Let's Talk About CBT

In this episode, Helen talks with Lizzie, a beauty content creator and disability advocate, and Bex, a CBT therapist, about Lizzie's journey navigating living with long term health conditions, trauma and the transformative impact of Cognitive Behavioural Therapy (CBT). Lizzie shares her experiences living with Crohn's disease, POTS (Postural Orthostatic Tachycardia Syndrome), and hypermobility spectrum disorder, alongside the emotional challenges of managing these conditions. She discusses her initial scepticism about therapy and how CBT helped her address anxiety, PTSD, and prioritising her own well-being. Bex offers insights into the therapeutic process, addressing common misconceptions about CBT, and highlights the importance of building trust and tailoring therapy to individual needs. Together, they discuss the interaction between physical and mental health and strategies for balancing driven lifestyles with well-being. Useful links: Explore Lizzie's content on Instagram and TikTok (@slaywithsparkle). Listen to our sister podcasts: Let's Talk About CBT - Practice Matters and Let's Talk About CBT - Research Matters: https://babcp.com/Podcasts Find us on Instagram: https://www.instagram.com/babcppodcasts/ Learn more about CBT www.babcp.com Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This episode was edited by Steph Curnow Transcript: Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies What we've got for you today is a conversation with Lizzie and Bex. Lizzie's going to talk about her experiences of having CBT and living with a number of conditions that she'll tell us more about in the episode. We're going to talk to Bex, who is a CBT therapist, and she's going to talk with us about working with Lizzie as well. Welcome to you both. Lizzie, would you like to introduce yourself? Lizzie: Hello! Thank you so much for having me. So as Helen's just said, my name is Lizzie. I am also a beauty content creator known as @slaywithsparkle on Instagram and TikTok and a little bit of YouTube and I'm also a speaker that talks about disability awareness. And I try and raise awareness about the health conditions I've got and general sort of disability awareness and activism about that. Helen: Thank you Lizzie, and welcome. Thank you for coming to talk to us today. And Bex, would you like to tell our listeners about you? Bex: Hi. Yes, I'm Bex. I'm a CBT therapist and worked with Lizzie a little time ago, when I worked in a physical health service for IAPT at the time. And I currently work more with trauma in Sheffield both in the NHS and privately. Helen Thank you, Bex. And maybe I should just say, when you said IAPT, we're now talking about NHS Talking Therapies. Bex: That's right. Yes. Thank you for providing the update. Helen: So Lizzie, can I ask you a bit about what was happening for you? What was going on that meant you ended up having CBT? Lizzie: So for me, I really had quite a negative opinion about any sort of talking therapy and had very much been brought up with the idea that if you have some sort of mental health problem, you should be able to solve it yourself. And if you just think positively and carry on, then everything should be fine. Because of my health conditions, so I will just mention just briefly so people are aware what my health conditions are just for context. So I have, Crohn's disease, which I was diagnosed with when I was 21 and then later about 9- 10 years later, I was diagnosed with hypermobile spectrum disorder and also POTS, which is a condition that affects my blood pressure and heart rate. And when I had a first flare of Crohn's disease. I'd obviously had it a long time without realising, but when I first flared with Crohn's disease, I really struggled with the concept of having a physical health condition that I couldn't push through. So with my Crohn's, I ended up ignoring a lot of the doctor's advice because I had this idea that I should be able to cure myself. I really pushed myself to look at alternative therapies. And then, because of that, I ended up ignoring what the doctor said and becoming a lot more ill. Unfortunately, because of a combination of the Crohn's having been misdiagnosed for a long time as IBS, and then because of all of those sorts of ideas about that I should be able to cure myself, my Crohn's did get so bad that I ended up having to go to hospital and have emergency surgery on my bowel. Years later, so about two or three years later, I started having real panic attacks, which I'd never had before. I was anxious all the time and I couldn't sleep. I would sometimes wake up in the middle of the night at like 4am and get the urge to clean the entire house and was sometimes just up in the middle of the night pacing up and down. And my partner at the time said to me, you know, this is not normal. Something's going on. You really need to think about getting some help for this. And I was devastated at that concept because I obviously had this idea that I should be able to fix myself. And so that was the sort of wakeup call that I had to go and get some help and I applied to IAPT at the time and had my first round of CBT. Since then I've had three rounds of CBT and a course of EMDR as well but yeah, that was the first thing that sort of led me to CBT. Helen: Thank you, Lizzie. And it just strikes me what a difficult combination of things you experienced that not only were you having a number of quite complicated and long-lasting physical symptoms, also the experiences you'd had when you were younger meant that it was really difficult to seek help for the panic attacks and the anxiety and so on. Can I ask you just to say, in case anybody's not familiar with the terms, can you just say a little bit about what the symptoms of Crohn's disease are? Lizzie: Yes, absolutely. So Crohn's disease is different for everybody. For me, I really struggled with pain and one of the biggest symptoms that I had was pain. I also struggle with diarrhoea. It's not the most glamorous disease. It's quite embarrassing sometimes. Some people have a lot of nausea and vomiting. For me, that's not been as much of a problem. To me, the biggest problem has been pain. And it got so bad that when I was actually in my final year of university, I'd been told by the doctors repeatedly that it was IBS, and it was just stress related IBS and I just needed to make sure I watch what I eat, tried to up my fibre, which made me a lot more ill. And eventually it got to the point where I literally couldn't even drink water because my oesophagus was closing up. I was in absolute agony and I finally went back to the doctor and I was like, really, honestly, there's something seriously wrong here and then they finally sent me for the right tests and they found the Crohn's disease. The other big symptom with Crohn's disease as well is fatigue. So, most people actually say that fatigue is the most debilitating symptom of Crohn's disease. And for me, I mean, at the moment I am in a flare and I am sleeping 14 hours. And if I don't get that 14 hours, I cannot function and I need a full day in bed to recover. Helen: And again, you've said about some of the symptoms being a little bit similar to IBS or Irritable Bowel Syndrome but having a really far reaching impact on every area of your life, really. You also mentioned that you had POTS, which can affect your blood pressure. And if I have this right, it's Postural Orthostatic Tachycardia Syndrome? Lizzie: Yeah, so it affects your, for me, it affects my blood pressure. Not everybody has problems with their blood pressure all the time. But what happens is your heart isn't getting the right signals. And so you end up having a really high heart rate when you stood up and then that can lead to you passing out. It also leads to symptoms again, like nausea, fatigue and for me, it just feels horrible. Like, it's just that feeling of like sometimes the world's sort of closing in on you and when you're about to go you just feel really sick, really like something's pulling you to the floor. It's a very frustrating condition. I think out of all of them, Crohn's is the most dangerous and that one is the one that when that's flaring, I'm always a little bit nervous because mine is quite severe, but POTS is definitely the one that is the most infuriating. I've had to lie down in the middle of shops. I once had to lie on the floor in the middle of Poundland because I was passing out and honestly, it's just mortifying. It's really embarrassing. Helen: And I'm noticing there as well, Lizzie, that you've just said that the Crohn's disease because of the symptoms of diarrhoea and you know that can be embarrassing. We all know that the impact of eating a lot of fibre, which you were advised to do can be, can lead to embarrassing symptoms and then the POTS as well, that having to lie down somewhere public, more embarrassment. And in addition to that, you also said that you have hypermobility syndrome. And again, can you just say a little bit about what that's like? Lizzie: Yes, so for me, I have a late diagnosis of hypermobile spectrum disorder. There are a couple of things that are related, so similar, sorry. So there's hypermobile EDS and then there's also hypermobile spectrum disorder and they're very similar conditions. But the one that I have is hypermobile spectrum disorder and with that, it just basically means that my joints are too floppy. They extend past the natural point where they should extend because my collagen is built in a way that means it can stretch further than it should. So it was okay when I was younger. I used to be able to just do amazing, you know, bend my back really far back and look very bendy. And then as I got older, as the rest of my connective tissue ended up getting looser, as it naturally does when you get older, my joint started to get worse. I got more and more joint pain. I'd had joint pain my whole life, but it became a lot more severe. And it's now got to the point where I am not able to walk any distance with, any significant distance without a walking stick. And in order to go around, say, for example, like a supermarket, I need a wheelchair. Helen: Thank you for explaining all that, Lizzie. Again, I'm listening to you and I'm hearing lots of things that could make it also really hard to manage your mental health. And I want to come back to you and talk to you a bit more about what it was like having the CBT. Before we do that, can I just ask Bex what it was like for her when she first met you? Because we've heard a bit about your background and maybe what you were thinking before you first went to see her. So, Bex, what was it like meeting Lizzie for the first time? Bex: So, you can't see Lizzie but Lizzie is a lovely, warm person. So that was obvious from the start and I guess I was, with any physical health problem, the thing we're trying to do at the start is to understand what someone's experiencing and making space for someone to kind of tell their story a little bit about what they've experienced and what they're finding difficult so that we can kind of map that out and work out how we could potentially help too by working on this together. I think when I first met Lizzie, we fumbled a little bit at that process. I don't know if you want to say a little bit more about that, Lizzie, and I think, you know, I was trying to explain how pain and mental health might interact, and I might've done that a bit clumsily. Lizzie: I think, to be honest, I went in with this real prejudice, I guess, against mental health. So when I came to you, I had actually already had one round of CBT to start with, but I was really still coming from this place of prejudice against talking therapies and fear about whether I was going to be believed about my health conditions. The first round of CBT that I'd had, it was in a place I used to live down south, and it was very much focusing on the anxiety. And we talked about it being to do with the fact that I've been diagnosed with Crohn's disease and the fact that I'd had a lot of hospitalisations and the fact that I had emergency surgery, and also the fact that I'd been told that I might have a shorter life expectancy as well. And so it very much focused on the anxiety of dealing with those concepts. But underlying it all, I still had this fear of not being believed about my health conditions. I also, I will just share now, because it is relevant as well, that while I was in hospital for the emergency surgery, the night of that emergency surgery, I was physically abused by a doctor. He was a locum doctor that the hospital had employed just for, you know, a couple of nights. And he insisted on doing a physical investigation on me despite me asking him not to and then he purposefully inflicted pain on me and he enjoyed it, it was a really unpleasant, horrible experience and thankfully a nurse walked in as he was doing this and she got him to stop and he got reported and he no longer works in hospitals and that has all been dealt with. But when I first went into CBT, I hadn't even thought about that as something to talk about because I felt like that was my fault. And I felt like that was my fault because I was in pain because I hadn't done a good enough job at curing my conditions. And so that narrative was in my head when I came to see Bex. And I already had this idea of like, I'm not good enough at curing myself, but I'm now getting to the point where I do need to believe that I've got these health conditions because I'm seeing physical evidence of it more and more. So I was sort of in this halfway point between trying to accept it, but also thinking, nobody else is going to believe this because I don't really believe it. And that's what I came to Bex with, which must not have been the easiest patient. And then at first we did have, I think there was a very slight miscommunication about the fact that CBT can help people with physical health conditions with pain. And I saw that as, oh she's saying it's all in my head and that if I just talk about this, then my pain is going to be completely cured, and they don't believe me that I'm in real pain. But then Bex was brilliant and stopped me and said, no, I really do believe you and you explained it. So, Bex, I'll go back to you because I think you explained it really well and it really helped me. Bex: Well, I think I just said, I believe you and your pain is real. Can we just have that as a starting point and think about how what you've experienced has contributed to living with it and how some of those beliefs you have about yourself might make it harder and maybe they're the bits that therapy can support you with. Helen: Thank you for that, Bex. We've just heard Lizzie talk about, not only having those health conditions and those beliefs, but also about being assaulted when she was supposed to be in a safe place. And you started to talk there about the interaction between the physical conditions and perhaps the emotional beliefs thinking. How did that then help you decide with Lizzie what to do next? Bex: So we talked about it together to decide what to do next. And I guess part of that process was understanding kind of the emotional impacts of both the physical health conditions, you know sometimes there's understandable uncertainty, anxiety, maybe grief associated with those things and the adjustments that are necessary, but also the huge emotional impact of her trauma experience and how that contributed to the stress she was experiencing day by day. And really it, originally, it's mapping that out and understanding it as much as we can to inform Lizzie making a choice about what she wants to prioritise. And, if I remember, we started with some work on physical health and understanding that, partly because of you already alluded to that kind of disbelief you had about your own kind of symptoms and in your own body and listening to that. So I think we did some work to start with on that before doing a kind of CBT for trauma approach that Lizzie was very much leading that decision. Lizzie: Yes, I think the other thing that I remember as well is that I didn't, I don't think I opened up to you about the thing that happened with the doctor straight away. I feel like I went knowing that I had still got anxiety because of things that had happened in hospital and the Crohn's and everything generally and the fact that I was being diagnosed with POTS, I think that was what was going on as well. I was just about to be diagnosed with POTS, so this new diagnosis had sort of triggered a lot of anxiety because of what happened when I was diagnosed with Crohn's disease. It was sort of like coming back. But I don't think I actually mentioned the doctor to you straight away. I think that came out naturally when you sort of asked me to talk about what had happened and what were the things that I sort of was getting in terms of flashbacks because I was having PTSD flashbacks as well. Sorry, I forgot to mention that, and I think we pulled it out by having those conversations. So it was really important that you worked with me on it because that enabled you to be able to pull out this major thing that I probably didn't even see as a priority because I blamed myself for it. So I thought that was really useful. Helen: And I'm hearing from what you're saying that combination between very difficult to manage physical symptoms and how those interacted with what you believed and how strong that was. And I think it's really interesting that sometimes people talk about long term health conditions, as if they were all in the mind and that being completely wrong. And coming to someone like Bex, who's got psychologist or psychotherapist or something like that in her title, being particularly difficult at the same time as for you, believing that it really was something that you had control over by the power of your mind or something like that, that somehow, if you only tried harder, you could change what was happening. Lizzie: Yeah, absolutely. It was, I was terrified. Honestly, I was so confused about what was going on in my own brain. I felt like I needed to do something because I was getting flashbacks at that point. In any sort of moment where I wasn't actively doing something, I was getting flashbacks every 15 seconds, I think. Honestly, it was it was awful. I was getting certain colours were triggering things, and it was constant. It was exhausting and I knew there was something that I needed to do about it. I had my first round of CBT which was successful at helping me bring my anxiety down, so I had that sort of stepping stone, but I was still coming from this place of fear and doubt. And I think part of that is because I was told by the doctors when I was first diagnosed with Crohn's that I should have CBT. And I thought that was them saying that it was all in my head, but it was actually that they were prescribing it as a way of helping me cope with the pain, but the way it was communicated to me made it sound like they just thought, Oh, well, if you have CBT, then you'll be cured of Crohn's disease, which is not what they meant. And I now know that having spoken to people who work in the sector more, I now understand that. But I think that a lot of people, when they are first told, oh, I think you should have CBT. They think, oh, this is just the doctor trying to fob me off, but it's not, it's them using their toolkit of things they've got available to them to try and help. It's just not necessarily communicated that well. And I think if it was communicated to me differently, back when I was first diagnosed with Crohn's, maybe I would have had CBT back then, and maybe I might have had a bit more support as I was going through the diagnosis. And some of that fear might have been mitigated a little bit back then. Helen: I think that's really important for you to have explained that actually, that sense of, for people like myself and Bex, perhaps, to understand how to explain why what we've got to offer might be useful and not to make assumptions that someone that we're recommending for CBT will automatically know what we meant. So that's an important message. I think. Once you did go to CBT, can you tell us a bit about what was actually helpful? What did you actually do or talk about? What was it that seemed to make a helpful difference? Lizzie: So the first round of CBT that I had was very much focused on mindfulness and being able to be in the moment. I did have PTSD and my PTSD score was very high, my anxiety score was very high. I think my depression score was lower at that point, I'm not sure if I scored for depression at that point, but the main thing that I found helpful was being able to stay in the moment because I was constantly worrying about the future, worrying about death, worrying about what was going to happen if my Crohn's flared again, worried about what was going to happen if I had to stay in hospital again, and I was constantly writing all these stories for myself that weren't happening, and living in fear that I didn't need to be thinking about. So that really helped me just to be mindful and to focus on the moment. And when I first heard the term mindfulness, I was like, right, okay. Are we just going to be like sit in a circle and go "ohm" or something? And it wasn't that at all. It was very much using strategies that are very simple to just help my body and my mind realise that I am safe in this moment. And that for me was really helpful. And as somebody coming from a place of doubt, I think again, if that had been communicated to me before I'd gone into it, I think I probably would have been a lot more open, because I think even back then, my first therapist probably had a lot of resistance from me as well. And then when I came to Bex, the main thing that I was struggling with then, I think was the PTSD flashbacks, but I think I also scored for anxiety and depression at that point. I was, again for context, I was a teacher still then, so I now have had to medically retire, unfortunately. But when I first saw Bex, I was still a teacher, and I was really pushing myself past the point that I should have been. I was exhausted. I was in pain all the time. I was determined to have a successful career, which I did have. Despite all of this, I did have a very successful career as a teacher, but the reason I had that successful career was because I pushed myself despite all this pain. And it was also a way for me to take my mind off the PTSD, because if I was busy, if I was constantly go, go, go, it meant I didn't have to think about it. So that was where I was at when I first came to Bex. And I think one of the things that she did was, like I said, pulled out the key things that were kind of coming up in flashbacks. And then we did a sort of narrative about the trauma, which was horrible. I'm not going to say it was really horrible, but it helped. So I think that's another thing to say, like, if you're having CBT and the therapist suggests something that is horrible, it's probably going to be good for you because yeah, so we had to basically go through the story of the most traumatic time of my life ever. Over and over again, and I was given homework of going home, reading it through this narrative of like everything that happened over and over again. And it was one of the hardest things I've ever done. Honestly, it was horrible. But by the end of it, I got to the point where I can now, you know, come on a podcast and tell you I was assaulted by a doctor. When I first saw Bex, I couldn't even say the words about anything that had happened. And the fact that I can now come on publicly and talk about this is, you know, that just shows how helpful CBT was for me, because I honestly, I would have never imagined talking to anybody about it. I didn't even tell my partner who I'd been with for, I think over 10 years at that point, I didn't even tell him until I'd gone through that process of CBT. Most of my friends and family had no idea. Helen: Thank you, Lizzie. It strikes me from everything that you've just been telling me that between working on the post-traumatic stress disorder, the PTSD symptoms and working with Bex to do something that you really didn't want to do and actually deliberately, repeatedly going over it until you could talk about it until, like you say, you can come and talk publicly about it with us, which we're extremely grateful for, but also hearing how hard that is. And in a moment, I'm going to be asking Bex about what she does both to persuade you and other people to go through something that's that difficult, and how you make it manageable when clearly it's a horrible thing to go through. What I might also want to come back to you about as well is you really conveyed how driven you were about that wanting the career, keeping busy, pushing it. And I want to come back about the impact of that as well, if I may. But first, can I go to Bex and just talk about, Lizzie just told us that you've essentially asked her to do the worst thing and do it repeatedly. Bex: Yes, we did. So yeah, it's intuitively the last thing you want to do when you've experienced, you know, something so, so awful and life threatening, that the last thing you want to do is talk about that. So, we do prepare for it, we do some sort of exercises to make sure that we have the tools to calm down if it's distressing, and we explain the theory for why we're doing that because these are kind of stuck, emotional responses and perspectives from being in a situation that was too much for your brain to process at that time. So we're making the space for it subsequently to understand what happened, connect to the feelings that were overwhelming at the time and sort of safely release them through this process. And as well as doing that, we also understand, you know, look at the beliefs that became stuck at that time. And we challenge those together to see if we can get some kind of perspective. So, for example, you were talking about the self-blame, that is so, so usual with trauma. And we looked at that from a different perspective now we had all the information, and I guess the way we encourage people to do that is very much making sure it's their choice, you know, nobody has to do this, but explaining what the benefits might be if we were to try doing this together and try doing it at the pace that you feel like you're able to tolerate and that you're in control of the process. And it's also important to have that story heard and understood by both of us in that process. Helen: And can I just talk to you both about that experience of being really driven. And there was something about the way you described that, Lizzie, that part of that was trying not to be triggered or think about all the bad things that had been happening for you. But also that general style of pushing for a career, being really busy, being highly motivated and I just wondered how the two of you managed that aspect, you know, during your sessions or between them, perhaps more importantly. Lizzie: I think one of the things I can remember was in the first session. So I explained that I was, you know, determined to still be a teacher and how I loved my job, which I did, and I still wish I could be a teacher, I'm not going to lie, I really did genuinely love being a teacher which is part of why I was so driven, because I actually did really enjoy it. But there was definitely that element of me trying to kind ignore everything. But one of the things that Bex did very early on, I think it was the first session, she just said, your homework is to do something fun. And honestly, the concept of doing something fun for myself at that point was unimaginable. And I found it really hard. I found it really hard to think about something to do just for fun for myself. And I think that was just a sign of how much I needed that help because I couldn't even think about what to do. And that really helped me to start to come out of this really, like, blinkered existence where I was thinking, go, go, go, go, go. And it just gradually, bit by bit, helped to pull me out of it. And I think you kept suggesting things like that. And then we talked about what was nice in my week and things like that. And it just helped bring me out of this sort of bubble that I was in. Helen: And Bex, will you tell us a bit about how you were thinking about that as a CBT therapist? What's going through your mind when you're working with somebody like Lizzie, who's working really hard, but is almost stuck for finding something fun or rewarding to do? What's going through your mind as a therapist? Bex: I didn't remember that actually, Lizzie, but I think, well, I guess I'm just noticing how driven and how exhausting it sounds to be kind of pushing so hard, despite feeling so ill. And I'm encouraging a new pattern of behaviour, I guess. I'm encouraging a different way of responding just to try it out. You know, with CBT, we're always just testing stuff, see what works, what doesn't, and so I guess I'm encouraging that early doors to get a bit of a buy into the concept, you know, are you're okay with this approach? And I do remember that we did throughout, we did do bits and pieces around understanding the consequences of working that hard or noticing, cause sometimes you might want to and it might be the right thing for you, but sometimes it might have more impact in ways that are less helpful and you might want to try out a different pattern. And I think we might've looked at working pattern and problem solving that or negotiating with work about trying different approaches and different working weeks to see what was more manageable and more sustainable. Lizzie: Yeah, I remember doing that. And also remembering you helping me a lot with being able to actually have time off work before I was forced to by my body. So, I used to get to the point where I was completely exhausted or in such agony that I couldn't move. And that would be the point when I'd phone in sick, but I think we did a lot of work looking at what my body was doing, thinking about, actually would it be helpful to have some time off before I get to that point rather than waiting until, you know, I need to end up in hospital or something, and giving myself permission to relax every now and then and prioritise my body and that really helped me. Helen: There's something there about finding a balance, whether it's a work life balance or a fun and effort balance, or a, I don't know, resting and doing things balance, but there's something about finding a way of managing your activity and energy levels and ending up actually being able to do more rather than pushing it beyond what your body could manage and then having to take enforced rest at a time, which was already kind of too late in terms of the symptoms. So I'm hearing what you were working on together was about managing day to day life as well as other pieces of work that was specifically to do with resolving incidents or traumas that had happened in the past. So you were fitting a lot into therapy sessions. It sounds quite busy. Lizzie: Yeah, it was, it was useful. Helen: And I wonder, looking back on it, you've already told us that doing that repeatedly going over the traumatic event was one of the hardest things that you've had to do. Was there anything else that you found really challenging that you and Bex agreed on, but you found it really challenging? Lizzie: I think probably what I've just been talking about, about having time off work, I think I was quite resistant to that. I think I was scared to have time off work and to prioritise my health. At that point I'd just been diagnosed with POTS, I'd had a long-term absence from work and was feeling really guilty about that. Obviously as a teacher there's an added level because you've got your students who don't necessarily understand why you're not there. I was a secondary school teacher, so I did actually talk to some of them about my health conditions a little bit just to give them context, but some of particularly the younger ones, the year seven students really struggled with where I'd gone and were worried about me. So I think I had a priority in my mind to be at work and Bex's priority was my wellbeing overall, as well as making sure I had this fulfilled career. And I think I was willing to sacrifice my physical health for my career, but didn't see the big picture of that actually if I do that constantly I'm not going to be able to do this job anymore anyway, which did end up being the case naturally because of the way my health progressed. But that wasn't because of me pushing it. That was just because it got to that point. And when I did have to come to that point where I needed to medically retire, the work we had done ended up setting me up for that. And, I'm not saying as well that my, you know, the work we did in CBT was it. I've had more CBT, I had another round of CBT in the pandemic. Afterwards, I needed to have some more support because obviously all of this stuff to do with the pandemic and I was shielded. So I was actually picked as one of the most vulnerable people in society. And that was scary and brought up all this confusion about, Oh, I'm really ill. Like they, they actually believe me, the government messaged me, they told me I'm ill, you know, it scared me. And then I've also had a round of EMDR as well, which was focused on childhood trauma as well, which actually did weave its way into the physical health and also why I am so driven in terms of what I want to achieve as well and in terms of accepting my health conditions. But I would say that CBT helped me get to the point where I'm at now, where I'm medically retired in one way. I still do my content creation work. I still work as a speaker, so I will work a couple of times a month doing talks, and I am able to do that in a way where I'm still driven to help people, and I'm still driven to get that out that message out to people, but I spend most of my time in bed and that's okay and I can do a bit of both and if something needs to go because my health needs to take priority, then it does. Helen: I'm really curious to hear about that, the things that you still put into practice now from what you've learned from the CBT and giving yourself permission to rest so that you can do things that you care about, things that you value. Can you tell us more about the key things from what you've learned from CBT that you still use the most? Lizzie: It's a combination of things really, I use things from all of the rounds of CBT I think I've had, from the first round I still use some of the mindfulness techniques, I struggled to use those when I was really depressed. I think I was most depressed during the pandemic. I think that really, you know, everybody struggled, I think, during the pandemic but my depression got really bad and those techniques didn't work so well. But, for example, if I'm in a hospital waiting room, I will use those mindfulness techniques to try and just remind myself I'm safe. It's not that I'm going to be admitted to hospital immediately. Sometimes that's like a genuine fear that I think they're going to kidnap me. But I use those mindfulness techniques still there. I think with the second round of CBT, when we did the narrative therapy, I think that just genuinely changed me internally in terms of the way I think about those memories, and I've also learned to give myself permission to be kind to myself. And I think that is just something that it was like a switch that, that turned on when we did the sessions. I don't know when it happened, but that switch is still on most of the time. Sometimes it turns back off again, and sometimes I have to stop. And actually either talk to a friend and they have to talk to me about some things and I'll then parrot back to them the things that I learned in CBT or sometimes it's just me quietly thinking to myself and thinking, no, it is okay for me to have time off. It's important to prioritise my body. And I'm not saying I do that all the time. I definitely don't. I still struggle with, you know, anxiety. I still have suicidal thoughts sometimes it's horrible, but I'm able to cope with those in a way that allows me to function a lot, lot better. Helen: Thank you, Lizzie. And, if it's okay, I do want to just pick up on that. You said that you still get suicidal thoughts sometimes. Can you tell us a little bit about how you make sure that you stay safe when that happens? Lizzie: For me, I very much don't actually want to kill myself and I never have. It's never been that I have suicidal thoughts in that way. It's that I think it's more to do with the fact that I'm exhausted with the battle going on in my mind. I'm exhausted with having to fight the negative side of my thoughts that's telling me, you know, you're useless, you're ill, you might as well give up. Those sorts of thoughts come into my mind. And my friends actually nicknamed that voice, Karen. So I apologise to anybody called Karen. it's one of those things that's picked up on the internet, but we've just called her Karen and so it's just helps me sometimes to think, Oh no, that's Karen speaking. It's not me. And so I'll sometimes have those thoughts, but now I'm at the point where I can just disregard them and they'll come in and I'll go, that's horrible. And then I'll carry on and it'll go away. And sometimes I have darker moments, but it would never get to the point where I'd actually hurt myself because I've got people I can talk to, I've got the techniques I learned in CBT to draw back on. I also have things in my life that I care about and I want to live for, and I can remind myself of those. It is difficult having physical health conditions. When you're living in pain, you're in bed for days on end, months on end. I, you know, I've had periods where I have been in bed for months on end and people listening will have had the same and it's horrible but it's just about looking at those little tiny things in a day that make the day worth living still, even if it's just having a nice cup of tea. And I think for me, those are the things that keep me going, but it's not easy and I think that's the thing with CBT and any sort of talking therapy is I don't think it's about completely eliminating any, you know, any trace of you having mental health problems. It's not that. It's about training you to live with them in a different way. And for me, I feel much more safe in my life. I feel like I can cope with those thoughts, and I've accepted that is not a nice part of me but it's something that is natural for me because of the pain I live in and because of the difficult things I've gone through and I'm not going to act on them, but they just, it's just there. Helen: Thank you, Lizzie. And I just want to come back to Bex about that as well. And just hear what Bex is thinking about what you've just said about carrying on living with difficult days, difficult weeks, difficult months and really difficult thoughts. Bex: Yeah, I think you've shared the kind of toll it takes to live with the extreme pain and tiredness that come with your conditions and the uncertainty and the sort of natural kind of phenomena really of living with those experiences and how you kind of navigate those really well now in terms of accepting, in terms of acknowledging what you're experiencing, but also putting them in perspective and focusing on stuff that's really important to you. And you know, that might be small things if you're really unwell, but I know from working with you from both that time and more recently that you do so well at sharing how you're feeling, at reaching out to people that you have a really positive relationship with, that you're actively managing those things so well when it is difficult and that's really fantastic to see. And it's really helpful how open you are about those things for other people who feel like that it's really valuable, thank you, Lizzie. I guess the other thing I would say that maybe we haven't mentioned is that I've observed over time as well is the way you interact with medical professionals now. I don't know if you want to say something about that, but there's been a real difference in terms of, I guess, assertiveness or handling those relationships really well. So I don't know if that's something you wanted to reflect on. Lizzie: Yeah, definitely, I feel like it's important to mention that actually, but I also did want to just say that you mentioned that I've been really good at reaching out and opening up to friends. And I think that is another thing that I got from CBT actually, because like I said, I didn't tell a lot of people that I was close to about what happened in the hospital and I did used to be a lot more closed off when it came to talking about my health conditions and I think I just thought I was annoying people when I talked about it, and one of the things I learned with CBT was that the people who choose to be in my life care about me, and that's why they choose to be in my life. And so they want to help me. And I was reminded that obviously I want to do that for them. So obviously why wouldn't they do that for me? And so that helped me to reach out to people. And it's not necessarily that I can always reach out. I think that's an important thing to say as well. A lot of the time, my friends are the ones that reach out to me when I'm in a difficult position. I think that's really important because sometimes when you're in the darkest sort of places, you're really not able to even see that you need that help. But I think the important thing is that if somebody in your life reaches out to you and asks you how you are, you're honest with them. And I think that's the thing that changed for me is that I used to just be like, yeah, yeah, fine, carrying on, you know, stiff upper lip type attitude. And I think it's really important to be honest and be authentic with the people in your life. The other thing that you mentioned as well was about the health professionals. So not my proudest moment, but I did actually once punch a nurse. Not like, you know, like a proper thump, but it was a reflex reaction because I was so anxious in hospital. So she was, I think she was taking my blood or giving me an injection. And I was so anxious that my reflex was to just thump her on the arm. I felt so guilty because I've never, I'm not like that at all. I mean, hopefully you both, you've both interacted with me and you know, I'm not the sort of person to go around beating people up. So she was very professional and she just carried on completely like unfazed and I was like, I'm so sorry, I can't believe I just did that. She was like, don't worry, it happens all the time. I was like, wow, she really shouldn't have to deal with that. But I used to be so anxious around medical professionals. I didn't trust them. With that nurse it was slightly different, but I genuinely didn't trust medical professionals. I still don't to a certain degree because I've been misdiagnosed a lot. I've had lots of conversations with doctors who don't know as much about the condition as I do. I've had conversations with doctors who haven't read my notes. You know, recently I went into an investigation, it was important that they knew that I was immunocompromised, and he was like, Oh, you're not immune. You're not on any immunosuppressants are you? And I was like, Oh, only the three that I'm on. Yeah. And you know, that happens a lot. But I have learned to be more assertive in those sorts of situations. And now I'm able to communicate in a way where I can get across what I need to get across without having a huge panic attack. Because what used to happen is I used to just get completely overwhelmed and then I had to leave the room, or I just bursts into tears. And it does still happen. Even recently I've had a couple of things that happen where I get really overwhelmed, but it's nowhere near the level that it used to be. And now I've got again, another toolkit where I know what to do before an appointment. At the start of the appointment, I explain to the medical professional, you know, these are the mental health conditions I've got, I'm making you aware because this might happen. If this does happen, this is what I would like you to do and it's usually just a case of I just want them to be quiet and let me just process for a couple of minutes and then I'm usually fine. And then after the appointment as well, I've also got some things that I do afterwards to make sure that I'm as okay as I can be, but it's again, still difficult. It's not like it's taken it away and it's still something that I will always find hard and I need support with. So a lot of the time I'll have somebody come with me to appointments because I've recognised that is a need for me. And it's something that I can't do by myself, but that is part of me dealing with it. That's part of me managing it. And I think that's something that I've learned because of doing CBT and doing therapy in general. And it's changed my life. And it's helped me to get the diagnosis and also the treatments that I need. So it's been really important for my physical health as well. Helen: Thank you very much, Lizzie. I'm thinking one of the things I would like is for people listening to hear what are the most important things that you would like them to know. And I'm going to go to Bex first. If there are people out there who are having similar experiences, whether it's long-term health conditions, whether it's having panic attacks, whether they've experienced trauma, struggling to manage what's happening to them? What are the key things that you would want people to know from what we've been talking about today, Bex? Bex: I guess the key thing I'd want someone to know that if you're really struggling with those things, that matters and that there is support available where we can work out, you know, maybe some things can't be changed, maybe some things have to be adjusted or two, but the things that are possible to make different, maybe some ways of responding that can support you with what you're experiencing. With trauma, I guess I'd want people to know that there are treatments that work for trauma that can make a vast difference in terms of re-experiencing and levels of anxiety associated with that past event. And I'd want people to know that they're entitled to that support and it's available for them if they want it and if they're ready for it because it might not be the right time. And that's entirely their decision. And often, you know with physical health we see quite a lot of physical health problems with people who've had chronic stress for a very long time as well and that there's an interaction there, and that we're interested to understand more. Helen: Thank you. And Lizzie, what would your kind of key messages be, would you say? Lizzie: I think the biggest message I want to get across is that it's not a replacement for the treatment that you'd get for your physical health conditions. It's something that can complement it and help to make life easier for you, but it's not about being something that you do instead of another treatment. And I think if you ever are in a conversation with a doctor where they suggesting that, so they're suggesting they're going to stop investigating and just send you to talking therapy, I would say it's important to advocate for yourself and say, you know, that's fine, but what's the differential diagnosis here and what else can we do to investigate what else might be going on? Or, you know, I'm happy to try that, but I would also like a plan for if this doesn't help me, what can I do after that? I think that's really important. The other thing that I would say as well is, I would say to somebody, if you are thinking about the possibility that doing CBT or some sort of talking therapy might help you, the likelihood is it probably will, because I don't think people would be considering it unless they're in the position where they probably would benefit from it. And the other thing I would say as well is I got very lucky with having Bex as my therapist, and I think if you have started some sort of therapy or you're going to start and you don't feel like you gel or mesh with the person that you are speaking with, I think it's important to try and see if you can maybe change to somebody else, or be open with that therapist. You know, with Bex, if I hadn't have been open with the fact that I was anxious about her saying, you know, about the connection between physical and mental health, we might never have gelled, you know, that might have really stopped the relationship from progressing. I could have just never turned up to the next session if I hadn't been open about it. So I think that's the other thing is if you're feeling like something's not right, be open, and I think the vast majority of therapists go into the profession because they are genuinely caring people. I think it naturally attracts those kind of people. So the likelihood is they probably will want to try and help you and if it doesn't feel right after that, then try and find somebody else and see if it can find something that fits. Helen: Thank you so much. I'd just like to say how much I appreciate you both coming to speak with me today. Bex and Lizzie, I'm really grateful for your input. Thank you very much indeed. Bex: And thank you so much for having us. It's been really lovely to reflect on that, the experience together, and it was a joy to work with Lizzie. Lizzie: Thank you so much. And yeah, I'm so grateful for honestly, having been able to have the experience and the experiences that I've had. I'm very lucky to have had the support that I've had. So thank you Bex for that. And it's great to be able to talk about it and hopefully this might help some of the people as well. So I really hope that if anybody's listening, who needs some support out there that this helps a little bit. Helen: Thank you. So, our listeners will find more information on our show page and, I'm just going to say one more thank you to you both. Thank you both. Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at podcasts@babcp.com, that's podcasts@babcp.com. You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested. 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In this episode of Let's Talk About CBT, host Helen Macdonald speaks with Sarah, Sally, and Leanne about Sarah's experience of having Cognitive Behavioural Therapy (CBT) after giving birth. They explore how CBT helped Sarah regain control during a challenging postnatal period, addressing struggles such as insomnia, anxiety, and adjusting to new motherhood. Sarah shares her journey of balancing therapy with the therapeutic benefits of movement and time spent in nature. CBT therapists Sally and Leanne discuss the powerful combination of therapy, physical activity, and connecting with nature for improving mental health. Useful links: NHS Choices- Insomnia-https://www.nhs.uk/conditions/insomnia/ NHS Guidance on feeling depressed after childbirth: https://www.nhs.uk/conditions/baby/support-and-services/feeling-depressed-after-childbirth/ MIND information on how nature can help mental health: https://www.mind.org.uk/information-support/tips-for-everyday-living/nature-and-mental-health/how-nature-benefits-mental-health/ For more on CBT the BABCP website is www.babcp.com Accredited therapists can be found at www.cbtregisteruk.com Listen to more episodes from Let's Talk About CBT here. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This episode was produced and edited by Steph Curnow Transcript: Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen MacDonald, your host. I'm the senior clinical advisor for the British Association for Behavioural and Cognitive Psychotherapies Today I'm very pleased to have Sarah, Sally and Leanne here to talk with me about having CBT, in Sarah's case, when you've recently had a baby and also the value of getting more active and getting outside into nature and how that can help when you're also having CBT. Sarah, would you like to introduce yourself, please? Sarah: Hi, I'm Sarah. I'm, 37 from Sheffield and like I said, just recently had a baby, and she's absolutely wonderful. She is a happy, loud little bundle of joy. I ended up having CBT though, because the experience of having the baby wasn't what I thought it was going to be, I think is the reason. And I, just went a little bit mad, so I got some help. Yeah, I'm normally a very happy, positive, active person. Lots of friends, very sociable, always like to be doing things, always like to be in control and have a plan. I like to know what I'm doing and what everyone else is doing. And all that changed a little bit and I didn't really know what to do about it. So yeah, got some therapy. Helen: Thank you Sarah. So, we'll talk with you a bit more about what that was like. And first, Sally, would you like to just briefly say who you are? Sally: Yeah, so I'm, my name's Sally. I am a Cognitive Behavioural Therapist, working both in the NHS and in, in private practice at the moment. Helen: Thank you. And Leanne, Leanne: Hi, I'm Leanne. and I'm a cognitive behavioural therapist as well. And I also work in the NHS and in private practice with Sally. Helen: Thank you all very much. What we're going to do is ask Sarah to tell us a bit more about, when you use the term mad, perhaps I could ask you to say a little bit more about what was happening for you that made you look for some therapy. Sarah: Wel the short answer to that is I developed insomnia about 12 weeks postnatally, didn't sleep for five days. Baby was sleeping better than most, you know, so it was equally frustrating because there was no real reason I didn't think that I should be awake. And sleep obviously is very important when you've had a baby. As I said, I like to be in control, like to prepare, like to know what's going on. So I did hypnobirthing, I prepared, I planned, I packed the biggest suitcase for this birth of this baby that I was really excited for and I thought I'd prepared mentally for every eventuality- what kind of birth, what would happen afterwards, but all very physical because they're the sorts of things that I could understand and imagine. And basically I ended up having an emergency C section, which in the moment I was fine with and I didn't think I was bothered by it, but the level of pain afterwards, that then again affected my level of control over looking after the baby. And the level of debilitation it created that I wasn't expecting- this is the key thing, I wasn't expecting it. That meant that I wasn't able to be me, really. I wasn't able to not least look after a baby, but get myself dressed, get myself showered, walk to the shop, drive a car, play netball, walk my dog. And I wasn't able to do any of that. I didn't appreciate that I was struggling with that, with accepting that. And because it went on for so long, and of course with this comes the baby blues that everyone talks about, but that's meant to only last apparently a couple of weeks. I, you know, you kind of just think, oh, well, I feel all this. I feel pain. I feel sad. I can't stop crying. But all that's meant to happen, all that's normal and it's sort of became the norm. So I was like, well, this is normal. This is how I'm going to feel forever. At this point I didn't have insomnia. I just could not stop crying. And I mean, like I couldn't, I didn't talk to anyone for two days at one point, because I knew if I opened my mouth to say anything, I would start crying. Like literally anything, I would just start crying. What the clincher for me was when I spoke to a doctor, I thought they were going to say get out and about, do some therapy, which at the time, I'm going to be honest, I thought, I can't sleep. I need a fix now. What I now know is I was doing a lot of behaviours that over time culminated in my body going, you're not listening to me, you're not well. Right I need to do something physical so that you wake up and do something about it. And that was the insomnia. So, I went to the doctor fully expecting them to say, do some mindfulness, do this, do that. And at that point I was just, you need to fix this now. I need to sleep. I need drugs. And yes, that's what they gave me, but they did say you need to do CBT- but what they did say what the first thing the doctor said was, you need antidepressants. Now, as a nurse working in GP surgery for them to jump all the self-help stuff and go take these tablets was like, Oh, right. I'm not okay. and it gave me that like allowance to say, I need to take tablets. But I already had said to myself, but I want to do not just mindfulness and helpfulness for myself. I want to do structured CBT because that way it is something I'm doing to give me back my control and I've got a plan. And because I already knew CBT was wonderful. Yeah, I didn't really understand what it was, how it worked, the structure of it. And I get that there's different types for different problems. but I knew that's what I wanted to do, once I had tablets to help me sleep and knew the antidepressants were going to work eventually, which did take a while. I was at least doing something myself that would help me forever. And I just thought, what have I got to lose? I need to do something. And until I started CBT, basically, I just felt like I was running around in circles in the dark. And the CBT gave me control and focus and, right, this is what we're doing going that way. Because until I started CBT, you know, I was Googling everything. Right, I'll try this. Right, I'll try that. And because it didn't work within 24 hours, I'd then try something else and try something else. Now it was making it worse, obviously. So, to have the CBT and have my therapist say, do this one thing for a whole week. I was like, all right, okay. That's quite a long time, but there's obviously a reason. Helen: Sarah, thank you for telling us all about that. What I'm hearing is that you had a combination of massive changes in your life, which will happen when you've had a baby, all sorts of things about the kind of person that you are, kind of added to all your really careful and sensible preparations for having this baby and then really being taken by surprise almost by all the other impact that it had on you and taking a while really to look for help and to look for a very specific kind of help then. And I'm just wondering in the context of all that, what it was like when you first went to see Sally for therapy? Sarah: Well, like I say, it was brilliant. It was like having someone turn the lights on and point me in the right direction and say, right, head that way and don't turn off and don't go any other direction. Just keep going that way. And it will eventually result in this. It's like if you go to the gym and you're running on the treadmill and you're thinking, well, is this going to achieve what I want it to achieve? And until it does start to, you've not got that positive reinforcement, to keep going. So quite often you stop, and that's what I was doing. I was trying one thing, trying the next, because I was so desperate for it to just go away, this insomnia. Which obviously at the time was one thing, but I understand now there was a whole other problem going on but the insomnia was what I needed fixing. I found CBT for insomnia, but Sally said, do you want to do a more generic anxiety control type approach and I said, yeah, because that's what if before this, you know, five, six years ago, little things would happen. And I think, Oh, I should do CBT for that. So it's clearly the same thing. So yeah. Why don't we just tackle it as a whole? And that was definitely the best thing to do. Helen: It sounds as if one of the things that was really helpful was looking at the bigger picture, as well as focusing on taking enough time to make changes. Okay. Can you tell us about the specific things that you did in therapy that you saw as particularly helpful. Sarah: Yeah. Like you say, what was helpful was being given a timeline really, and a direction. Like I say, when you go to the gym, you're not sure if it's going to work, I had to just trust Sally that what was she was explaining to me was going to work. And of course, at the time I couldn't see how it was going to work, but at least someone I trusted was telling me it will this, just do this? What was most helpful I could say was being told you've got to do the homework yourself. There's no point in being just told stuff. It was explained to me. And then what was helpful was then being told, go away and do this one thing for a whole week and then we'll review. So it really just broke down my thoughts, behaviours, my thought processes that I was going at such a hundred miles an hour that I wasn't giving, even giving myself time to think or realise I was having, and essentially that's what CBT is, you know, making you stop, think and unpick your thoughts and your behaviours and then trying to change them accordingly. So yeah, that the homework was helpful. And then obviously reviewing that homework, which with, before I even got to the review, a week later, I was able to physically feel and see why I was being asked to do what I was being asked to do. Helen: And I'm just thinking the analogy that you used there about being in the gym that you wouldn't necessarily expect to be super fit or running five miles the first time you got on the treadmill, but there was something that was tending to make you, you use the word desperate really to make a difference immediately. Because things needed to change. And during the therapy, was there anything that you found particularly challenging or something that either you and Sally talked about it, but you really didn't want to try it? Sarah: Well, as the weeks moved on, obviously the challenges that the homework got harder because it asked you to delve further in and make the changes of what you've, you know, you've realized just to give an idea, essentially the first week, I was asked to literally rate my happiness per hour as to what I was doing. Sounds simple. It is simple, but very quickly I realised, well, this doesn't make me as happy. So why am I doing it? And then of course you stop doing it because you know, it doesn't make you happy. And then over time, there's less time that you're unhappy. The second week, it was a bit more detail, rate how anxious certain things make you., So that was all fine. But once it got to the weeks where it was highlight the things that you've found out make you anxious, now do them or don't do them. Or, you know, if there's something you're doing to make yourself feel better, but actually you've realised it doesn't really work, it actually has a negative effect later on, don't do it. And if there's something that you're avoiding, but you know probably will make you feel better- do it. So that's obviously that's the scary bit because you've literally facing the spider, if that's what your problem is. but again, like every other stage during the CBT, I found it really easy. The main thing was I trusted Sally and also had nothing to lose. One of the things, the behaviours that we realized I was doing was seeking reassurance from people on hypothetical worries. So you Google, you ask your experienced mums, why is my baby this colour or not sleeping or eating or the poo looks like this? They can't answer that. And you're wanting them to reply, Oh, it's this. And of course they can't. So, or I'd say to my husband, am I going to sleep tonight? He doesn't know that. And by doing that, I would reinforce the anxiety. But yeah, that was an example of something I stopped myself doing. And within days I realized, Oh, there was that thing that normally I would have asked about or Googled. I didn't. And actually nothing bad happened and I forgot all about it. Cause that was the worry was that it all comes back to sleep. If I didn't ask, would I then lie awake at night worrying I don't know what the answer is, but I didn't. So yeah, the hardest bit was actually stopping certain behaviours or starting certain behaviours. But actually I found it very easy once I had done because the positive reinforcement was there, you know, it worked. Helen: Thank you, Sarah. And, in a couple of minutes, I'm going to bring Sally into the conversation to talk about her reflections on what you've just been saying. Overall though, what are the things that you're still using now from what happened in therapy? What are the things that you learned and how are things now compared with when you first went to see Sally. Sarah: Well, things are great. I'm on antidepressants still. I'm going to see the doctor soon. Cause they want you to be on those for six months before you even think about coming off them. I feel myself now, so I feel confident to do that. Um, and because I'm healed, I'm back to being myself physically. I play netball, I walk the dog. I mean, I walked for four hours yesterday because of dog walking and pushing the pram around and played netball as well. So that helps, you know, being out and about physically, being in nature where I would normally be definitely helps my mood. The CBT a hundred percent has helped because there's been change again with the baby. So we've gone from breastfeeding to weaning, sleep changes, cause it's all about sleep, putting her in her own room, thinking when she's going to wake up, is she okay? Am I going to get back to sleep? Is there any point in me going to sleep? Cause she can be awake in this many hours. You know, that's a whole new challenge that I've had to deal with and there's been times that I've stopped and thought, Ooh. There's a thing I'm doing here and it's a behaviour that we recognised was what I was doing originally, which when I did it too much caused the problem. So, I've been able to really be more self-aware, basically, checking with myself and go, stop that. You don't need to do that. Everything will be fine. And guess what it is. Helen: Well, that's really good to hear. And what I'm also hearing is that it's not just that therapy helped, is that you're still using the techniques that you learn in the therapy. Sarah: I am. And also, I meant to say. This might not be the same for everybody, but it's quite important for myself because I'm not at work at the moment, you know, I'm a nurse. I've lost a sense of not purpose, but people come to me every day at work asking for help and support and advice. And I love to be able to do that and hear them say that's really helped, thank you. And since having the CBT, because it is something people are more happy to talk about nowadays, the amount of people I've spoken to that have said, Oh, I've done CBT or Oh, I'm thinking about, I've been told I should do CBT. Or none of that just I'm doing this behaviour and I'm not happy. I feel like I've been able to be a mini therapist to a few other people. I've been able to pass the torch a little bit because even though the problem they might be having is different to insomnia or anxiety, a lot of what Sally taught me was, I found, they were telling me things and I was thinking, well, I'll just say this thing that I do because it would work. And I've been able to relay what Sally said to so many people. And that's given me a lot of, joy because I've been able to help people. And they've said, Oh, right. Brilliant. You know, either they've gone to therapy because I've told them why they should because they didn't have anyone telling them that before, they've gone and then come back and gone, that was great. Or they've said to me, Oh, I didn't think anybody else was on Sertraline. 80 percent of the country are on Sertraline. It's fine. And that gives them support. Or like I say, the little technique Sally taught me, I've said, do this. And then they've come back and gone, do you know that really helped. So that's been nice for me too. Helen: Well, if there's somebody out there listening to this, who hasn't had that kind of conversation with you, or someone else who's recommended CBT or things that you can do to help in a situation like that. Is there anything that you would want to say about, CBT or looking after your mental health that anybody out there who hasn't encountered it before might need to know or want to hear. Sarah: It's free, most of the time. It's something that will help you for the rest of your life. Unlike, you know, a course of antibiotics. it's something that gives you control. It doesn't hurt, there's no injections. It's brilliant. Talk to people, I think is the key thing, not least your doctor, because obviously that's a private conversation. But again, as working in a GP surgery, I know that majority of health issues that come through the door, there's always an in for therapy. There's always a little bit of whatever they've come in with. Do you know what therapy could help that? It should be the crux of everything. You know whenever a patient comes to see me, I can't think of many situations where I don't say, do you know what would help? Drinking more water. I feel like it's just as important as that in terms of you can't fix something up here if you don't get your foundation and your foundation is nourishment and happiness and the therapy made me happier because I had more control, and was less anxious and more relaxed and, you know, just chill. So I think just talk to people, not least your GP, if you don't want to talk to someone personally. Helen: From my point of view, that's a great message, Sarah. Thank you so much for sharing that with us. And what I'm going to do now is I'm going to ask Sally, just to talk a little bit, I could see, I know our listeners can't see our faces, but I could see Sally smiling when you were saying some of the things that she told you to do. And I'd be really interested to hear Sally's reflections on her therapy with you and how you work together. Sally: Yeah, absolutely. It was brilliant working with Sarah and I think it's really nice to see where she's at now and also the fact that she's still using a lot of those tools that she learned and that she put into practice and, I think one of the things that was really good is that Sarah was ready. She was ready to engage. She wanted to do, you know, she wanted to do all of the things. She wanted to practice everything. She was ready there with the notebook, every session kind of, you know, making notes, taking it all in. And that's brilliant because that's what you need in CBT is really just to come with an open mind and just think about things in a different way. So that was really good. And I think as well, one of the things we discussed before we started the therapy was, time away from the baby. So this was Sarah's time, you know, this was an hour a week where, Sarah's husband or mum would look after the baby and this would be Sarah's hour where it's just about Sarah and it's just about this therapy and the CBT and so it was really important that she had that time and that space with no distractions. And so that I think that worked really well. We did some face to face and some remote via Teams sessions together. And I think one of the, one of the sort of challenges initially, as Sarah's mentioned before, Sarah's problem was that she couldn't sleep, that's what Sarah came with, it was a sleep problem. And it took us a little bit of time to sort of think about that together and unpick it together and go, actually, do we think it might be a symptom of a bigger picture, something else that's going on. And so we talked a bit over time and agreed as Sarah mentioned that actually it probably feels like more of a generalized anxiety and worry problem that was going on that was then impacting on the sleep. We spent quite a bit of time just exploring that and we did some fun experiments and things as the sessions went on, which is probably what I was smiling along to because I know it's not always easy for clients to, to sort of do those things and want to drop things like reassurance seeking. It's a safety net. And it's hard to drop that sometimes. Helen: Thanks, Sally. You've just said two things there that I would really like to explore a little bit more. You said fun experiments and reassurance seeking. So can you explain what you mean by those please? Sally: Of course. So, suppose I say fun because experiments are quite fun, aren't they sometimes. I know it's not easy to push yourself out of your comfort zone but I think we, me and Sarah had a bit of a laugh about some of the things that, you know, in the session, once we'd sort of sat down together and said, okay, so you're asking all of these other mums, for example, you know, what would they do in this situation, or like Sarah mentioned, what does it mean that my baby is this colour or that this is here and, you know, as we sort of broke it down together we could sort of see that, oh, actually, yeah, that they don't know. They're not going to be able to tell me this. My husband doesn't know if I'm going to be able to sleep tonight or not. So I'm asking this, but actually it's not getting me anywhere. So I suppose we almost got to a point where we could sort of see the funny side to those questions. And actually that helped, I think a little bit with then, right. How do we drop these things? How do we experiment with them? How do we move forward? And that really started to increase Sarah's confidence. And I could see that from session to session, you know, she wasn't asking other people, she was just allowing herself to rely on her own thoughts and her own experiences. And that worked really well for her. Helen: So there's something quite important about testing things out, finding out for yourself really having the experience of what it's like to do something differently and check whether that works in your particular situation. There was another phrase that Sarah used as well, which was positive reinforcement. I think we should just mention that's about essentially what reward you get or what is it that happens that makes you more likely to do something again. And that's what positive reinforcement means. It's just something that happens after we've done something that makes it more likely we'll do it again. And, to me, it sounds like one example of that was making it fun, testing these things out and actually getting something rewarding out of it was part of that journey. Sally: Yeah, absolutely. I think that's a big part of it. Helen: And one of the things that made me smile when you were speaking, Sarah, was when you were talking about what Sally told you to do. And what things you ended up trying out for homework and those sorts of things, the way Sally's talked about it was deciding together, discussing it. I'd be really interested to hear a bit more about do you get told what to do in CBT or is it more you end up in a position where you've decided to do it? Sarah: No, you don't get told what to do. Of course. It's all very, like Sally says, you talk about it and then together decide what might be the best experiments is a good word. Cause everyone's different. Obviously, my exact path of how we got from A to B probably might not work for somebody else. Like Sally says, I came with a notebook, wrote everything down, did homework, because that works for me. No, she didn't tell me what to do. And what was funny as well was Sally's very good at just sitting back and letting you talk, which works because I talk a lot. So she sits back and she's very good at just sort of nudging you to realisations on your own, because if someone tells you that you think something or that you should do something, it doesn't really mean much. If you think it through yourself, because someone's supported you towards that thought process, you believe it more. It makes more sense. And you're like, ah, you know, the cogs go a bit slower, but then you get there. And so over the weeks I would be reflecting on what I'd been doing for Sally, myself, but with the homework. And she'd just go, and so do you think, and what do you reckon? And then I'd go off on another blah, blah, blah, and come back to a realisation that, and she'd have this sort of pleasing grin on her face, of yes that's where I was hoping you'd get to, but you need to get there yourself, obviously. And I was just like, really proud of myself, but also proud of, chuffed for her that it was going in the right direction, it was working. Helen: It's good to hear that you are proud and also it's good for me here listening to you both talk about this because we do talk in CBT about guided discovery and that's exactly what you've just described to us is that idea that it's you that's looking at what's happening And the therapist is perhaps asking you some well-placed questions, but it is about you and what you need and your process and drawing your conclusions from what you've discovered. It's good to hear you talking about that experience. And I'm just thinking about, at the beginning, we did mention that getting active, getting out into nature and things to do with moving more were an important part of the therapy and I'd really like to bring Leanne in as well to talk about how getting active, getting out into nature might be an important part of that therapy journey. Leanne: Oh, lovely, yeah it's something that Sally and I do a lot in our CBT because we recognize that the cognitive behavioural therapy has a really strong evidence base. There's a lot of research that says that it works and it's useful for lots of common mental health problems. But we also know that there's a really strong evidence base for exercise. Exercise is known to be one of the best antidepressants. And there's research as well that says that being in nature has a massive mood boosting effect. And if you pull all those three things together, then surely the outcome can only be brilliant if you've got lots and lots of really good evidence to say that, you know, any one of these variables on its own is going to help you, but let's combine the three. So, so we are huge advocates of including that in the work that we do as much as possible for lots and lots of different reasons, but you know, that sits underneath it all. It can be so good for mood. And also from our own experience I know I feel better when I've blown the cobwebs off, or we've got outside, or I felt the wind on my face, or I've been in nature. I've just moved a little bit. So from personal experience, both Sally and I can say it works. Helen: That's really good to hear, Leanne. And I'm just thinking, I can hear the enthusiasm in your voice and certainly we do know about that effect on wellbeing on getting out in the fresh air, moving more, and how important that is. And without taking away from how important that is, Sarah was talking about she just had major surgery. A caesarean section is actually quite a big operation. She's also got a tiny baby, so at least in the immediate short term, it would have been really difficult for her to move much or get out in the fresh air very much. And it might be the case not only for people who've recently had a baby, even without the surgery, it can have quite a big impact on your body but also perhaps for people with other challenges to getting out and about and moving and I'm just wondering, how can people still benefit from combining getting more active with things that might help say anxiety and depression when they do have challenges about getting out and about? Leanne: I think the first thing that comes to mind is to get medical guidance to kind of find out from somebody who knows your body as well as you do about what's appropriate and what's doable, before you start leaping into exercise or doing anything. And I think it's about trying to find ways just to move a little bit, whether that's, you know, stretching or things like chairobics or chair yoga, those kinds of things can be things that people do at home when they have limitations or pain or, you know, anything like that, but within the realms of, I suppose you've got to pace it within your capabilities and what's appropriate for you. But things like connecting with nature. I was looking into this prior to was talking today and things like birdwatching and looking out of the window or doing a little bit of gardening or tending to window boxes and those kinds of things can give you the same powerful effects of connecting with nature and a bit of activity too. It's not about, I suppose when we think about exercise and we think about movement, we often think about the Olympics and we think about marathon runners and we think about going to the gym and lifting really heavy weights over your head. And it doesn't have to be like that. It can be small things often and Sally and I were talking about this before about, the NHS recommendations and we worked out that it's about 20 minutes a day of movement that's helpful. And also, if you add 20 minutes a day in nature so you do 20 minutes moving around in nature every day, that's going to have a huge effect. So if you can find a way to, to do a little bit, a little walk, a little stretch, look out the window, even watch a nature documentary, that has a massive effect on your mood as well, because it's connecting with nature but in a different way, you don't have to leave the house for that. How does that answer your question Helen? Helen: It does thank you, Leanne. And I'm really pleased to hear you say that it doesn't have to involve buying expensive equipment or joining the gym. You don't have to live on the edges of a beautiful park or something like that. It's something that you can do whatever your living circumstances are. There's all sorts of creative ways that you can incorporate this as part of recovering, improving depression and anxiety and your mental health more generally. And I wonder whether, Sarah has any comments about that, Sarah, because you did mention how important that was to you even before you had your baby, and of course there would have been quite a big change to what was available to you immediately after you had her. Just wondered what your responses to what Leanne's just been saying about that. Sarah: Yeah, I mean, like I said at the very beginning, my expectations of getting back to being myself were not met. And so the big things were, I actually made a list for and showed Sally of things that I'd written down saying, and I entitled it Getting Back To Me. And it was in order of, I just want to be able to make tea for my husband, walk the dog with the baby. These are all things that I just thought I'm never going to be. I don't understand how I'm going to be able to do these. And every time I did them, I was like, oh look, I'm doing that. You know, playing netball and the big one was paddle boarding, and I did it the other week and I was like, oh yeah paddle boarding. Like Leanne says, when it was very important for me as someone who's very active and I'm outdoors with the dog in the countryside all the time to get back to that. And like Leanne says though, it doesn't have to be going for a run. You know, my level of, well, what do I want to achieve was forced to be lowered, if you like, that's the wrong word, changed and because what I hadn't realized on top of taking the dog for a walk was whilst I'm there, I'm listening to the water. I'm listening to the birds. I'm feeling, I'm smelling, I'm all these things. And I didn't realise all that had been took away from me. And so that was adding to how miserable I was. And, like Leanne says, it doesn't have to be right. I need to be able to go for a run. It can just be find yourself back in something that makes you feel happy. And I think one of the techniques I wanted to just mention as well, that Sally taught me, when Leanne mentioned about you doing 20 minutes a day of being in nature or exercising, so that you make sure that you really are doing that to its fullest and you're not, you know, birdwatching whilst washing the dishes or thinking about what you need to make for tea. She taught me a five, four, three, two, one mindfulness technique, which basically is whilst you're tending to your bird box or whatever you're doing, think of five things that you can see. Four things you can hear, three things you can smell, two things you can feel, a one thing you can taste or something like that. And not only does that focus your mind for that minute on those things. It's really nice to think, Oh, I didn't know I could hear that I'm tuning into it. And then you do it again, five minutes later or as much as you want or, and it stops the thought processes that are negative as well, because you're focusing on that, but it just makes sure that when you're in the nature bit you are really soaking it all in as much as possible. Helen: Thank you for that, Sarah. And I'm just thinking, we've had a really interesting conversation about your experience of therapy, Sarah, Sally's and Leanne's thoughts about what they're doing in therapy and what. seems to help people to benefit from it. I was wondering if I could ask each of you in turn, what's your most important message that you'd want people out there to know? So, Sally, what do you think is one key thing that you would want people out there to know? Sally: I would say that mental health difficulties are common and it's not something that you have to sort of put up with or that you're stuck with, I suppose, for the long term, often there are a lot of quite often very simple techniques that you can practice and try and learn either with or without therapy, that can just really help to manage those, either the feelings of low mood or those anxiety feelings as well so, it doesn't have to be a major change. There's a lot out there and a lot of cost-effective things as well that you can get involved with that can just really help to boost your mood. Helen: Thank you, Sally. Leanne. Leanne: Oh, it's such a good question. I think what I'd really like people to think about is thinking about mental health, the way we think about fitness and physical health and spending time each day doing something that nourishes and nurtures mental fitness, let's call it. In the same way that we might, you know, drink some water, like Sarah said, take our vitamins and have something to eat and try and have good sleep, but moving in the direction of thinking about our mental fitness being on the agenda all the time so that I suppose it normalises asking for help and talking about things and looking after yourself and, and good wellbeing all round. Because I think people often really struggle, don't talk about it and then come for therapy when they've been on their own with it for a very long time. Helen: Thank you very much, Leanne. And Sarah, what do you think you would want people out there to know, one key thing that you'd like to say? Sarah: Probably that if you think something's not quite right or something really isn't right and you just don't, you're not sure what, you don't have to know, you don't have to be able to go to a doctor and say I've got this problem, can you fix it please? Doctors are just as, they're well trained to know when someone needs referring for therapy. So yes, that's who you need to probably go to first in a professional manner but if you just go and say, okay, this is how I feel, blah, blah, blah. They'll pick up and know, actually, you would benefit from therapy because it sounds like this might be happening or going on and then you get referred to someone obviously who's even more specialised, a therapist, and they can sit back and listen to you just offload and say, these are the things that's happening, I'm not happy because of this, that and the other, and they'll go, right, It could be this, shall we try that? And so, yeah, you don't have to have all the answers, I think, is my key thing. but you need to ask for them, Helen: Fantastic. Thank you so much. All three of you have been excellent at telling us about your experience and knowledge, and I'd just like to express how grateful I am for all three of you talking with me today. Thank you. Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at podcasts@babcp.com, that's podcasts@babcp.com. You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested. If you've enjoyed listening to this podcast, you might find our sister podcasts Let's talk about CBT- Practice Matters and Let's Talk about CBT- Research Matters well worth a listen.

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, and I was sitting next to him. He turned to Ashcroft and said, "Could you show where I M Blackburn is?" Dr Ashcroft said, "You're sitting next to her." Yeah. So that's how it all started, you know, we were a small group in those days, very small group. Dr Lucy Maddox: Do you remember what you were excited about by CBT at that time? Ivy Blackburn: I thought the research that Beck was doing about the factors in depression, about the role of thoughts I thought that was very interesting. The unit where I was working one of their things was working with treatment resistant depression. And they used to go through, the research was a series of drugs. You start with Drug A. If Drug A doesn't work, you go to B, to C to D. By the time they'd got to E and had nothing else to do I said, "I'll take them." And that's how I started. I just thought it was very meaningful to me. They loved it, people talked to them and they could talk about what mattered to them, and they actually got better. Not long after that we decided to do the famous first ever trial in cognitive therapy for depression. That was published in 1981. Oxford started at the same time, they also had started, John Tisdale and his group, a treatment trial. So ours came out in 1981 and theirs came out in 1984, I think. So we were actually the two centres, Edinburgh and Oxford. But cognitive therapy has developed so much. There's all sorts of offshoots, I don't know very much about. But another big person who did his PhD with me, big one at the moment who's still active I think is Paul Gilbert. He was one of my PhD students. Dr Lucy Maddox: Was he? Wow, yes. Because of course he founded compassionate mind therapy, yeah. Ivy Blackburn: That's it. Dr Lucy Maddox: If you want to hear more about compassion focused therapy, you can check out the earlier podcast with Paul Gilbert. And in fact, if you're interested in any of the different flavours of CBT which are now around, series one is a really good place to start. We go through lots of different types of CBT there and we hear from therapists and also people who've had those different types of CBT. Am I right in thinking as well you were a chair of BABCP? Ivy Blackburn: That I was a what? Dr Lucy Maddox: A chair? Like a president of the organisation, is that right? Ivy Blackburn: Yes, I was. I was president, yes. Dr Lucy Maddox: Yes, and were you the first woman president? Ivy Blackburn: Yes. And I am of mixed race, so that was a bit of first as well. I went to Newcastle from Edinburgh in 1993. I think it was 1993. Dr Lucy Maddox: And what was your experience like of being president? Ivy Blackburn: As I say, we were so small in those days, you know, we had these little cosy conferences. We met in Newcastle every month. I was very, very well supported by Paul Salkovskis so he sort of guided me through. It was easy and of course some of those people are still there. Dr Lucy Maddox: Yeah, you're the big names. Ivy Blackburn: (Laughs) We are, we are the oldies. Have I enjoyed it? Yes. Yes, I have enjoyed this work very, very much, yeah. Dr Lucy Maddox: What have you enjoyed about it? Ivy Blackburn: My work was very diversified because I was obviously also an academic so I did research, I did teaching, I organised a course. But I always carried on with my clinical work and I think that's what I enjoyed the most, clinical work. This is what's rewarding, isn't it? Dr Lucy Maddox: For sure. Yeah, absolutely. David Clark: It was an exciting time. And people talked about it as a cognitive revolution. And I think it was a revolution. Dr Lucy Maddox: That's David Clark. He's based at the Oxford Centre for Cognitive therapy, which Ivy was talking about. We also met David in the very first episode of this podcast. He joined the BABCP in the late 70s, when the dominant approach was still behaviour therapy. But as we heard from Ivy Blackburn, there was a crosspollination of ideas from the United States, where Aaron Beck was working on cognitive therapy for depression. The idea that the way we perceive the world and our future can affect how we feel about it is now rather taken for granted. But at the time it was quite a radical idea. David Clark: We suddenly started looking at a whole range of different potential therapy manoeuvres. There are thousands of ways you can change people's beliefs and it was really exciting. Dr Lucy Maddox: The interlock between beliefs, behaviours, memory and attention was really the basis of cognitive behavioural therapy as we now know it, with the model of thoughts, feelings, behaviours and bodily sensations, which is a fundamental part of most explanations of CBT today. Another root which CBT grew out of was rational emotive behaviour therapy, which Albert Ellis pioneered in the 50s and which also included thoughts, behaviours and emotions in its way of thinking about problems. In the late 80s and 90s, CBT as we now know it, grew out of all of these roots, behaviourism, rational emotive behaviour therapy, and influenced by the work of Aaron Beck and the bringing together of all of these different ideas. Through the 80s and 90s, lots of disorder specific psychological models were created, to try to tackle specific problems. For example, models for panic disorder, obsessive compulsive disorder, posttraumatic stress disorder, and other problems were developed and really changed the treatment for those difficulties. David Clark: And then, of course people start spotting ah, yeah, but some of the maintenance processes that had been invoked in a disorder specific model are also applying in other disorders. safety behaviour which Paul Salkovskis of course really pioneered is a good example of that. And also changes in attention, ways in which memory processes can go wrong. And so, you start moving into this way of thinking which is a bit more transdiagnostic. Dr Lucy Maddox: Yeah, lovely, so actually it's kind of gone from a very transdiagnostic one treatment fits all at the very start to then getting much more specific and nuanced. To then zooming out again to a bit more of a broader picture again. David Clark: Yeah. And I think this is the sort of healthy dialectic that you experience when a field is moving forward. Dr Lucy Maddox: And I suppose that's one thing that I feel like CBT I mean, other therapies too perhaps, but CBT in particular it feels like it really is a learning therapy, where it's very good at creating an evidence base. And then holding that evidence base up to the light and saying, "Hang on, what could we be doing better here?" And it does feel like it's continually evolving perhaps because of how well evidenced it is. David Clark: I think that's right. I think it's always had a very close link to the evidence base. But I think other therapies are going in a similar way, and I think this is really all to the good. Dr Lucy Maddox: What do you think of the? Because the sort of family of CBTs if you like, I think of them as a family, there different therapies that have developed I guess a little bit more recently which still draw on cognitive and behavioural principles. But maybe sort of run with a different strand of it each time. So I suppose I'm thinking about APT and DBT and compassion focused therapies. How do you see those fitting? David Clark: I'm just an empiricist, so I think what I think of them depends on what the outcome data is (laughs) with the particular conditions that they're involved with. But when you get an approach which seems to be doing well and maybe improving on something else, then one always has to look at it. One of my friends, close friends through much of my career was Tim Beck who sadly died last year. But he was a very jokey person in many ways. But one of the points that he would sometimes make when someone said to him, "Well, what's cognitive therapy?" He would say, "Well, anything that works." And of course, it was a joke in a sense, but it was also serious because he was always watching for what other people did in other therapy approaches to see if they'd got something which cracks open beliefs in a way that he hadn't seen before. And if so, it miraculously got incorporated into cognitive therapy. It's really important that we as therapists always keep our eyes open to these things. One of the big developments more recently in the field has been to think well, how can we bring these advances to the public so that really large numbers of people benefit? Dr Lucy Maddox: Yeah, and of course improving access to psychological therapies has been a massive part of that. David Clark: Yes. It's been a great honour to work with so many wonderful people who put in such hard effort to lobby for that. And then, to create the services and crucially, to make them work so effectively that successive governments across the whole political spectrum have cherished and expanded the programme. At the moment it is the only aspect of our mental health services where outcomes are recorded on everyone and are published. In my worst nightmares I would not have dreamt that we'd still have almost every other area of mental health provision in the dark ages in terms of public transparency. And also in terms of learning. Dr Lucy Maddox: As David said there, a national improving access to psychological therapies programme in England doesn't only include CBT. But it has been instrumental in increasing access to CBT as well as other evidence-based therapies within England. It's also been responsible for creating a whole generation of low intensity therapists, who deliver CBT as part of a stepped care model. Where briefer interventions, often in the form of guided self-help, are offered for less severe presenting problems. Now we move a little later in the history of CBT. I got in touch with the outgoing president of BABCP, Andrew Beck, and asked him how he first came across CBT. He told me about his first experience of the BABCP conference as a trainee clinical psychologist back in 1997. Andrew Beck: I managed to get a free ticket to it by DJing at the social party afterwards. Dr Lucy Maddox: Did you? Andrew Beck: Yeah, I did, I DJed at that and got a load of Rod Holland's photographs from past conferences and made a sort of slideshow of them, which we showed, while I was DJing and it was great. But I really felt like I'd come home because there was such a wide variety of people there. It was people from all different professional backgrounds, all coming together and talking about the real practical aspects of working in mental health. Yeah, it was a real eye opener for me. Being around people who you feel share the same concerns, the same interests, who want things to be better in the same kind of way that you do is great. You feel like you're part of a community then, don't you? And being part of that community sustains you in what you're doing in a really nice way. Dr Lucy Maddox: What was it about CBT that you liked? Andrew Beck: It was pragmatic, and I think there was something about it that was very much about being in the room with someone and helping them to get past the things that were stopping them getting on in life. And it was that really present focused aspect of it that appealed to me. That I felt like as a cognitive behaviour therapist, you were going to help someone find something to take home with them and do differently to improve things. And I think that was what really clicked for me, to be honest, Lucy. I came in 25 years ago, at a point where CBT had begun to be thought about as a therapy in a very coherent way. A lot of the models that we use now and are familiar with, were all really well established. And it was easy to imagine that it had always been like that. But of course, talking to some of the people who were around in those formative years, it's been really interesting to hear that history of how the therapy has developed. And I'm told that there was a raging argument about whether these ideas about behaviour therapy and those ideas about cognitions could be brought together in one therapeutic organisation. And how that might look. Because they were quite distinct camps at times, really, with quite different ideas about what therapy ought to be like. And whether these very disparate ideas could sit well together in one organisation and what that organisation ought to be called. But of course, by 25 years ago attending conference, what we now think about as second wave CBT felt very formed, actually. And what's happened in the 25 years since is the third wave therapies have developed their evidence base, developed their theoretical foundations and have really grown in popularity. And there's a whole group now of therapies that are considered to be part of the family of cognitive behaviour therapies but are the kind of next wave. Dr Lucy Maddox: So Andrew talks there about first wave CBT, which was really just behavioural therapy. Second wave CBT, where the thoughts got added. And third wave CBT, which is the larger family of therapies we now think of. As I said before, if you want more information on the different sorts of CBT, check out the podcast in series one. As we heard from Howard earlier, not everything about the past history of CBT is rosy by any means. Is there anything that you're glad that we've left behind in terms of how CBT has changed in the last 50 years? Andrew Beck: Yeah, I am, actually. There's a few things I think are real problems in the history of our therapy. And probably the one that stands out the most is the role of behaviour therapy predominantly in conversion therapy for people that are LGBT identities. And if you look back at conference proceedings from BABCP conferences 30, 40 years ago this was something that was seen as unproblematic. That there was an idea that people who were unhappy with their sexual identity could have their sexual identity changed through behaviour therapy. And looking back now that was appalling and actually for many people at the time it would have been seen as appalling, too. So it's not just one of those things that with the benefit of hindsight doesn't look great, actually it didn't look great at the time, I think for a lot of people. And if you were a gay member of our organisation and came to conference and saw that as part of the conference proceedings, that would have been a really alienating process, really. And I think the other thing is because CBT has often been aligned with diagnostic frameworks over the course of CBT's history, really see now and understood now as being quite unhelpful. And the one that most stands out for me, I think is borderline personality disorder, which is a way of describing people who generally experienced extraordinarily abusive and invalidating environments growing up, who have developed all sorts of strategies to manage those difficult environments. But who have been understood by services as having a problematic or disordered personality. And I think broadly speaking, the world of mental health is moving away from that as a diagnostic category. Dr Lucy Maddox: Andrew is the outgoing president of BABCP, and he's just about to hand over to Saiqa Naz, which is the last person I spoke to. Her perspective on CBT comes from her training as first a low intensity therapist, then a high intensity therapist and now as a trainee clinical psychologist. Saiqa Naz: I really enjoyed my training, there was a core group of us. We had a routine, we'd go to Costa and have a coffee beforehand. So for me, I remember that (laughs), the social aspect of it. I think that really makes a difference to a training experience, just having that network of support around you. We're actually celebrating our 10 years of friendship this year. So I've been in CBT for 10 years now this year, so it's nice to be part of BABCP and hopefully be part of its future as well. And I'm mindful I'm probably a bit different to the other presidents in terms I might be a bit younger, or not a professor. But hopefully bring something different to the organisation. Yeah, I think when I trained as a low intensity CBT it was in the early days of the IAPT programme. So just really interesting to see something so huge being rolled out nationally. And how it was being developed locally, so I trained in Sheffield and we were based in GP surgeries. And I really liked that model, working a little bit more closely with other healthcare professionals, GPs. I've still held onto the skills that I learnt as a low intensity CBT practitioner, when I trained as a CBT therapist. So it lent itself really well to training as a CBT therapist. And again, I think both are valuable in their own right. The step care model is really important if you're thinking about long waiting lists and people having access to treatment sooner rather than later. So I think in that sense, the low intensity CBT role has really revolutionised mental health and how services are delivered today. Dr Lucy Maddox: David and Andrew both had similar respect for the low intensity role and how it's changed access to CBT. David Clark: We now have people with a wide range of backgrounds, non-medical backgrounds, who are delivering evidence-based therapies and are considered on an equal basis and are considered to be real experts. So that sort of democratisation of mental health provision has been obviously an incredibly good thing. Andrew Beck: We're really lucky in BABCP in that we've got a bunch of great low intensity members who are involved on board level, at committees. And I think that's going to be a big part of who we are as an organisation. Dr Lucy Maddox: Saiqa and Andrew were also two of the authors of the IAPT positive practice guide for working with Black, Asian and minority ethnic service users, which is available at www.babcp.com and also in the show notes. Saiqa had some ideas about what would help this to be rolled out more fully. Saiqa Naz: I think there's quite a few things that will help. So people like Andrew and myself can take a step back and that's having representation in those senior leadership roles, decision making roles. What we see is that IAPT has opened the doors for people from underrepresented groups, so working class backgrounds, BAME backgrounds, men, people with disabilities. But what we need to see is those people in more senior leadership roles. And personally I would like to see ringfenced funding now, to help the implementation of the guide. Otherwise, I think the system will keep relying on goodwill and it could be a bit exhausting. Dr Lucy Maddox: What about the future of CBT? We don't know how it will change in the next 50 years. But everyone I interviewed had some ideas. Saiqa Naz: I think for me looking forward I want us to learn more about our CBT heritage. We were just talking about it at the beginning, thinking about who are we inheriting the knowledge from? Where has it come from? Because it will help us to connect with CBT and also think about what's the legacy of CBT long after we're gone what we're leaving behind for the next generation. And also, how are we going to support the development in a way we are privileged here with the amount of resources that we do get in mental health and the level of training. But how can we pass it on to more lower middle income countries? Taking CBT to communities I think is really important because sometimes I think an organisation can become too insular and just be focused on the inward and on itself. But having that one foot in, one foot out is really helpful. Dr Lucy Maddox: Andrew agreed that involving people with lived experience of having had CBT is really important when we think about the future development of the therapy and how it might evolve over the next 50 years. Andrew Beck: It enables us to think a little bit more about barriers to engaging in therapy, what we need to do differently to bring people in, what we need to do once people are in therapy. And it's been a really lovely development, I think in CBT to think more about that. We really don't know, we're very much at the edges of thinking about how our therapies might develop over the next 25 and 50 years. So it's a really exciting time. We need to keep pushing and refining our ideas to improve. But the other one for me is about access and outcomes for diverse populations. CBT needs adaptation and therapists need to be able to take into account cultural contexts in order to do that because the large datasets that we've got show that for many communities their outcomes are not as good. Now, part of that I think is because those communities experience particular social and economic hardship and marginalisation, and therapy can't fix that. But part of it is because therapists just need to get better at thinking about difference in the way we work. So I think that's going to be an exciting project over the coming years. And we're just at the start of that, really. Ivy Blackburn: I think it will be still there with a lot of development, side developments, as we see at the moment, like compassionate and all sorts. Different branches. But I don't see it disappearing to be replaced, developing as it should be. The beginning was very, very quick developing from depression it quickly went to anxiety. And then, Paul and David went into panic disorder, all this. One after the other, different methods. David Clark: I just hope that the speed of progress in the next 50 years is at least as fast as we've had in the last 50. And we get to a situation where helping people learn how to deal with setbacks in their life and deal with mental health problems becomes much more routine in society. I assume we're going to have much more digital. I'm sure AI is going to help with a number of things. But I'm also sure that the absolutely basic qualities that are in therapy about having someone who really cares what's going on with you, being warm and empathic and really wanting to understand the world from your perspective will remain dominant and really important. Isaac Marks: Well, I imagine that new methods will continue to be developed from time to time by people in different countries. And as far as I can see, it's the sort of approach that I think is likely to continue for the foreseeable future. Dr Lucy Maddox: I hope that's given you a bit of a flavour of how CBT has grown and developed, especially in the last 50 years from its behavioural roots to the diverse and flourishing therapy that it is today. Do check out the other episodes of the podcast to hear from people who have actually had the therapy to hear in their own words what it's been like for different problems and with different types of CBT. Meanwhile from me, that's goodbye. Take good care and enjoy your summer wherever you are. END OF AUDIO Shownotes Photo by Ryan Gagnon from Unsplash Music by Gabriel Stebbing Produced for BABCP by Lucy Maddox For more on BABCP check out www.babcp.com The Memorandum of Understanding Against Conversion Therapy can be found online here: https://babcp.com/Therapists/BAME-Positive-Practice-Guide The IAPT Positive Practice Guide for BAME Service Users can be found here: https://babcp.com/Therapists/Memorandum-Against-Conversion-Therapy For more on different types of CBT check out series 1.

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 Incredible Years programme together with parents who are experiencing similar difficulties. Sue: The other offer would be an individual based programme, which we tend to offer for parents who find it hard to access the group. Or maybe they've tried a group before and it hasn't necessarily worked. Or a parent that doesn't feel quite ready or confident enough to go into a group so we would offer those parents a sort of one-to-one. Building a very similar model but the child is involved in those. So, the group one is just for parents but the individual programme, the child comes along to those sessions as well. Lucy: That's great. And it's lovely that it can be so flexible so it can be group or individual. That sounds really important. Sue: Both have been able to go remote now. That's been quite a spectacular shift and I think that It's gone down quite well for parents because it means they don't have to organise childcare in order to be able to attend groups and things. You know, practitioners have been able to offer them in the evenings, perhaps when kids are in bed or at school, when parents aren't working. So yeah, it's gone down really well. Lucy: That's fantastic. Yeah, that sounds really helpful. I was really curious about the sort of key skills and techniques that you teach in the evidence-based parent training. What are some of the topmost important skills do you think that get taught? Sue: The first quarter of the programme, I would suggest, is focused on building that relationship. And that's largely done through child-led play, spending time together. Jane: One of the things that we were asked to do was to set aside 15 minutes dedicated time each day to play with him. And I loved it and I felt like I learned loads about him in terms of some of the things he could do with play that I didn't even know about because I was probably too busy doing the washing up, previously. Rather than me just getting frustrated and shouting. It really kind of built our relationship. Lucy: That sounds really fun, actually, yeah. Jane: Yeah, yeah, it's nice to be a big kid rather than just be adult all the time. Lucy: Back to Sue. Sue: There's a particular way of playing and it's not just what you do, it's the way that you do it. We particularly look at noticing what a child's doing well. If you've got a child who is inattentive, for example, it might be very helpful for the parent to notice when that child is paying attention and focusing. Quickly jump in with praise to encourage that child to do it again. So, that's the bit of social learning that we're building on there. So, the child is paying attention, the parent notices the child is paying attention. The parent says, well done to child, so child is more likely to pay attention in that way again. Jane: Another thing that I learned was like the attention rule. So, it's kind of drummed into us so what they always say is whichever behaviour you pay most attention to you will see more of and kind of flipping that on its head. So, thinking about what attention I was giving to Jack, whether it was positive or negative and trying to focus on the positives, really, which kind of gave me a little bit of perspective. I just felt as though he was really difficult all the time, whereas, actually, if took a step back and focused, I realised that he wasn't and there were lots of really good things that he was doing that I didn't always necessarily notice. Sue: We also look at the ways of praising a child or rewarding a child. Quite often – and I've definitely been guilty of it myself – is putting a tag on a praise statement, for example. So, we might say, "Ooh, well done for tidying your bedroom. Why can't you do that all of the time?" And that's the tag. The tag there is, "Why can't you do that all the time?" So, we've given with one had the praise, "Well done for tidying your bedroom." But quite often as parents, we will take away the praise by adding that, "I wish you could do that all the time," or, "Why can't you be more like your brother?" Or we'll add a something that actually negates the praise. So, parents, by week five, six are really becoming conscious of the language that they use and how impactful that can be. And this really works well with the group of kids that I've talked about already because they're quite selective with their listening, perhaps or they don't really hear it all. So, it's very powerful for kids to make sure that they're genuinely hearing praise. What else do we do? We then go on beyond praise and start thinking about our ability to remove that attention. So, we think about how we ignore a child. And quite often, parents will tell me, "Oh yeah, yeah, yeah, I ignore my children. I can ignore my children for five hours." We're not talking about not being with a child or the child being occupied very happily doing something else. We're actually talking about an active removal of a parental attention, which is then when the child complies again, then the parent comes back and uses their attention in a particular way to reinforce the positive behaviour. Lucy: When would a parent do that kind of taking the attention away? Would that be in response to something in particular? Sue: Yeah, ignoring a particular behaviour. And we suggest that those are the behaviours that are annoying type behaviours. So, we're talking about whingeing and whining and grumbling and answering back and nagging, you know, "Mummy, can I have a biscuit? Can I have a biscuit? Can I have a biscuit?" The parent has said no and that potentially could escalate between parent and child, where the child says, "You are the worst parent in the world. I hate you. It's not fair." But the parent needs to be ignoring that the whole way through. Kids are brilliant at this, absolutely brilliant, really clever at trying to get parental attention. So, they will up their behaviour. So, they may be saying, "Yeah, you're the worst parent in the world. I don't love you anymore. It's not fair. Lucy down the road, she's allowed to do this, that and the other." Quite often, parents will snap at that point, therefore, no longer ignoring the negative behaviour that the child is presenting. So, the skill is for the parent to be able to keep a lid on it until the child has run out of energy in their negative behaviour. And when the child comes back down, that's when we want parents to reengage with the child and respond in a positive way to the quiet, calm, polite behaviour that you hope your child is now exhibiting. Jane: Sue helped me, teaching me strategies to calm down, things like breathing techniques and stuff, obviously, for me and for him so that when he was on the verge of losing it, he could count to 10 or take some deep breaths. It wasn't like I was just shutting the door and leaving him to lose his mind. And that really helps. I understand ignore sounds awful but I think it's about, it's like what you do and how you do it, rather than ignoring and leaving him to it. Because that's not very nice. Sue: The idea of an ignore is only for the duration of the negative behaviour. So, if you think about the whingeing and whining for the biscuit, how long can a child continue to ask you for that biscuit? Five, 10 minutes, tops. You're not leaving them in a room, you're not walking out on them, you have just got to develop this sort of Teflon coating where you hear what they're saying but you choose not to respond to it. But it's the parent's removal of attention that's key. So, if a parent is actually leaving the room, then they're not actively ignoring, they are doing something else. But an active ignore, which is what we're talking about, the parent has to be very present because the moment the child has come back down that sort of angry curve, they come back down the other side. So, what you try to do if you wait for them to deescalate and then move on and get them involved in another task. Lucy: I'm just thinking it's sometimes really difficult to do, isn't it, just as you describe that kind of… Sue: Yeah. Lucy: …snap. Just as things are escalating, particularly in a public situation. Or I guess if you feel that you're worried that the child's upset as well, it's hard, isn't it? Sue: Desperately hard, especially if you understand why your child is worried or you understand why your child is fearful, you know, if you've got an anxious child, for example. So, parents have to be able to work out which is a behaviour that they want to encourage or which is a behaviour that they want to see less of. And we spend a lot of time thinking about those things. Parents will say they're very good at ignoring children but they quite often forget to reengage at the other end. So, the active ignore is a big step. Lucy: I wanted to know from Jane how it felt to remove a tension in more difficult settings like in public. Jane: Because I had – well, script is the wrong word – but like a thing to follow, it kind of built my confidence in being able to do it. I think once he kind of learned where the boundaries were at home, it kind of like resolved itself a little bit when we were out in public because he knew from the beginning that it wasn't going to wash and he was just going to get ignored. And flipping it on its head in terms of the negative tension, the positive tension, it just kind of got a bit easier because I felt a bit more confident and then I had the skills to cope. Lucy: Another important aspect which Sue talked about is how we think about the language that we use when we talk to children. Sue: Quite often, we use a lot of negative commands, "Be careful." It's sort of an empty command, what does it actually mean? Whereas autistic spectrum children who probably need very, very clear communication, if they're playing on a climbing frame, for example, "Be careful," could be replaced with, "Hang onto the bars," or, "Use both feet on the climbing frame," really clear for children to know exactly what they should be doing. And it's amazing when you tune in to that and you start listening to your friends and your relatives and things, you do realise that in everyday English, we use a huge number of negative commands for children. You listen to teachers in schools and they're saying, "Don't wriggle, don't poke him next to you, don't do this, don't do that." But what we should be saying is, "Please do, please do this, please do that," because children quite often only hear the last word that comes out of our mouth. So, if we said, "Don't run," the only word they hear is run. Lucy: Absolutely. And it's also quite negative, isn't it, if someone's constantly telling you stuff not to do. I don't know, it feels different in tone, doesn't it to telling you stuff that they would like you to do. Sue: And when you set them off, in the same CBT-type model, you set them off with homework and home practice and things to do, when they come back the following week, they often say, "Well, the atmosphere in my house completely changed because we were focusing on positives, not negatives." And again, it begins to shift what you notice as well. Jane: It's kind of a bit of a bugbear of mine and now I've realised it. Like, quite often, a lot of my friends and even my in-laws or my parents will say, "Oh, you've done really well, good boy, good boy." And for me, it was like thinking about what that even was. Sue really helped me see the importance of being specific around the praise that you're using. So, that kind of then links it to their behaviour rather than just being, "Oh yeah, that was really good." So, specific praise for me was really important. I saw a really big impact on Jack's behaviour when I was able to use really specific praise with him to, kind of, you know, highlight the good stuff that he'd been doing, like putting his plate in the dishwasher or calming down after an ignore, you know. Like when he was able to use his breathing strategies and then come back and then when we started to play, I've said, "Well done for calming down," or that kind of stuff. So, the specific praise, brilliant. I think also, thinking about some of the phrases and the language that I use with him. So, if he's really wanting something like, I don't know, wanting loads of ice cream or something but he won't eat his dinner, a little phrase like, "When you've eaten your dinner, then you can have your ice cream," the when-then thing worked really well for me and made me think about the kind of words I was using and the impact that was having. Because, obviously, what I was doing before wasn't helping. And I guess the other big thing for me that helped was the use of rewards. So, it helped me think about a specific target for Jack in terms of how we could get him to stay in his own bed. We used like Batman stickers when he was able to do it. Lucy: That sounds nice. Jane: And then when he did it consistently for like five nights, we then went ten pin bowling, which was lovely. Sue: Oh great. Jane: Yeah. Everything just became a lot more positive, really. Lucy: That sounds really powerful. Jane: It was, actually, yeah. Lucy: Often, parents find that things like time out just aren't necessary once praise and play and positive attention are in place. Sue: Absolutely, absolutely. And I don't know whether you've noticed that while I've been talking to you, I keep doing this, I keep forming a sort of pyramid with my hands. And the fundamentals of the parent training is really about building that broad base at the bottom, which includes play and attending to a child and listening and problem solving. These are all the building blocks of a really strong relationship. And we've got praise in there and we've got rewards in there. And then as you move up the pyramid, you've got to start thinking about the other sort of techniques. We've got the children stuff at the bottom, you know, all the stuff that you can do with your children to build the relationship. And then you start thinking about the techniques that parents can apply to kind of modify behaviour. So, that's when we start talking about ignoring or the language that we use, thinking about command statements and starting to put in boundaries. And then as you get to the tippy top of the pyramid, you're thinking about time out and the use of consequences. But fingers crossed and a lot of periods experience this when they're going through our programme, they start by saying, "I just want to hear about time out. I just want to hear about how to do it better." We say, "Hey! No, no, no, we're going to start at the bottom. We're going to build that relationship." And by the time we get to the point where we want to tell them about time out, they actually find that they don't need to use time out as much as they did at the beginning because they have so many other effective strategies on managing behaviour and noticing different behaviours before we get to the top, before we get to the point where we may need to put in a consequence or a time out. Lucy: And the very, very end bit of that pyramid that you were describing, the time out is probably something that people kind of are really familiar with, actually, because it's around because of programmes like Supernanny. Sue: Yeah, you're right and people love it on Supernanny, because she spends a lot of time talking about "naughty steps," doesn't she? Lucy: There's a lot of naughty steps in Supernanny. Is it the same in evidence-based parenting training or is it a bit different? Sue: It's similar but it does hang onto that idea of differential attention. So, you can't just put a child on a naughty step or a naughty spot – and we wouldn't necessarily use that phrase – we would encourage a parent to be removing their attention on purpose for a period of time. And that time is linked to age, which is very much similar to the Supernanny model. But one of the things that we would absolutely advocate is making sure that when the child has completed their moment of exclusion, the child comes back into the family activity in a calm state and they're not expected to say sorry. They're just expected to come back calm and quiet and you just move on with your activity. A lot of parents don't necessarily like hearing the bit about not saying sorry. One of the ways I try to describe it is if you've ever had an argument yourself, you don't immediately calm down. You're not always receptive to apologising or hearing somebody else's view. So, by asking a child to apologise in that moment, you either get a, "Ugh, sorry!" which doesn't mean anything anyway or you will get a reignition of the fire, of the flames of the heat of that moment. So, it's actually better to choose your moment to have that discussion, have that teaching element of your parental relationship when the child is calm or by modelling calm yourself or reminding them of what they do well, going back down that pyramid and through play. And the child will enjoy the attention they're getting so much when they're being played with in a particular and positive way versus the attention they get when they are simmering and smouldering. So, that's the rationale. Lucy: It also sounds less shaming because there's something tricky, isn't there, about when any of us have been told off, that rush of shame that you get to begin with. I guess your kind of avoiding like really going over that by getting a child to go over things and say sorry. Sue: Yes, when they've thrown something at their brother and that's why you've removed them from that scenario for a few minutes, they know that they shouldn't have thrown that thing at their brother or they shouldn't have kicked you or they shouldn't have sworn at you. So, that's the sort of step on from the ignore and ignore is in the moment hoping that the child can deescalate, wind themselves back in. But if you feel like they have gone beyond that, so there are some behaviours that we completely see as being completely unacceptable and those are the sort of violent behaviours, then that's when we would put them into the total removal of parental attention, the sort of time out type space. And so, we do spend quite a bit of time thinking about parents' thoughts and their physical emotion. So, we think about how cross they are when they're ignoring or how wound up they are when they're trying to do time out and we think about how they choose to behave, how they choose to respond to their child as a result of those thoughts and those feelings. So, we try to incorporate those three elements as best we can. Lucy: I was curious to know whether Jane used any of the techniques from the top of the pyramid like time out with her son. Jane: I don't really feel as though we had to use it so much, I think mainly because of Jack's age, he's a bit bigger now. The ignore and the praise and the play and the positive attention and also building the relationship had the biggest impact. And like Sue talked quite a lot about your pyramid being upside down beforehand or properly ignoring, you know, with any like real idea of how to do it or what I was doing. Or maybe trying to put him on the step and then he wouldn't and then it just all goes wrong. So, I was probably doing a lot of that at the beginning whilst trying to get through my day and not spending enough time with him and not doing the bottom stuff, which I think, obviously, is what for me has made the biggest difference. Lucy: But you were doing the best you could, weren't you, at the time? Jane: Yeah. Lucy: Super hard. Jane: I feel like they don't come with a manual, do they? But that's why the group kind of helped really. It gave me a bit of perspective like to stand back and think about things that are kind of happening on a day-to-day and what was going on for both of us, really. And also like a checklist in my head about what to do and when and that was amazing in terms of my confidence, really. Lucy: I asked Sue what changes she saw from the start of the programme to the end. Sue: Yes, most parents want to come in and they really, really want to hear about these big time out, big guns approaches, potentially as a little bit of resistance to the idea of building a relationship. "Oh come on, come on, come on, let's move on. I just want to hear about the big stuff. Why are we wasting our time on this little stuff? I just want to hear about the big stuff." But by week three or four, they really do begin to see shifts in the way their children are responding to them and the tone in the house about noticing the positives rather than just looking at the negatives. So, we really see shift early on. And like I say, by the end, fingers crossed, you would hope that parents are not needing… you know, they feel quite proud when we get to the sort of time out stage of the programme and they go, "Yeah, I get this but I don't need it," you know. So, we do see big, big, big shifts through parents. And one of the things I love and one of the reasons I just keep going with this is because I see that confidence building in parents. And we have parents coming back and saying, "Yeah, we only talked about getting my child to bed but I now realise that if I just apply the same ideas and the same principles, I can use that with, ooh, getting him into school or encouraging him to do his homework." So, there are all sorts. We are building skills which you then hope can be sort of expanded out and used in all sorts of settings. Lucy: And it's called evidence-based parent training. What is the evidence base like for it? Sue: The evidence base for both of the programmes that I've mentioned so helping the non-compliant child and in particular the Incredible Years, I mean, Incredible Years has had 25 years of research and has been developed over, I think it's now delivered in 32 countries in 32 different languages to all sorts of different communities. And it isn't prescriptive. Parents come along and you work with parents' individual goals. So, each individual in that group will be working towards their own goal in that group but they'll have the support of the leaders plus their colleagues in that group who will help them reach that goal. So, it's sort of tailor made, if you like, to fit individuals who are going through similar things but individuals within a group. Or in the individual programme it's even more tailor made by definition, I suppose. But yes, the shifts are huge and it doesn't necessarily happen in two or three weeks. I think sometimes, parent training has been thought to be done to somebody. But you definitely have to have this sort of collaborative relationship, there's no other word for it, but this joint working in order to reach the parents' goals. So, I think that's really important to get the outcomes that you want. If I was just telling somebody to do this, you know, "Go home tonight and do this," that wouldn't necessarily have the impact of exploring how it's going to work in your house. And thinking about the parent, well, they know their children the best, don't they? So, you work with whatever the parent is bringing to you and thinking about how these principles will apply in that instance. Lucy: And what do you like about your role delivering evidence-based parenting training? Sue: I like the fact that parents become much more confident in their parenting skill. I love the fact that they come in a little bit like sort of timid mice and go out like roaring lions with the confidence that they've got by the end. I think it changes the way they relate to their children, I think it changes the way they relate to each other as parents and I think it just changes atmospheres in households, which I think is really magical. Lucy: I asked Jane if there was anything she didn't like about the sessions and she had no bad things to say. So, I asked her what she enjoyed about it. Jane: Learning about how to play properly, I think. With Jack, I'm not being like too directive. Like before I was like, "Jack, do this, do this, build your tower, build your train track like that, that's wrong, dah, dah, dah," and I didn't realise how negative I was being. So yeah, I guess the most enjoyable bit for me was having that dedicated time to spend with Jack playing and watching him play and kind of getting to know him a bit more. Playing and building our relationship really was my favourite. Lucy: And what sort of difference has it made? Jane: I just think everyone's a lot happier at home, which is great. I'm not shouting as much. Jack's a lot happier because he's not being shouted at. And the whole house is just a lot calmer and a lot happier and everyone is a lot more positive towards each other and it just makes the atmosphere a lot nicer. There's a lot less whingeing and moaning and whining from all of us and nagging. (Laughs) And yeah, I feel like, because Jack's now able to sleep in his own bed properly without me, it's really had a positive impact on mine and my husband's relationship because we actually get an evening together to watch Strictly Come Dancing or, I don't know, something that's not to do with the kids. So, that's really helped. And I think also because Jack's now sleeping better and things are happier at home, school is better as well, he's not so tired. So, he's able to focus a bit more and get on with his schoolwork a bit more. So, that's the kind of feedback I've had from school, which is nice. Lucy: It sounds like a really good result. Jane: Oh yeah, I loved it, yeah, I loved it. It changed my life, anyway. I'd recommend it to anyone. And no matter how hard a problem seems, there will be someone else out there that's got a problem like you. You're not on your own and it's okay to struggle. Pretty life changing, really. Lucy: If you're listening and you want to know more about how to access this sort of support, you can explore your local services online and check out Incredible Years groups in particular. You can also ask your GP who may refer you to Child and Adolescent Mental Health Services. If you've got a child with a diagnosis with ADHD and you want this sort of support, you can ask, "Where can I access parent-based intervention?" Thank you so much to both of my experts, Sue Howson and Jane. If you'd like more information on evidence-based parenting training, have a look at the show notes. And for any parents juggling home school and work at the moment, my thoughts are with you and I really hope you're doing okay. For more on CBT in general and for a register of accredited therapists, check out BABCP.comand have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with. There are quite a few episodes to do with children, including Shirley Reynolds on values-based activities in the pandemic and Maria Loades on helping children with loneliness during Covid-19. That's all for now, take care. END OF AUDIO

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 us in the cognitive science of depression is once mood becomes depressed, thinking becomes more negative in content. It also becomes more concrete and more over general, so it's hard for us to be specific in our recall. And another important factor, a thing that occurs once mood becomes depressed is our memory more readily recalls past unpleasant painful memories and actively screens out positive or neutral memories. The reason why this is important is that our ability to solve problems is really based on being able to retrieve information from the past about how we did that. But once mood becomes depressed, you're trying to do an everyday thing like say, I don't know, mend a broken sink pipe, and you're trying to do that, but because your mood is depressed and your concentration isn't great, it's harder to do. But also, all that's coming back to you is all the times things have gone wrong, not the times when they've gone well. There's a tendency when mood is depressed for thinking to be very all or nothing. Or you might predict that if you try something it won't work and therefore you don't do it. So it's really about trying to work at that level as well. The second part to CBT is really what I would call a more psychological component which is really trying to look at some of what the theory might refer to as psychological vulnerability. So trying to look at some of our beliefs that might underpin our depressive episodes or might make it difficult for us to make progress. Lucy: Looking at the underlying beliefs was something Sharon remembers as being important for her. Sharon: So the group was great and from that I then moved into a yearlong one-to-one CBT. And that went into, right back to early life experiences, what sort of things have actually helped to develop you, it's not your fault, these things happened to you, you were too young, you had no control. And a lot of forgiveness, which I've never been able to forgive myself even though I now accept I never did anything wrong. And I wouldn't have been able to do that before. But the outcomes from that yearlong – it's longer than a year because I became very unwell – but when we got to the end of it, we'd worked through looking at the rules that I live my life with and deconstructing them. Where have they come from? Do they stand up to scrutiny? What might be better rules to live with? All with this compassionate focus. And at the end of it, I've still got it now, I've got it with me now actually, it's like a little credit card size piece of card, laminated cardboard with the rules on it, my new rules in case I need a little sort of quick fix of reminder of it. But they're there, so it's there all the time. Lucy: Would you be able to give an example of one? Sharon: I mean the major one, I was a perfectionist. I had to do everything right. And that's because I used to get punished, I had a very traumatic, abusive childhood and was punished quite a lot, quite severely. And so I had to get everything right and it had to be right the first time and if I didn't, I'd get really stressed and worried about it. In order to replace that now is, I like to do things to a high standard, but it's okay when they don't go to plan. Good enough is okay. So things just have to be good enough. Lucy: That's great, it sounds a really nice modification because it's not like you're giving up on liking to do things to a high standard but you're just being a bit kinder to yourself with that. Sharon: Yes, that's right and to say good enough is okay, yeah. And the other thing, I'm very obedient, still. If somebody tells me to do something, I'm very likely to do it because I fear consequences. And so that was one that guided, was a very strong guiding thing. And then the other one, so once you've got that, it's okay to be myself, I can let my own needs and feelings be known. I get along with others, but I don't have to do what they say. Lucy: Lovely. Sharon: So they're just a couple of examples for the way it changed from my rigid control of myself to get through life safely. It was all about safety with me, and security, being safe. To actually thinking, you don't need to do that, it's not necessary. You can relax and enjoy yourself and there are no consequences of any significance, to me personally. Lucy: Some of Sharon's unhelpful rules for living came from difficult early experiences, although sometimes it's less clear where these rules come from. You don't have to know to be able to use CBT. It's super helpful to have those examples because I think it can feel so abstract can't it, when somebody is referred to therapy and they're not really sure what it's like. I just think it really helps to hear the exact experiences that somebody else has had. Sharon: Lots of things actually. You don't realise, I found, you don't actually realise you're living by these rules. It sounds ridiculous (laughs), I didn't realise until it was discussed in detail with me, gently probing and not going any further than I wanted to. But each time a bit further until actually it was out there. I kind of realised, that's how I was thinking because it's so tightly hidden. Lucy: I asked Anne if someone was a fly on the wall watching a session, what would they see going on? Anne: I guess they would see really, in terms of starting at the very beginning, trying to help the person to consider the links between events in their environment and then biological symptoms, thoughts, feelings and behaviour. Just to give you a very simple example of that, say you've been depressed for six months and your sleep is affected, it's taken you until 3:00 in the morning to get to sleep and the alarm has gone off at 7:00, so you've woken up in bed. That would be your event in your environment. You feel exhausted and your head is like cotton wool. That would be biological symptoms. And importantly there, most of us when we're deprived of sleep might feel that way but that becomes intensified in depression. You might have thoughts like, I can't be bothered to get up, I feel really tired. You might notice that your mood is really low and so you might lay longer in bed. But also then you might have overslept, so you might then start to have critical thoughts like, you're really useless, you can't even get out of bed on time, you're going to let people down at work, you're going to be in trouble. You might then start feeling anxious and perhaps a bit guilty. So you'd really be trying to help people to see that sort of connection. The aim of antidepressants, if people use them, is really to try and help them to influence some of the biological symptoms of depression and lift mood slightly. So some people do recognise in taking an antidepressant that their mood lifts slightly, some of the symptoms are a bit better. They can do a bit more and therefore their thoughts are not necessarily as negative in content or they're not as harsh with themselves. What we're trying to do in CBT is add to the effects of that by tackling behaviour and thoughts. Usually one of the first homework assignments is to complete an activity schedule. An activity schedule is a diary with every day of the week broken down into hourly slots and what we ask the person to do is keep a record of what they're doing on an hour-by-hour basis. We ask them to rate two things there. One is mastery, which is how well you engaged with the activity given how you were feeling. And given how you were feeling is really important because an important part of that initial rationale is making an allowance for the symptoms of depression which are real. And then the second rating is how much you enjoyed it. So it's really important to check out if the person feels able to do that. On the basis on that you'd look for patterns and quite often what you'd see is a pattern between inactivity and low mood and that's often a marker for rumination. Also you'd be trying to look for if there had been any activities that are giving the person any sense of pleasure and when you do the ratings, you rate it on a scale of nought to 10. So nought is low and 10 is the high end. And really anything over a four is quite good when your mood is depressed, so that's what we'd be looking for. Then we might try and look at activities that the person used to do and enjoy but they've given up. Or activities that the person is avoiding and try and think about how we can re-engage with some of those. Lucy: Here's Sharon on how her life has changed through doing activities that make her feel good. Sharon: I had a big fear of meeting up with people, so I wouldn't go to anything social. I've been on my own since the relationship ended 20 years ago and I just won't take the chance, I won't risk it again. And all of these things I've relaxed now – not that I'm going out with anybody – but I am actually more willing. I meet people for coffee now and I'll join up with a dog walk and things with other people. Whereas before I'd always make an excuse at the last minute and not go. And I stopped doing that. Anne: Another important factor in these early stages is really just trying to think also about the effects of not eating and not having a good sleep routine because those two things can really amplify biological symptoms. Trying to get people to eat regularly and again, with the sleep, trying to re-establish a sleep routine. Thinking about things like caffeine consumption and perhaps not drinking any caffeine after lunch. So very practical things to start with and then trying to begin to schedule pleasurable activities. And also, as I said before, breaking tasks down into manageable chunks. Lucy: It sounds like breaking stuff down, making it really small and manageable and scaling things back is really important. What other sorts of things might somebody see if they were observing a CBT session? Anne: I guess they would see us working together. It's very much what's referred to as a collaborative endeavour. The person receiving treatment, they bring their expertise and knowledge in how depression affects them on a day-to-day basis. And I bring my expertise and knowledge in terms of how to help people begin to tackle their depression. We'd also be writing lots of things down. Working towards goals as well, goal setting is a very important part of CBT. So the beginning of treatment you'd be thinking about what problems the person wanted to tackle and what would be the goals that would indicate you'd started to work on those problems. So it's very much a participative activity, is CBT. So the person really needs to make an active commitment to try and work within the model. Now obviously depressive symptoms in themselves can make that a challenge because lack of motivation is a key symptom of depression. So again, in the early stages you might see the therapist working very hard to help the person to engage with treatment. Lucy: Negative automatic thoughts are those which occur to us automatically. So we don't have control over thinking that way. And they tend to frame the experiences that we're having in a way that makes us feel bad about ourselves, or what we're doing, or about the world around us. They can have a really big impact on our mood and sometimes we don't even notice that they're happening. For people who experience depression, automatic negative thoughts such as 'I can't cope', can often be problematic and persistent. How might CBT help people to manage those thoughts? Anne: Well, there's a variety of methods that can be used. The first one is really just trying to help the person to recognise when they occur, so what are the triggers to them. And also how do they make them feel and what is the impact of that. And then you can try what's called modifying or challenging automatic thoughts. So you can apply a series of questions to a thought, what is the evidence for the thought? What is the evidence against the thought? What is the alternative perspective? And this is a really useful strategy when you're working with depression because people with depression apply rules to themselves that they wouldn't apply to other people. So very typically I might ask the person, "Can you tell me the name of somebody whose opinion you respect?" And then I would say, "If you heard your friend Jane say that she was lazy, what would you say to her?" And then I might reverse that and say, "If Jane were here, what would Jane say to you?" What you're trying to do is bring flexibility to the thought processes because in depression thinking processes are very rigid, they're very all or nothing, so they don't see the shades of grey and they're very over general. You then also try to help them to think about what is the impact of thinking this way, or what can you do next? How can you test this out? Which is where the idea of behavioural experiments come from. Lucy: Behavioural experiments are planned activities to test the validity of a belief. They're an information gathering exercise, so we test how accurate an individual belief is. For Sharon re-joining her group helped her test some of her beliefs about what the group members thought about her having left. Sharon: The group was a challenge because I don't like being in a group with people. It's an effort to keep smiling. But I learnt there that I didn't need to. So I'd be stressed before I went there for quite a number of them and actually I just stopped going, just after halfway through because I just couldn't cope with it. It was just too intense, it was too much. And so Catherine phoned me and persuaded me back and I said, "I can't go in there, I can't go in there," and I walked out. I can't go back in that room when I've walked out. And it was just gentle nudging and when I went in they were just, "Oh, hello," nobody made a comment at all and I was astonished because I thought somebody was going to say, "Oh, back are you?" Not at all, and that was another illustration of my disordered thinking. So that was a tiring six months, but at the end of it I felt quite upbeat that I'd achieved something. The individual sessions for the year, they were always extremely positive. But I always came out of there feeling that it was a job well done, I'd achieved something. I never felt, "Ugh, I'm not coming back," not once. It was excellent from start to finish. Lucy: I wanted to know from Sharon how she coped with negative thoughts and if she uses the techniques which Anne mentions. Sharon: I still use all those CBT techniques of the alternative way of looking… What's another reason that this could be…? Is that really the way this is when you're feeling down? Deconstruct it. What actually is it that's a concern here? And are you actually…? Are you thinking about this clearly or could something else be happening? So I still use all of those techniques every day. Lucy: Do you? It's really hard isn't it when you're having a worry or a thought about how things are in your own head that's distressing. It feels real doesn't it? We all feel that our reality is real. How do you manage to capture those thoughts and to sort of use those techniques? Sharon: I write it down. Things, when they start to swirl around my head and then I know from experience when I'm feeling well, this is just going to look nothing like the original issue unless you get it out of your head. And so I write it down and then I think, what's actually… I deconstruct it and then put it back together again. Lucy: And when you're coming out of it, did you notice yourself coming out of it? Did you notice things changing or was it after it's gone that you kind of look back and see it differently? Sharon: Coming out of it, in some ways it's a bit scary actually because you get used to being in that gloom and that dark. And it requires effort to re-engage and make contact with people and all the rest of it. It was a year ago that I finished; I've been well since then, yeah. So I felt smiley, I've had a few, we all have in the last year haven't we, had a lot of low… Even thinking like that, thinking it's not me not trying hard enough, I'm thinking why wouldn't I feel like this? Everybody is feeling like this. So I consider that, when I think like that, I give myself a little mental pat on the shoulder for thinking, "Excellent thinking Sharon." Lucy: I asked Anne what the evidence base was like for CBT for depression. Anne: Well, there's a very strong evidence base that goes right back to the 70s and 80s really. Essentially, if you summarise, if you look at NICE guidance, what the research tells us is that CBT used alone is as effective as an antidepressant on its own. The two things in combination produce the best outcome. Particularly for people who have moderate to severe depression. For people who have more mild depression, you might actually just start with CBT and that can be highly effective. Lucy: The current NICE guidelines recommend CBT for depression and also a range of other treatments. I've put a link in the show notes for those guidelines. Anne: If you look at the evidence base for people with more persistent treatment resistant depression, there is evidence from two studies that I was involved in. One back in the 90s with Jan Scott and Eugene Paykel who were both professors of psychiatry who have now retired. And a more recent one that Richard Morris, Professor of Psychiatry in Nottingham and I conducted where we looked at using CBT in combination with pharmacology for people with more, either chronic depression or persistent treatment resistance. And there is a lot of evidence that it's very effective in helping people manage the disorder rather than trying to get rid of it completely. Lucy: That's really helpful for people to know isn't it? I suppose not everything might totally resolve and it might be more a case of living with it effectively. Anne: Exactly, yeah. Lucy: Are there things you think people should know before they come for CBT? Anne: I think particularly just picking up on that last point as well, thinking about the impact of childhood trauma can have in terms of depressed mood. When we think about trauma we're thinking about that in a broad context of it might be sexual and physical abuse, but much more commonly, it's actual emotional abuse and neglect, childhood neglect, particularly in terms of how that impacts on what psychology would refer to as attachments. Our ability to make and maintain reciprocally beneficial relationships with other people. And there's increasing amount of evidence to show that where attachments are disrupted, then that can have a profound effect in terms of adult depression. And I think that's where a lot of the research is focusing now in terms of thinking about how you might develop more focused interventions in CBT terms. I think the other thing is that CBT is a very practical therapy. So there's an idea that you participate, you will be asked to complete, what we refer to as 'homework', which isn't a phrase many people like. So you'd be asked to work on your problems in between sessions. Initially it's very here and now focused. So it's really trying to think about what your problems are on a day-to-day basis in terms of how the depression affects you. And then later in therapy if necessary, we might go back to some childhood events. But generally speaking you only go backwards to the degree to which it tells you how that influences what goes on in the here and now. It's also about doing, it's not just about talking. Lucy: For Sharon, although she doesn't feel depression has disappeared completely from her life, she's found a way to cope and see her thoughts for what they are, thoughts, rather than acting on them. I wanted to know what she would say to anybody thinking of trying CBT for depression. Sharon: Go for it! Definitely! I think the thing is to be prepared; you've got to put some effort into it to get something out of it. Lucy: The experience that Sharon had of trying therapy more than once and finding it a better fit at a later date can happen to anyone, either because the therapist is a better fit, the type of approach works more or sometimes because the therapist has had more experience in a particular model of therapy. It's always okay to raise it with a therapist if you feel like things aren't working for you. It's also important to be able to check out what training or experience the therapist has had with treating the problem that you're going to see them for. One way to check this out is by seeing if they're accredited with BABCP. Sharon: As I say, it was a revelation. In fact one of the biggest things was listening to people talking. You think, gosh, that's how I think! Lucy: If you'd like more information on CBT for depression, have a look at the show notes. For more on CBT in general and for a register of accredited therapists, check out BABCP.com. Have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with. There's one with Paul Gilbert, who Anne mentions and also Chris Winson, who speak about compassion-focused therapy for depression. And there's loads more on other common problems that CBT can help with including anxiety. Thank you to both of my experts, Sharon and Dr Anne Garland. Thank you for listening and I hope you're keeping well in these odd times we're all living through. Until next time, take care. END OF AUDIO

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 well. Lucy: Fiona met her therapist at the start of treatment, but from then on she worked through online modules and she also had regular contact with weekly phone calls and messaging in between sessions. Fiona: There were phone calls with the therapist, they were quite lengthy, but all of the way through it she would send me text messages, saying, "Don't forget to take a tea break." There was a lot of talk about tea. (Laughs) Or, "It's a beautiful sunny day Fiona, can you get outside for a bit?" Just little nudges, little reminders to take time. I found it much easier to have a telephone call with her. I think it did help that I'd met her once, so I knew what she looked like. But there was a complete and utter trust and we got on, and I really, really liked her. And I liked the fact that she understood me straightaway. And it didn't bother me that it wasn't face-to-face. And there was something that was really quite comforting about still being in my own home, and with my own surroundings, and with things that comforted me. And if I'd finished the modules, or I'd finished a conversation, and I was feeling low, then I was instantly able to do something. I mean we had this one thing where I had this one particular piece of music that we actually played at my husband's funeral, but it's a northern soul track. And if I was feeling really low, I was told to put that on really loudly, which I did. I probably annoyed the neighbours, but anyway, it worked. It just felt like someone had your back; that someone was just there who understood and was helping you along. It was sort of invisible support and it was fantastic. Lucy: The content of the modules that Fiona was working through were developed to be as close to the content of the face-to-face therapy as possible. Graham explained. Graham: I'm lucky to work with some very clever and creative people, who have been able to adapt certain treatment elements that we would do face-to-face, to think about how they could work online. So the PTSD programme, again is really trying to faithfully replicate the same elements that would be done in face-to-face CBT treatment for PTSD. So the modules focus on a range of different topics. I guess beginning with some sort of information and explanation about what PTSD is, and why some of the difficulties that people might be experiencing are understandable, given what has happened. And then the modules go on to help people start to think about the idea of reclaiming their life; trying to get back elements of their life that might have got a bit stuck, or have dropped off in terms of what they've been doing since the trauma. And then as people progress through therapy, they would go on to actually working on the memory of the trauma itself. The idea being really trying to process what's happened, so that it can be put away in the past where it belongs, so that it doesn't keep popping back up and causing those difficult re-experiencing type difficulties. Lucy: I asked Fiona what sorts of things she remembers from the modules. Fiona: There was a lot about working on your triggers, which was great for me, although it was really hard to work out what the triggers were. So for instance one of my triggers was dark, rainy nights, because I associated that with driving back from the hospital. And wet leaves sent me into a… But then you don't think, "How can wet leaves possibly make me feel this terrible?" But it's true, it did. And there are certain smells; the smell of copper coins reminded me of the smell of blood. Because my husband died of oesophageal cancer there was an awful lot of vomiting of blood. So things like that, that are in the back of your mind; you work on them to bring them forward and deal with them. It's hard. It's really hard. But when things start to make sense, you start to feel better. Or that's how it worked for me anyway. Lucy: You said about being able to identify the triggers. What did you then do with that knowledge? Fiona: If I just take you to an example of what happened for me, is that I was driving home from work; I picked my car up and I was doing my journey home, from getting off the bus from work. And it was a dark, rainy, winter's night, and I started to feel like I was going to have a panic attack. And I was on the dual carriageway, and there was not a lot I could do. And that's when we worked out that dark, wet, November nights, were a real trigger for me. So what my therapist did was uploaded an image of a dark, wet street with wet leaves everywhere. And I then had to go and look at the image, concentrate on the image, until I could cope with it. And the first time I looked at it, I fell apart. It was awful, it was the most awful feeling. And then I'd keep going back to it. It was about taking yourself… You are no longer in that situation which I was in six and a half years ago. My daughter's at home, I'm doing this tomorrow, Paul's no longer suffering. So yeah, it was about the here and now, and not being in the past anymore. Not believing it was those same nights when my husband was dying. Lucy: So some things that you could say to yourself that would remind you that you were safe now. Fiona: Yes. A lot about being safe, and a lot of thinking that my husband was no longer suffering. That I was safe, my daughter was safe, he wasn't in pain. Lucy: That sounds really important, yeah. Fiona: I found it worked incredibly well for me, because I could keep going back to it. Or if I wanted time to think about something, I could stop, go and make a cup of tea, and let things in gradually, to try and work out why I was feeling the way I was. So it was like 24/7 therapy, seven days a week. The modules were released for you, so you could never race ahead. My therapist released a module when she thought I was ready for that module. There was a lot of work before we worked on the death of a loved one, which I was dreading. But it just meant that if it was 2:00 on a Sunday afternoon and I was feeling really, really low, I could go back in and go through something that I thought might help. Lucy: And the module that you were dreading, the death of a loved one, what was that like when you got to it? Fiona: It wasn't as tough as I was expecting, but that's kind of always the way, isn't it? The death of a loved one all made sense. And I think it was the right time that I did it, because I'd already started to feel better. So that's what was brilliant about it; it was all done at exactly the right time. So there weren't any of them that weren't tough. I mean the toughest one of all was when I had to write my story. So you physically write your story, about what happened to you. And I had no trouble remembering the events and in which order they happened, but when you actually see it written in front of you, and you write it yourself; for me that was the breaking point, that was when things started to turn around. Because that's when I realised that I had been through something utterly horrific. And I was allowed to feel the way that I was, because anybody would do in that situation. So it's almost like when I read my story, as hideous as it was, and as upsetting as it was, and I cried a lot when I wrote it. That was the point where I let myself off the hook a bit, for want of a better expression. Lucy: Yeah, so you could kind of witness what had happened to you almost. Fiona: Yes. Yeah, it's exactly that. Lucy: The programme for PTSD that Fiona did, and another similar one for social anxiety, have shown promising results. I asked Graham to explain the evidence base for this sort of therapy. Graham: Yeah, we have done a few studies so far, starting with some initial pilot studies, to test the programmes. And also some randomised control trials; so comparing them to other forms of treatment. And what's been really, really pleasing to see so far, is that the results that we've been getting are really encouraging. Really showing that people can make great improvements using this format of treatment, and actually can really overcome their difficulties. So we're very excited about the potential for our programmes, and for this format of treatment in general. Because I think it really can change people's lives and make a real difference, in the same way that face-to-face therapies can. One other thing to add perhaps is that another possible advantage of programmes that have some of the treatment content written down, is that they can be translated into other languages and shared around the world a little bit more easily. So some of my work has been working with some teams in other countries to try and see how these treatments perform in a different culture to where they were originally developed. And I think the format there can be quite helpful in terms of translating and sending it to other countries and cultures who would like to use it, and feel that it could be helpful for them. Lucy: Yeah, absolutely. And even different people in this country, who don't have English as a first language. That sounds really helpful, yeah. Graham: Yeah, absolutely. Lucy: In general, although some people sometimes worry about whether digital CBT will be as good as face-to-face, Graham thinks that the evidence is promising overall. Graham: So it's quite an interesting one. I think there's a sense amongst many people, both members of the public, and therapists and researchers, that digital CBT and online treatments are quite a new development. But actually when you look at the literature, it's really quite extensive; these kinds of things have been being researched for over 20 years. There's now over 300 randomised control studies looking at the effectiveness of different internet-based programmes. So there's actually a lot more evidence out there than people realise. There are a few things I guess that we can conclude from the evidence so far. Obviously it's a very rapidly growing area, and lots of people are doing more studies all of the time. But generally it seems that online treatments, when they're compared – they're most usually compared to people on a waiting list, or a group that aren't receiving any treatment at the moment. And so generally those studies will find that actually an online treatment is much better in terms of your clinical outcomes, compared to waiting or doing nothing. Treatments that have support from a therapist generally do a little bit better than ones that are unguided; that don't have that therapist support. Studies have generally done follow-up, usually up to one year, or the longest I think I've seen is up to five years after treatment. Those studies all generally seem to find that the gains that people have made during the treatment have been maintained over that time. So that's really encouraging. Lucy: One limit to the evidence base is that there are not as many studies comparing digital to face-to-face treatment. Graham: Generally what those studies have found is where the digital treatments have support from a therapist and have been compared to a face-to-face treatment, the outcomes are similar. It's really exciting I think to know that actually the outcomes might be similar; it could be just as helpful for you doing your treatment online as it is face-to-face. There is need for more studies doing that direct comparison, because they're not quite as common as other forms of research in this area. Some of those review studies have suggested that maybe there are some studies within that that perhaps aren't the highest quality at the moment. So I think there is need to do more work on that. Lucy: And is digital CBT better for any particular people, or any particular problems? Graham: I don't think we have the evidence yet to know that. But I think there are a number of potential advantages that people might experience doing their treatment digitally. I tend to see it as being that we're not necessarily looking for digital treatments to be replacing face-to-face work. It might be a really helpful option for people. They are quite flexible for people, so people can do them maybe in the evenings, at weekends maybe, if they're working, or they can fit it around other commitments that they have. I guess it avoids the cost and the time that they might need to take off work or travelling to an appointment. And as I mentioned before, the idea of going at your own pace and maybe going back and re-reading, or re-looking at something from earlier in treatment, that you wanted to kind of refresh on. Lucy: Fiona sometimes used her commute on a coach to London to work through the modules. Fiona: It helped me doing that, because if I started to feel panicky or anxious, I'd then concentrate on my surroundings. Lucy: And how have things changed since having had the therapy? Apart from there being a global pandemic and everyone going into lockdown. Fiona: Well, for a start I wouldn't have been able to deal with the global pandemic and going into lockdown, I don't think. My mother did mention that to me the other day, how proud she was of me, because I was dealing with it. So that was a good thing. I'm calmer. I'm not going to say that my panics have… I haven't had a panic attack since. I've nearly had them, but I can get out of them easily – well, easier. I'm calmer, I'm more relaxed. I've got a sense of wellbeing, apart from the global pandemic. I'm just happier. I'm not saying it's all completely gone away, because I miss my husband, but it's not crushing anymore. And I can think of him and smile, whereas before all I saw was the illness and the pain. And it still flashes into my head, but it was flashing into my head all the time before, and it's not doing that now. And I think I'm better equipped to deal with things now than I was before. Lucy: That sounds really different, yeah. Fiona and Graham had some advice to share for anyone thinking about having digital CBT. Graham: I definitely recommend asking what sort of studies or research had been done on that particular internet programme. Because as we've said they do vary a lot, and so I guess it would be good to know that what's being considered has been tested and shown to be helpful for people. Then I guess the other questions; one would be what format is the treatment? Because I think even though it might be called digital CBT or something, that might still vary a lot. So is it going to be done over webcam sessions, or typing, or a written programme online? And then I guess a last question to think about, or to recommend people ask, would be about what support there is from the therapist. So particularly what format that support would come in and how often they would get to speak or interact with their therapist in some way. Is it messaging once a week, or is it phone calls? Because I think it's important to get a sense of that. Lucy: Graham has also been part of writing some guidelines, to help people know what to ask when they're offered digital provision of therapies. I've linked to this document in the show notes. Graham: So I guess at the moment, in the context of the coronavirus, it might be the case that some people are a bit worried about seeking help, because of concerns about having to go and see someone, or meet them face-to-face. But I would encourage people not to put off trying to make contact and reach out to people. Most services at the moment are offering a lot of digital and telephone options, so it really wouldn't necessarily be the case of having to go and see someone in person. And obviously this is a tough time for all of us, placing many strains on our mental health. So I would encourage people to reach out if they're struggling and need some extra support. Lucy: Graham also had a thought for people who might worry about the relationship that can be built with digital CBT and whether it can be as good. Graham: Actually there have already now been a few studies looking at the idea of a therapeutic relationship online. What those studies have found is that actually the people who have been going through an online, digital treatment, do report a similar level of connection to their therapist as people who are doing their treatment face-to-face. One idea I have about that, and that might be interesting to explore a little bit more in some studies, is I guess in online treatments you have the ability to send your therapist a message at any time. And obviously it's not possible for them to get back to you instantly all of the time. But I think for many people that can give quite a powerful sense of their therapist being there for them. That might go some way to really strengthening that connection. Which perhaps is slightly different in face-to-face. Where you would perhaps have an hour together with your therapist, and then it wouldn't be common that you would be speaking to them or contacting them too much until your next session. Lucy: It's really nice to hear about the difference between the two types of therapy. It's making me think it would be nice if people had the choice sometimes, between the different types, because they do feel maybe slightly different. Graham: Yeah, definitely. I think it would be nice to move towards a place where we have these options easily available and that then people could be able to make a choice about what they think is going to work best for them. I don't think we're quite there yet, because a lot of these programmes are still in the earlier stages of development. There is obviously also quite a lot of work to train therapists in how to use them and to actually get them embedded within clinical services. But certainly that work is happening, so hopefully we are moving in that direction. Fiona: I would say do it. Even if you've got reservations, absolutely do it. You've still got someone there who's got your back and wants to help you get better. So I certainly wouldn't shy away from it just because it's a different format. It didn't seem any different to me, and it really did change my life. But the fact that it was always there if I needed it was invaluable, absolutely invaluable. Because to be able to message your therapist at – it didn't matter what time. If I was awake at 1:00 in the morning, I mean she wasn't going to answer, but it didn't matter. I could still send that message because the next day she'd respond. And I'd got it out of my head and I wasn't dwelling on it, because I'd sent that question out there. So just try. Even if it takes you out of your comfort zone, even more than you're already out of, because you're having therapy. I feel really lucky that I got that type of therapy, I really do. Lucy: Do you have any advice for people who maybe are trying to comfort loved ones who are grieving? Do you have any advice for them? Fiona: I think the awful thing about grief, everyone thinks – unless it's happened to them – the number of people who said to me, "Come on, pull yourself together." I mean it was absolutely astounding. A lot of people who didn't, but also their lives go on. And so at the beginning when someone dies you have an awful lot of support, and then it disappears. Don't tell them to get over it, (laughs) don't tell them to pull themselves together. I think the thing is to listen; to listen and to be sympathetic. Just to not try and make it right. I think that's what I found, is a lot of people just didn't want me to be in pain anymore. So they tried to jolly me up or push it away. And I think it's really hard if you haven't been through it to be really, truly, truly sympathetic. But I think the best thing to do is listen and comfort, and not try to make it better. Because the only thing that's going to make it better is for your loved one not to be dead, and that can't happen. So you just need gentle support, I would say. What's so great about the therapy is I can say it was terrible, it was awful. But then in just a matter of fact way. My heart doesn't hurt any more. I know that sounds like a real Disney thing to say, but it's true. And it took ages to get there, to get the help, but I got it. And I'm just really grateful I got it. Yeah, I feel really lucky about that. Thank goodness. (Laughs) Lucy: That's all from me. Massive thanks to both Graham and Fiona for sharing their experience and knowledge. Both digital therapy and traumatic grief are very relevant at the moment, as the effects of the pandemic continue to impact. And I've put information in the show notes if you'd like to know any more about either of those things. Take good care and please do fill out that survey if you get a moment, I'd love to hear from you. END OF AUDIO

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 schools but also policymakers to support is that as schools return and resume their normal activities, that they focus on allowing children and young people to reconnect rather than emphasising catching up academically. We know, again, from lots of studies and reviews that have been done that having mental health problems gets in the way of academic attainment. We've got a strong rationale really for arguing, okay, let's make sure now that we try and overcome loneliness rather than prioritising catching up with school work in the short-term because actually in the longer term that's going to be beneficial to school work as well as to wellbeing more generally. Lucy: I was curious to know if Maria thought any children and young people might actually have benefitted from lockdown. I see children and young people in my clinical practice and I've seen a real mixed bag of responses. Maria: I do think that there are some young people who have actually found lockdown to be a real relief, particularly young people who struggled more with school and who struggled more with social interactions. Again, they're young people who might struggle particularly with the return to school as things get restarted again. Lucy: Another group Maria highlighted were children and young people with particular transition points at this time. Maria: People who, for example, had exams cancelled. Whilst in the short-term that might be a real relief not to have to study and not to have to face GCSEs or A-Levels for instance, I think again, going forward, then there's worries for those young people about what did that mean for them and how do they pick up from where they left off. Lucy: Super hard isn't it, because there's such a range of experiences that will be going on in people's homes as well. I suppose one thing that has been really on my mind is children and young people who are from backgrounds where they will be disadvantaged by being at home, or perhaps even in danger for one reason or another. Maria: I think that's a real problem and I do a lot of work with colleagues in South Africa, for whom lots of what we've been talking about as helpful strategies just don't apply. Most children and young people don't have access to the internet and can't continue to keep in touch by virtual play dates, for instance. So what do you do for those kind of populations who are disadvantaged in terms of being able to remain in digital contact with one another. It's really tricky. I think we should all be concerned about those young people for whom home isn't a safe place. And that's a small minority of children, but a really big concern. Schools often have a function of being able to do that check-in and that noticing of when children aren't doing okay and to pick up on that and we haven't had the ability to do that. So I think the needs of those children are going to be really important to thoroughly meet as we resume education contact and so forth. Lucy: Maria's overall message was one of realistic optimism. Maria: I think parents are understandably fearful about what this is going to mean for the wellbeing of their children going forward and, what's that phrase? Realistic optimism. I do think the vast majority are going to bounce back and a few wobbles, a bit of encouragement, a bit of a push sometimes, but they'll manage it. And the few who get a little more stuck, we do have things that we can offer to help. Lucy: That's all for now. I hope you enjoyed this episode and found it useful. If you'd like to listen to more on children and young people, there's another episode with Shirley Reynolds, talking about how to help young people do more of what matters to them at this time. There's also loads in the back catalogue about different types of CBT and different problems it can help with. For example, compassion focused therapy or CBT for hoarding disorder. As ever, if you have ideas for new topics, feel free to get in touch with me at lucy.maddox@BABCP.com. Take care for now. END OF AUDIO

We're all living through uncertain times at the moment. What does research from CBT tell us about what tends to help people tolerate uncertainty? Dr Lucy Maddox interviews Professor Mark Freeston about what might help. Show Notes and Transcript 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 and a new small thing he's noticed is that he started to eat Marmite again, which he hasn't had since he was a boy. Mark: So I guess it was one of the signals of safety that would go back a long way. It's these small routines that can help us feel safer, even when there's a lot of uncertainty. Lucy: That's really nice because that's something we have some control over actually isn't it? Mark: Yes. Lucy: Whether we can keep some of those small routines in place. Mark: Many, many, many people have been taken, if you like, out of their comfort zone. What are the different things that help us feel settled and safe? And then that means that if we can get those, our perception of uncertainty will go down, our perception of danger will go down a bit and we'll be a little less distressed and anxious. Lucy: So two things there which might help at this time based on the research that Mark has done. Number one, thinking about which information we seek out and how often. And number two, thinking about how we signal to ourselves that we're safe. Perhaps in quite small, but still significant ways. Mark: There's other types of information that says the world is still as we know it and that's sort of the link between feeling safe and information management. That's where the two come together. Lucy: Although we're all experiencing uncertainty at the moment, Mark acknowledged that some people may be finding things extra hard if they have personal experiences in their past which resonate with what's happening at the moment in some way. Mark: There'll be things happening, whether it's due to isolation, whether it's medical threat, whether it's seeing one part of your life being disrupted. This is going to, I guess wake up or trigger things that you might not have thought about for a long time. So I think it's being able to recognise that it isn't just what's going on outside in the world, it's what's going on inside your own mind as there's a degree of match between some of the things that you're being exposed to, that we're all being exposed to, and things that we've lived through in the past. Lucy: If you feel like that's the case for you at the moment, do please try to reach out and seek help, whether from friends and family or from professional sources of support. I've put some links in the show notes to some different resources and also to the BABCP register of accredited CBT therapists. Also in the show notes is a link to the survey that Mark has been sharing and a recent journal article that he's written. If you liked this episode, there are loads more you can listen to at the Let's Talk about CBT website, or wherever you get your podcast from. There's a short episode featuring Jo Daniels about anxiety in relation to coronavirus and a new episode about CBT bipolar disorder too. If you have ideas for other episodes, feel free to get in touch at lucy.maddox@babcp.com. Meanwhile, stay safe and stay well. We spoke in this episode about how the birds are still singing, so I thought I'd leave you with a little bit of birdsong recorded just outside of Bristol after the theme tune plays us out. END OF AUDIO