around the children. Rachel begins to feel better, and life starts returning to how it was before the birth of her second child.
However, Rachel is still bothered by thoughts that she’s not good enough and isn’t measuring up to others. Arguing with her thoughts is hard work, so she just resorts to saying to herself “just stop being silly” and “pull yourself together”. Then Rachel’s husband is unexpectedly made redundant, and things become stressful at home. Rachel feels powerless to help him and goes back to seriously berating herself for not being good enough. Feeling unable to ask her husband to continue helping her whilst he’s stressed, she once again cuts down on things she’s doing for herself, like seeing friends and attending her exercise classes. Her husband finds a new job, but his salary’s lower, and the hours longer. Rachel continues limiting her activity to just caring for him and the children. She notices she’s starting to feel tired and unhappy and – you guessed it – now begins beating herself up about that – “Here I go again . . . I’m so useless, being depressed and pathetic when I should be grateful, I have healthy children and we have money coming in again – I’m such a loser!”
Research shows that relapse or recurrence of depression, and indeed other psychological problems, can happen because even though we’re feeling better, frequently we still keep some of our old, unhelpful ways of thinking and behaving. This means we’re quite vulnerable when life becomes hard or stressful. The old patterns kick in and down we spiral . . . again. While many of us look after our physical health, knowing all about diet, exercise, check-ups, and screenings, we’re not so aware of our mental health. It’s equally important to work on our mental health when we’re well as when we’re not.
Prioritising our mental wellbeing, and learning to keep ourselves mentally “fit”, means we’re less likely to spiral down into depression or develop anxiety-related problems when life gets stressful. Think of it as like losing weight. If you really want to lose weight and stay trim, crash dieting and then going back to eating exactly the same way as before is useless. You’ll very quickly regain your former size. If you really want to lose weight and stay in shape you have to permanently change the way you eat. The same is true of maintaining your improved mood and mental health. To help you do this, a number of ideas will now be presented which can increase your resilience and reduce your vulnerability to ongoing mental health problems.
Keep up good habits
It is hoped that readers of this page will develop many useful strategies for managing their mood, mental health, and indeed for their whole life. All the ideas that have been expressed can be applied to everyday life, even when you’re not feeling particularly down or anxious. The strategies discussed in the sections above ‘Managing anxiety’ and ‘Dealing with depression’ can be used to develop habits to keep you feeling well rather than just being used when you are struggling.
Take activity scheduling, for example. It’s important that we all ensure that our weekly schedule includes pleasurable activities, or those which provide a sense of achievement. If you build this into your normal week, you’ll be less vulnerable to problems when things are stressful or challenging. Equally, watching out for distortions or unhelpful thought patterns and being aware of the ways we interpret the world, even when we are well, can increase our future resilience.
As you begin to feel better it can be really easy to drop new good habits because you don’t need them as much – try to maintain them in order to keep your mental health in good condition.
When everyday blues become toxic – what is normal?
Everyone has down days. It’s perfectly normal to feel sad, lonely, or blue, at times in our lives. Sometimes we know exactly why we feel that way, and sometimes we don’t. Unfortunately, if you have experienced depression, you can sometimes feel very frightened by even “normal” low mood. You find yourself feeling a bit low or flat, and start panicking that this means you are becoming depressed again. This in itself can trigger a cycle of negative thinking which actually worsens your mood. Thoughts like “here I go again, I’m never going to get over this” and “nothing I do makes any difference – I’ll always be depressed” lead to unhelpful behaviours like avoidance or withdrawal. This then triggers further negative thoughts and unhelpful behaviours, and before you know it, the downward spiral has begun again. It is really important to allow yourself to have low times without panicking or by labelling them as depression.
Remember these key points:
. I wouldn’t be normal to never be sad
. This is just a difficult time
. Get active – even if you don’t feel like it – do anything that might lift your mood
. Don’t give in to the urge to shut yourself away and brood – do the opposite
. Talk to someone
. Escape into a good book or by watching a film
. Do anything which takes you away from ruminating on negative thoughts
. Remind yourself that going over your worries or negative thoughts right now won’t be helpful – you don’t come up with your best solutions while you are feeling down
. If you need to take some time out and have a “duvet day”, that’s okay now and then, but don’t let it become a habit
. Don’t beat yourself up for anything you think is lazy or frivolous
. Recognise and try to meet your needs
. Be kind to yourself.
Sometimes when someone has been depressed the people around them can also assume they are becoming depressed again if they have a low day. Talk to your loved ones about this – they need to allow you the normal ups and downs of life without panicking that you are once again depressed.
Spot your early warning signs
When we have recovered from a period of depression it’s often very tempting to want to move on as quickly as possible and not think about what happened. However, learning from what’s happened can decrease the likelihood of recurrence. Think back to when you first became depressed. The chances are that it built up gradually over a period of time. In your wellbeing journal, write down the answers to these following questions. Try to be as accurate as you can.
. What happened around that time?
. What sorts of things were going through your mind?
. What did you stop doing?
. What did you do more of?
. What did other people around you notice?
Really think this through. Talk to those close to you – they may well have noticed things you overlooked. Now write yourself a plan. What is it that you have to watch out for? What should you do if you notice early signs that all is not well with your mood? Doing this can enable you to head off future problems. Tackle problems early, before they get out of your control. Notice your urges to do things you now know are unhelpful to you, like avoiding social events or dwelling on sad memories from the past. Help yourself not to act on those urges – remember that the thing you feel like doing (like staying in bed or cancelling all engagements) might not be the right or most helpful thing for you to do. Let someone else in on your plan – ask for help in detecting problems and in heading them off before they seriously interfere with your quality of life.
Expect setbacks and learn from them
Recovering from any psychological problem is never a smooth process. There will always be setbacks and days where you feel as if you are back to square one. Remind yourself that it isn’t really so. However bad you feel right at that moment, it cannot undo what you have learned from the progress you’ve already made. If you did it once, you can do it again, even though it may seem really difficult at the time. Trying seeing setbacks as an opportunity to learn more about staying well. Don’t jump to conclusions that this means nothing is working and all is lost – imagining catastrophes before they have happened is just counterproductive. Instead, try identifying what tripped you up this time. How could you avoid this kind of thing in the future? What will you need to do differently? Record all your answers in your wellbeing journal which will prove to become an invaluable resource for you, both now and in the future. Recovering from any kind of mental health problem is always a bumpy process. Expecting and preparing for setbacks will help you to learn from them.
Practise being “mindful”
Mindfulness has become quite trendy in mental health over the past few years. Based on ideas within Buddhist traditions, it goes back hundreds of years.
The basic idea of mindfulness is a very simple one – it’s the process of becoming aware of what is going on inside our minds, of stepping back and observing the way in which our minds work and becoming aware of our thoughts. Being able to observe your thoughts without necessarily being caught up in them, or needing to react to them, can be very helpful in managing your mood.
This site has a dedicated page to mindfulness.
Remind yourself that:
. Thoughts are simply mental events taking place in our minds
. They are not facts
. They may or may not be true
. They may or may not be helpful to us
. We can choose which thoughts we hold on to and act upon and which we simply let go.
When people meditate, they practise this technique of mindfulness – letting go of thoughts and simply watching from a distance.
Tackle underlying negative beliefs
Earlier, we looked at the way in which negative beliefs about ourselves, the world, and other people, can make us vulnerable to mental health problems such as depression or anxiety.
Sometimes, even when we recover from these difficulties, these underlying negative views still remain, just waiting to be re-activated when we face difficulties in our lives, so they can trip us up all over again. When you have recovered from a mental health problem and you are feeling well, this can be an excellent time to work on altering some of these negative ways of viewing the world. Low self-esteem or lack of confidence can make us much more vulnerable to mood problems. Spend some time thinking about your beliefs about yourself. Then start to plan how you can test out those beliefs – perhaps using the behavioural experiment ideas discussed above under the section ‘Managing anxiety’. Allow yourself to recognise the good things about both you and your world. The more you build up a positive view of yourself, other people, and the world in general, the less weight those negative beliefs will carry, reducing their chances of damaging your mood.
Look after your relationships
We all lead busy lives. It can be very difficult to prioritise our relationships with other people. However, research shows such relationships are really important in improving everyone’s mental health. If we try getting close to others only when we need them, we are likely to find that they’re unavailable. Spend time on a regular basis with the people who are important to you.
Get the balance right
Frequently, people with problems have very little balance in their lives. Think of the overworked executive doing a 60-hour week, seldom seeing his family; the plumber so focused on keeping his business afloat that he never has time to slow down, relaxing with friends. Then there is the office-bound employee with no time for physical exercise, or the exhausted mother with three small children who hasn’t had an adult conversation for what feels like months. Though these are stereotypes, nonetheless they’re often the kind of people who end up at their doctor’s surgery with mental health problems. Take a look at your own life and daily routines. What’s important for you to build in if you are to keep yourself as mentally well as possible? What needs to change? Small changes which keep your life in balance can make all the difference to your mental health.
So, what could Rachel from our case study earlier have done differently following her period of depression to have reduced the chances of it happening again? Rachel’s done all the right things to help herself get over her depression. She’s worked on her thinking patterns, become less self-critical, and started including things in her routine to lift her mood. She’s tested out some of her negative beliefs and gathered evidence that questioned her depressed view of herself, and which helped her both feel and act in more positive, helpful ways.
However, she didn’t recognise how important it would be to keep these things going both when she was well and, particularly, during stressful times. Rachel also didn’t deal with her underlying low self-esteem, leaving her still vulnerable to depression. Another factor is that she and her husband hadn’t discussed how to work together to prevent a relapse in her mood. Finally, she hadn’t really altered her view of her role in the relationship, not recognising how important it is for her to feel good about her role as wife and mother, even though this doesn’t include increasing the family’s income. She certainly hasn’t taken onboard how much she does which otherwise the family would have to pay someone else to do.
The good news? It’s never too late. After this second period of depression, Rachel learns from her relapse. She ensures she devises structures that will stand firm in both good and stressful times and makes an agreement with her husband about this. She also works hard developing her self-esteem. Rachel learns to recognise the good things she’s doing, begins to appreciate her contribution, and spends time developing skills which she knows she does have, which she can feel good about. The result? Rachel feels better about herself and is better equipped to manage when the inevitable stresses of family life come along.
Most important of all, Rachel gains strength from reminding herself of a phrase that helps her get through difficult times. Remember, if you too find yourself re-experiencing problems you thought you had completely overcome, then, like Rachel, it’s worth reminding yourself of that same phrase:
This, too, will pass.
What now?
Helpful resources
There are many other resources out there which can assist you even further in overcoming difficulties or making the life changes you would like to make. Most people seeking help benefit from multiple sources.
This final section on CBT contains some recommended sources for accessing additional help if you are facing anxiety, depression, or other emotional problems. There will also be some resources recommended for those people facing relationship difficulties or managing physical conditions like chronic pain. The resources will range from people in your immediate circle, to professional and voluntary services, to additional self-help alternatives.
Family and friends
Almost everyone turns to friends or family for help from time to time, and that should be encouraged. Although many of your friends and family probably don’t have the expertise to do more than support and listen to you, this can be invaluable at stressful times. There are plenty of organisations providing support and information to your family and friends too, if they want to support you but aren’t sure how. Some of the sources suggested in this section will be useful for them to find the information they need.
Avoid trying to make those close to you feel responsible for your mental health. Doing so may jeopardise your relationship and is unlikely to help you in the end. You must take ownership of the task of dealing with your difficulties, getting better, maintaining improvements, and coping with any relapse. Alternatively, do ask for professional help if you feel you can’t do this by yourself.
Finding professional help
There are many ways to access professional help for your difficulties. Many of the types of professionals mentioned here will offer CBT; some may offer different types of psychological therapy. It is recommended that before you start work with a professional you ensure that they are trained in those treatments that have a sound evidence base and are recognised by the National Institute of Clinical Excellence (NICE) for your condition. The NICE website at www.nice.org.uk will give you more information about this. It is always a good idea to inform yourself about the types of treatment you might find helpful. Don’t be afraid to ask for what you think you need – but do also be open to changing your mind if you are offered advice that a different approach would be best for you.
The National Health Service (NHS)
The advice under this particular heading is tailored to those within the UK who have access to the National Health Service (NHS). If this doesn’t apply to you, some of the advice is likely to still be relevant.
There is always the possibility that your anxiety, depression, or other emotional difficulties, are due to physical health problems. Your GP is the person to rule this out and then refer you on to the most appropriate mental health professional if necessary. It’s therefore normally a good idea to go to see your GP in the first instance.
Your GP is the first point of access to psychological services and will be able to assess your symptoms and advise you on services in your area. Services do vary from area to area in terms of the types of treatment provided, waiting times, and the number of sessions which can be offered.
Many GP surgeries have in-house counsellors who may work in a variety of ways, perhaps including CBT. Additionally, if you are over 18, in many areas of the UK your GP will have access to new services called IAPT services (IAPT stands for “Improving Access to Psychological Therapies”). All IAPT services will offer CBT as one choice of treatment. If you are particularly interested in CBT, you should let your doctor know this.
Some IAPT services will allow you to self-refer. You can usually find these by searching the internet for IAPT services in your area. They will often also offer appointments outside of normal working hours in order to make help more accessible for working people.
If you are under 18 your GP will be able to refer to sources of help specifically for young people and their families.
If your GP feels your difficulties are somewhat more severe the doctor may recommend that you are referred to a Community Mental Health Team (CMHT). These teams are generally made up of psychiatrists, psychiatric nurses, clinical psychologists, occupational therapists, and social workers. Any of these professionals might be involved in your care. The clinical psychologists within these teams will often be able to provide CBT.
Clinical psychologists may also work in primary care in some areas. They have a doctoral qualification, for which they’ve undertaken extensive training in the understanding and treatment of mental health problems. They primarily utilise psychological therapy, which involves one-to-one or group sessions where you work together on overcoming your difficulties. For the best results, make sure your psychologist is familiar with scientifically validated therapies. If you are specifically interested in CBT, ask about this. If you particularly want to see a clinical psychologist, then do ask your GP about this, too.
A word about medication – your GP may feel that you should try medication for your condition. They may also ask you to see a psychiatrist so as to get a more expert opinion on what medication might be helpful for you. Psychiatrists are medical doctors who specialise in illnesses of the mind, rather than the body. They have extensive training in diagnosing and treating mental disorders. Most psychiatrists primarily use medication in treating these disorders and can help you manage any side effects the medication may cause. Many people feel very worried about taking medication. However, it should be considered carefully and not automatically ruled out. Medication can be very helpful to people and can sometimes work well alongside psychological therapies. Your doctor will be able to discuss all your questions with you. There is also a wealth of information available on the internet but do be selective about what you read. The Royal College of Psychiatrists has some useful information on medication on their website at www.rcpsych.ac.uk
Private healthcare
If you have private health insurance, this may include cover for psychological therapy. You may also choose to pay for private therapy yourself. Once again, it is often best to go through your GP, but private medicine may offer a wider choice of specific therapists and of therapies, including complementary therapies. Insurance companies normally have a list of the practitioners they recognise. However, many therapists may not be on these lists but still be appropriately qualified. Various professional organisations have mandated lists of qualified practitioners.
It is strongly recommended that you find out about the qualifications of anyone you would like to see before making an appointment. Each professional organisation’s website has a “practitioner search” to help you. If someone is accredited by one of these professional bodies, it means they have gained appropriate qualifications in their particular area of expertise. Any professional should be willing to discuss their qualifications and approach if you have questions for them.
Self-help books
Bookshops and libraries display a bewildering array of self-help books. It can be very difficult to know where to start. It’s important to be aware that quite a few of these books aren’t based on scientifically validated treatments. This doesn’t necessarily mean they won’t be helpful for you as an individual, but you are probably more likely to feel confident using a book that has a strong and clear evidence base.
Helpful websites and electronic resources
Readers will be able to identify several additional sources for both self-help and professional help. If you type “depression”, “anxiety”, “self-help”, or similar terms into a search engine, you’ll uncover an endless stream of possible resources. Do be aware, though, that the internet not only has valuable, reliable resources, but also contains thousands of advertisements and gimmicks.
Be especially cautious about official-sounding organisations that heavily promote expensive materials. Don’t believe absurd promises of instant cures for any problems, psychological or otherwise.
Many web forums host chat rooms for people who have a variety of emotional problems. If you do access them for support, bear in mind that you have no idea who you are talking to when you join a web forum. Others in it may know very little about your particular difficulty, or, even worse, be trying to take advantage of a person in distress. However, if you are aware of these possible problems and exercise caution, you may find these forums supportive and helpful. Do be vigilant, and don’t get drawn into unhelpful communication which may be masquerading as support.
Good quality information is most likely to be found on websites provided by governmental, professional, and charitable organisations.
Professional organisations
In addition to providing information to the general public, professional organisations also issue and enforce the codes of practice for their profession. The codes of practice ensure that employers, colleagues, service users, carers, and members of the public, know what standards they can expect from that registered profession. They protect the public by requiring high standards of education, conduct, and practice of all members of the profession.
NHS Choices http://www.nhs.uk
This website is the UK’s biggest health website, designed to give all the information you need to make choices about your health. NHS Choices is described as the online “front door” to the NHS. It contains information about hundreds of different conditions, advice on healthy living, and support for those looking after others.
The National Institute for Clinical Excellence (NICE) www.nice.org.uk
This is a government organisation which makes information available about causes, prevalence, and treatments of disorders of both children and adults. It provides guidance, sets quality standards, and manages a national database to improve people’s health and prevent and treat ill health.
NICE makes recommendations to the NHS on new and existing medicines, treatments and procedures, and on treating and caring for people with specific diseases and conditions. In addition, NICE makes recommendations to the NHS, local authorities, and other organisations, in the public, private, voluntary, and community sectors on how to improve people’s health and prevent illness and disease.
National Institute of Mental Health www.nimh.nih.gov
NIMH reports on research concerning a wide variety of mental health issues. They provide a range of educational materials on a wide variety of difficulties, as well as resources for researchers and practitioners in the field.
The Mental Health Foundation www.mentalhealth.org.uk
The Mental Health Foundation brings together evidence-based help and information to influence UK policy and practice, and to support people with mental ill health or with learning disabilities. Their aim is to reduce the suffering caused by mental ill health and to help people lead mentally healthier lives. They help people to survive, recover from, and prevent mental health problems, by carrying out research, by developing practical solutions for better mental health services, by campaigning to reduce stigma and discrimination and by promoting better mental health for all. They work across all age ranges and all aspects of mental health to maximise everyone’s mental wellbeing.
Anxiety UK www.anxietyuk.org.uk
This is a user-led organisation, run by sufferers and ex-sufferers of anxiety disorders, supported by a high-profile medical advisory panel. They work with people suffering from anxiety disorders, providing information, support, and understanding, via an extensive range of services, including one-to-one therapy, telephone support, and groups.
The British Psychological Society www.bps.org.uk
The BPS provides information about treatment and facts about a variety of emotional disorders. It also holds a register of qualified psychologists, and information on their areas of specialisation.
The Health and Care Professions Council www.hpc-uk.org
The HCPC is the regulator for specified professions including practitioner psychologists, set up to protect the public. They hold a register of health professionals who meet the required standards for their training, professional skills, behaviour, and conduct.
OCD-UK www.ocduk.org
This organisation is run by sufferers for sufferers, and works with and for people with obsessive-compulsive disorder.
This concludes the narrative for the page ‘Cognitive Behavioural Therapy’. Amendments to the above entries may be made in the future.
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