Let's Talk About CBT

We’re back! Let’s Talk about CBT has been on hiatus for a little while but now it is back with a brand-new host Helen Macdonald, the Senior Clinical Advisor for the BABCP. Each episode Helen will be talking to experts in the different fields of CBT and also to those who have experienced CBT, what it was like for them and how it helped. This episode Helen is talking to one of the BABCP’s Experts by Experience, Paul Edwards. Paul experienced PTSD after working for many years in the police. He talks to Helen about the first time he went for CBT and what you can expect when you first see a CBT therapist. The conversation covers various topics, including anxiety, depression, phobias, living with a long-term health condition, and the role of measures and outcomes in therapy. In this conversation, Helen MacDonald and Paul discuss the importance of seeking help for mental health struggles and the role of CBT in managing anxiety and other conditions. They also talk about the importance of finding an accredited and registered therapy and how you can find one. If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on X or email us at podcasts@babcp.com. Useful links: For more on CBT the BABCP website is www.babcp.com Accredited therapists can be found at www.cbtregisteruk.com Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF   Transcript: Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the senior clinical advisor for the British Association for Behavioural and Cognitive Psychotherapies. I'm really delighted today to be joined by Paul Edwards, who is going to talk to us about his experience of CBT. And Paul, I would like to start by asking you to introduce yourself and tell us a bit about you. Paul: Helen, thank you. I guess the first thing it probably is important to tell the listeners is how we met and why I'm talking to you now. So, we originally met about four years ago when you were at the other side of a desk at a university doing an assessment on accreditation of a CBT course, and I was sitting there as somebody who uses his own lived experience, to talk to the students, about what it's like from this side of the fence or this side of the desk or this side of the couch, I suppose, And then from that I was asked if I'd like to apply for a role that was being advertised by the BABCP, as advising as a lived experience person. And I guess my background is, is a little bit that I actually was diagnosed with PTSD back in 2009 now, as a result of work that I undertook as a police officer and unfortunately, still suffered until 2016 when I had to retire and had to reach out. to another, another psychologist because I'd already had dealings with psychologists, but, they were no longer available to me. And I actually found what was called at the time, the IAPT service, which was the Improving Access to Psychological Therapies. And after about 18 months treatment, I said, can I give something back and can I volunteer? And my life just changed. So, we met. Yeah, four years ago, probably now. Helen: thank you so much, Paul. And we're really grateful to you for sharing those experiences. And you said about having PTSD, Post Traumatic Stress Disorder, and how it ultimately led to you having to retire. And then you found someone who could help. Would you like to just tell us a bit about what someone might not know about being on the receiving end of CBT? Paul: I feel that actual CBT is like a physiotherapy for the brain. And it's about if you go to the doctors and they diagnose you with a calf strain, they'll send you to the physio and they'll give you a series of exercises to do in between your sessions with your physio to hopefully make your calf better. And CBT is very much, for me, like that, in as much that you have your sessions with your therapist, but it's your hard work in between those sessions to utilize the tools and exercises that you've been given, to make you better. And then when you go back to your next session, you discuss that and you see, over time that you're honing those tools to actually sometimes realising that you're not using those tools at all, but you are, you're using them on a daily basis, but they become so ingrained in changing the way you think positively and also taking out the negativity about how you can improve. And, and yeah, it works sometimes, and it doesn't work sometimes and it's bloody hard work and it is shattering, but it works for me. Helen: Thank you, Paul. And I think it's really important when you say it's hard work, the way you described it there sounds like the therapist was like the coach telling you how to or working with you to. look at how you were thinking and what you were doing and agreeing things that you could change and practice that were going to lead to a better quality of life. At the same time though, you're thinking about things that are really difficult. Paul: Yeah. Helen: And when you say it was shattering and it was really difficult, was it worth it? Paul: Oh God. Yeah, absolutely. I remember way back in about 2018, it would be, that there was, there was a fantastic person who helped me when I was coming up for retirement. And we talked about what I was going to do when I, when I left the police and I was, you know, I said, you know, well, I don't know, but maybe I've always fancied being a TV extra and, That was it. And I saw her about 18 months later, and she said, God, Paul, you look so much better. You're not grey anymore. You know, what have you done about this? And it was like, she said I was a different person. Do I still struggle? Yes. Have I got a different outlook on life? Yes. Do I still have to take care of myself? Yes. But, I've got a great life now. I'm living the dream is my, is my phrase. It is such a better place to be where I am now. Helen: I'm really pleased to hear that, Paul. So, the hard work that you put into changing things for the better has really paid off and that doesn't mean that everything's perfect or that you're just doing positive thinking in the face of difficulty, you've got a different approach to handling those difficulties and you've got a better quality of life. Paul: Yeah, absolutely. And don't get me wrong, I had some great psychologists before 2016, but I concentrated on other things and we dealt with other traumas and dealt with it in other ways and using other, other ways of working. I became subjected to probably re traumatising myself because of the horrendous things I'd seen and heard. So, it was about just changing my thought processes and, and my psychologist said, Well, you know, we don't want to re traumatise you, let's look at something different. Let's look at a different part and see if we can change that. And, and that was, very difficult, but it meant that I had to look into myself again and be honest with myself and start thinking about my honesty and what I was going to tell my psychologist because I wanted to protect that psychologist because I didn't want them to hear and talk about the things that I'd had to witness because I didn't think it was fair, but I then understood that I needed to and that my psychologist would be taken care of. Which was, which was lovely. So, I became able to be honest with myself, which therefore I can be honest with my therapist. Helen: Thank you, Paul. And what I'm hearing there is that one of your instincts, if you like, in that situation was to protect the therapist from hearing difficult stuff. And actually the therapist themselves have their own opportunity to talk about what's difficult for them. So, the person who's coming for therapy can speak freely, although I'm saying that it's quite difficult to do. And certainly Post Traumatic Stress Disorder isn't the only thing that people go for CBT about, there are a number of different anxiety difficulties, depression, and also a wider range of things, including how to live well with a long term health condition and your experience could perhaps really help in terms of somebody going for their first session, not knowing what to expect. As a CBT therapist, I have never had somebody lie down on a couch. So, tell us a little bit about what you think people should know if they are thinking of going for CBT or if they think that somebody they care about might benefit from CBT. What's it like going for that first appointment? Paul: Bloody difficult. It's very difficult because by the very nature of the illnesses that we have that we want to go and speak to a psychologist, often we're either losing confidence or we're, we're anxious about going. So I have a phrase now and it's called smiley eyes and it, and it was developed because the very first time that I walked up to the, the place that I had my CBT in 2016, the receptionist opened the door and had these most amazing engaging smiley eyes and it, it drew me in. And I thought, wow. And then when I walked through the door and saw the psychologist again, it was like having a chat. It was, I feel that for me, I know now, I know now. And I've spoken to a number of psychologists who say it's not just having a chat. It is to me. And that is the gift of a very good psychologist, that they are giving you all these wonderful things. But it's got to be a collaboration. It's got to be like having a chat. We don't want to be lectured, often. I didn't want to have homework because I hated homework at school. So, it was a matter of going in and, and talking with my psychologist about how it worked for me as an individual, and that was the one thing that with the three psychologists that I saw, they all treated me as an individua

The British Association for Behavioural and Cognitive Psychotherapies, the lead organisation for cognitive behavioural therapy (CBT) in the UK and Ireland, is 50 years old this year. In this episode Dr Lucy Maddox explores how CBT has changed over the last 50 years. Lucy speaks to founding members Isaac Marks, Howard Lomas and Ivy Blackburn, previous President David Clark, outgoing President Andrew Beck and incoming President Saiqa Naz about changes through the years and possible future directions for CBT. Podcast episode produced by Dr Lucy Maddox for BABCP   Transcript  Dr Lucy Maddox:        Hello, my name is Dr Lucy Maddox and this is Let’s Talk about CBT, the podcast brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP. This episode is a bit unusual, it’s the 50th anniversary of the British Association for Behavioural and Cognitive Psychotherapies this year. And I thought this would be a nice opportunity to explore some of the history of cognitive behavioural therapy, especially the last 50 years.                                     Some of the roots of CBT can actually be traced way back. Epictetus, an ancient Greek Stoic philosopher wrote that man is disturbed not by things, but by the views he takes of them. This is pretty close to one of the main ideas of cognitive behavioural therapy, that it’s the meaning that we give to events, rather than the events themselves which is important. But actually, cognitive behavioural therapy started off without the C. To find out more, I made a few phone calls. Isaac Marks:               Hello, Isaac Marks here. Dr Lucy Maddox:        Isaac Marks was one of the founding members of BABCP and a key figure in the development of behavioural therapy in Britain. I asked him if he could remember what CBT was like 50 years ago. Isaac Marks:               Originally it was just BT and a few years later the cognitive was added. At the time, the main psychotherapy was dynamic psychotherapy, sort of Freudian and Jungian. But just a handful of us in Groote Schuur Hospital psychiatric department, that’s in Cape Town, developed an interest in brief psychotherapy. And I was advised if I was really interested in it and I was thinking of taking it up as a sub profession, that I should come to the Maudsley in London. Dr Lucy Maddox:        Isaac and his wife moved to London from South Africa and Isaac studied psychiatry at the Maudsley Hospital in Camberwell. What was it about CBT that had interested you so much? Isaac Marks:               Because it was a brief psychotherapy, much briefer than the analytic psychodynamic psychotherapy. We were short of therapists and there wasn’t that much money to pay for extended therapy, just a few sessions. Six or eight sessions something like that could achieve all what one needed to. They had quite a lot of article studies. Dr Lucy Maddox:        And I guess that’s still true today, that those are some of the real standout features of it, aren’t they? That it is a briefer intervention than some other longer-term therapies and that it’s got a really high quality evidence base. Isaac Marks:               I think that’s probably true, yes. Howard Lomas:          There was a group that met at the Middlesex Hospital every month. And that was set up by the likes of Vic Meyer, Isaac Marks, Derek Jayhugh. Dr Lucy Maddox:        That’s Howard Lomas, another founding member of BABCP remembering how the organisation got set up 50 years ago from lots of different interest groups coming together. Howard Lomas:          These various groups that got together and said, “Why don’t we have a national organisation?” So that was formed back in 1972. Dr Lucy Maddox:        Howard’s professional background was different to Isaac’s psychiatry training, but he found behaviour therapy just as useful. Howard Lomas:          I’d originally trained well in social work, but I was a childcare officer with Lancashire County Council. Dr Lucy Maddox:        And how were you using CBT or behaviour therapy in your practice? Howard Lomas:          Well, as a general approach to everything, thinking of everything in terms of learning theory. How do we learn to do what we do and maintain it with children? Things like non-attendance at school and other problems, behavioural problems with children and then later problems with adults. But I suppose when I moved to Bury in 1973, I was very much involved in resettlement of people with learning disability from the huge hospitals that we had up here in the north. We’d three hospitals within sight of each other, each with more than 2,000 patients. Dr Lucy Maddox:        Wow. Howard Lomas:          They’re all closed now long since, but yeah, the start of that whole closure programme of trying to get people out into the community. You learn normal behaviour by being in a normal environment, which people in institutions clearly aren’t and weren’t. So it’s trying to create that ordinary valued environment for people. And simply doing that would teach them ordinary behaviours, valued behaviours. It was evidence-based, it was also very effective.                                     It looked at behaviour for what it was rather than what might be inferred. I suppose I saw psychology as more of a science (laughs). I’m still in touch with some of the people that are resettled from way back. People who had been completely written off as there’s no way they could ever live in their own home are now thriving, absolutely. Dr Lucy Maddox:        Now, Howard’s and Isaac’s memories of CBT 50 years ago highlight that an important route of CBT is behavioural learning theory. This includes ideas of classical conditioning, where in a famous experiment which you’ve probably heard of, Pavlov, taught his dogs to salivate in response to the bell that he rang for their dinner rather than the dinner itself. And operant conditioning, where animals and humans learn to do more or less of a behaviour based on the consequences which happen in response to that behaviour. Howard Lomas:          Half a dozen of us sitting with Skinner, chatting for three hours. So that was quite influential (laughs). Dr Lucy Maddox:        Skinner was another of the early behaviourists, and Howard has memories of being lectured by Skinner at Keele University. The formation of BABCP was important for therapists at the time because behavioural therapy back then was quite a niche field. Howard Lomas:          It was publicly very unpopular indeed. Behaviour therapy was known very much as behaviour modification, which has got an involuntary feel about it, even the name that it was being thrust upon people. And even at that time, aversion therapy was being used for trying to change homosexuality in people, aversion therapy then. Which is quite topical now with the whole debate on conversion therapy. Dr Lucy Maddox:        Absolutely. We’ve signed up to the memorandum of understanding against conversion therapy. Howard Lomas:          The aversive is horrible. And there was a big scandal at I think it was Napsbury Hospital about their clinical programme, which was allegedly based on behaviour modification, more aversive techniques. So there was a big scandal and that led to a major government inquiry, and they asked for anyone to offer, submit evidence on the whole question of behaviour modification, which BABP did. And that then formed the basis of our guidelines for good practice. Dr Lucy Maddox:        Just a note, if you’re listening to this as a cognitive behavioural therapist, please do read the memorandum of understanding against conversion therapy online at www.babcp.com.  It makes it clear why we’re opposed to conversion therapy in any form. I’ll put the link in the show notes, too. Like Isaac, Howard remembered that shift from behaviour therapy to cognitive behavioural therapy. Howard Lomas:          Well, I was always against adding the C. I was always taught that behaviour has three components to it: motor behaviour, cognitive behaviour, and affective behaviour. So behaviour included cognitive, so why did you have to have it as a separate thing? Although in those early days I used to get told off if I spoke about thoughts and feelings. Dr Lucy Maddox:        Did you? Howard Lomas:          Yeah, because you can’t see them. You can’t measure them. Dr Lucy Maddox:        Yeah, interesting, although there’s still a lot of measurement, isn’t there? But maybe it’s like you say what we think we can measure has maybe changed. Howard Lomas:          That’s right, yeah. Yeah, I think the measurement and the evidence is so important. Ivy Blackburn:             We actually changed the name when we started it was called the British Association for Behaviour Psychotherapy. So at one of the conferences we passed a motion and added the C. Dr Lucy Maddox:        That’s Ivy Blackburn, another founding member of BABCP. Ivy Blackburn:             At that point well, I was a qualified clinical psychologist. I’d just finished my PhD, I trained in Edinburgh. And I was working in a research set up, an MRC unit called the Brain Metabolism Unit. Dr Lucy Maddox:        And so, CBT at that time was quite a new thing? Ivy Blackburn:             Very, very new. I actually had just discovered Beck as it was, while I was going the research for my PhD, which was in depression. And I used to correspond with him and he used to send me his early papers and things like that. Dr Lucy Maddox:        Ivy’s talking there about Aaron Beck, also sometimes known as Tim Beck. Also sometimes called the father of CBT. Ivy Blackburn:             With Aaron Beck I always signed I M Blackburn. And the story he used to tell at conferences was he always thought I M Blackburn was an old Scottish man. (Laughs) So once he came to Edinburgh, he was on a sabbatical, and we were sitting at I think it was a case conference. He was sitting next to my boss, who was somebody called Dr Ashcroft, a

In this bonus episode of Let's Talk About CBT, hear Dr Lucy Maddox interview Dr Tom Ward and Angie about SlowMo: digitally supported face-to-face CBT for paranoia combined with a mobile app for use in daily life. Podcast episode produced by Dr Lucy Maddox for BABCP   Transcript Dr Lucy Maddox:        Hello and welcome to Let’s Talk about CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not, and how it can be useful. In this episode, I’ll be finding out about an exciting new blended therapy, SlowMo, for people who are experiencing paranoia. This digitally supported therapy has been developed over 10 years with a team of people including designers from the Royal College of Art in London, a team of people who have experienced paranoia. And a team of clinical researchers, including Professor Philippa Garety, Dr Amy Hardy and Dr Tom Ward. The design of this intervention really prioritised the experience of people using the therapy in what’s called a design led approach. To understand more I video called Tom Ward, research clinical psychologist based in Kings College London, and I had a phone call with Angie, who’s experienced using the therapy. Here’s Angie’s story. Angie:                          I mean, I’ve had psychosis for many years. About 20 years ago I was really poorly, I was in and out of hospital. Going back about 20 years ago they kept giving me different diagnoses and I expect everybody else had the same thing. Anyway, then I met a psychiatrist and I was with him for over 20 years until he retired. And he really helped me a lot, I was actually diagnosed with schizophrenia. Part of me was really scared and another part of me was sort of relieved that I knew that I was dealing with. I get voices, sometimes I see or feel things that aren’t really there. But part of my diagnosis is I also get very depressed. And when I get very depressed, that’s when the voices are at their worst because I haven’t got the strength to sort of fight them off, if you like. If I’m having a good day, then I can use the skills I’ve learnt in the past to not listen to the voices and to have a reasonably good day. If I’m having a bad day and it’s a duvet day, then that’s when I really suffer with the voices. Unless you can actually accept that you have this issue, and you actually accept that you need the help, it doesn’t matter what they do to help you, you’re just not going to take it on board. Dr Lucy Maddox:        Angie wanted some help, specifically with paranoid thoughts she was experiencing about people looking at her or laughing at her. She found out about the SlowMo trial and applied to be a part of it. And ended up being one of the very first people to try the therapy. Tom led on the delivery of therapy in the trial. Dr Tom Ward:              I’ve worked and have worked for the last couple of years trying to develop and test digital interventions for people experiencing psychosis. So I’ve been involved in developing interventions that help people who are experiencing distressing voices. And been involved in work in a therapy called avatar therapy and more recently I’ve been working with colleagues to develop an intervention designed to help people who are experiencing fear of harm from others, which we would sometimes refer to as paranoia. Dr Lucy Maddox:        In case listeners wonder what avatar therapy is could you just briefly say what that is? Dr Tom Ward:              So in avatar therapy, digital technology is used with the person to create a representation of the distressing voice that they hear. So we work with the person to create an avatar which has an image which matches the image the person has of their distressing voice. And which comes to sound like the voice that they hear. And we use this avatar direct in dialogue. Very much with the rationale that many people who are experiencing distressing voices have relationships with their voice where they feel disempowered and lacking power and control. And we try to use the work with avatars and the dialogue with avatars to provide an opportunity for the person to reclaim power and control. And so we’re very much working directly with the experience in quite a potentially powerful way for people. Dr Lucy Maddox:        Could you tell me about the current project you’re working on, so SlowMo? Dr Tom Ward:              Yeah, so the first thing to say is that SlowMo stands for slow down for a moment. And so, it’s a therapy which is a targeted therapy for people who are experiencing paranoia. And it’s based in the idea that’s been popularised by Daniel Kahneman and other people that human thinking can be sort of thought about in terms of two different types of thinking. There’s fast thinking where we approach situations and we go with our first impression. We go with our intuition and gut feeling and we don’t take time to think it through. And slow thinking is more around taking a step back from situations and weighing things up and considering different ways of looking at situations. So one of the things to say is that fast thinking is part of human nature, we all do it and in many different times in our lives. But what we know from research into the experiences of people with psychosis is that people who worry about harm from other people, people who have significant paranoia can often be very likely to engage in this fast thinking. And find it difficult to feel safe in situations and to slow down and consider what else might be going on in the situation. So the therapy is designed to help people build an awareness of this fast thinking which is a part of human nature but can be particularly difficult if we’re feeling unsafe. And it’s designed to support people to be able to slow down and feel safer in their lives. And managing situations so they can really engage and enjoy their lives in a way that perhaps in the past has been difficult. Dr Lucy Maddox:        Fast thinking I guess that’s something like you were saying that we all can get into a bit. Dr Tom Ward:              The first message that we try to get across within the therapy is that fast thinking is part of human nature, it’s natural. And there are times when thinking fast is actually very helpful for people, sometimes we need to react to situations, and we need to recognise where we are unsafe and there’s danger. But in the context of when people are feeling unsafe throughout so much of their life, and in situations where perhaps the danger isn’t quite as much as the fear suggests it is, fast thinking can leave people feeling unsafe in situations where it might start to be a barrier to people living their lives. And slow thinking is something that we’re all capable of, but all human beings find it difficult and people experiencing psychosis and worrying can find this difficult as well. But we’re really trying to find ways to support people to do that, to feel safe in their lives. Dr Lucy Maddox:        And how does the therapy work? What does it look like? Dr Tom Ward:              We would describe it as a blended digital therapy. And it’s important to explain what that means. The blending aspect of this is that we try to take the best of face-to-face therapy and the building of a relationship with someone. But we try to improve the therapy through using, through blending digital technology into what we do.                                     So the therapy involves eight face-to-face sessions, but each of these sessions is supported by an easy to use website effectively, an interactive website. So within a session, you’d be talking to the person or the person would be talking with the therapist but also interacting with a touchscreen laptop. And this provides information, it provides interactive ways that the person can build a picture of their own worries about other people or situations.                                     And really visualise what’s happening in a way that in psychological therapy we talk about a formulation. A formulation, an understanding of somebody’s difficulties. But the digital technology in SlowMo is trying to really bring the person into that process of understanding what’s going on and making it very engaging and interactive and visual and memorable for the person.                                     In order to try to support the person to make changes in their daily life, there’s also a mobile app that comes alongside the therapy, which is very much aimed at taking what the person has learnt in the therapy and applying it into their daily life. Dr Lucy Maddox:        Here’s Angie on what she remembers this digitally supported therapy being like. Angie:                          You could choose pretty much where you wanted to do the therapy, you could have it at home, or you could have it in a café or somewhere else where you felt comfortable. So I did it in a café, a local café, with a lady called Alison. And what it consists of the clinician, Alison, she had a laptop. My heart sank originally because I thought oh no, I’m no good on computers. And I explained to her that I wasn’t very good on a computer. And she was so lovely, so patient, she said, “I can do most of it for you.” So that was fine. What the therapy was it did what it says on the tin, really. It taught you to slow your mind down, and to break things up into little pieces, like for instance I used to be terrified of getting on the bus because I thought people were talking about me and laughing at me. Dr Lucy Maddox:        That’s a horrible feeling. Angie:                          Yeah, yeah. And this sort of therapy taught me to break it up. To say myself, “Well, hang on a minute, these people aren’t looking at you. They’re talking to their friends, they’re on their phone.” Just take it easy. And it’s a very simple idea but it works because although you know in your heart of hearts that that i

Children don't come with a manual, and parenting can be hard. What is evidence-based parenting training and how can it help? Dr Lucy Maddox interviews Sue Howson and Jane, about their experiences of delivering and receiving this intervention for parents of primary school aged children.  Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Sue and Jane both recommended this book: The Incredible Years (R): Trouble Shooting Guide for Parents of Children Aged 3-8 Years By Carolyn Webster-Stratton (Author) Sue also recommended this book: Helping the Noncompliant Child Family-Based Treatment for Oppositional Behaviour  Robert J. McMahon, Rex L.Forehand 2nd Edition Paperback (01 Sep 2005)  ISBN 978-1593852412 Websites http://www.incredibleyears.com/ https://theministryofparenting.com/ https://www.nurturingmindsconsultancy.co.uk/ For more on CBT the BABCP website is www.babcp.com Accredited therapists can be found at www.cbtregisteruk.com   Courses The courses where Sue works are available here, and there are similar courses around the country: https://www.reading.ac.uk/charliewaller/cwi-iapt.aspx   Photo by Markus Spiske on Unsplash This episode was edited by Eliza Lomas   Transcript Lucy:   Hello and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not and how it can be useful. This episode is the last in the current series so we’ll be having a break for a bit, apart from a cheeky bonus episode, which is planned for a few months’ time so look out for that. Today, I’m finding out about evidence-based parenting training. This is a type of intervention for the parents of primary school aged children. It draws on similar principles to cognitive behavioural therapy about links between thoughts, feelings, behaviours and bodily sensations and ideas from social learning theory. It also draws some ideas from child development such as attachment theory and parenting styles. To understand more about all of this, I met with Sue Howson, parenting practitioner who works in child mental health services and Jane, a parent who has experienced the training herself. Jane:  My name is Jane and I’ve got a little boy called Jack who is seven and he’s in Year 3. Lucy:  And you’ve experienced evidence-based parenting training, is that right? Jane:  Yeah, I have. It’s something called the Incredible Years. And there was a really nice lady called Sue and my school put us in touch to form a group to kind of help me manage Jack a little bit more at home. Lucy:  So, your journey into it was that the school let you know about it? Jane:  Yeah. Basically, I was having a few issues with Jack at home and I think it was kind of impacting on school as well. So, I was working with the special needs coordinator and she, obviously, had me, Jack and my family in mind as someone who might benefit from working a little bit with Sue.  I was a bit nervous at first, you know, like professionals coming in, getting involved. But she was really nice and it was really beneficial. Lucy: Is it okay to ask what sort of difficulties you were having at home, sort of what was going on? Jane:  Yeah, I can tell you now because it’s all changed, it’s much better. Lucy:  Oh good, that’s great to hear. Jane:    I mean, Jack’s a lovely boy. He’s my eldest and he’s really nice and just a bit of a joy – he is now. But I think one of the main things that I was struggling with, with him, was kind of difficulties with falling asleep. In the evenings, he would always want me to fall asleep either next to him or in his bed and that was kind of impacting on our evening, mine and my husband’s quite a lot. And it was taking up a lot of time and I think evenings are quite hard because you’re so tired and you just want to go to bed. So, that was one of the issues. And the no sleep was impacting on all aspects of our family life, really. I would just be really tired all the time and quite short, and end up shouting at Jack when I just wanted him to go to sleep and he wouldn’t. And shouting wasn’t ideal and doesn’t help but I’d just get frustrated, really and I think quite a lot of us were quite unhappy. Lucy: That sounds super hard. Jane: Yeah. I mean, he is seven but he’d kind of throw a massive wobbly if he didn’t get what he wanted, like, I don’t know, like an extra biscuit or chocolate finger or something from the cupboard, he would just kind of lose it. And that was really hard to deal with, particularly when you’re tired. I know you shouldn’t but you always kind of end up giving in a little bit, don’t you, because you just want the easy life. And you know that you shouldn’t but… Sue: It’s really hard when you’re being shouted at or when you’re exhausted like that. Jane: And I’d also feel like the path of least resistance, like sometimes it just easier to give in, even though I knew that I shouldn’t. So, I guess those are the main issues, really, kind of thinking about his behaviour. And there were a few concerns from school in terms of his behaviour. Obviously, he was tired at school and maybe not doing as much as he could be schoolwork-wise. It was kind of impacting everything, really. So, that’s where Sue came in. Sue: My name’s Sue Howson and I am a parenting practitioner and I’ve worked in CAMHS for many years, background in social work. I’ve been working with children and families for years and years and years. But I also have a role of teaching practitioners at the University of Reading. Lucy: And do you teach practitioners about evidence-based parenting training? Sue: Yeah, absolutely. So, I have trainees coming from various different parts of the country to Reading University where we teach two really strong evidence-based parenting interventions where the practitioners become super equipped to go out into the community and offer the support that the parents need. Lucy: Fantastic. And this is all extremely topical because BABCP have recently launched the evidence-based parent training accreditation pathway. Sue: Yes, which means that the parent training pathway is now on par with the CBT pathway, which is hugely exciting for all those people out there that are actually during parent training and offering parenting interventions. It’s a really great way to get those skills and practices recognised. So yes, I’m really excited by that too. Lucy: Could you say a little bit about what evidence-based parent training is? Sue:  It is a practice that is based in social learning theory and really focuses on the attachment relationships and building the relationships between parent and child and building on parental self-confidence and self-efficacy and trying to equip the parent and skill up the parent to notice particular behaviours in a child and them then feeling confident in applying a particular technique or a particular method in the moment which will make a difference to – fingers crossed – to the outcome of that little interaction between parent and child. Lucy: When we’re talking about social learning theory, by that do you mean the way that we all learn from what we see around us? Sue: Yeah. It’s learned from our environment and the things we see around us. Lucy: So, it’s kind of providing parents and carers with a different model of how to do things. Sue: Yes. So, perhaps in their upbringing, they were brought up with one particular style of parenting and parent training offers, perhaps, a selection of different ideas on how they may choose to interact with their child that’s different from the way that they were brought up. Lucy: Which is very interesting, actually, isn’t it? Because, you know, it’s not something that’s taught in school, is it, parenting? So, it’s very much something that people do quite intuitively or in the way that they’ve been brought up or that their friends are doing it. So, there’s a lot of social influence involved, actually, isn’t there? Sue:  A huge amount of social influence. And quite often, in homes, both parents don’t do it the same way. So, just because you do it one way, your partner might do it in a different way and you may never have even discussed that until you reach a point where you’re having challenges with your child. So, you may end up having to think about things and being much more consistent. Especially with children with ADHD and autistic spectrum difficulties, the consistency element is really, really important. Lucy:  I asked Jane what she’d expected from evidence-based parenting training. Jane: Oh, I was a bit nervous and apprehensive to begin with because, you know, it’s bit embarrassing, isn’t it? You’re the one with the naughty kid that doesn’t do what they’re meant to. Sue kind of made me feel super relaxed from the start. She’s really approachable and just like normal, like not too expert, not using all these words that I didn’t understand. And she was quite relaxed so that kind of made me feel quite relaxed and let me feel comfortable to ask questions, even though they might have been silly or they might seem obvious. So, that was really nice in the beginning. I liked how she said things about the group rules, like intense confidentiality and respect and that made me feel like it was okay to share, really. Lucy: That sounds really important. Jane: Yeah. And I think one of the biggest things, obviously, apart from the actual strategies she gave me, was being able to meet other parents in a similar situation who had a child like mine. And we kind of set up a WhatsApp group after, which is really nice. Now Sue’s worked her magic, that kind of keeps us going. Like if you’re having a bad day, you can still speak to someone who knows. Lucy:  I asked Sue to talk us through what evidence-based parenting training involves and she said there are two methods. The first is the group process, which Jane did. This is usually two hours a week minimum for 12 to 14 weeks on the

In this episode Dr Lucy Maddox speaks to Sharon and Dr Anne Garland, about CBT for depression. Hear how Sharon describes it, and how both group and individual therapy helped.  Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Books Overcoming Depression by Paul Gilbert Podcast Episodes CBT for Perfectionism Compassion Focussed Therapy Websites www.babcp.com www.cbtregisteruk.com Image by Kevin Mueller on Unsplash Transcript   Lucy: Hello and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not and how it can be useful.   In this episode we’re thinking about CBT for depression. I spoke with Dr Anne Garland who spent 25 years working with people who experience depression and Sharon, who has experienced it herself.   Both Anne and Sharon come from a nursing background. Anne now works at the Oxford Cognitive Therapy Centre as a consultant psychotherapist, but she used to work in Nottingham, which is where Sharon had CBT for depression. Here’s Sharon.   How would you describe what depression is like?   Sharon: When I was going to school, when I was a little girl, an infant, we would have to go over the fields because I lived in the country, and go down. I could hear the bell of the junior school but couldn’t find it because of the fog. I walked round and round, I was five, walked round and round and round in those fields trying to get to the bell where I knew I would be safe and being terrified on my own. And that’s how it feels actually. Darkness, cold, very frightening.   Lucy: I asked Anne how depression gets diagnosed and she described a range of symptoms.   Anne: In its acute phase it’s characterised by what would be considered a range of symptoms. So, tiredness, lethargy, lack of motivation, poor concentration, difficulty remembering. Some of the most debilitating symptoms are often disturbed sleep and absence of any sense of enjoyment or pleasure in life and that can be very distressing to people. People can be really plagued with suicidal thoughts and feelings of hopelessness that life is pointless.   I think one of the most devastating things about depression as an illness is it robs people of their ability to do everyday things. So for example, getting up, getting dressed, getting washed, deciding what you want to wear can all be really impaired by the symptoms of depression. I try and help people to understand that the symptoms are real, they’re not imagined. Often people will tell me that they imagine these things or that they aren’t real and that it’s all in their mind.   Their symptoms are real, they exist in the body and do exert a really detrimental effect on just your ability to do what most of us take for granted on a day-to-day basis.   Lucy: And so it’s a lot more than sadness isn’t it?  Anne: Absolutely. It can be very profound feelings of sadness but often that’s amplified by feelings of extreme guilt, of shame, anger and anxiety is another common feature of depression.   Also, when people are very profoundly depressed they can actually just feel numb and feel nothing and that in itself can be very distressing because things that might normally move you to feel a real sense of connection. Say for example your children or your grandchildren, you may have no feelings whatsoever, and that in itself can be very alarming to people.  Lucy: The way that depression and its treatment are thought about can vary depending on who you speak to. Just like with other sorts of mental health problems. More biological viewpoints prioritise thinking about brain changes that can occur with depression while more social perspectives prioritise thinking about the context that people are part of.   Anne: As CBT tends to take a more pragmatic view of thinking about a connection between events in our environment, our reactions to those in terms of biology, thoughts, feelings and behaviour and how all of those things interact and that’s a very pragmatic way of thinking about things really. And I guess traditionally in CBT there’s the idea of making what is referred to as a psycho biosocial intervention. What that essentially means is that you can use medication plus psychological therapies – particularly CBT in this instance – and interventions that may influence your environment.   If you do those things altogether then you’re more likely to get a better outcome, which is really what our service in Nottingham is predicated on that idea. That if you think about all of those aspects in a practical, pragmatic way, then that may maximise your chances of seeing an improvement in depression.   And I think one of the challenges in depression, if you look at the research literature, is once you’ve had one episode of depression, you have a 25% chance of another. Once you’ve had two, a 50% chance. And once you’ve had three, a 95% chance of another episode. So the concept of recurrence becomes really important.   A lot of the work we do with people who have more persistent treatment resistant depression is really trying to help the person develop strategies for managing the illness on a long term basis. So it’s very much about trying to manage your mood and how you structure your day and your life and activities and that type of thing. I can be a very complex illness to work with.   Lucy: For Sharon, her first experience of depression was 20 years ago when depression suddenly had a huge effect on her and her life.   Sharon: And at the time the word they used was ‘decompensated’. Like a little hamster in a wheel and I just couldn’t keep going anymore and everything fell apart. I ended up being admitted to a psychiatric hospital for a few weeks.   Lucy: Ten years later, Sharon had another episode.   Sharon: I just couldn’t manage everything, working full-time, single parent, no family support and it just all imploded, I just couldn’t manage, I became really depressed again.   Lucy: This time she saw a psychiatrist who suggested she try CBT alongside medication. Although reluctant, she went ahead with it. At the time the therapy offered had little effect on her.   Sharon: I can’t describe it, it juts was an academic exercise to me.   Lucy: However, a few years later he doctor encouraged her to try CBT again.   Sharon: Because I like to please, not upset anyone, I went along to it. And it was a group CBT and it was compassion-focused, compassionate-based CBT and it was over about 20-24 weeks, something like that. We met every week, this small group.   Lucy: This time it was different, things started making sense for her.   Sharon: We went through that limbic system, the old brain, the new brain, the threat, soothing, drive, and all this explanation which for me, was a very good fit. Because suddenly, it was like a revelation, “So it’s not just me being weak then.” Even though people had told me, I didn’t really believe it.   So this information was important for me and from that we started to develop the discussions of, “Why do I think the way that I do?” Which was what the early CBT had done but somehow this meant more. It actually touched me.  And being in that small group and hearing other people talking and the two therapists that were there guiding, compassionate responses and, “What would we say to this person?” enabled me to see actually far more clearly the relevance of what they were doing.   Lucy: That sounds super helpful.   Sharon: You could offer a compassionate response and you could see the effect it was having and when they said to me I found it very hard to take, I couldn’t accept anybody being kind or compassionate.   Lucy: Sharon had a combination of group compassion-focused CBT which you can also hear more about in the episode on compassion-focused therapy, as well as individual CBT for depression. I asked Anne to talk us through how individual CBT for depression works.   Anne: Well, CBT for depression has two aspects to it really. The first aspect is the idea of symptom relief and really the purpose of that aspect of the treatment is really to try and help people re-engage with activities.   Say for example you feel too tired to get up out of bed, get washed and dressed and make your breakfast in the 30 minutes you normally would have done that, you might try and break that down into smaller tasks. So you might get out of bed and have a cup of tea. You then might get your breakfast and have another break and then you might get dressed.   So this idea that if you make an allowance for your energy levels, your concentration and try and approach tasks by breaking them down into manageable chunks, that will start to get you active again. So that’s really the first step of symptom relief.   The second aspect of symptom relief in depression is really trying to look at the role thoughts might play in the context of depressed mood. And what the research tells us in the cognitive science of depression is once mood becomes depressed, thinking becomes more negative in content. It also becomes more concrete and more over general, so it’s hard for us to be specific in our recall.   And another important factor, a thing that occurs once mood becomes depressed is our memory more readily recalls past unpleasant painful memories and actively screens out positive or neutral memories. The reason why this is important is that our ability to solve problems is really based on being able to retrieve information from the past about how we did that.   But once mood becomes depressed, you’re trying to do an everyday thing like say, I don’t know, mend a broken sink pipe, and you’re trying to do that, but because your mood is depressed and your concentration isn’t great, it’s harder to do. But also, all that’s coming back to you is all the times things have gone wrong, not the times when they’ve gone wel

Anxiety is one of the most common mental health problems, but there's a good evidence-base for CBT as a helpful intervention. In this podcast, Dr Lucy Maddox speaks with Dr Blake Stobie and Claire Read, about what CBT for anxiety is like, and how anxious thoughts can be like the circle line.  Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Websites BABCP https://www.babcp.com Accredited register of CBT therapists https://www.cbtregisteruk.com Anxiety UK https://www.anxietyuk.org.uk NICE guidelines on anxiety https://www.nice.org.uk/guidance/qs53 Apps Claire recommended the Thought Diary Pro app as being helpful to use in conjunction with therapy to complete thought records.  https://www.good-thinking.uk/resources/thought-diary-pro/ Books Claire recommended this workbook on Overcoming Low Self Esteem by Melanie Fennell https://www.amazon.co.uk/Overcoming-Low-Self-Esteem-Self-help-Course/dp/1845292375/ref=sr_1_2?dchild=1&keywords=self+esteem+workbook+melanie+fennell&qid=1605884391&s=books&sr=1-2 And this book by Helen Kennerley on Overcoming Anxiety is part of the same series https://www.amazon.co.uk/Overcoming-Anxiety-Books-Prescription-Title/dp/1849018782/ref=sr_1_1?dchild=1&keywords=overcoming+anxiety&qid=1605884437&s=books&sr=1-1 Credits Image used is by Robert Tudor from Unsplash Podcast episode produced and edited by Lucy Maddox for BABCP Transcript   Lucy: Hello and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not and how it can be useful.   In this episode we’re thinking about CBT for depression. I spoke with Dr Anne Garland who spent 25 years working with people who experience depression and Sharon, who has experienced it herself.   Both Anne and Sharon come from a nursing background. Anne now works at the Oxford Cognitive Therapy Centre as a consultant psychotherapist, but she used to work in Nottingham, which is where Sharon had CBT for depression. Here’s Sharon.   How would you describe what depression is like?   Sharon: When I was going to school, when I was a little girl, an infant, we would have to go over the fields because I lived in the country, and go down. I could hear the bell of the junior school but couldn’t find it because of the fog. I walked round and round, I was five, walked round and round and round in those fields trying to get to the bell where I knew I would be safe and being terrified on my own. And that’s how it feels actually. Darkness, cold, very frightening.   Lucy: I asked Anne how depression gets diagnosed and she described a range of symptoms.   Anne: In its acute phase it’s characterised by what would be considered a range of symptoms. So, tiredness, lethargy, lack of motivation, poor concentration, difficulty remembering. Some of the most debilitating symptoms are often disturbed sleep and absence of any sense of enjoyment or pleasure in life and that can be very distressing to people. People can be really plagued with suicidal thoughts and feelings of hopelessness that life is pointless.   I think one of the most devastating things about depression as an illness is it robs people of their ability to do everyday things. So for example, getting up, getting dressed, getting washed, deciding what you want to wear can all be really impaired by the symptoms of depression. I try and help people to understand that the symptoms are real, they’re not imagined. Often people will tell me that they imagine these things or that they aren’t real and that it’s all in their mind.   Their symptoms are real, they exist in the body and do exert a really detrimental effect on just your ability to do what most of us take for granted on a day-to-day basis.   Lucy: And so it’s a lot more than sadness isn’t it?  Anne: Absolutely. It can be very profound feelings of sadness but often that’s amplified by feelings of extreme guilt, of shame, anger and anxiety is another common feature of depression.   Also, when people are very profoundly depressed they can actually just feel numb and feel nothing and that in itself can be very distressing because things that might normally move you to feel a real sense of connection. Say for example your children or your grandchildren, you may have no feelings whatsoever, and that in itself can be very alarming to people.  Lucy: The way that depression and its treatment are thought about can vary depending on who you speak to. Just like with other sorts of mental health problems. More biological viewpoints prioritise thinking about brain changes that can occur with depression while more social perspectives prioritise thinking about the context that people are part of.   Anne: As CBT tends to take a more pragmatic view of thinking about a connection between events in our environment, our reactions to those in terms of biology, thoughts, feelings and behaviour and how all of those things interact and that’s a very pragmatic way of thinking about things really. And I guess traditionally in CBT there’s the idea of making what is referred to as a psycho biosocial intervention. What that essentially means is that you can use medication plus psychological therapies – particularly CBT in this instance – and interventions that may influence your environment.   If you do those things altogether then you’re more likely to get a better outcome, which is really what our service in Nottingham is predicated on that idea. That if you think about all of those aspects in a practical, pragmatic way, then that may maximise your chances of seeing an improvement in depression.   And I think one of the challenges in depression, if you look at the research literature, is once you’ve had one episode of depression, you have a 25% chance of another. Once you’ve had two, a 50% chance. And once you’ve had three, a 95% chance of another episode. So the concept of recurrence becomes really important.   A lot of the work we do with people who have more persistent treatment resistant depression is really trying to help the person develop strategies for managing the illness on a long term basis. So it’s very much about trying to manage your mood and how you structure your day and your life and activities and that type of thing. I can be a very complex illness to work with.   Lucy: For Sharon, her first experience of depression was 20 years ago when depression suddenly had a huge effect on her and her life.   Sharon: And at the time the word they used was ‘decompensated’. Like a little hamster in a wheel and I just couldn’t keep going anymore and everything fell apart. I ended up being admitted to a psychiatric hospital for a few weeks.   Lucy: Ten years later, Sharon had another episode.   Sharon: I just couldn’t manage everything, working full-time, single parent, no family support and it just all imploded, I just couldn’t manage, I became really depressed again.   Lucy: This time she saw a psychiatrist who suggested she try CBT alongside medication. Although reluctant, she went ahead with it. At the time the therapy offered had little effect on her.   Sharon: I can’t describe it, it juts was an academic exercise to me.   Lucy: However, a few years later he doctor encouraged her to try CBT again.   Sharon: Because I like to please, not upset anyone, I went along to it. And it was a group CBT and it was compassion-focused, compassionate-based CBT and it was over about 20-24 weeks, something like that. We met every week, this small group.   Lucy: This time it was different, things started making sense for her.   Sharon: We went through that limbic system, the old brain, the new brain, the threat, soothing, drive, and all this explanation which for me, was a very good fit. Because suddenly, it was like a revelation, “So it’s not just me being weak then.” Even though people had told me, I didn’t really believe it.   So this information was important for me and from that we started to develop the discussions of, “Why do I think the way that I do?” Which was what the early CBT had done but somehow this meant more. It actually touched me.  And being in that small group and hearing other people talking and the two therapists that were there guiding, compassionate responses and, “What would we say to this person?” enabled me to see actually far more clearly the relevance of what they were doing.   Lucy: That sounds super helpful.   Sharon: You could offer a compassionate response and you could see the effect it was having and when they said to me I found it very hard to take, I couldn’t accept anybody being kind or compassionate.   Lucy: Sharon had a combination of group compassion-focused CBT which you can also hear more about in the episode on compassion-focused therapy, as well as individual CBT for depression. I asked Anne to talk us through how individual CBT for depression works.   Anne: Well, CBT for depression has two aspects to it really. The first aspect is the idea of symptom relief and really the purpose of that aspect of the treatment is really to try and help people re-engage with activities.   Say for example you feel too tired to get up out of bed, get washed and dressed and make your breakfast in the 30 minutes you normally would have done that, you might try and break that down into smaller tasks. So you might get out of bed and have a cup of tea. You then might get your breakfast and have another break and then you might get dressed.   So this idea that if you make an allowance for your energy levels, your concentration and try and approach tasks by breaking them down into manageable chunks, that will start to get you active again. So that’s really the first step of symptom relief.   The second aspect of symptom relief in depression is really trying to look at the role thoughts might play in the context of depressed mood. And what the research tells

We tend to think about therapy as something that is helpful for individuals, but what about when you want to address problems which affect you and a partner or spouse? In this episode, Dr Lucy Maddox speaks to Dan Kolubinski about cognitive behavioural couples therapy, and hears from Liz and Richard about what the experience was like for them.  Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Dan recommended the book Fighting For Your Marriage by Markman, Stanley & Blumberg https://www.amazon.co.uk/Fighting-Your-Marriage-Best-seller-Preventing-dp-0470485914/dp/0470485914/ref=dp_ob_title_bk Some journal articles on couples therapy are available free online here: https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/information/let-s-talk-about-cbt-podcast The podcast survey is here and takes 5 minutes: https://www.surveymonkey.co.uk/r/podcastLTACBT The BABCP website is at www.babcp.com And the CBT Register of accredited CBT therapists is at https://www.cbtregisteruk.com Photo by Nick Fewings on Unsplash   Transcript Lucy: Hello, and welcome to Let’s Talk About CBT. It’s great to have you listening.   When we think about therapy, we often think of one-to-one conversations between one person and their therapist. But what about when the problems that we’re going for help with are related to how we’re getting on with a partner or a spouse? Cognitive behavioural couples therapy helps with these sorts of difficulties. To understand more about it I spoke to a married couple, Richard and Liz, and Dan Kolubinski, their therapist.   Richard and Liz did this therapy privately, but couples therapy is also available on the NHS to help with some specific difficulties. We hear more about that from Dan later on. For now though let’s hear what Richard and Liz thought of their couples therapy in this interview which I recorded with them remotely.   Richard: My name’s Richard. I’m 37 years old and I’ve been married to Liz for just over seven years now. I’m a postie at the moment, and kind of lived in Essex most of my life.   Liz: It’s like a dating programme.   Richard: It is, isn’t it? Yeah, a little bit. (laughs)  Liz: So I’m Liz and I make cakes for a living, and write about mental health. So that’s us.   Lucy: That’s great. So thanks so much for agreeing to speak with me about your experience of couples therapy, and specifically cognitive behavioural couples therapy. Would you mind telling me how you came across it and what made you think you might want to try it?  Liz: Yeah. So I think it’s something that we’ve spoken about in the past. And we’ve both had therapy separately, and I think we’ve both had various different types of therapy. So Richard has had CBT before, I think we’ve both done psycho-dynamic counselling.   So when we decided we were going to do it, we realised that for us it was more beneficial to almost do a crash course, as it were, together. So to do a whole weekend, rather than a little bit once a week. And that was how we discovered Dan, and were able to book in with him.   Richard: Yeah, I think we both understand the value or had both experienced and understood the value of therapy individually. So it was kind of an easy step for us then to decide there could be a lot of value in doing this together.   Lucy: That makes total sense. So you already had a bit of an understanding of what it might be like, or what it’s like on an individual level?  Liz: Yeah, definitely. And actually very early on in our marriage we had some couples counselling, which I don’t think was actually as successful, and it was after that that we had separate counselling. And I think it was after we were both able to get ourselves into better positions, as it were, that that’s when we were able to come back together and experience some therapy together.   Lucy: That’s really interesting. Do you think that helped you access the conversations together in a different way?  Richard: Yes, I think it did. I think we both had an experience of therapy, of CBT and of other therapies, and the structure they would take or how they engaged you and enabled you to talk safely, and the prompts that might be used.   When we did it together, it did make the conversations a bit freer, a bit more open. And I think we both felt it was a safe environment, which when we first had it I don’t think we did feel. And that made a big difference I think.   Liz: Yeah. And I think as with any relationship, until you’ve got a level of happiness with yourself, it’s very difficult to have a relationship with somebody else that involves vulnerability or trust.   And I don’t think we had that the first time we tried having counselling together. I think we were almost so reliant on our relationship to form who we were, that the first time around we put too much pressure on ourselves, on the relationship, and also on the counselling, and we expected some magic wand. Whereas now we’ve realised it actually does take a bit of work.   Richard: Yeah.   Liz: But obviously the pay-off is huge, so that’s brilliant.   Lucy: That’s so nice. Sometimes you see adverts for couples counselling, or couples conversations, when people are thinking of getting married. Was that something that was around for you?  Liz: (Laughs) Yeah, slightly ironically we started it and it was meant to be three sessions long, or four sessions long, and I think before the second or third session we had such a big argument that we never went back.   So yeah, again it’s something that I think in hindsight there were warning bells that both of us were probably having our own inner struggles, as it were. And that we weren’t really able to reap the benefits of that pre-marriage counselling. But I would definitely recommend it to any friends who were getting married.   Richard: Yeah, absolutely.   Liz: I’d definitely recommend it, even if it’s just to get the conversation started.   Lucy: Yeah, it’s interesting. So there are some conversations it feels like almost we don't quite have permission to have without somebody prompting it or some kind of structure around it.   Liz: Yeah, definitely. And I think it takes a certain amount of emotional maturity to have conversations like that, or the difficult conversations, and not to take something personally or get defensive. And I think that that’s something as a society we don’t necessarily encourage people to have those conversations, or to be able to freely explore things without there being some element of self-worth dependent on it.   Lucy: Liz and Richard went for therapy after experiencing a bit of a rocky patch in their relationship.   What was it like going for the weekend?  Richard: I think it was really beneficial. It’s certainly something that – hopefully we’ll never be in that similar circumstance again – but in a situation where we thought it was beneficial, doing it over… was it three nights?  Liz: Yeah, three nights.   Richard: Was really valuable, because it kept you in that space. So there were no distractions from, I don’t know, going to work, having to get back, get to the session.   Then inevitably when you finish the session you get home and normal life kicks in straightaway. So whether it’s cooking dinner or having to get ready for the next day, that’s unavoidable. But in this situation we were really able to take ourselves away from normality and the routine, and really focus on it. And I think it had a great impact doing it that way.   Liz: Definitely. And also I think that having – because the sessions each day I think ran from 10:00 till 1:00, and then 2:00 till 4:00. So having those extended sessions meant you could really get down to what was happening and really attack that. As opposed to when it’s say weekly, hour long sessions, having to almost get past the initial boundaries that you might have set up and break those down, and get into a place of being able to talk freely.   Lucy: And were there other people there as well? Were there other couples there or was it just you?  Liz: It was just us.   Richard: Yeah.   Lucy: And what was it like before you went? Was it frightening to think about going?  Richard: I suppose for me it was a sense of that nervous excitement. So I didn’t quite know what was going to happen. I knew what I wanted from it. And it was the kind of knowledge that this was going to be good for us, at least for me.   Liz: Definitely. And I think one of the first things, on our first evening there, we had the initial introduction session together. And Dan did say it was quite unusual to be dealing with a couple who were in such a good place. And that was quite nice actually, and we definitely subscribe to the idea that therapy isn’t just for when something goes wrong; it’s actually really useful to keep things right, as it were.   And I think it was funny because the things we thought we were going to end up talking about over the weekend, actually it all came down largely to communication, which I think is often the case with couples. And learning how to communicate with each other.   Lucy: Before we hear more about Richard’s and Liz’s experience, here’s Dan to give the bigger picture on this type of therapy.   Dan: My name is Dr Dan Kolubinski, and I am the clinical director of Reconnect UK, which is a CBCT based intensive retreat programme.   Lucy: And what’s your professional background?  Dan: My master’s degree is in counselling psychology, and a PhD in psychology as well. And I’ve been a CBT therapist for about 15 years now.   Lucy: Cognitive behavioural couples therapy might be something that people haven’t heard of before. Could you explain what it is?  Dan: Well, as in CBT, in cognitive behavioural therapy, there are these two different aspects; there are cognitions and there are behaviours. The ideas are that if you change those two things you might change how a pers

What is digital CBT? How does therapy work over the internet? Can it ever be as good as face-to-face? Dr Lucy Maddox hears from Dr Graham Thew and Fiona McLauchlan-Hyde about an internet-based CBT programme for PTSD. Fiona shares her experience of how this therapist-supported programme helped her through traumatic grief, and also has some helpful advice for people trying to comfort those who are bereaved.    Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP BABCP website is at www.babcp.com CBT Register of accredited CBT therapists is at https://www.cbtregisteruk.com BPS Top tips for psychological sessions delivered by video call for adult patients https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Top%20tips%20for%20psychological%20sessions%20by%20video%20%28adult%20patients%29.pdf Resource from OCD-UK on getting the most out of online CBT https://www.babcp.com/files/Therapists/Oxford-OCD-Making-the-Most-Out-of-Remote-Therapy-for-Patients-by-OCDUK.pdf Graham’s recent paper in the Cognitive Behavioural Therapist can be found on the podcast journal article page https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/information/let-s-talk-about-cbt-podcast Information from Cruse about traumatic grief https://www.cruse.org.uk/get-help/traumatic-bereavement/traumatic-loss The Good Grief Trust https://www.thegoodgrieftrust.org Image is by Cassie Boca on Unsplash Transcript   Lucy: Before we get started, I want to remind you about the survey which I released at the beginning of August. I really would like to know more about who is listening to these podcasts and what you would like. The link to the survey is in the show notes and it takes about five minutes to complete. If you have time to fill it in I would be really grateful.   Hello, and welcome to Let’s Talk About CBT, with me, Dr Lucy Maddox. This podcast is all about CBT, what it is, what it’s not, and how it can be useful.   Today I am exploring digital CBT. I speak to a therapist who has been researching internet based CBT programmes that are supported by a therapist, and I speak to someone who has experienced this first hand.   The particular programme that we talk about is for PTSD, which we’ve heard about before in a previous episode. In this case PTSD was related to an experience of traumatic grief.   Fiona: I think I started last September and I finished just before lockdown, actually.   Lucy: Gosh, so in a way good timing.   Fiona: Yeah, it was great timing to finish just before lockdown. It put me in a good place I think, to be able to deal with what was going on, rather than if it had been six months earlier it would have been a very different experience I think.   Lucy: It took Fiona, who is based in Oxfordshire, a long time to find this type of therapy.   Fiona: It all started six and a half years ago, when my husband died of cancer.   Lucy: I’m so sorry.   Fiona: He was diagnosed in the June, and he died in the December, and it was really horrific. He was 49, I was 42 at the time. And so it was heartbreaking and I couldn’t cope. I couldn’t cope afterwards. We had a little girl, she was seven when he died. And my world was turned upside down.   And I got help at first. But then, as with all things, life goes on around you and everyone thinks you’re fine. And I was still putting my lipstick on, so therefore everyone thought I was okay. And I felt I was getting worse and worse, and no one would believe me.   And it wasn’t until I threw all of my toys out of the pram; after having therapy through my local GP – so this was last year, last summer – sitting in my car afterwards for about an hour just sobbing, because no one believed me that I was feeling as bad as I was.   And I asked to be put in touch with TalkingSpace. And they put me forward for a trial with Oxfordshire Mental Health, and it changed my life. It absolutely changed my life. Because I was drowning and no one believed me, it was awful.   Lucy: It sounds like such a dark time.   Fiona: It was a really dark time. And everyone just kept saying come on, you know, it’s been so many years. And I was functioning, but I think it was last year… So I suffered from panic attacks; I suffered from panic attacks from before my husband died, and they got worse. They’d gone away for years and then they came back when he was diagnosed.   And last summer, around this time last year, I had such a severe panic attack, I was driving my daughter and she had to call an ambulance. And that was when I decided that come what may I needed help.   But it was still quite some time after that. I still had to go through about six weeks of people going, “Come on, you’re fine. Take a pill.” And I didn’t want to take a pill. So yeah, I was lucky, eventually.   Lucy: It sounds like you had to be really tenacious to get access to the therapy?  Fiona: It was a real, real battle. And as much as I really liked my GP, and my GP was the person who was there when my husband was dying. So he knew what happened and how horrific it was. But in the end his last thing was, “No more therapy. You’re lonely. You need to go out and find yourself another man.” And that was when it just – that was when I sat in my car for an hour and a half and cried.   Because it wasn’t that, I knew it wasn’t that. I knew there was something really wrong, and that I really, really needed help. And TalkingSpace came in, and I had a huge amount of telephone conversations and meetings in person, just for them to try and work out which way to send me.   Lucy: Fiona was diagnosed with post traumatic stress disorder. Fiona’s experience of losing her husband was deeply traumatic; not only the death but the lead up to it.  Fiona: I mean obviously it didn’t just happen to me; a lot of us were affected by it. But it was a particularly brutal and nasty way to die.   And you see the other thing is I did most of the nursing when my husband was sick. I don’t know how it happened like that, but it just did. So all of a sudden I became a nurse, which is not on my CV.   Lucy: Super, super hard. Yeah.   Fiona: And for us, Paul’s death was so horrific. He had a lot of failed operations, there was a lot of emergency surgery, there was an awful lot of blood everywhere. There were ambulances called in the middle of the night. He didn’t just have cancer and pass away, he suffered every day for those however many months it was.   And all of those things that we did automatically; like he had a feeding tube, because he had oesophageal cancer. So with me setting up the feeding tube every night, and flushing all of the feeding tubes out in the morning. And all of those things that you do automatically, because you’re trying to keep your loved one alive, they hit you later.   So his death, apart from – it sounds terrible to say this – apart from his death being the trauma, his illness was a trauma too. Because I did everything I could, but I couldn’t make him better. And this is part of my therapy, just my guilt at not being able to save him.   Lucy: The therapy that Fiona was referred to was a trial based at the Oxford Centre for Anxiety, Disorders and Trauma.   Graham: My name is Graham Thew. I am a clinical psychologist. And I do a job that’s split between research and clinical work.   So my research work I do at the University of Oxford, at the Oxford Centre for Anxiety, Disorders and Trauma. And my clinical work I do at two different services that are part of the IAPT programme, the Improving Access to Psychological Therapies programme. So that’s the Healthy Minds service in Buckinghamshire and the TalkingSpace Plus service in Oxfordshire. And both my research work and my clinical work all focus on digital treatment and digital therapies.   Lucy: Graham wasn’t Fiona’s therapist, but he’s involved in the trial that she took part in. I asked him about what digital therapy is.   And when you say digital CBT, what do you mean?  Graham: Yeah, that’s a great question, because I think terms like digital CBT can actually cover a range of different things.   So as we’ve just mentioned, we might be referring to webcam sessions; so video conference sessions that would perhaps cover the same content as a face-to-face therapy session. So you would still be able to see your therapist on webcam, and you both agree to meet at a specific time.   But digital CBT and other online treatments can be broader and look a little bit different to that as well. So for example there are some forms of CBT that still take place online with a therapist at a specific time, but instead of seeing them and talking to them via webcam, you’d actually be typing; you and the therapist would be typing to each other live, in real time.   Lucy: Like a kind of Messenger chat?  Graham: Exactly, like a sort of instant messaging chat.   And then another different category altogether is more of a sort of internet-based CBT programme. So that would be where there’s a website or a programme that has a lot of the therapy content written, perhaps in the form of little treatment modules. So written texts, videos, that sort of thing. And you would therefore work through those in your own time, and perhaps have some support from the therapist every so often; maybe in the form of messaging or a phone call or something.   So it can be a bit confusing because terms like digital CBT can mean different things.   Lucy: Is your research looking at all of those types of digital CBT?  Graham: The work that I’ve done has mostly focused on the last category that I talked about; the forms where treatment is partly written down and put into an internet programme in a series of modules, but that there’s support from a therapist. In the programmes that I’ve worked with most closely, the therapist would communicate with you by telephone, by messaging, and also occasionally via webcam as

Let's Talk About CBT Survey Have you got 5 minutes to complete a quick survey about your experience of listening? It would really help us to know who is listening and what you would like from the podcast. Thank you! https://www.surveymonkey.co.uk/r/podcastLTACBT Podcast episode produced by Dr Lucy Maddox for BABCP   Photo by Emily Morter on Unsplash

  What does existing research tell us about the possible impact of the pandemic on children and young people's mental health? Dr Lucy Maddox speaks with Dr Maria Loades about Maria and colleagues' recent rapid review of the literature on isolation and mental health, and what CBT principles suggest can be helpful to head off problems, in particular with loneliness during the pandemic.  Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Maria recommended lots of helpful resources on loneliness and social isolation which we've listed here: Books Together: Loneliness, Health And What Happens when we find Connection – Vivek Murthy https://www.amazon.co.uk/Together-Loneliness-Health-Happens-Connection/dp/1788162773 Overcoming social anxiety and shyness https://www.amazon.co.uk/Overcoming-Social-Anxiety-Shyness-Gillian/dp/1849010005 Overcoming your children’s social anxiety and shyness https://www.amazon.co.uk/dp/1845290879/ref=cm_sw_em_r_mt_dp_U_6p13EbZ0ER2XD Websites Mind - https://www.mind.org.uk/information-support/tips-for-everyday-living/loneliness/about-loneliness/ How to cope with loneliness during coronavirus – https://www.verywellmind.com/how-to-cope-with-loneliness-during-coronavirus-4799661 TEDx talk by Will Wright ‘Loneliness is literally killing us’ - https://www.youtube.com/watch?v=ruh6rN5UrME&feature=youtu.be Loneliness and isolation in teenagers – a parent’s guide https://www.bupa.co.uk/newsroom/ourviews/2019/05/teenager-loneliness As always if you want more information on BABCP check out www.babcp.com If you want to find a CBT accredited therapist check the register of BABCP accredited therapists https://www.cbtregisteruk.com/ Articles The rapid review we talked about is here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267797/ Podcast That podcast episode with Shirley Reynolds on teenagers doing more of what matters to them is here: https://letstalkaboutcbt.libsyn.com/helping-teenagers-do-more-of-what-matters-to-them   Transcript Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. In this episode brought to you by the British Association for Behavioural and Cognitive Psychotherapies, we think about the possible effects of quarantine on children and young people’s mental health. I’ll let my guest for today introduce herself.   Maria: My name is Dr Maria Loades and I’m a clinical psychologist and I work at the University of Bath as a lecturer on the doctorate and clinical psychology programme.   Lucy: Maria and her colleagues have been especially interested in the effects of the pandemic on children and young people. She co-authored a rapid review of evidence to try to understand what this effect is likely to be.   Maria: What we wanted to do was to look at two things. One is the studies that have been done that have looked at social isolation in a pandemic context in children and young people and how that’s impacted on their mental health. Secondly, we were also interested in thinking, okay, if these measures mean that young people experience this increase in loneliness, what do we know about how loneliness might be related to mental health for children and young people.   Lucy: So obviously there’s not loads of pandemics to study, but you’re trying to work out from what’s been done before, how does loneliness impact on mental health problems for children and young people? You turned the review around really quickly didn’t you, because normally it takes months to do something like this.   Maria: Yes, we really felt like it was particularly important to pull this together as quickly as we could to inform policy and practice going forward.   Lucy: And what did you find?   Maria: As we expected, there isn’t much known about the impact of pandemics specifically. There was just one study that looked at mental health in children and young people in a pandemic context and it did find that there was significantly increased rates of mental health problems for those who had experienced disease containment measures like quarantine or social isolation. And the study focused on trauma symptoms and they found really much higher rates of trauma symptoms amongst those young people who had experienced those disease containment measures. But that is only one study.   More broadly though, there were over 60 studies that looked at loneliness and mental health. And we found that there is good evidence that loneliness increases the chances of developing mental health problems, both anxiety and depression, up to nine years later.   So there’s not only a loneliness and depression and anxiety linked when we measured them at the same point in time, but there’s good evidence that being lonely now will mean an increase in risk of mental health problems at a later date.   Lucy: Maria thought one study was particularly interesting. It looked at duration of loneliness compared to intensity of loneliness.   Maria: Now what we mean by that is how long the loneliness is going on for, as compared to how strong the loneliness is. And what this study found, and it was a big study, is that actually the longer we’re lonely for, the more closely linked that is with mental health problems than how strong the loneliness is.   Lucy: What are some things that might be helpful to head off these problems?  Maria: We know that loneliness is that feeling we get when our social connections are not what we would want them to be. In the current context, of course, socially connecting in the normal ways, like at school or at college, for young people, is curtailed. But we can still connect in other ways.   Lucy: Maria emphasised how important connecting for play dates over video calls can be, as well as meeting up for play now lockdown is easing, and using more old school ways of communicating as well, like sending friends cards or letters.   Maria: The other thing we can do is more broadly to think about how we promote activities amongst young people that support wellbeing in every which way we can. As well as making sure we’re providing a listening ear for young people and being open to hearing what they might be worried about or what they might be feeling sad about and problem solving that where we can. Actually giving them permission, this is a really unusual circumstance and it’s okay and it’s normal for it not to feel very good.   Lucy: Some things that we know promote wellbeing include regular exercise, good quality sleep, healthy eating and time spent on activities that young people enjoy and feel proud of.   Maria: As one goes for a walk you see rainbows in the windows and my little one looks and points and knows that those rainbows mean that there are other children out there. And I think that’s incredibly helpful in terms of feeling a sense of community, connectedness, which also helps to overcome that loneliness.   Lucy: So although there may be an increased risk of mental health problems as a result of the pandemic, there’s also lots and lots that we can do that would be protective.   Maria: Definitely. I think it’s really important too that we make a distinction between young people who might be feeling lonely now and during this context, but who were pretty well socially connected beforehand. And of course, other young people who might have been lonely beforehand and this has maybe made things worse, or that their loneliness is ongoing at this stage.   For those young people who have maybe been feeling lonely for a much longer time, we might need to do something more individualised and more specific in terms of helping them to think about how they can make social connections going forward, as we resume life to some degree.   Lucy: I asked Maria whether she thought that as we are able to see people more, there might also be some anxiety around socialising.   Maria: You know, the reality is, we haven’t been practicing socialising nearly as much as we’d normally do. So we might well feel rusty and we might well even be worried about connecting socially with each other again. Add into that, of course we’ve had a lot of messages in recent weeks about the risk of interacting with each other because of the risk of infection. And so I think anxiety about getting physically close to each other and interacting with each other is going to be really natural in weeks going forward.   And I think again, the CBT principles can really help us to deal with those social anxieties too. So the first principle that I think is really important to remember is: The first step to tackling fear is facing it.   Lucy: CBT principles suggest breaking down a scary situation into steps and gradually building the confidence to face the fear by conquering one step at a time. So starting with a text message to a friend and working up to meeting face-to-face, for example.   Another tip to help with social anxiety is trying not to focus on how we’re coming across to someone but to focus on what someone is saying rather than getting caught up in thoughts about what they think about us. Thinking about thoughts, just as thoughts rather than facts is one thing that can help with this too, both for children and adults.   Maria: There’s certain developmental reasons why children and young people may be struggling particularly and those are about the key importance of play and of social interaction to development at those ages. But actually this is something that everybody is experiencing.   I do think the majority of children and young people, and adults more generally, will have a few wobbles, but will manage and will bounce back as we go forward. But for some, I think it will be a little more difficult and they’ll need to maybe engage in a bit of self-help using some of these CBT principles or indeed actually to go on and get some more professional help.   Lucy: Maria’s review has implications for school policy.  Maria: What we’re really encouraging, both sch

How does doing more of what matters help teenagers with low mood and depression? And what can we all learn from this, particularly at the moment? Prof Shirley Reynolds speaks to Dr Lucy Maddox. Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP If you want to know more the following resources might be helpful. Books Shirley has written two books about depression in teenagers, one for teens and one for parents: For parents: Teenage Depression:  CBT Guide for Parents https://www.amazon.co.uk/Teenage-Depression-CBT-Guide-Parents/dp/147211454X For adolescents: Am I Depressed and What Can I Do About It? https://www.amazon.co.uk/Am-Depressed-What-Can-About/dp/1472114531/ref=pd_lpo_14_t_0/260-4076808-4951665?_encoding=UTF8&pd_rd_i=1472114531&pd_rd_r=bd1ea151-b4d3-40bc-99bc-583aa3824613&pd_rd_w=xtKq9&pd_rd_wg=CFBxI&pf_rd_p=7b8e3b03-1439-4489-abd4-4a138cf4eca6&pf_rd_r=MFANFKSAD9RE92R6XS65&psc=1&refRID=MFANFKSAD9RE92R6XS65 Websites BABCP website www.babcp.com Register of BABCP accredited therapists https://www.cbtregisteruk.com/ These resources about child and adolescent mental health might also be useful Young Minds https://youngminds.org.uk/ MindEd https://www.minded.org.uk/ Association for Child and Adolescent Mental Health https://www.acamh.org/ Other resources Shirley is running a course with Future Learn from 1st week in June about adolescent depression – aimed to help parents and professionals understand and help young people who struggle with low mood: https://www.mooc-list.com/course/understanding-depression-and-low-mood-young-people-futurelearn Have you seen the BABCP animation about what CBT is? Only 1 minute long and available here: https://www.youtube.com/watch?v=ZRijYOJp5e0 Photo by Daria Tumanova on Unsplash Podcast episode produced by Dr Lucy Maddox for BABCP Transcript  Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. This podcast is all about CBT, what it is, what it’s not and how it can be useful. Today I’m speaking to Professor Shirley Reynolds from the University of Reading about how doing more of what matters can help teenagers boost their mood, and how this might be particularly helpful for all of us to remember at the current time.   Shirley: The thing I’m really mostly interested in is understanding more about adolescent depression in order to help us really develop better treatments and better ways of preventing young people from developing depression. So that we can really try and divert them away from a path that can lead into a lifetime of problems with low mood.   Lucy: Fantastic. And at this time in particular when we’re all shutting doors a bit because of the pandemic and teenagers are shutting doors as well, what can your research tell us that might be helpful at this time in particular do you think?  Shirley: I think there are some general points and some more specific points. I think the general point is that one of the things we know, not just from our own research but from many people’s research is that when you’re a teenager, most teenagers are going to be incredibly attached to and reliant on having relationships with their friends, their peers.   The family becomes a bit less important, it’s not unimportant, but the importance of it becomes a little bit less and that’s replaced by a really, really strong focus on needing to be part of a social group. Being accepted by other people, contributing to things with your friends, being part of something bigger than yourself.   And so what that tells us then is that a period like now when young people simply cannot have those relationships in the normal ways, that this is a potential point of really massive stress for them and distress for them. And we need to try and support them; to maintain any relationships they already have, in whatever way is possible.   And what most parents are currently struggling with, but I think getting a handle on, is that currently that is going to be on a computer.   It’s not just young people, we all need these things. This is a lifelong thing for most people, but it’s a particular importance at that critical development period when we’re teenagers.   Lucy: So making sure that we’re supporting the young people in our lives to maintain contact with their friends in whatever way is possible.   Shirley: In whatever way is possible, absolutely. And accepting and understanding that it’s frustrating and difficult and anxiety provoking and that that’s true for everybody, parents, children, and everybody else.   There’s a degree to which we have to kind of let our normal expectations just be shifted around a bit and learn to live with that and be okay with that.   Lucy: Actually, just you talking about teenagers in particular made me think about that tension that can happen sometimes between teenagers really wanting to be independent and maybe family really wanting to comfort teenagers during this time. And sometimes that can be a really tricky balance to walk, can’t it, if you’re a parent who wants to offer comfort and your teenager is saying, “No, leave me alone.” Is there anything, from your point of view, that you would say about that?   Shirley: I think that’s absolutely right because the other task of being an adolescent or a teenager or growing up is to learn to be independent and to learn to do things on your own. And at the moment everybody is forced to spend 24/7 with their families and that exploration and getting out there and taking a bit of a risk and learning about yourself in the world is something, it’s very hard for teenagers to do at the moment. So they are going to need time to be separate and to be on their own.   And it is fine for them to tell you to back off and it’s inevitable that people will feel a little bit pushed away and maybe left out or maybe tempers will be frayed and there’ll be a bit more irritability. But again, I think that’s one of those inevitable challenges that there’s no right answer for this.   So I think that tension between needing support and also needing to be separate is really a massive struggle, especially for people who live in very small houses, don’t have outside space. So sharing bedrooms. I think trying to find a space for young people to call their own, for at least some of the time is going to be really important, if that’s at all possible.   Lucy: Yeah, really helpful. And helpful to remember that in the midst of trying to homeschool and all the rest of it as well actually, that to be somebody’s teacher and mum and seeing them all the time is not possible.   And some of the research that you’ve done that I found really interesting has been about valued actions. I wondered if you could say a little bit more about what valued actions are?  Shirley: Yeah, so this comes from the research we’ve done with teenagers with depression and low mood. What we see when somebody has depression or beginning to become depressed is that as we feel a little bit worse, what we tend to do – this is in normal life – is to take ourselves out of our normal social activities. So young people who have got problems with depression very often, nearly always, spend more time on their own than they would have previously.   And as they do that, as they take themselves further out, they get less reward from life. So fewer of the things that would have just happened in their normal daily life, a smile from somebody or a shared joke or something that you notice outside of the house that just made you feel good about yourself, those things just are less available to you. They happen less because you take yourself out of what’s happening in life.     As you withdraw what we see is you get less reward from life, or less of what we would call the ‘feel good factor’. And when you get less of the ‘feel good factor’, that makes you feel worse. And as you feel worse, you withdraw a little bit more and you get less reward and then you get less of the ‘feel good factor’.   So you find that young people with depression and adults with depression get themselves into this very hard to escape from cycle, this vicious cycle.   Lucy: Shirley’s research looks at ways of trying to break the cycle of low mood and doing less.   Shirley: So, we want to break the cycle and the way we turn it around when we’re working with young people is we help them to do more of what matters. More of what matters are things that are important to them and we help them decide what matters to them by talking to them about their values.   Lucy: Values are guiding principles in life, the things that show us the direction we want to go in. To work out what matters sometimes takes some real reflection on what it is that’s important to us.   Shirley: Now, they’re really big questions, why am I here? What am I doing? What is the point of it all? They’re massive questions, but they’re brilliant questions and lots of teenagers are sort of playing around with them anyway. So if we can tap into that need to work out why I’m here and what I’m doing and what my values are, it becomes a really exciting, interesting conversation.   Lucy: Shirley told me about three main areas that she tends to ask young people to think about. Values to do with themselves, like health or fun, values to do with things that matter, like education or politics and values to do with people that matter, like family and friends.   Shirley: And then the idea is that once we’ve helped them think about what their values are, which we can do in a very structured way, we then help them to do a little bit more of what matters. These are the valued activities.   So tiny little, small, easy to do activities that help them get a little bit more of that ‘feel good factor’.   Lucy: By increasing time spent on things that matter, that vicious cycle Shirley talked about before can be reversed.  Shirley: And as that reward comes back, we start to reverse the cycle.

We're all living through uncertain times at the moment. What does research from CBT tell us about what tends to help people tolerate uncertainty? Dr Lucy Maddox interviews Professor Mark Freeston about what might help.   Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP For more on BABCP our website is www.babcp.com For Mark's research survey follow this link: https://www.ncl.ac.uk/who-we-are/coronavirus/research/uncertainty/ A preprint of Mark's research paper on coronavirus and uncertainty is available here: https://www.researchgate.net/publication/340653312_Towards_a_model_of_uncertainty_distress_in_the_context_of_Coronavirus_Covid-19 If you feel like you're struggling here are some resources: https://www.nhs.uk/oneyou/every-mind-matters/ https://www.samaritans.org/ https://www.nhs.uk/conditions/stress-anxiety-depression/mental-health-helplines/ https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-services/how-to-access-mental-health-services/ The register of BABCP accredited CBT therapists is here:  https://www.cbtregisteruk.com/ Photo by Katie Mourn on Unsplash Episode edited and produced by Lucy Maddox Music by Gabriel Stebbing Transcript  Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. This podcast is brought to you by the British Association for Behavioural and Cognitive Psychotherapies, BABCP. It’s all about CBT, what it is, what it’s not and how it can be useful.   Today in another post-pandemic special episode I’m speaking remotely to Professor Mark Freeston from Newcastle University. Mark’s research is about how intolerance of uncertainty relates to anxiety and he spoke to me about how findings from this research can be relevant at this current, very uncertain time.   Mark was clear that feelings of anxiety and distress in response to the current pandemic are totally normal.   Mark: Anxiety problems that we see in mental health services have an element that is recognised to be excessive about them. But what we’re looking at at the moment, which is anxiety and distress in response to the coronavirus pandemic doesn’t necessarily have this excessive element about it. So it’s not a disorder, it’s just a lot of very anxious and distressed people.   Lucy: How is your research particularly relevant at the moment?   Mark: Since the early 90s, we’ve been looking at a thing called ‘intolerance of uncertainty’. This is particularly timely given the high level of uncertainty that’s going on. Some people find not knowing, the unknownness of things as particularly difficult to manage.   Lucy: It’s quite an existential problem almost, isn’t it? It’s quite a human problem that we all might have at different moments.   Mark: The evolutionary theory, so some very clever evolutionary psychologists and they say that everyone is probably born to be intolerant of uncertainty, but to greater or lesser degrees we become more able to tolerate uncertainty. So it’s not like a personality trait that is sort of stuck at the same level all your life. When different things happen your ability to tolerate the unknownness of things is likely to change, not necessarily on a day-to-day basis, but you may have periods of greater tolerance or intolerance of uncertainty.   Lucy: Is it that intolerance of uncertainty which leads us to feel very anxious?   Mark: Eventually, yes. The way we’ve been looking at it in our current research and we’ve been working on this for over a year, because we’ve been thinking about before the pandemic came along, we’d been thinking about caregivers of people with dementia or people living with chronic and fluctuating illnesses. And so we were thinking about a lot of different types of contexts where there’s both scary things happening and a lot of uncertainty going on at the same time.   If you are intolerant of uncertainty and there is real uncertainty around, you are going to probably perceive the situation as being more uncertain than it is. So you start off not liking uncertainty, then when things are uncertain, not only do you not like it, but you see the situation as even more uncertain. And you probably also look at the things that might happen, particularly the bad things that might happen as more likely. It’s that combination we think, that makes people anxious.   Lucy: And then at the moment, do the same things apply, might some of us feel more anxious in response to what’s going on with the pandemic than others?   Mark: Yes, and obviously people who have got more at stake, so people who are at greater risk, also about financial things. It’s at multiple levels that there’s lots of uncertainty going on and some people find this more difficult than others.   Lucy: Mark told me about some research which suggests that over the last 30 years we’ve all been finding uncertainty harder to tolerate.   Mark: What we found is that intolerance of uncertainty scores have been going up since the 1990s.   Lucy: Oh really?   Mark: Yeah, so essentially year on year. One of my colleagues in Canada, Nick Carlton did a very nice study where they looked at all the published North American studies of similar types, examples, and then they looked at the extent to which people had mobile phones or high speed broadband.   And so if you think from the early 90s through until the mid-2015s, then there’s been a massive increase in our degree of connectedness, the access of information. And so one of the ideas is that the more information that we have available, the less certain we are about things.   Lucy: This research suggests that sometimes too much information can be unhelpful, can make us more uncertain.   Mark categorised information about Coronavirus into three types. Information that we need to know, like the current rules that we’re all expected to follow. Information that might be interesting to know, like answers to responsible questions that are being asked about what’s happening. And then less helpful information which is unreliable or even malicious.   Even the responsible questions might sometimes be problematic because they’re often unanswerable, so they might just generate more uncertainty.   Mark: There’s a lot of people working on the assumption that the answer is out there if only I can find it. From the point of view I’ve been working from, we can’t information our way out of this, out of feeling uncertain.   Lucy: We will likely all have had other times in our lives when things have felt uncertain and when it’s felt difficult to tolerate this.   Mark: I was reflecting on my own life and I’ve emigrated three times in my life, okay? From the UK to New Zealand, from New Zealand to Quebec and Quebec back to the UK. And so obviously they tend to be very uncertain times because you don’t quite know what to expect.   So things like emigration or becoming a parent for the first time or moving in with a partner for the first time. So it’s not just bad things, but these are just things where you don’t know what it’s going to be like because you haven’t done it before.   Everyone has had experience of big changes, sometimes they’re chosen sometimes they’re imposed. And there’s only so much you can find out, the rest you have to wait and see and that’s an uncomfortable state to be in. But the belief that drives people to try and get more and more information is that the answer is there, but it probably isn’t. It would be nice to say that the information is there, but it’s not.   Lucy: What do you know about, from your research, into intolerance of uncertainty that might help people at this time?   Mark: I think there’s two main things to do at this time. I think one thing is people really thinking about their use of information and where they’re getting it from and is that being helpful or not. Those are the things you want to manage the intake.   But there might be other types of information that might be worth finding out, that might put a bit more balance back into things. Are the birds still singing? What are some of the things that people are doing to help each other out?   Rather than stories about all the things we don’t know, there’s plenty of stories about people who are actually getting on and doing things, groups of people getting organised. So being a bit more selective in what news you go looking for.   Lucy: I really like that. The birds are still singing in Bristol, happily! (Laughs)  Mark: They’re still singing here in Whitley Bay as well and as usual, as for every year, we’ve got a particularly noisy group of sparrows that have taken up residence and I’m pretty sure the starlings will be under the eaves and they’ll be making noise for the next few months. That bit hasn’t changed.   Lucy: So managing information could be about restricting input of stuff that’s not so helpful, but also looking for information that balances the picture out a bit, it’s really nice.   Mark: Yeah, certainly. And I guess that looking for information, that balances things out a bit leads onto the next point, which is the thing about intolerance of uncertainty is that we need the presence of safety rather than just the absence of threat. So if we don’t have the presence of safety, that’s when we feel uncomfortable and that’s when intolerance of uncertainty kicks in.   So it’s not just that there’s no possibility of bad things happening, it’s about the presence of signs that things are okay in very small ways. Hence are the birds still singing? That’s an example.   We know how disrupting the pandemic has been at all sorts of levels, but it’s very easy to focus on the big disruptions, right? So people cannot go out, they cannot socialise, they cannot go to school, but there’s probably lots of little disruptions that people don’t even notice as much. Small routines of everyday life.   Lucy: One of the everyday routines that Mark has made sure to keep the same is his morning cup of coffee

Note: This episode was recorded before government guidance on restricting travel due to coronavirus. We all experience ups and downs in mood, but what happens when the highs are so high and the lows are so low that it really interferes with your life? In this episode we hear from Cate Catmore and Professor Steven Jones about CBT for bipolar disorder.   Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP For more resources check out these links below. Books Coping with bipolar disorder by Steve Jones, Peter Haywood and Dominic Lam https://www.amazon.co.uk/Coping-Bipolar-Disorder-CBT-Informed-Depression-ebook/dp/B07ZWQ877T/ref=sr_1_1?dchild=1&keywords=coping+with+bipolar+disorder&qid=1585237730&s=digital-text&sr=1-1   Overcoming Mood Swings by Jan Scott https://www.amazon.co.uk/dp/B003GUBILQ/ref=dp-kindle-redirect?_encoding=UTF8&btkr=1   Online resources NICE guidelines on bipolar are summarised here https://www.nice.org.uk/guidance/cg185   Cate spoke about mindfulness. You can hear more about mindfulness-based cognitive therapies here https://letstalkaboutcbt.libsyn.com/lets-talk-about-cbt-mindfulness-based-therapies   This BPS report is called Understanding Bipolar Disorder https://shop.bps.org.uk/understanding-bipolar-disorder.html   Recovery toolkit for friends and relatives of someone with bipolar disorder based on research at Lancaster University https://reacttoolkit.uk/   Guardian article on CBT for bipolar disorder by Lucy from a few years ago https://www.theguardian.com/science/sifting-the-evidence/2016/feb/08/nice-critique-a-call-for-more-research-not-an-excuse-for-less-treatment-psychotherapy-cbt   If you’d like to read more academic journal articles this range of papers about bipolar disorder has been made free until 30th April 2020 from the BABCP journals  https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/bipolar-articles-from-bcp-and-tcbt   The photo is by Claire Satera on Unsplash This episode was produced by Lucy Maddox.   Transcript Lucy: Hello and welcome to let's talk about CBT, with me, Dr Lucy Maddox. This podcast brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP is all about CBT. What it is, what it's not and how it can be useful. As an aside, if you listen regularly to this podcast and like it, please do consider rating and reviewing it, it helps other people to find it.   And if you have ideas for other episodes that you'd like to listen to, just let me know at lucy.maddox@babcp.com. Right then, I thought I'd start this episode with a quote from Kaye Redfield Jamison, who's a clinical psychologist and writer. She writes, "When you're high it's tremendous, the ideas and feelings are fast and frequent like shooting stars, and you follow them until you find better and brighter ones.  But somewhere, this changes. The fast ideas are far too fast and there are far too many. You are irritable, angry, frightened, uncontrollable and enmeshed totally in the blackest caves of the mind." That was about Kaye's experience of bipolar disorder which is the diagnosis that this episode concentrates on.   For this podcast, I went to Lancaster and met Cate, who's experienced the highs and lows of bipolar disorder and what CBT can do to help. And Steve, whose research team works on a CBT-based intervention for bipolar disorder.   Cate: I'm Cate Catmore, I'm 64, and I live with my husband, got two children, two sons and two granddaughters. I did CBT a while ago and then I had a course of recovery-based CBT recently.   Steve: Hi, I'm Steve Jones, I'm co-director of the Spectrum Centre for mental health research at Lancaster University. The focus of our work is on trying to learn more about the psychological and social factors underpinning bipolar disorder and related conditions. And to use that information and learning to develop new interventions that are developed with the service user in mind. We've been in existence for about 11 or 12 years, and we've always had people with lived experience of bipolar disorder as colleagues as well as collaborators.   Lucy: Cate had her recovery-based CBT as part of a research study at Lancaster University, delivered by one of Steve's colleagues. It's not the first time Cate had CBT for bipolar disorder, but she felt she was more able to access it this time round.   Cate: In the very first place I had CBT when I was hospitalised about 10 years ago. I hadn't kept up with it, and I'd just let it slide, really. And then, I heard about recovery-based CBT through a bipolar support group at Lancaster University.   Lucy: I asked Cate about her experience of having bipolar disorder.   Cate: I didn't have too many manic episodes, but I have to say that was how it was diagnosed, and I must admit I did enjoy the manic phase.   Lucy: What did it feel like?  Cate: It felt free and exciting and I wanted to do everything that I could, and I felt that everything that I did I was doing very well. The main thing that I remember or being very enthusiastic at work and doing a lot more than I was called on to do. I was lucky that I didn't spend all that much, but I did give a lot of money away to charity.   But the best thing (laughs) and it sounds so self-important, but we went out a lot then, probably instigated by me. Me and my husband went out a lot. I used to say, "Oh got to get to this party early, because nobody will enjoy themselves if I don't get there."   Lucy: What a lovely feeling, though.   Cate: It was a lovely feeling, and sometimes I think I wish I could be a bit more like that. And I don't really get the highs anymore, I get the lows, but not the highs. And I know that they're dangerous and they're not healthy, but when you experience them, they are quite nice (laughs).   Lucy: Yeah, it sounds nice.   Cate: Mine wasn't destructive, I have to say, so I was lucky that I just had the nice inside feelings. I didn't gamble like some people do, and I didn't go out and buy a car or anything like that, just made me feel really good and bigger than I was.   Lucy: Yeah, that's a really nice way of describing. Bigger. Yeah. And what's the other end of the experience? So, the lower bit like?   Cate: Well, the lower bit was very low. Part of the manic bit eventually made things quite stressful because I was jumping from one thing to another. And so, work did become stressful and then home life became stressful because I was trying to do so much at home. And then, I got an eating disorder, and they both seemed to feed one another. So, losing weight so much made me more manic, I think.   And then, the more manic I was, the less I ate because I was doing so much, didn't have any appetite. So, it was that, really that led to me to be admitted to hospital. And then, I wasn't really high anymore after that. Then, the low bit started, which lasted a long time. So, I was in hospital quite a long time.   I think I left a lot of myself behind in that hospital. I don't really think I've ever been quite the same person that I was before. Even though I was assured I was, I think it does have a big effect. Yeah.   Lucy: Steve described the definition of bipolar disorder to me.   Steve: I guess bipolar disorder is typically defined in terms of experience of substantial variation in mood. So, most people with bipolar disorder will have experience of both periods of mania where mood is extremely elevated, people can feel very euphoric. They can have lots of energy, but often that can be mixed together with other things, which make it more complicated like feeling very irritable or frustrated.   And then, periods of depression, which are not unlike periods of depression, feeling rather hopeless and very down, and finding it really hard to get going and engage in normal life. And historically, bipolar has been seen as those two things, really. And what tends to be missed out is that often people are experiencing quite a lot of challenges in between those sorts of episodes, where they're not really experiencing mania and they're not really experiencing depression, but there's often quite a lot of mood variation going on.   And people are also working quite hard to make sense of the variety of experiences that they have. So, quite a lot of our work is targeting that middle period, which seems to be actually pretty crucial for people to then develop a platform for getting on with their lives.   Cate: Mood swings but extreme ones. Yeah, and they can last a varying length of time as well. So, people can be manic just for a short length of time, mine was relatively short, I suppose, two months. But then, I've found that the other side of it is quite dark, the depression can be quite dark. So, I think it's just like an exaggerated way of how a lot of people are, that just manage it normally in their day-to-day life.   I sometimes think that people are a bit wary of mood swings and think that something that they say that's wrong might cause a sudden up or a sudden down. And it isn't like that, at all. It's not so erratic as that.   Lucy: So, what does CBT for bipolar disorder involve?  Steve: An important part of any successful intervention with people with experience of bipolar and a core aspect of the recovery-focused approach is really working with the person initially, to get a shared understanding of their experiences that have brought them to the intervention.   Which isn't just a symptom history, because obviously with things like variable mood, the point, the continuum between something that's a problem and something that's normal experience and parsing those things out is one of the challenges people live with. So, people will often be able to for instance identify experiences where mood elevation has been in some ways amazingly good for them.   It allowed them to get a promotion or complete a task they otherwise might not have been able to

This is an understandably stressful time and it's normal to feel worried. What can we learn from CBT for health anxiety that might help us with feelings of anxiety during the pandemic? In this short bonus episode, Dr Lucy Maddox interviews Dr Jo Daniels from Bath University, about things we know are likely to help.    Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Read an article by Dr Jo Daniels on how to stop anxiety about coronavirus spiralling out of control here:  https://theconversation.com/coronavirus-how-to-stop-the-anxiety-spiralling-out-of-control-133166 Another article about panic here: https://thepsychologist.bps.org.uk/truth-about-panic And this about how it's normal to feel worried:  https://www.ft.com/content/d6c65a50-6395-11ea-abcc-910c5b38d9ed BBC piece on protecting your mental health at this time: https://www.bbc.co.uk/news/health-51873799 BABCP: www.babcp.com Photo by Kelly Sikkema on Unsplash Transcript Lucy: Hi, I’m Dr Lucy Maddox and this is Let’s Talk About CBT. This is a podcast brought to you by the British Association for Behavioral and Cognitive Psychotherapies.   This is a bit of an unusual episode. I’ve come to Bath University to interview Dr Jo Daniels who has experience in researching health anxiety in relation to medical conditions. There’s obviously a great deal of worry around at the moment, understandably, in relation to coronavirus.   I’ve come to ask Jo about how we can look after our psychological wellbeing as well as our physical health. The information that Jo talks about is based on cognitive behavioural therapy principles for anxiety. Obviously there’s no evidence base for this in relation to coronavirus in particular, but really health anxiety in relation to any physical illness has some very similar features, so we hope that this advice can be helpful.   Jo: My name is Jo Daniels and I’m a senior lecturer in clinical psychology and also a clinical psychologist working in health.   Lucy: Could you say a bit about the work that you’ve done that’s relevant to our reactions to the coronavirus pandemic?  Jo: The research that I’ve done so far is focused on health anxiety and distress in medical conditions. I do some work in the emergency department and think about why people keep coming back in and it’s usually to do with anxiety rather than pain. I’ve also worked in health anxiety in complex conditions such as Addison’s disease, chronic fatigue syndrome, also stroke, looking at how important anxiety is in both emotion and physical experience.   Lucy: Fab. I mean it’s really understandable that people are feeling worried at this time because there’s loads of stuff around about Covid-19 and about what we should be doing about it. What advice would you have about how we can avoid spiralling out into panic about what’s happening?  Jo: I think the first thing to say, which feels quite important, is it’s very, very normal to have a fear response, to feel anxious because this is a threat really and that’s the way that our brains are interpreting it, as a threat. Important to just accept that we’re all a little bit worried at the moment and we’re really in it together.   In terms of the things that we can do help ourselves, it’s a digital age, so a lot of people are accessing various sources of media and information at the moment. Thinking about where the notifications are essential, thinking about the sources of information that we access, where some of the new stories are designed to be alarmist.   Keeping perspective is really, really important and we can do that in a number of ways. So keeping in touch, especially if we’re moving into having to be at home, we need to be in touch with people to keep perspective and also to keep ourselves happy.   Also trying to stay calm. It’s really important that we go about our normal daily business as much as we can. Things are going to change over the next few months, but normality is really important. So ensuring that we do the same things that we normally do and don’t adapt too much because sometimes when we do that, we start to do things that are actually counterproductive.   Lucy: So like a balance between following the advice that’s out there, the sensible advice on reputable websites, but doing as much as we can to keep our routine and keep in touch digitally with people that we care about?   Jo: Exactly. It’s really important to be vigilant, but not hyper vigilant. If you look for trouble, that’s what you’ll find.   Lucy: What does hyper vigilance mean, just in case people don’t know that?   Jo: That’s when we’re really paying extra attention to things. You see that a lot in health anxiety and at the moment I think a lot of us may be doing that, looking for signs of coronavirus.   The interesting thing is, is that actually if we become quite anxious; we will product physical symptoms in our body that may mimic it. So things like chest pain, you can get a bit of chest pain or dizziness, nausea, feeling a bit hot, all of those physical sensations can be anxiety or they can be something like coronavirus, which is another reason why it’s important to stay calm. As obvious as it sounds, to keep breathing.   Lucy: I find that really interesting because if I get anxious or worried, I normally feel like I get quite short of breath. Is that quite a common symptom that you would say?   Jo: Yes, definitely. We see hyperventilating – even if it’s at moderate level you might not even notice – in anxiety. Some shallow breathing and again, that sends signals to the brain that there is a threat and it does trigger off, it can trigger off a ‘fight or flight’ response, or an anxiety response. And there is a lot that we can do to help ourselves at this time, but panicking and anxiety is not helpful.   Lucy: Could you say a bit more about ‘fight or flight’ response, I expect people would have heard about that, but just a bit more detail?  Jo: So fear is a very normal response and that fear response is ultimately designed to keep you safe, it’s a survival mechanism. We can receive incoming information that triggers off a ‘fight or flight’ response that actually isn’t a real threat to us. It’s designed to deal with threats such as seeing a scary lion chasing us in the African plain, but actually we still get an anxiety response, a ‘fight or flight’ response when we send a text message to the wrong person, for example.   What happens then is we have a lot of hormones released around our body and people might be familiar with breaking into a sweat or hyperventilating a little bit or palpitations. Many, many symptoms are essentially designed so that we can fight really hard or run really fast just to keep us safe.   Lucy: But not very helpful to run away from a mobile phone when we send a wrong text message.   Jo: No, not really, that’s where it doesn’t work very well, ‘fight or flight’ response because we haven’t evolved, if you like, to be able to distinguish between what’s a real threat and what’s being perceived as something like a social threat where a ‘fight or flight’ response actually can be quite unhelpful and actually stressful.   Lucy: It’s tricky with this isn’t it, because it is a real threat and at the same time there’s a quite a lot of panic around which might be unhelpful.   Jo: Yes, exactly and that again brings on further symptoms associated with anxiety. So it’s really important to, as much as we can, give our bodies and our brains the message that actually there is a threat, but we can deal with it in a pragmatic way.   Lucy: If someone has an existing mental health problem, any advice about how to stop that being exacerbated?  Jo: I think it’s a difficult time for people who have got anxiety already because they’re already going to be quite sensitive to anything else that can be perceived as a threat.   The same applies really, so trying to maintain distance from the difficulty, just following the sensible precautions, making sure that you’re in contact with the people who care about you, both friends and family, but also GP as well, if things are escalating a little bit and it becomes unmanageable or you become preoccupied. It’s really important to put into place strategies that you know that work.   Lucy: So still that balance between making sure you’re accessing information about what to do, but not over checking, either symptoms in yourself or over checking websites that might be showing quite scary stories.   Jo: That’s right. We know that panic breeds panic. So if we see other people panic buying, then we’re more inclined to do that as well. So just trying to, again, take a step back when we feel ourselves becoming anxious and trying to retain that perspective.   Lucy: One of the things that’s so tricky about this is that there’s a lot of uncertainty around about what’s going to happen and what we’re going to be advised.  Jo: We are mostly intolerant of uncertainty and that in itself can be problematic in the sense that this will perpetuate anxiety, that’ll keep anxiety going. Rather than the actual illness itself, or the fear of the illness, it’s the uncertainty of, “Will I catch it? Will I be able to manage it? Will I be badly affected?”  Lucy: And actually it can get us checking online news a lot more can’t it, to see what are we being advised on a moment-to-moment basis.   Jo: That’s right and that’s the problem sometimes with anxiety. Even mild anxiety, because some of us who may not be usually prone to anxiety, will feel a little bit anxious at this time, for understandable reasons. But some of those strategies we use are counterproductive. I don’t know of any good examples of where people have Googled their symptoms and come off feeling better.   So check that checking behaviour, it can make us feel better momentarily, but really serves to increase our anxiety and of course then we get stuck in a loop feeling like beca

Imagine being asked to give up the most effective strategy you have for coping with stressful situations... this is often what it can feel like to people trying to give up self-harm.  In this episode, Dr Lucy Maddox talks to Jane, who first used self-harm when she was 14, and Dr Lucy Taylor, who works with young people to try to overcome self-harm.  This episode contains discussion about self-harm and reference to suicide.  Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Books Cutting Down by Lucy Taylor, Mima Simic, & Ulrike Schmidt https://www.amazon.co.uk/Cutting-Down-workbook-treating-self-harm/dp/0415624533 Websites www.cbtregister.uk for a list of BABCP accredited therapists https://youngminds.org.uk/ for resources for parents and children about self harm https://www.minded.org.uk/ for resources on child and adolescent mental health and development www.babcp.com for more CBT resources You can also listen to our podcast on Dialectical Behavioural Therapy, or DBT, for more on a different approach to self harming. Transcript Lucy: Hi, and welcome to let's talk about CBT, with me, Dr Lucy Maddox. This podcast, brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP, is all about CBT. What it is, what it's not, and how it can be useful. Today, we're focusing on CBT for self-harm.   We obviously talk a lot about self-harm and we also mention suicide, so please look after yourselves and if you know that's something that's especially hard for you to listen to, then maybe just skip this one.   Jane: I think self-harm is something that is a way to control your feelings. It was a way for me to feel something and know why I was feeling it, and know that I was doing it, and know that I could understand it.   Lucy: That was Jane, who we're going to hear more from in a bit. For this episode, I also went to speak to Dr Lucy Taylor, a clinical psychologist, who has worked for 20 years in the NHS, mostly with children and young people. And who now works in private practice in Surrey.   Lucy T: My main interests are self-harm and cognitive behavioural therapy and how to engage young people that might be struggling a little bit to come to therapy.   Lucy: Could you say a little bit about what self-harm is?  Lucy T: Yeah, I think generally, the way we think about self-harm is on a dimension, and when we look at the literature and we look at the studies on self-harm, we talk about causing deliberate harm to your body. And that might be through cutting yourself or burning yourself or taking an overdose. But when we're talking about the dimension, it might mean also maybe drinking a little bit too much alcohol or not eating nutritionally rich food or restricting your diet.   So, it can mean lots of different things, but when we're talking about it within the clinic, it's a deliberate act of hurting yourself. And sometimes that can mean you want to die, and often that isn't because you want to die, but it is a way of coping.   Lucy: So, it sounds like a bit of a spectrum of experience, actually.   Lucy T: Yes. And I think when people come to the clinic, it's starting to cause problems. So, it might be that we all occasionally do things that actually aren't great for us, but it doesn't necessarily cause a problem in our everyday lives.   When it's becoming more it's affecting functioning or it's starting to affect relationships, or work or jobs or school, or when people are concerned about others, that's usually when they come to the clinic.   Lucy: For Jane, self-harm was first around for her when she was a teenager. But she didn't actually get help until her early 20s.   Jane: My name is Jane, I self-harmed from the age of 14.   People spoke about it openly.   Lucy: Like in your class, you mean?  Jane: Just in general, but it was still very looked down upon. I remember being in school, and I had these colourful bits of material over my arms, because I had cut myself. And because they weren't uniform, the teacher made me stand up in front of the class and take them off.   Lucy: That's so grim.   Jane: Yeah, (laughs) I don't think she knew, I don't think that's intent. But that's another thing, had it been talked about the way it is now, that would have probably been the first thing that came to her head, maybe it's that. It doesn't mean that it is, maybe I'm just being defiant and want to wear my rainbow armbands, but I don't think she was aware.   But then, even then, there was no conversation with a counsellor, they told my mum, that was it, but my mum already knew.   Lucy: It's disappointing, though, isn't it? I don’t know, it makes me feel sad to think of you as a young girl, not getting help at that point.   Jane: Yeah, but it was just something that I think a lot of kids of did, and a lot of people that I knew did it for different reasons, in different ways.   Lucy: I spoke to Lucy Taylor about the prevalence of self-harm in young people.   Lucy T: I think recent statistics suggest that at least one in 10 young people self-harm at some point. And I suspect it's probably more than that, but that's what we know about.   Lucy: That's an awful lot, actually, isn't it?  Lucy T: Yeah, it is, and I think it's a growing problem. And I think part of the problem is that when you talk to somebody, self-harm is often a very effective way in the short-term of managing a very difficult feeling. It can feel like the emotions which can feel very muddled up and complicated and overwhelming, that actually using the physical act of hurting yourself can reduce that in the short-term.   I think through CBT and through exploration, what people find is that actually, there are more longer-term difficulties that get associated with it, and it's not helping them to move forwards in their life and to manage those emotions. So, part of the initial stages would be figuring out what the pros and cons might be of self-harm.   Lucy: I guess they might be different in the long-term and in the short-term.   Lucy T: Absolutely, yes. And also, different situations might have different triggers, might have different functions for the young person. It's really getting them to be very good at taking a step back and recognising what they're doing, rather than just launching straight into it. So, giving them a little bit of a choice point.   Often, people aren't brilliant or don't have great skills in managing difficult emotions. So, part of CBT would be to help introduce and offer them skills and strategies to test out, to deal with emotions in a maybe less harmful way.   Lucy: For Jane, it was a bit later on in her early 20s that she found herself suddenly struggling again.   Jane: I didn't really see any big issues within myself until I was about 20 and I started having panic attacks. I had just moved to London from Scotland, and my gran had passed away, and I think a lot just happened that I didn't necessarily deal with. But it took about a year for them to realise that it was anything anxiety-based.   I was given medication for an ear infection, because I told them I was dizzy. I was put on heart monitors. I was given an MRI.   And then, eventually, I did my research, and went to the doctor and said, "Look, I don't feel like I'm having panic attacks, because I can breathe, but from what I've read, that might be what's happening to me." So, they put me in the local CBT programme.   I was eventually diagnosed with panic disorder, which is that you live in a panic attack, it never ends, you wake up and you panic because you're panicking. But you don't know that you're panicking, and you just go like that from day to day to day. And it is exhausting.   Lucy: That's a really long wait to be living in a panic attack. That's a beautiful description of it.   And so, it was anxiety that had brought you to the CBT pathway. But then, you were talking about self-harm in that therapy as well, is that right?  Jane: Absolutely. I think everybody has different kinds of panic attacks, but mine were all-consuming, all the time.   And I think self-harm is something that is a way to control your feelings. And so, it's very, very easy to slip into, I had stopped for years. And then, when that all happened, I just slipped right back into it. Because it was a way for me to feel something and know why I was feeling it, and know that I was doing it, and know that I could understand it.   I think the good thing about CBT is they let you come to your own conclusions. They're more trying to get you to understand your feelings and find a way to break a cycle. And to disassociate the feelings of panic and anxiety and sadness and depression and self-harm and all those things… Especially with self-harm, you do relate it to feeling good, no part of it is good, but at the time it makes you feel good, which is awful, but when you're desperate…   Lucy: Really understandable though as well. There's a reason for doing it, isn't there?  Jane: Absolutely.   Lucy: Lucy agreed the reasons for self-harm are very individualised.   Lucy T: There's numerous different reasons why people might self-harm. What people have said in the past is sometimes it's a way of managing difficult emotions. Sometimes it's a result of having had quite a difficult traumatic time in the past. Sometimes it might be about feeling nothing, feeling numb and wanting to feel something.   And I think it's really important to understand and help the young person to think through why they might be self-harming.   So, part of the initial stages of CBT would be thinking with maybe some education around why other people self-harm. Normalising self-harm, not that it's acceptable and a great way of coping, but actually there's a lot of people out there who are self-harming.   Lucy: And what sort of thing happens in the clinic? What does cognitive behavioural therapy for sel

Striving for achievement has got to be a good thing, right? But what if it starts to get in the way of our happiness? What if the standards we hold ourselves to are unattainable or unrealistic? What if we feel like we'll never measure up?  In this episode, Sam and Professor Roz Shafran speak to Dr Lucy Maddox about CBT for clinical perfectionism - what it is, what it's not, and how it can be useful.  Show Notes and Transcript  Podcast episode produced by Dr Lucy Maddox for BABCP For more information here are some resources. Books This is Roz's book on Overcoming Perfectionism https://www.amazon.co.uk/Overcoming-Perfectionism-scientifically-behavioural-techniques/dp/1845297423 Or for a shorter booklet this is also written by Roz and published by the Oxford Cognitive Therapy Centre https://www.octc.co.uk/product/booklets/changing-perfectionism-2 Other Reading This is a short article on clinical perfectionism by Roz and colleagues https://nopanic.org.uk/perfectionism/ For some free ACT resources from Dr Russ Harris check out his website (Sam talked about ACT) https://thehappinesstrap.com/free-resources/ The bullseye worksheet in these resources is the 4 quadrant image that Sam talks about: https://thehappinesstrap.com/upimages/The_Complete_Happiness_Trap_Worksheets.pdf The clinical perfectionism questionnaire  is on p39 of this article - it is 12 items long and gives you an idea of the sorts of problems that clinical perfectionism can exacerbate. If you are worried speak to your GP: https://www.researchgate.net/publication/259530421_The_Clinical_Perfectionism_Questionnaire_Further_evidence_for_two_factors_capturing_perfectionistic_strivings_and_concerns Some worksheets are available here on clinical perfectionism https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Perfectionism Podcasts Check out other podcast episodes on ACT https://letstalkaboutcbt.libsyn.com/lets-talk-about-cbt-act-episode And compassion focused therapy http://letstalkaboutcbt.libsyn.com/lets-talk-about-cbt-compassion-focussed-therapy-episode-0 Websites For BABCP accredited therapists visit www.cbtregister.co.uk For BABCP visit www.babcp.com Transcript   Lucy: Hi, and welcome to let's talk about CBT with me, Dr Lucy Maddox. This podcast is from the British Association for Cognitive and Behavioural Psychotherapies or BABCP. It's all about CBT, what it is, what it's not and how it can be useful.   In this episode, we'll be finding out about clinical perfectionism, it's a bit of an unusual episode, because clinical perfectionism is not a typical diagnosis. It's a problem which can go alongside many different diagnoses, for example, depression or anxiety.   To understand more, I met with clinical perfectionism expert, Professor Roz Shafran, and Sam, who's experienced CBT for perfectionism. Sam currently studies for a master's in psychology in London. Before this, he worked for a couple of years, and before that studied English at Oxford. Through all of it, he experienced perfectionism-based anxiety, this is where it started.   Sam: So, I think I've always been interested in academics and I know a lot of people aren't. But it meant that at school I enjoyed working hard, but I think the praise I got as a child for doing well became quite addictive. And so, the more I did well, the more I wanted to continue to do well. And then, pressure mounts, and I think I wasn't aware of that as a child.   But suddenly, it wasn't just about doing the best I could in class, but doing the best that could possibly be done, getting full marks. And that's unreasonable, and I think an unhelpful aim. And then, I also felt there was an uglier side of that, which was more comparative, doing better than people around me because I think I found the education system very relative. And it was about being judged against others as well.   And I think while that in itself is stressful, I think what was perhaps most difficult was the way it then grew and eclipsed other aspects of life, resting or doing hobbies, or socialising. Even at a young age was tinged with guilt, or it was in the shadow of the work I could be doing.   Lucy: So, hard to stop?  Sam: Yeah, I think so.   Lucy: How would you describe perfectionism? What does it mean to you?  Sam: So, for me, it's only recently that I’ve viewed it as a potentially bad thing. I think generally it meant to me doing my best at things and striving to feel devoted to things. And I think certain aspects of that feel quite rewarding and energising to feel motivated is good. And I think a lack of that can feel unsettling or depressive.   But recently, especially through therapy, I've started to relate to the more harmful sides of my perfectionism. And the way it relates to my anxiety, and so I feel it's not just about having high standards, but unreasonably high standards and inflexibly high standards. So, it's not just about trying hard, but needing to try my hardest and needing to do my best. Or a conception of my best that is sometimes beyond what I have the energy or the capacity for and that is really draining.   In different ways I think I've experienced perfectionism, so I think academia and education particularly flares it for a lot of people, because from such a young age we're rated and ranked. I've certainly felt sorted by the way we perform, and I think that even now is being flared up by being back in education.   Lucy: Roz Shafran is professor of translational psychology at the UCL Great Ormond Street Institute of Child Health. She's been working in the field of perfectionism for a decade and got interested in it first of all in relation to eating disorders.   Could you start off just by explaining what perfectionism is in a clinical sense? Because it's the sort of thing people sometimes say they have in a job interview maybe. But actually, we're talking about something a bit different, aren't we?  Roz: You will get different answers from different people and different researchers. So, I think many people would view perfectionism as a personality characteristic, it's something that's you're born with, you're a perfectionist, and it has that positive context to it of striving for excellence and trying to do well and an eye for detail that can be very helpful to people. But it's long been recognised it's also got a dysfunctional or unhealthy kind of element to it.   And some researchers think about perfectionism in the interpersonal domain, so perfectionism in relation to other people. But when I was beginning my work with Chris Fairburns, Afra Cooper and the team in Oxford, we were working with people with eating disorders. So, the sort of perfectionism that we were seeing was really very self-driven. And we called it clinical perfectionism because it was the type of perfectionism we were seeing in our clinical practice.   That's not to say that other forms of perfectionism can't also be a clinical problem. But the area we focused on was the clinical perfectionism that was around your own striving for success and achievement, and your own reaction to failure.   And the reason that we put it in a CBT context rather than the personality context, really is because we know that the treatments that are successful have taken that approach. And we wanted to have a treatment that worked, so we wanted to have a formulation and a model in terms of maintaining factors, to give us ideas about where to intervene.   So, we took the same approach to perfectionism that had been taken to bulimia nervosa, that had been taken to panic disorder and we saw it in terms of cognitive behavioural maintaining mechanisms.   Lucy: By cognitive behavioural maintaining mechanisms, Roz just means patterns of thinking or behaviour that inadvertently keep a problem going.   How would you recognise perfectionism that's really causing a problem? What sort of problems do people come with?   Roz: So, sometimes people themselves find it very difficult to recognise and it's other people are telling them that they have a problem with perfectionism. But people do recognise it's interfering with their lives, when we started the idea of being the best at losing weight is actually inherently more problematic than necessarily being the best at work or being the best at sudoku or something like that.   So, the domain in which the perfectionism is expressed is important and can raise alarm bells. But it makes people very unhappy, they don't often come in saying, "I'm a perfectionist." But they come in, they're depressed, they're anxious, they're stressed.   And then, it is the common theme for all of that might be that they have these very high standards for themselves, they constantly feel like they're failing. Nothing they do is ever good enough. They're not sleeping because they're spending so much time on various tasks. And it's just not working for them anymore, even if it did work for them in the past.   Lucy: And is it that the standards are too high? That they're unrealistic or unachievable?   Roz: So, for many people, the standards are not necessarily unrealistic or unachievable, for many they are. But for some, they're not, but it's the striving and the effort that needs to go into them that makes it dysfunctional in that way.   So, we do often have very successful people, the work was started at the University of Oxford our patients were often students or staff members at Oxford. So, objectively, they had reached and attained very high standards, so the dysfunction comes in in terms of the reaction to failure and the importance of it to their self-evaluation.   Lucy: So, something about the amount of effort that goes in and something about the reaction if that standard isn't met.   Roz: So, the central point for us was the way we defined it, clinical perfectionism, is that people's self-worth is overly dependent on striving and achievement of personally demanding standards. And you'r

How can a talking therapy help with a problem that feels as physical as chronic fatigue syndrome?  Ben Adams talks to Dr Lucy Maddox about overcoming his initial scepticism about CBT and why he's glad he did. Professor Trudie Chalder explains the ideas that cognitive behavioural therapy for chronic fatigue syndrome is based on.    Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP More information is in the the links and books below. Websites For more about BABCP check out: www.babcp.com To find an accredited therapist: http://cbtregisteruk.com NHS Webpage about treatments for CFS: https://www.nhs.uk/conditions/chronic-fatigue-syndrome-cfs/treatment/ Books Overcoming Chronic Fatigue Syndrome by Mary Burgess and Trudie Chalder Note At the time of recording all information was accurate. NICE guidelines are currently being reviewed and due for release in 2021   Transcript     Lucy: Hi, and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, or BABCP. This podcast is all about CBT, what it is, what it’s not and how it can useful.   In this episode we’re going to find out about CBT for chronic fatigue syndrome, also known as myalgic encephalomyelitis or ME. Throughout the podcast you might hear ‘chronic fatigue’ sometimes used instead of the full name. But it’s chronic fatigue syndrome or ME that we’re talking about.   I went to a specialist clinic at the Maudsley Hospital in London to meet Ben who’s experienced chronic fatigue and its treatment. I was there on the hottest day of the year so the tube was pretty horrific.   Ben: I’m Ben Adams and I was diagnosed with chronic fatigue syndrome back in, gosh, 2015 I think it was now.   To give a little bit of a history I was healthy, broadly healthy, in as much as anybody is, until about sort of 2012. Then I became… I had a period of depression, there was difficulties in my personal life and relationships and all sorts of family things. And I think my body sort of chose to break down in some way or stop me a little bit.   And I started feeling very tired, really unwell, my brain wasn’t clear. I thought originally it was the depression, but actually I think that morphed into the chronic fatigue. I think one sort of caused the other. And they can go hand in hand quite a lot.   It took me about a year or so – or a bit longer – to actually get the diagnosis of chronic fatigue as opposed to trying to treat depression which wasn’t really doing it. Because I wasn’t actually that depressed (laughs). My mood was actually fairly good. I was just concerned about why I felt so weak and so feeble all the time.   And, yeah, it had a lot of impacts on me. I missed a lot of work during that time. I was working full-time beforehand, had rarely had any sickness over the last sort of 20 years of work. The odd day off here and there but I had… I mean over about four years or so, I had about 18 months off totally in sections. And when I was at work I was on phased returns and doing short hours and not doing a great deal to be honest.   So I had a really long period of sort of getting worse and worse, trying to get back to work, making myself worse. And I actually felt that each time I’ve tried to get back to work after a long period of sort of being unwell and being off sick, it would be hard and after a while it would be… it would feel like I was making myself worse. Like the activity, the mental and physical activity of going to work, each time there’d be a sort of a breakdown afterwards and I’m thinking, “God I’m getting worse and worse, that my baseline is getting lower each time of what I can do.”   And so it was getting to the point where I was almost housebound when I was at my worst. I think, yeah, I’d had about nine months off sick in my longest sort of period off sick at once. And it felt like it was getting up to the end really.   I’d tried all sorts of things beforehand. I’d had a very short period of CBT at the start of my illness, but that was also a bit sort of to do with depression as well. So maybe it wasn’t targeted as well.  And so that didn’t work brilliantly and so during those four years I was trying all sorts of remedies that you read on the internet. Vitamins, testosterone, I don’t know, everything I could try. And nothing helped. And then eventually I got into the Maudsley Hospital.   Lucy: We’ll hear more from Ben and his experience of therapy. At the clinic I also met Trudie Chalder, Professor of CBT at King’s College London, and Director of the Persistent Physical Symptoms Research and Treatment service.   I asked Trudie, who’s treated lots of people with chronic fatigue, what it means to have the condition.   Trudie: Chronic fatigue syndrome is defined by, obviously, its symptoms. So the primary symptom has to be fatigue, but it’s also associated with lots of other physical symptoms such as pain, painful muscles, so myalgia, sleep difficulties, concentration and memory problems to name but a few.   It’s also associated with lots of disability. So people who have chronic fatigue symptoms are often unable to carry out normal activities that we all take for granted.   Some people are not able to go to work, even though they would like to. Other people manage to go to work but are not managing much else in the way of social activities or being able to do things at home – the hoovering or washing up or whatever.   So it has a very profound impact on people’s lives. There are some people who seem to be managing it reasonably well at one end of the spectrum, and then there are other people at the other end of the spectrum who are very severe, who may be in a wheelchair or may even be bedbound.   Lucy: Before starting the therapy, Ben had reservations about whether it was right for him.   Ben: I was incredibly cynical at the time. I’d been on the internet a lot. I’d been looking for cures, looking for hope for a long time and I was very much of the thought that extra activity, increasing my activity, would make me worse as it seemed to have been doing throughout those phased returns to work.   Lucy: That sounds quite scary actually. If you get worse every time you go back that sounds quite frightening.   Ben: Yes, it was. It was really frightening. And so that was, when Antonia was saying we could have a treatment here and I was like, “Well, I don’t want to get any worse and at the moment I’m housebound but I can just about live on my own.” And I have friends who would come round and empty the bins for me and things like that and do heavy stuff. But I could sort of potter around my flat and get out occasionally for a little walk.   There was a few emails going back and forth with Antonia at the start. And I was saying sort of, “What guarantees can you give me? I’m really scared.” And she said she couldn’t really give 100% guarantee that it wouldn’t get any worse but she said in all her sort of 10 years of treatment in this field at the Maudsley that none of her patients had ever got significantly worse. A lot have got better to various degrees. So I thought, “Well, weighing it up I’ll give it a go.”   And so I started treatment with her. I think that was towards the end of 2016.   Lucy: There was something else that concerned Ben before trying CBT which is quite a common concern for people experiencing chronic fatigue.   Ben: I think as a chronic fatigue syndrome sufferer, when you come into the Maudsley Hospital it’s a sort of mental health unit. And you’re kind of thinking, “Hang on a minute, I feel like I’ve got really bad flu all the time. Why does somebody want to talk to me about my mind?” Some people get really angry about on the internet. We all know about that.  And I can understand that. You kind of think, “Why are you trying to treat my head when I feel my body’s so awful?” And so I think maybe trying to get over the fact that the CBT, even though it’s talking therapy, your physical symptoms are there and it’s a slightly different way of managing them as opposed to taking a pill.   But it’s a hard thing to explain to people who think, “I feel very ill, I need some sort of pill, there’s something wrong with me physically. I need a… talking to somebody’s not going to help.”   Lucy: Yeah, it’s a really, I can totally understand how frustrating that must feel if you’ve got very physical symptoms then you're being asked to come and talk about it.   Ben: Yes.   Lucy: Trudie explained a bit more about this link between physical symptoms and how CBT can affect them.   Trudie: Well I suppose the first thing to say is that the fatigue is not the sort of tiredness that we all feel on a day like this when it’s nearly 100 degrees.   Lucy: It’s really hot.   Trudie: Yeah. (Laughter)   The fatigue that people are feeling is abnormal. It feels very out of control and it feels extreme. And there’s no doubting the fact that the symptoms are real and they’re physical. But that real physical symptoms, which will be potentially perpetuated by physiological factors, so hormones and all sorts of different things that are happening in your body, as well as what do you, that those things can be altered by you doing things differently.   Lucy: What is cognitive behavioural therapy for chronic fatigue syndrome? What’s it like?   Trudie: Well, cognitive behaviour therapy is a practical approach primarily. It’s a talking therapy. And it helps people to reengage with some of the things that they value very highly. And gradually build up their activities over a period of time.   Obviously at the start people feel very daunted about any change. And at the beginning they may feel very sceptical about whether it’s going to even work. But obviously with all CBT everything is negotiated with a therapist, so nothing is imposed upon anybody unless they decide that that’s what they want for themselves.   And at each session

How do you talk about something in therapy when all you want to do is avoid thinking about it? And why might it help to be able to tackle it?  Nick Gilbert talks to Dr Lucy Maddox about how he sought help for post traumatic stress disorder (PTSD) and his therapist, Dr Jen Wild, explains the theory behind the treatment, and dispels some myths about what it's like.  This show includes reference to suicide.   Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Some more sources of information are listed below. Websites For more about BABCP check out: www.babcp.com To find an accredited therapist: http://cbtregisteruk.com NHS Website about treatments for PTSD are described here: https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/treatment/ Support for veterans can be found here: https://www.combatstress.org.uk/ Books Overcoming Traumatic Stress by Claudia Herbert Trauma is Really Strange by Steve Haines Jen has a book coming out soon too - watch this space for details.  Transcript Transcript  Lucy: Hi, and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. The podcast all about CBT, what it is, what it’s not and how it can useful.   In this episode we’ll find out about post-traumatic stress disorder, known as PTSD. I went to Oxford to record this episode and apologies in advance for the drilling, there were some building works going on outside where we were recording. We did try recording in the bathroom but it didn’t really work.   I met Nick Gilbert who was diagnosed with PTSD in 1990, six years after the event that triggered it. This is his story.   Nick: I’d reached a point where I was sat in my car and had no idea what I was going to do next. I was actually considering ways of ending my life.   So I’m sat in the car considering these things and I phoned my GP who was aware that I’d got issues – got some problems. He put me though to or put me in front of Talking Heads I think it’s called. And they phoned me and said would I be prepared to take part in a study. And, quite frankly, I was so desperate at the time, if they’ve have suggested witchcraft I’d have probably gone along with it.   Lucy: Nick started having CBT in 2012.   Nick: And then I met Dr Jennifer Wild and I don’t think it’s too much to say that that lady changed my life.   Jen: The people I work with are suffering from post-traumatic stress disorder and the treatment I’m giving is trauma-focused cognitive behavioural therapy.   Lucy: Jen Wild is a consultant clinical psychologist at the Oxford Centre for Anxiety Disorders and Trauma.   Jen: Post-traumatic stress disorder, or PTSD as it’s commonly known, is a severe stress reaction that can develop after natural disasters like a tsunami, a physical assault, sexual assault, car accidents, really unpleasant events where people flooded with unwanted memories and can’t get them out of their head. It’s very debilitating, it’s very terrifying, it takes up their concentration. They feel very hyperalert.   Lucy: What does hyperalert mean?  Jen: Hyperalert is feeling very on edge, very aware of your surroundings. And I think what happens with PTSD is people’s focus of attention shifts. So instead of being very absorbed in their environment or with their work or their family, for example, suddenly people are very focused on something bad could happen, “I could lose my life at any moment. Something might happen to my kids.”  So the shift of attention is from being absorbed in the environment to something terrible could happen. And when people are focused on danger they notice danger.  Lucy: It sounds just like it’s very scary all of the time.   Jen: It’s very scary, it’s very unsettling. There are four clusters of symptoms with PTSD.   So the first cluster called the reexperiencing symptoms, and that really means people are reexperiencing the trauma in the form of unwanted memories or nightmares or physical reactions in response to trauma reminders.   The second cluster of symptoms are the avoidance symptoms. So understandably when we’ve been through something horrendous, we want to push it out of our mind, avoid reminders, avoid people who remind us of the situation, avoid TV programmes that might remind us of the horrible trauma. So the second cluster of symptoms are the avoidance symptoms.  The third cluster of symptoms are what’s called, in our language, negative alterations in cognition and mood. That basically means people feel and think more negatively. So they might have thoughts like, “I’m permanently changed for the worse,” or “This trauma happened and it’s 100% my fault.” So they may be excessively blaming themselves.   And then the fourth cluster of symptoms are what we call the hyperarousal symptoms. So that’s the sleep problems, the concentration problems, that feeling of being on edge, hyperalert to danger. And that they’re usually caused, these hyperarousal symptoms, by the trauma memory, so the memory of the trauma keeps people feeling like danger is just around the corner.   Lucy: This was Nick’s experience of PTSD.  Nick: I sometimes burst into tears for no reason. And in my head I know I’m crying and I can’t understand why I’m crying and I don’t want to cry but I do. I feel angry and frustrated. I have no idea why. Little things upset me a lot. Stupid things.   You know that you shouldn’t react in the way that you do but you're almost a spectator. You don’t have any control over it. And you try very hard to break out of that but it sometimes is very difficult to do.   It goes after a while. And lots of other things, different reactions to things, triggers you see on TV and things.   And one of the weird things actually is not reacting. The incident that triggered my condition involved climbing down a cliff. For a long time I couldn’t even consider looking at a cliff. But now I see it on TV and it doesn’t bother me. And that bothers me.   Lucy: That bothers you that it doesn’t bother you?   Nick: Yeah. Because does that mean I don’t care anymore? Because there was a fatality. Should I feel that way?   For me, I don’t know about others, but for me there’s a, if you like, survivor guilt. And shame for surviving. And not understanding why I was the one that survived and other didn’t. So you almost feel offended on their behalf.   Lucy: Is it right that quite often feelings of shame might come along with it as well?   Jen: People can feel ashamed after their trauma when they start to question what they did during their trauma, if they have thoughts, “I should have acted quicker, I shouldn’t have been in that situation, I’m not happy with how I responded in that particular trauma.” Then that can lead to feelings of shame.   Of course people can also feel ashamed with trauma like sexual assaults where they felt very violated and very ashamed to talk about what happened. Maybe they were humiliated by their perpetrator and they may internalise the voice of their perpetrator and it may become very difficult to talk about what happened because they think their clinician or their therapist will judge them in the same way.   Lucy: So it sounds like something that’s understandably really difficult to seek treatment for actually. What is the treatment like?   Jen: The treatment is very effective. That’s the first point to make. And it has a scary title; it’s called trauma-focused cognitive behavioural therapy. The therapy is really looking to update the horrible trauma memory.  When we go through something horrendous we’re really focused on surviving and we don’t always pay attention to information at the time that is really helpful to link to the trauma memory.   So, for example, somebody might have had a horrendous car accident and thought they were going to die at the time. And then when they’re reminded of the trauma today they see a car, they get that feeling they’re about to die again. They may have unwanted memories coming to mind of the moment just before impact. And then in their mind the memories will stop at the worst moment, the moment before impact, for example.   And then what treatment would do is help to flesh out that memory in a little bit more detail. So we know if somebody’s sitting in our office that they have survived the trauma. So we want link that information, “I’ve survived,” to the memory of the car accident.   So by the end of treatment the trauma memory would be so much less threatening and it would be something around, “I’ve had a car accident, I thought I was going to die, I felt very afraid, I was injured, I now know I have recovered from some of the injuries, I’m safe and I have survived. It’s in the past.”  And you can see how that new information gives context to the trauma and makes the meaning much less threatening, which is what helps people to feel a lot better.  Lucy: And so does it involve sort of talking through the trauma quite a lot?   Jen: I think the common misconception is that the trauma-focused CBT really is about talking about the trauma a lot. But I’ve just looked at a case series where I counted the number of times I actually went into the trauma memory in a lot of detail with clients. And in a 12 session treatment I actually went into the trauma memory in a lot of detail in one session. So it is a misconception.   Of course we work with the trauma memory but we’re often working with trauma triggers. And that’s really breaking the link between the present and what’s going on now when the trigger appears to what happened in the past. And that’s not really talking through the trauma memory. It’s really about, “What’s going on now that’s different to the past that shows me that I’m safe?”   Lucy: So anyone listening to the podcast who’s thinking about having trauma-focused CBT could be quite reassured by that, that it’s not every session at all that you’re going through the trauma in detail.   Jen: It’s not every session

What are 'intrusive thoughts' (we all have them) and what has CBT for OCD got to do with a polar bear? People sometimes talk about being "a little bit OCD", but the reality of obsessive compulsive disorder is much more difficult than a tendency to line your pens up or be super tidy.  Ashley Fulwood talks to Dr Lucy Maddox about his journey towards recovery from OCD with the help of CBT, and Professor Paul Salkovkis explains how CBT works.   Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Want to know more?  Websites For more about BABCP check out: babcp.com To find an accredited therapist: http://cbtregisteruk.com Ashley's charity, OCD-UK is here, and there is a lot of useful information on their website: https://www.ocduk.org/ And another OCD charity, OCD Action, is here: https://www.ocdaction.org.uk/ Books Break Free From OCD by Fiona Challacombe, Victoria Bream Oldfield and Paul Salkovskis Overcoming OCD by David Veale and Rob Wilson Transcript Lucy: Hi and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. This podcast is all about cognitive behavioral therapy, what it is, what it’s not and how it can be useful. Today we concentrate on cognitive behavioral therapy for obsessive compulsive disorder, or OCD.   Before we meet this week’s interviewees I’d like you to try really, really hard not to think of a polar bear. Do not imagine a polar bear. What did you notice? Did you see a polar bear in your mind’s eye? We’ll come back to that later.   For one of this episodes interviews I took a train up to Belper, near Derby to meet with someone who has had personal experience of OCD.   Ashley: My name is Ashley Fulwood and I work for the charity, OCD UK. OCD UK is a charity founded by me and a colleague in 2004. We’re completely service user led. So everybody involved in our charity at the moment has been affected by obsessive compulsive disorder, either directly, sufferers like myself, or through a loved one.   But it’s been good because through my work the charity is how I’ve actually made progress with my OCD and I’m now certainly on my recovery journey.   Lucy: Life for Ashley now is really different from how it was at the height of his OCD.   Ashley: I thought I was managing my OCD and it’s only years later when I started working with the charity that I realised, actually I wasn’t managing my OCD. I was able to go to work and hold a full-time job, so that’s why I thought I was managing it, compared to other people. But looking back, it tainted every aspect of my life, so it became a very regimented day. I would get up, go to work, avoid eating or drinking during the day. Obviously as a guy we can urinate without having to touch the toilet, so I could just about do that.   As my workday ended at 6pm, my colleagues who I’d got on brilliantly with, they would all go off to pubs and restaurants and clubs and they would always invite me but I would make excuses because I knew that I’d have to go home and go through my rituals.   So I’d head off home, I’d probably grab a takeaway or something to eat on the way home so that I was ready to use the toilet when I got in. I would use the toilet. By the time I’d finished doing my shower rituals it would be 9:00/10:00 at night, which is more or less time for bed and repeat-repeat-repeat.   Lucy: Ashley is not the only person I spoke to for this podcast. I also spent an afternoon in Oxford speaking to the current president of BABCP board and international expert in cognitive behavioural therapy for OCD.   Paul: I’m Paul Salkovkis, I’m the director of the Oxford Centre for Psychological Health, which includes various bits, but particularly the Oxford Centre for Cognitive Therapy and the Clinical Psychology Training Course.   Lucy: I asked Paul to explain what OCD is.   Paul: OCD is much misunderstood. What it is, is people experiencing really unpleasant intrusive thoughts, things which pop into their head, but also images, impulses or doubts which upset them. And those are the things we call ‘obsessions.’   They’re things which pop in the head which are unacceptable and then compulsions that are actually related in the sense that they’re things that people do to try to prevent bad things from happening. For example, to wash their hands that feel contaminated or say a prayer if they’ve had some sort of very unacceptable thought. Try to wipe thoughts out and so on. And those are compulsions.   Together they both occur actually in everybody. So everybody experiences occasional upsetting thoughts and do things that perhaps are driven by those kinds of thoughts. The disorder bit is when it interferes with their life and stops you doing things that you want to do. So it’s not just the obsessions and compulsions, but it’s the interference with life, taking time, distress to the point of torture sometimes. And at its most extreme. This is a life destroying problem.   Lucy: Could you say a little bit more about what sort of intrusive thoughts people might experience?  Paul: Classically obsessional thoughts are often thought of being about contamination and so on. But actually they hit you wherever you’re most vulnerable. So if you’re a religious person, you tend to have obsessional thoughts, say blasphemous thoughts. Clean people have thoughts about being contaminated. Careful people have thoughts of being careless. People can have thoughts of sexually abusing children, including their own children and so on.   They’re the thing which you’re most afraid of and then the compulsions are pretty much logically related. There is always a rational link, it’s just you need to get it from the perspective of the person who is experiencing those obsessions and compulsions.   Lucy: Right and so the compulsions are kind of to cancel out or neutralise the upsetting thoughts?   Paul: Compulsions in my view divide into two types. There’s those which are meant to prevent bad things from happening, so you wash your hands to make sure that you don’t pass contamination to other people. And there’s others that are meant to undo things. You say a prayer because you had a blasphemous thought and so on. You have an image of your mother dead, so you then try and form an image of her alive.   There’s things which are designed to really check whether or not something has happened and then the other things are called restitution, like putting it right.   So they’re either meant to forestall it or undo it basically.   Lucy: You said it’s only a disorder if it gets in the way of somebody’s life. Sometimes people say they feel a little bit OCD or that kind of thing. What would you have to say about that?   Paul: The idea of being a little bit OCD is kind of quite controversial and you get people claiming they’re a little bit OCD. OCD is of course a life destroying problem and so to say that your, say your preoccupation with putting things in a straight lines is OCD, is probably unhelpful in terms of the way that we think about things.   That being said, the roots of OCD, as far as I’m concerned, sit in normal behaviour. So I’m a little bit OCD in the sense that I experience intrusive thoughts, which map on very closely to things that are experienced by people with OCD. I absolutely don’t have OCD myself though, and I’m not claiming that.   So it’s a bit of a tricky one, it’s a bit more complicated than it just being insulting to say you’re a bit OCD. The way it’s often used though is essentially belittling those people who suffer from the problem. And I think it’s best avoided really.   Lucy: Is it okay to ask what sort of intrusive thoughts you have?   Paul: Sure. Over the years I had to explain to people that I’ve worked with, about the normal intrusive thoughts that I have, which are not at all normal.   So I’ve had thoughts about harm coming to my children, me harming my children, me sexually abusing my children and so on. It sounds horrific stuff. Most people though will have experienced something like this. Perhaps in a fleeting way and they kind of think, oh, there’s a funny thought.   Other examples, when you’re standing in the tube and you think about either jumping in front of the tube or pushing somebody else, off a cliff. Ideas of being contaminated, of course lots of people have lots of intrusive thoughts about being ill. They notice a blemish on their skin and think it might be the first sign of cancer and so on.   I’ve had all of those things and I think, well, I know that the majority of other people have something like that and so on. At one level they’re every day, they don’t terrify me, but for somebody who has OCD, they are hell, they’re just torture and they consume the person’s life and destroy it. So they’re something and nothing, but for the person with OCD, they’re a lot more than nothing.   Lucy: I get the one about pushing people down the stairs actually, quite frequently (laughs), promise not to do it! (Laughter)   Now Paul and I were able to have a bit of a laugh there about that intrusive thought that I get, but these thoughts are no laughing matter when they’re part of OCD. I asked Ashley to tell me about his experience of OCD and the impact that it had on his life.   Ashley: Yeah, of course. So obsessive compulsive disorder, most people call it OCD. And for me I had intrusive thoughts and fears and worries around germs, around using the toilet. Often it wasn’t a case of washing until I saw that I was clean, I would have to feel clean and of course the more you try and feel something, the less certain you become.   And it’s the same with any type of OCD, whether it’s checking or other parts, the more you try and convince yourself that you’re okay, the less certain you become.   My OCD meant that throughout my 20s and 30s effectively I couldn’t use the toilet, I couldn’t even use my own because I couldn’t touch the toilet lid or seat without then having the urge to shower.

Maggie's flat was so full that the council threatened to clear it out themselves. CBT helped her understand the reasons behind her hoarding disorder and start to let go of some of her possessions.  Maggie and Dr Victoria Bream speak to Dr Lucy Maddox.   Show Notes and Transcript Podcast episode produced by Dr Lucy Maddox for BABCP Want to know more? Some useful resources are included here.  Websites For more about BABCP check out: babcp.com To find an accredited therapist: http://cbtregisteruk.com Hoarding UK's website has resources including support group listings: https://hoardinguk.org/ Centre for Anxiety Disorders and Trauma website: https://www.kcl.ac.uk/ioppn/depts/psychology/research/researchgroupings/cadat Books Overcoming Hoarding by by Satwant Singh (Author), Margaret Hooper (Author), Colin Jones (Author) https://www.amazon.co.uk/Overcoming-Hoarding-Self-Help-Behavioural-Techniques/dp/1472120051 Transcript     Lucy: Hello, and welcome to Let's Talk about CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT. What it is, what it's not and how it can be useful.   In this episode, we're going to find out about hoarding disorder. I speak to someone who has experienced hoarding and the treatment for it and a clinical psychologist who specialises in CBT for hoarding disorder.   Maggie: My name's Maggie and I've been fortunate to have received therapy in a group and individual therapy. So, I would like to be able to share some of my experience that I hope will be of help to people.   Lucy: Could you say a little bit about how things were for you before therapy?  Maggie: Hoarding is how I coped with life because it kept people out and it kept me in, where I didn't have to deal with the outside world. Being alone has always been my comfort zone.   Lucy: So, it kind of kept you from having...   Maggie: Kept things at bay. I saw the outside world and people as the ‘other’. The enemy. That's what I've had to deal with. There was a lot of pressure from the borough where I live with the fire risk that hoarding causes.   Lucy: So, you were quite unsure about it to start with?  Maggie: I wasn't happy because I was being challenged and I felt threatened. I had a way of life that suited me.   Lucy: Is it okay to ask what your house was like?  Maggie: It's a council flat that I've had for 18 years, now. It just built up and up. I just didn't try and stop it. I have always seen books as my best friend. I always felt books would be the solution to my problems.   When I retired 13 years ago, I was able to indulge in a lifestyle that I'd always wanted, where I'd just ride around on buses and read what books I want. Go deep into things and study what my hobbies are.   Lucy: It sounds quite nice, actually.   Maggie: Well, it is. It's a selfish life. But family life didn't mean happiness to me and relationships didn't spell happiness. My comfort zone was living life vicariously. Learning about life and people through biographies, books, magazines, rather than going straight in to the physical reality. Which suited me.   Lucy: I'm sure a lot of people can recognise that. There's something very nice about that, isn't there? But it sounds like it was really getting in the way.   Maggie: Well, it doesn't give you deep, ultimate satisfaction. You're always on guard, in a way. When I first started individual therapy, it seemed very threatening. But it isn't threatening, now. It's almost like I can feel creative more instead of not moving beyond that defensive position.   Lucy: We'll hear more about Maggie and her reasons for hoarding later. But first, here's Dr Victoria Bream, clinical psychologist at the Centre for Anxiety Disorders and Trauma and the Maudsley hospital.   Victoria: Hoarding is characterised by a large volume of possessions in the home. Things can sometimes be somewhat organised but generally are in disarray. It can be a mixture of items, often paper, books. Also, food, clothes, bric-a-brac. Things inherited from other people.   All these items are of such a volume that someone's home is difficult for them to use in the way for which the home was designed. So, the bathroom... The bath may be full of clothes. In the kitchen, there might be books all over the worktops. We'd characterise it as hoarding disorder when someone's life is actually impaired and they're experiencing a certain amount of distress from this.   I think everybody has the capacity to form a strong attachment to any item. People with hoarding difficulties, for various reasons – some of which we understand and some of which I think we don't – form that level of attachment to a greater number of objects.   Lucy: Has it made you think about your relationship with possessions differently, doing this work?  Victoria: Oh, constantly. I think that might be one of the things that draws me to it. I really get it, with understanding how possessions can mean so much. My home is far from immaculate and I hang on to all sorts of things for sentimental reasons.   If my children give me a picture that says, "I love you Mummy" on it, in that one second they give it to me, I feel very attached to it. I can't let it go. There's no way I could rip it up and put it in the bin.   I think it's made me think about how we're all kind of battling with these beliefs about possessions. What is it that then tips it over into being something where it becomes a problem that takes on a life of its own.   Lucy: What's CBT for hoarding disorder like? What does it look like?  Victoria: At the moment, the main work we do is based on the work of Gail Steketee and Randy Frost and colleagues in the States. They've been working on things in the last 20, 30 years or so to come up with a CBT model.   They have identified the main beliefs that people have about possessions. So, having an emotional attachment to possessions. Seeing the utility of an object far more so than other people might. So, everything would have a purpose. A yoghurt pot, once the yoghurt has gone, isn't just a container. It could be a plant pot. Also, the intrinsic beauty and aesthetic properties of objects. These things seem to be particularly potent belief systems in people with hoarding problems.   The Steketee and Frost model also acknowledges the influence of past experiences, early experiences, whether there's a familial history of hoarding problems, whether people have experienced a trauma or other kind of life event that might precipitate hoarding in some way.   Also, there's a component of information processing differences. So, that's much more tricky to investigate. There are a couple of papers that do look into that but there's a lot more we need to learn about the way that people handle information and how it affects their ability to order the items they do have, make decisions about the things that they do have in terms of discarding, and then how to carry that plan out.   Lucy: That's really interesting. If I were sitting working at a desk that's really cluttered, say for example... (Laughter) I'm thinking of my desk, which is quite cluttered! That could have an impact on how our attention is?  Victoria: When we're working with people trying to make decisions in their home, sometimes just the volume of stuff around them makes the decision process difficult. Peoples' attentions flip from object to object.   We quite often get people to bring bags of things to the office and say, "You can take it all back home again if you want. But let's try and sort through it while we're here." People are usually quite effective at doing that. Not everybody. But we get people to stick things in the recycling and the bin or take them straight to a charity shop.   Lucy: You mentioned about early experiences sometimes having an effect or an impact, or perhaps it being more likely for someone to have a hoarding disorder. Could you say a tiny bit more about that?  Victoria: Yeah. What's in the literature so far is that, if people have had some family history of hoarding, that might be associated with hoarding themselves. They've just grown up not knowing another way of doing things but to have a lot of clutter. And then often inherit those items into their own home, as well. So, have two houses' worth of stuff in one go.   Sometimes if people have come from very impoverished backgrounds where they haven't had enough when they were growing up, then when they have had the means to buy things and acquire things, it's felt very loaded to keep those items. It would be extremely wasteful to get rid of everything. Then it's working with people to update those beliefs and think, "Is that a helpful idea to have around at the moment?"  Lucy: So, how did Maggie find CBT?  Maggie: We looked at why I was doing this. First of all, the big change for me was being unconditionally accepted because I'd never had that from my parents. It was an emotionally cold upbringing, like some people have.   I think the common element in hoarding is some sort of, I feel, very primal trauma. Where you're not given unconditional love and acceptance, for whatever specific reason. I think that is the basic that you have to feel because every baby really does need unconditional acceptance, otherwise it won't feel love. It's about replacing fear with love. It sounds simple but it's not easy.   Lucy: No. I was going to say, how does that happen? What would I have seen if I was in your therapy sessions? What kinds of things did you do or talk about?  Maggie: Well, we reviewed the week and set an agenda through how things had developed. And looked at what I had or hadn't done. I found it particularly helpful because it helped to ground me. Because I tend to be a bit above it all and beyond it all. I've had to look at those issues. To look at why I don't really want to be here.   I think you have to face y