Jan 16, 2018
What is cognitive behavioural therapy?
What's it like to have it?
How can it be useful?
Is it just 'positive thinking'? (spoiler - it's not).
Prof David Clark, Prof Sarah Corrie, Jo and Frank talk to Dr Lucy Maddox.
A mix of interviews, myth-busting and CBT jargon explained, this accessible podcast is brought to you by the British Association of Behavioural and Cognitive Psychotherapies.
Transcript
Lucy: Hello, and welcome to Let’s Talk About CBT, a new podcast exploring cognitive behavioural therapy; what it is, what it’s not, and how it can be useful.
My name is Dr Lucy Maddox, and I’m a consultant clinical psychologist. I use cognitive behavioural therapy, or CBT, a lot in my work, alongside other therapeutic approaches. I also work as senior clinical advisor for the BABCP, which stands for the British Association for Behavioural and Cognitive Psychotherapies.
I thought that a podcast might be a great way of explaining CBT to people who are curious to know more about it. I’m getting lots of experts in the field to come and help me do that. In this episode I’ll be interviewing Prof David Clark about what CBT is, I’ll be speaking to Jo and Frank, two people who have experienced what it’s like to have CBT first hand, and I’ll be busting some CBT myths with Prof Sarah Corrie. I’ll also be picking a bit of CBT jargon to explain.
First, let’s hear what David Clark has to say about what CBT is. David Clark is a professor of experimental psychology at Oxford University, and national clinical advisor to the Department of Health. I caught up with him at the annual conference of BABCP in Manchester, back in July. I started by asking him to explain just what is CBT?
David: So CBT is a psychological therapy which is designed to help people who are troubled by excessively severe or persistent negative emotions.
Emotions are part of everyday life; things happen to us which make us feel happy, make us feel sad. That’s an intrinsic feature of just being a human being. But for some of us we get into phases in our lives where we get excessively down or excessively anxious, in a way which persists. And CBT is based on a very old idea about what might be happening in that situation.
It really goes back to the Greeks. And there was a Greek philosopher, Epictetus who said we are not disturbed by the things that happen to us on their own, but rather the way we think about them. And so the central idea of CBT is that when we have excessive negative emotions, it’s partly to do with distorted patterns of thinking. We see the world as much more dangerous than it really is, we view ourselves in a much more negative way than is realistic.
So the first thing in CBT is to help people spot their excessively negative and unhelpful thoughts. But it’s called CBT because the second thing is behaviour – the first is cognitions, the second is behaviour – and that’s because once we start thinking in a negative way, that changes the way we behave, and that can often keep the problem going.
If, for example, you are someone with one of the most common anxiety problems, social anxiety, you would really like to make new friends and things. But when you go to a party and you feel a bit self-conscious, you think maybe people don’t like me, you’ll leave the room immediately; you’ll avoid. And then of course you don’t get a chance to meet other people. And so the way in which your thoughts change your behaviour keeps the whole problem going.
And so your therapist will work with you to try and identify your negative thoughts, and also the way in which it changes your behaviour. Nowadays it has got quite elaborate, so there isn’t really one thing that you would say is CBT. Really CBT is a lot of different therapies, all of which have a focus on the way you think, the way the thinking changes your behaviour. And also two other things: the way it changes what you remember – and in some conditions, like post-traumatic stress, that’s very important – and also what you pay attention to.
In life there are lots of things going on, and we can choose to attend to some things more than others. And when we’re distressed, we tend to focus on the things which fit with our negative view. What we do in CBT is try and work out, for the particular problem that you’re coming to therapy for, how does your thinking affect your attention, your memory and your behaviour. When we find unhelpful patterns, then you work with your therapist to change those patterns of thinking and behaviour.
It’s very practical. You don’t just sit and chat; quite often you’ll leave the office with your therapist and test things out.
Lucy: So more of a doing therapy, really?
David: It’s a doing and thinking therapy.
So what are the doings you could do? Well, if you get sudden attacks of anxiety, what we call panic attacks, which are quite common for some people, they might think in a panic attack, when they notice their heart racing and a tightness in their chest, they might think they’re having a heart attack. As a consequence they may tend to avoid exercise now and keep on ruminating that there’s something wrong with my heart.
In therapy, your therapist would discuss with you all of the evidence there might be to say your heart’s actually fine, it’s more just an anxiety problem. But then they would test it out in action. They might pop out of the clinic with you and do a bit of jogging in the street. And if you focus on your chest and start to feel a little bit of tightness in your chest, instead of just stopping – which is what you might normally do – they would encourage you to do more, and then discover that actually my heart is absolutely fine. So it’s testing things out in action.
Similarly, in social anxiety, people it turns out often have very negative pictures in their mind or images of how they think they look to someone. If they’re worried about blushing, they might when they feel hot in the face think they look beetroot-red and very humiliated, and everyone must have thought they looked very odd.
Your therapist actually might, with your permission, video you while you’re having a conversation with someone. And when you think I look really dreadful, they will then review with you afterwards what you looked like in reality, on the video. And people find that an incredibly helpful thing, because they discover they looked very different from the way they felt.
So these are all very practical things that you do, to test out your beliefs.
Lucy: What’s the most unusual think you’ve ever done with anyone?
David: I think the nice thing about cognitive behavioural therapy is that everyone’s beliefs are slightly different. And as a consequence, often your therapist will work with you to develop very specific tests of those beliefs.
So what would be a nice example? A while ago I was treating someone who was very worried that in a panic attack she would run out of air. She breathes very quickly, and thought if she was in a closed space then there would be no oxygen left. And we discussed this a bit. And I said, “Well, that’s really not likely to happen, because in any normal room there’s always air coming in, even with the doors and windows closed. Through the keyhole, under the doors and things. And so we could spend a year in the room and we wouldn’t run out of air.” And she said, “I don't believe you.” And that’s always a good point in therapy, if the patient says they don’t believe you. Because they’re being frank with you, they’re explaining what is unconvincing, and then you can work together to sort it out.
So I said to her, “Well, you might be right, but let’s test it out. How could we find out whether air comes into the room even with all of the doors and windows closed?” And we thought for a while, and we said, “Well, if a smell can come in then air could come in.” So we agreed I would go out of the room, we closed the doors, and then I would just let off an air freshener in the corridor. And after just about 30 seconds, the lady said, “Oh that’s a disgusting smell. Who bought that air freshener?”
And this really tested for her this belief that she had. And she realised she was never going to run out of air wherever she was.
Lucy: I was just thinking about what you said about it’s the way we think about things that matters. Some people might wonder what if things just are quite difficult in life, or for some reason they’re up against quite a lot of things that are challenging or hard. Is there a way of thinking out of that or is that just that things are difficult for them?
David: Well, the first thing to say is that cognitive behavioural therapy isn’t about the power of positive thinking. It isn’t saying just think positively and then there won’t be any problems. We often are in difficult circumstances in life, and it’s very important in therapy to accept that and acknowledge that. But then what we can do to deal with those difficult circumstances depends very much on our thinking patterns and our behaviour.
So the CBT therapist really works with you to look at what you can change, and help you do that, rather than trying to get you to ignore the realities. And we do know, in all circumstances, that there are things that we can do; that’s one of the great powers of human nature.
CBT isn’t a one-size-fits-all. You only get the best results if your therapist works with you to get you an individualised formulation of exactly how your problem pans out, and what we can do to very precisely target the traps of thinking and behaviour that you’re involved in at the moment.
Lucy: Do you think CBT ideas can be useful for everyone?
David: The evidence is that we don’t have any psychological therapy that works for everyone. So on a straightforward answer, no. For many of the conditions that CBT is used for, if you have a well-trained therapist who does a careful formulation, and you’re at a point in your life where you feel you also want to work with them to do the work. We get very high response rates, depending on the condition, between 40% and 70% of people recover, and many more people show worthwhile benefit.
But CBT isn’t the only psychological therapy around, there are other ones which have also got an evidence base. And for some people they may do better with a different approach.
Lucy: Do you think CBT ideas can be useful not just as a diagnosed problem, but do you think there are ideas that people can draw from it in their everyday lives?
David: In general in CBT we see severe emotional problems as just at the extreme end of a dimension. And that many of us find there are times when we get quite upset about something or other, and we can spot in retrospect maybe I got that out of perspective. And so a lot of the key ideas of CBT can be used on a much more daily basis, but some of us perhaps aren’t so motivated to use them unless we’re feeling really upset.
Lucy: And are there top tips you would particularly recommend, or that you yourself draw on in your life?
David: It depends a bit on the emotional reaction. So if you’re angry, then a good strategy is to actually just pause and withdraw from the situation; don’t take action immediately. Because often you find that this sort of hot emotion eases down after a while and your thinking becomes much more in perspective. So if someone sends you an irritating email, don’t fire off a response straight away. So for anger that’s really very important I think.
For fear, I think a key thing is to try not to go with the feeling of escape and avoidance, but to stay in the moment and to ask yourself, “Is it really going to happen and can I test it out?”
And for depression or when we’re sad, it’s very important to realise that we’re usually excessively hard on ourselves. When you feel depressed, it’s really quite important to think I need to be a bit kinder to myself, a bit more self-compassion.
Lucy: Would you say something about improving access to psychological therapies?
David: Yeah. So in almost all countries in the world we have a strange situation at the moment. So the prospects for people with mental health problems have vastly improved in the last 20 to 30 years. There have been really big advances in developing effective psychological therapies; CBT and some other treatments. And the public want them.
So there have been surveys where people have been asked, if you had a choice between a psychological therapy and a drug therapy, both of which work, which would you prefer? And in a ratio of about three to one, people prefer psychological therapies. But there isn’t a country anywhere in the world where the public is getting what they want. Nowhere have we got three times more provision of psychological therapies than drugs. And in most countries you get much less provision of psychological therapy.
So we have this extraordinary gap between scientific advance and public benefit. And here in England, as you know, we’ve been trying to address that with the government’s Improving Access to Psychological Therapies programme, which has now been running for almost 10 years and has changed things a lot.
So we now have what we call IAPTs, or Improving Access to Psychological Therapies services, in all 209 CCGs in England. And around about 560,000 people a year have been treated in those services. And they’ve revolutionised public transparency about mental health, because the services take objective measures of how anxious and depressed you are at the beginning and end of treatment, and they publish that data. That’s never been possible before.
So this is closing the gap between science and public benefit, but there’s a long way to go. Before the IAPT programme started, we estimated less than 5% of people with anxiety and depression would get an evidence based psychological treatment. We are now at 16%. That’s great; a threefold increase. But 16% is still very much a minority, isn’t it? This government has committed to moving up to 25% by the end of this parliament, and we need to keep them to that commitment.
It is a very big project, the IAPT project, but it’s very big because we have an enormous number of dedicated professionals who are working in these services. So we have nearly 8,000 therapists working in these new IAPT services, and they’ve achieved an extraordinary amount.
It had very ambitious targets. When it started we said 50% of people who had a course of treatment would recover, would get completely out of the clinical range for their symptoms, and many more would show worthwhile benefit. At the time that was considered an almost outrageous target; people thought no. But the ambition was there, and in the last three months the government has got to that target, which is wonderful.
It has taken a lot of hard work to get there. But people have learnt a lot from the data we are now getting, and we discover much more about how we should optimally organise a service to get really good results for people.
Lucy: Sometimes I’ve heard people wonder whether people get better but then need to come back.
David: The research evidence shows that if you follow people up after a course of psychological therapy, some people just stay very well, some people have quite a big relapse in the next year, and some people are sort of going along with somewhere in between.
The key thing is to monitor that, and to give people the necessary support they need to build on the initial gains that are made in therapy. And so for some people I think the ideal is some continuing support, and allowing them to learn extra things in the process.
Now at the moment many IAPT services are not really well organised to do that. Commissioners have been very reluctant to fund some continuing follow-up and support. And I think that needs to change; I think in the future commissioners will see that it makes much more sense to follow people up, and if there’s a bit of a setback developing, to intervene early. And then very modest intervention can ensure that someone stays well. So I think there’s work to be done to set up our services so they really focus not only on recovery, but also on what we call relapse prevention.
But the reason why psychological therapies are so interesting is that when you compare them with medication, there is pretty good evidence that they have much lower relapse rates than medication. And that’s because in a psychological therapy you learn something new about how to deal with emotional setbacks and difficulties. And that learning stays with you.
So that’s really the magic of psychological therapies; they don’t just help you recover from a bad time in your life, they give you some new knowledge, some new learning, that you can apply to the future.
Lucy: Do you think people should be taught these techniques early – in schools, for example?
David: Well, it’s certainly true at the moment that very little of the time in our national curricula is devoted to the things that are most important for people later in life. Of course it’s very important to learn to read and write, and to develop your numeracy skills and to study what you want to do for GCSEs and A Levels. But throughout our lives we’re going to have emotional challenges, and it does seem very strange that very little of our education system is devoted to preparing us for that.
We certainly hope that in the future there will be two things that would happen in schools. One is much more education about what we understand about emotions and how to manage them; what’s normal about them, when they get out of hand and what you can do about it. Secondly, I think we need much more opportunities for young people to have psychological therapy that’s evidence based, early in life when they’re developing their problems, rather than having to wait until they’re adults. Because there are some things that getting depressed or anxious as a child can do, that you never really recover from in life.
If you take one of the problems we deal with, social anxiety. If you’re very socially anxious as an adolescent, you will feel very self-conscious in the classroom. You won’t hear much of what the teacher says, you’d be lost in your head. However high your IQ is, if you don’t get to hear much of what the teacher says, you won’t do so well in your exams. It’s actually very difficult to recover from that later in your life.
We need an initiative which makes the best treatments available to people in schools and in local settings, where they can easily access them, and involving parents and teachers as well. And I hope that that’s a direction that our next few governments will take. Because there’s nothing more important to a nation than looking after the next generation.
Lucy: Is there anything that you would recommend that people read if they’re interested in this podcast?
David: Something that I would strongly recommend is a Penguin book, that Richard Layard and I wrote recently, called Thrive: The Power of Psychological Therapies. That has quite a lot in it about the ideas behind CBT. It talks about how different treatments are developed. But it also puts out the very strong economic and clinical arguments for why we as members of the public should have much increased access to psychological therapies in the NHS; why the whole of society benefits from that.
So for those people who are interested in learning a bit about how therapies help your own emotional responses, but are also interested from a more political angle, about how can we help improve the mental health of the nation and allow us all to achieve our potential in the way that we’d like to.
Lucy: And actually some of the political context has been quite controversial hasn’t it? About the idea of therapists perhaps being provided in job centres for example. And concerns around whether that is coercive in some way; feeling like they have to have a therapy in order to get their benefits. Do you have anything you’d like to say on that?
David: Yeah, I mean it’s very clear; psychological therapies only work if you want to do the therapy. We should never be in a situation where people are being coerced into having therapy. It’s just a silly direction to go in, because the therapy isn’t going to work. Psychological therapies involve establishing a good, collaborative relationship with your therapist, and you working together.
So no one should feel forced into having a psychological therapy. They’re there to free people from difficult emotional problems when they want to do that work, but not otherwise.
Lucy: A big thanks to David Clark for being interviewed.
Next up let’s hear from some people who have experienced CBT for themselves. I went to meet with Jo and Frank at the Centre for Anxiety, Disorders and Trauma, or CADAT, which is part of South London and Maudsley NHS Foundation Trust in Camberwell, London. First up is Jo.
Could you just say a little bit about what CBT is like?
Jo: I think the main thing about CBT, in my experience, is that CBT isn’t really talking therapy, CBT is doing therapy. Unlike the idea that people have about therapy as the couch and the man in the white coat and all of that, what CBT does is go, “Okay, well we have this problem, we can’t change what has happened, but what do we do about it moving forward?” And I think that can apply to CBT, whether you’re having it for a depressive disorder, for an anxiety disorder, or for something else.
CBT is time limited. Most people get 12 sessions as an average. Here at CADAT we get up to 20, which is great. But it should be time limited, because what CBT does is it teaches you how to deal with the issues that you are having on your own, without the need to constantly keep going back to a therapist. My therapist is wonderful, and humorous and warm, but it’s quite scientific; so we have an agenda, we catch up from last time, we’ll go through the homework that I was set, and what I managed to do. And then we’ll talk a bit more about what I’m going to do next week.
Another point that I wanted to make was that with OCD specifically it rarely sleeps alone. I had severe depression as well. So it wasn’t, with Fiona, just dealing with my specific OCD fears but about ways of being kinder to myself and enjoying leisure time, and finding things that I wanted to do for fun.
A really good CBT relationship would begin with a genuine understanding of the actual problem. The specific OCD worries which I had, which centred around harm, it was a case of something called exposure therapy, where you put yourself in those positions where you feel uncomfortable. Let’s say for example that my problem was I thought I would stab my boyfriend every time I was holding a knife – that’s not what my problem is, but let’s use that as an example.
So I’d have to just pick up a knife and not get freaked out at first, and then just get comfortable holding the knife. The next step would be that he might come into the kitchen whilst I was chopping vegetables with the knife. The next step might be that we would eat dinner together with the knife right in front of us. And so on and so forth, until you get to the point where you could hold a knife to his stomach and just know that you’re not going to, you know…
So that’s one prong of the approach. But the other one was very much about my lifestyle and things I had to change basically about the way I thought about myself really.
Lucy: What were the bits that you found particularly useful about CBT as an approach?
Jo: I like the way that you’re not asking someone else to get you better; it’s you getting you better, really, with the guidance from an expert professional. So it teaches you to be self-reliant. And I’ve found I’ve been so much more self-reliant recently, since having my treatment and being on the right medication as well, but that that’s a different aspect of it.
A good therapist will always have a variety of different approaches. So another thing that I did was to keep a positive data log every night of things that I’d done that day, things that I’d achieved, or if someone had said something nice to me, or I’d got a nice text message – all of the positive things that had happened. Because when you’re depressed you tend to think about the negatives. So loads of things. And Fiona’s always got ideas.
Lucy: Are there things that you wish were a bit different about it, or that you would critique a bit about the approach?
Jo: There’s nothing I would critique about the approach. What I would critique is the postcode lottery – which I have quite clearly won. I would criticise the lack of availability, particularly in peripheral areas, like Pembrokeshire, where my parents live. We all know CBT works, but it’s people being able to access it which is the issue. I might get a bit political here.
Lucy: That’s fine.
Jo: I think it’s very much worth stating as well that if you cannot access any NHS CBT, and you’re looking to go private, that you must always check that your therapist is accredited by the BABCP. I’m not just saying that because of who’s conducting this podcast. But I do have experience of a private therapist who wasn’t accredited, and I hadn’t checked, and lo and behold it hadn’t worked out so well.
Lucy: Is there anything else that you would like to add that you think people should know?
Jo: The sooner you get on any waiting list the better. Don’t delay. Try not to take no for an answer. Don’t forget that OCD UK and OCD Action provide an advocacy service for people who have been denied treatment. That’s specifically for OCD obviously, but Mind and charities like that, do have an advocacy service, if you’ve been denied the treatment that you need. And that’s not just for CBT, that’s for anything.
There’s a BABCP website where you can search for accredited therapists in your area. I think a big tragedy is that sometimes people get the NHS therapy, and they get maybe online CBT or they get maybe a CBT therapist that doesn’t really know much about their specific condition. And again, I’m thinking specifically about OCD here, and that isn’t necessarily particularly helpful.
Lucy: Massive thanks to Jo for sharing her experiences. Next up is Frank.
What was CBT like for you?
Frank: I mean it was massively helpful. It starts with talking; you just give the therapist more of an idea of the particulars of what’s troubling you. Then my impression is that they go away and form for themselves a kind of strategy, a treatment plan. That’s followed up by a kind of schematic diagram of the way you think and act, so that you can see the thoughts you have, the things you do in response to them, and the effect of those things.
So you see it as a kind of circuit. It makes it clear that the things you might be doing, what you think is helping yourself, in fact is just making things worse. And gradually, as it goes on, there are elements of exposure introduced where you are encouraged to face some of your worries – some of your ritual behaviours in my case – head on.
Once you start doing it, you’re very much helped to see the anxiety as something that will pass. It does reduce as well; the first time that you try something it feels like a huge barrier, the next time the barrier doesn’t seem so tall. As you take things on, it makes you feel stronger and more in control of your life.
Lucy: What did you find particularly useful about sessions of CBT?
Frank: There was a notion of theory A and theory B thinking, which is you look at your way of thinking. With OCD, which is theory A thinking, it will be things like if I do this something dreadful is going to happen. Theory B is more evidence based, the truth of the matter, which is that bad things happen whatever you do; there’s no magic force that you can summon up to stop bad things happening to you. So that was really important.
I think most people who do have OCD know that the condition, it wants to survive. That makes it sound a bit like the alien living in your chest or something. And it is part of you, it’s not a third party, but it feels like it is tweaking your good intentions to carry on being in control.
I think the notion of not just non-OCD behaviour, which would be not doing your compulsive rituals, not trying to repair things, but also going out and actively almost being provocative really, almost challenging the thought process. So you would go out and actually do the things that scare you, quite deliberately. And that’s an important step I think because just avoiding them or ignoring them, it really isn’t enough.
Lucy: Is there anything you would have wanted to be a bit different?
Frank: With this particular course, no. I’ve had CBT before that hasn’t been so precisely aimed, I think, and it perhaps hasn’t been by people who have a specific training in the OCD state of mind. And I think in the end no therapist can understand every condition. I think it does help if you go to a place that specialises.
And I also think it would be brilliant if younger people could have access to it. Because I mean I’ve been living with OCD for 40 years, and I feel I’ve made real, great progress in the last year with the CBT I’ve had here. But it would have been just fantastic if I could have had this treatment when I was 17 and this thing was just coming on, and I didn’t know what it was, and I didn’t know how to deal with it.
I wouldn’t actually change the experience I had here, because it was great. But I would change it countrywide, if possible, to give more people access to a more precisely guided form of CBT.
Lucy: So really important for it to be specific to your thoughts and feelings and behaviours?
Frank: I think it works better that way, yeah.
Lucy: And is there anything you would want to add?
Frank: For people who are thinking about it, who might be feeling it sounds really scary to address whatever condition you have, it isn’t as difficult as you might think it’s going to be. You will be helped, you will be encouraged, you’ll be comforted sometimes, if that’s what you need. Do it, I would say. You can’t lose.
Lucy: Again, huge thanks to Frank for sharing his thoughts on CBT.
Right, now it’s time for a bit of myth busting. I met with Prof Sarah Corrie, programme director of the postgraduate diploma and MSc in CBT, and consultant clinical psychologist at Central and North West London Foundation Trust, in her clinic in London, and we went through some CBT myths.
So I’ve got a few myths here. I wondered if we could think about them one by one.
Sarah: Let’s go for it.
Lucy: The first one is: CBT is just positive thinking.
Sarah: I think if we stop and think about it for a moment, it’s easy to see that positive thinking if taken to its extreme is just as problematic as negative thinking.
So the example that sometimes gets talked about, and which I use quite a lot, is it’s a bit like getting into your car on a cold, snowy morning. And you have a drive to do, maybe a drive to get to work, and you’re thinking it’s going to be a great day, I won’t bother with my seatbelt today because I know I’m going to be fine. Actually that would probably be something that puts the person at risk, if they’re going to do that.
And there are a lot of really good decisions that we make in life I think, that are based on healthy negative thinking; so taking out life insurance, insuring your house or your car. The idea of negative thinking being problematic is a myth, as indeed, if we take it to the other extreme as well, positive thinking becomes really problematic.
So the question then is what is it that we’re really trying to do. And the way that I try and think of my role as a therapist, is to help people really maximise their choices. And there are certain ways of thinking and certain types of thought that we tend to fall foul of, that can really limit our choices and exacerbate our distress.
Lucy: Because it can be quite irritating, can’t it, to be thinking you have to think in a certain way, whether that’s positive or negative. A bit like someone telling you to relax; whenever anyone tells me to relax it makes me really tense.
Sarah: Exactly.
Lucy: That kind of opposite. Second myth: CBT relies on techniques but forgets the person.
Sarah: Techniques are there to be used, but they’re there to be used in a creative way, in line with the formulation that we have of the client who is sitting in front of us.
If we are in a position where we are so focused on techniques, as therapists, that we’re forgetting our formulation, we’re forgetting the person, we’re not actually engaging with them in thinking around what role these methods have, then I think we’re doing bad therapy. And I think that’s something that we really need to watch against.
Lucy: Myth number three: CBT does not deal with feelings.
Sarah: In therapy people come to see us because they’re experiencing distress. So it’s really hard to imagine how we somehow give the message that we’re not at all interested in how people feel; it’s the heart of what we’re doing. And what we’re trying to do is to think with them about what is the most effective, most time efficient, most enduring way of helping people change how they’re feeling.
And obviously within cognitive behavioural therapy, what’s really key to our thinking always is the interaction, the interrelationship, between how we feel, what’s going on inside our bodies, how we think, how we process information and how we behave. So there may be a number of instances where, when we’re working with someone, we might make an informed decision as therapists, that to encourage them to dwell more and more on how they’re feeling may actually be disadvantageous to them.
Lucy: Myth number four: CBT does not address the real causes of distress.
Sarah: So almost as though it’s like sticking an elastoplast over a bullet wound?
Lucy: Yes, and that’s exactly the metaphor that’s sometimes used, isn’t it? That it’s a sticking plaster, and that it might not be that helpful longer term.
Sarah: Yes. What I think is really important is the idea that the set of factors that get a problem going in the first place, may or may not be the same set of factors that maintains it in the here and now.
Again, I’m just thinking of a metaphor here that sometimes gets talked about, which is the idea that if you’re in a position where you have an accident at home. Say you fall down the stairs and your arm is in agony and you can’t move it; you suspect you’ve broken your arm. The first thing that you need to do is to attend to the broken arm – the arm that you can’t feel or move; there’s something in the here and now that needs looking at. You probably wouldn’t sit there thinking, “I really need to figure out why I fell down the stairs; what was it at that particular point in time?”
These are really important questions, and you need to attend to those, but probably the first and most important thing is to get yourself to hospital. Then later on you can come back and look at your house; was there a nail sticking up or has the carpet come loose, or did something else happen?
So this idea of differentiating what causes something from what keeps it going in the here and now is something that we tend to talk with clients quite a lot about, I think. Of course that doesn’t mean we’re not attentive to the past, and that’s where the myth bit comes in I think.
People don’t come to us as blank slates, they come to us with personal histories, with stories, with narratives about who they are, about their lives, about other people, about life and how the world works, and we have to take account of those. The question for us is where are we going to pitch our intervention, and that’s going to vary from person to person.
Lucy: And I guess that goes a bit into the next myth which I’ve got, which is: CBT isn’t interested in people’s pasts. Which I think you’ve addressed really clearly actually.
Sarah: Yeah, that’s just not true. (Laughter)
Lucy: Yeah. So myth number six: CBT is a single psychotherapy.
Sarah: What I would say about cognitive behavioural therapy is that it’s a family of therapies, fundamentally. And those therapies would probably coalesce around certain assumptions. So one assumption might be the importance of investigating our hypotheses through the scientific method.
Another principle around which this family of therapies might coalesce would be around the causal importance of cognition. Now different therapists would have different ideas around in what ways it might be causal, how it exerts and influence, and how we should think about and work with cognition. But there would be an assumption that that’s a pretty critical idea.
But beyond that I think it’s really important to recognise that there are some really significant conceptual differences. Human beings are complex, their stories are rich and complex, and there isn’t any single solution, as far as I’m aware.
Lucy: So the next myth I’ve got is myth number seven, that CBT is simple.
Sarah: Yeah, I wish it were. (Laughter) I have some sympathy for how this misunderstanding might come about. It’s actually based on a very simple principle.
Lucy: Quite common sense, actually.
Sarah: Exactly. And I think that’s both a strength and a little bit of a pitfall when it comes to engaging stakeholders. Because there is a degree of common sense about it, it is then very easy to start thinking along the lines of, “So, if I just eliminate my negative thinking and think more positively, everything’s going to be fine.” Or, “This will be fairly straightforward,” or, “Just a bit of CBT will sort this person’s problems out.”
Lucy: Or, “I’ve been to a one day workshop, I can do CBT.”
Sarah: Exactly, exactly. And I think again that’s a real challenge, to not confuse what’s a really clear, beautifully simple idea, and how that translates into the delivery of particular interventions.
And when you come together to do some therapeutic work together, there are hopefully two forms of expertise coming together. So there’s what you have to offer as a therapist, but at the same time the only expert in the room on the client’s experiences, is the client.
And I think the danger within that myth – well, I think there are several dangers, including the idea that it’s possible to do a one day workshop and suddenly you’re qualified to do CBT. But also for clients as well, that there’s an expectation that it takes just a couple of meetings with someone, and that’s all they really need, and everything is going to be resolved. That can be problematic in terms of just the nature of change, and the nature of effort that might be required.
Lucy: Myth number eight: CBT works for everything.
Sarah: Again, of course we just know that that’s not true. Of course it doesn’t. To the best of my knowledge, I don’t think there’s any single intervention in any field that seems to be 100% effective, for 100% of people, all of the time. The field has progressed so significantly I think, partly because of people being willing to ask difficult questions about why isn’t this person recovering, or why do people with this particular kind of difficulty not seem to respond to our existing interventions in the way that others do?
I think it’s that ability and willingness to ask difficult questions, to gather data in a careful, thoughtful, and systematic way, that enables us to extend CBT into new and emerging areas. So I think that’s a real strength of the discipline, and I would hate for us ever to lose that.
And therefore we can say, with some degree of confidence I believe, that we are discovering that cognitive behavioural principles and methods can be adapted to an increasingly diverse range of client groups. I think that’s wonderful, and I think that would be perfectly accurate. But that’s very, very different from saying that CBT works for everything.
Lucy: Thanks to Sarah Corrie.
In this next section of the podcast, I’ll be taking a bit of CBT jargon and breaking it down. Today’s jargon is a hot cross bun.
The hot cross bun is a way of drawing out the links between our thoughts, feelings, behaviours, and our bodily sensations. These four things are all linked to each other in a way that tenuously looks like a hot cross bun, and the cross is surrounded by a circle that represents the situation.
So to take a classic example, say I am in the situation of watching a film at home alone at night, and I hear a massive crash outside the window. I have the thought that that’s a burglar, and I leap off the sofa to look out of the window; my heart is pounding and I feel scared.
The same situation, on the sofa, a massive crash; I have the thought, “Oh, that’s next door’s cat again.” My heart rate slows down again, I feel mildly annoyed but slightly amused too. I stay sitting down and carry on watching the film. The thing that happened was the same but my thought about it was different, which affected how my body responded and what I felt and chose to do.
A key idea in CBT is that changing any one of these four things – thoughts, feelings, behaviours, how my body feels – can change the others. So changing my behaviour can change how I feel. Challenging my thoughts can change how I physically react; changing my physical state might also change how I feel, and so on. Trying to draw out these hot cross buns can be helpful, particularly in helping us to spot the patterns of behaviour or thinking which have become less useful for us. So there we go, a hot cross bun.
Right, that’s it from me. I really hope you’ve enjoyed this podcast. Please do let me know how you found it, whether you’d like to know more on CBT topics, and whether you have a specific aspect of CBT that you’re curious about. You can contact me on Twitter, or at lucy.maddox@BABCP.com. And as Jo mentioned earlier, if you’re looking for a CBT therapist and want to check that they are BABCP accredited, you can do this on BABCP.com. That’s all for now. Thanks for listening.
You’ve been listening to Let’s Talk About CBT, with me, Dr Lucy Maddox. Thanks to all of the interviewees, to Gabe Stubbing for the music, and to Tim Ruffle for editorial assistance. Let’s Talk About CBT has been brought to you by BABCP.
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