Cognitive Behavioural Therapy – Tips For Therapists

Here are some tips taken from the CBT bible, Back to Basics, by Beck to help therapists carry out their work in the most effective way. 

Clients can be fearful of what to expect from treatment so it will help to set an agenda at the start of each session. This also allows you to curtail any tangential and less relevant diversions once the session has started. It will also help them to adjust to the structure of each session and to reach the end of the session at an appropriate point. In doing is it is important to also ask them what they’d like to address in session (problems, worries, concerns, what came up in the week?) so that they get an opportunity to discuss these issues.
If a client starts to talk for too long, interrupt them gently but check they’re OK with it. If they continually do this then make sure that you are making an effort to: 

  • socialise them to the agenda
  • ask them for a brief summary
  • ask them to write down agenda points for the session as part of homework
  • compromise by offering them 10 mins or a limited period where they can offload first then summarise
  • ask them to choose which issue to focus on 

Summaries

Summarise are essential and need to include:

  • You summarising what they’ve said 
  • Them summarising what the key learnings are and reasons for doing things 
  • You summarising each section of each session 

Homework

Homework is important because it brings lots of opportunity for learning and embedding learnings into the client’s memory; it also is essential if the client is to work independently. However often, clients struggle to complete it. They are more likely to do it if:

  • The client has the rationale for why it’s helpful
  • Homework is reviewed each session 
  • You talk through how to do it in session, or start it in session 
  • You ask about obstacles that will get in the way and problem solve that
  • Get patient to write down homework 
  • It is chosen in a collaborative way
  • You address negative thoughts about homework 

Homework can be:

  • Behavioural Activation
  • Thought record 
  • Challenge thoughts 
  • Problem solving 
  • Relaxation / assertiveness / time management 
  • Behavioural Experiments
  • Reading 
  • Prep for next session / do standard questionnaires
  • Using their summary or revised though or mantra cards  

Other helpful approaches to homework can be:

  • Get them to put frequency and deadlines on it 
  • Get them to do a decisional matrix of pros and cons of what will happen if they don’t do it
  • If they can’t do it, ask them to note down the thoughts that were getting in the way 
  • Pair the activity with their routine, i.e. do it straight after lunch  
  • Get person, diary, post its or phone to remind them to do it
  • Ask them to call the office and let you know when they’ve done it

Ask them how likely they are to do it and get them to envisage doing it. Ask them when and how they will do it, and what thoughts, feelings and behaviours will happen, and ask for what barriers may get in the way.

If they are unlikely to do it because of negative thoughts then role play it, with you arguing for doing it (the intellectual side of it) and them arguing against doing it (the emotional side of it) and then reverse
roles. If they make negative predictions and this stops them doing homework, then set them up to do a Behavioural Experiment, to see if it happens.

For Behavioural Experiments, get them to predict their feared outcome but also get them to figure out other reasons for that outcome if it did arise, just in case it does arise. Get them to write that down.

If their reason for not doing homework is:

Time: Problem solve this but also give the example of if they needed a blood transfusion they would find a way to do it. Explain that the homework situation is not life threatening but it shows that finding time is possible. Explain that it’s only during these sessions, not forever and also that it won’t take that long.

Energy: ask them how long they think homework will take. Challenge any unrealistic expectations and explain that you don’t need much energy to do it. Ask them to test their prediction of them being exhausted afterwards and report back to you.

Perfectionism: Explain that CBT and the homework is a skill to be learnt, and that no one can do it rig first time and that the getting it wrong is part of the learning process. You could even ask them to do it deliberately wrong
the first time to get them used to not striving for perfection but for growth.

Endings:

Clients may struggle to adjust to the end of treatment. To help them adjust, talk about it from the start
and manage their expectations that this support will not be forever, explaining that the aim is to get them to be their own therapist.

Put an emphasis on their effort and progress
throughout so they have a sense of self-efficacy before you talk about endings. Help them reframe their negative thoughts about endings
.

List the tools they’ve learnt with them:

  • Breaking problems down into chunks 
  • Brainstorming solutions 
  • Testing thoughts 
  • Thought records 
  • Relaxation 
  • Scheduling activities 
  • Distraction and refocusing 
  • Hierarchies of avoided tasks to build confidence 
  • Credit lists 
  • Decisional matrix 

Help them envisage realistic setbacks
and formulate a plan of action for when they occur. 

Schedule booster sessions if needed but get them to prepare by writing down how they’re using coping strategies along the way.

Problems occur in:

  • Diagnosis 
  • TA 
  • Structure and pace 
  • Socialisation 
  • Dealing with nats 
  • Accomplishing goals 
  • Processing of content 
  • Biology 
  • External environment 

Fix them by doing this:

  • Complete a more thorough diagnostic evaluation
  • Double check your formulation and discuss is with your client
  • Read up on their issues
  • Ask them for feedback on their experience working with you
  • Go over their goals for therapy
  • Consider your own negative though
  • Review the CBT model and discuss issues about understanding and applying this with the client
  • Check their understanding of the treatment plan and if they’re happy with it
  • Check the client’s understand of their responsibilities
  • Work on the key thoughts, feelings and behaviours in each session
  • Change pace, intensity, level of empathy, amount if coaching vs didactic approach, difficulty of session structure and homework
  • Refer for neuropsychological testing if something organic may be at play

    www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

    CBT – Core Beliefs

    Core beliefs in CBT

    We all have central beliefs are about ourselves and our relations to others; they are like short cuts to which we revert, time after time. The problem arises when they become maladaptive, and in which case they often highlight an underlying belief about us being one of three things: unlovable, helpless or worthless.

    They often originate in our childhood experiences, and can be related to our personality. For example, a child whose siblings are cruel to them and whose mother does not defend them, may start to believe that they are worthless. If their personality is perhaps more introvert, then they may never speak of their feelings to their mother which means they might never get the ‘your safety and wellbeing is important to me’ response which would quash the thought that they are worthless. So the belief continues.

    These beliefs surface during times of psychological distress when they become activated. At times like this we will start to see, in the world around us, only the information which supports the core belief; we almost start to build a case for it being true.

    What is hard, particularly when working as a therapist with such clients, is that these beliefs are not often articulated or easily articulated. If this is the case then we can follow the following structure:

    1. Hypothesise which category of core belief they fall into
    2. Present this idea to the client
    3. Educate the client about core beliefs
    4. Understanding the childhood origin of the belief
    5. Understand what maintained it through time
    6. Understand how it contributes to difficulties currently
    7. Monitor its activation in the present

    We would call them ideas at the first stage and explain that there are two options, either they ARE incompetent (or unlovable or worthless) or they BELIEVE they are incompetent (or unlovable or worthless) and thus act incompetently. We would then explain about how core beliefs stop the good stuff getting through and illustrate this by asking them for an example of when this happened in the last week, i.e. when some evidence to the contrary happened but they wrote it off.

    We would then help them gather information to strengthen a more accurate core belief by:

    • Ask them what their core belief was before they got depressed
    • Ask what their strengths are
    • Notice data and label that as strengths
    • Ask for positive experiences from last week
    • Keep a credit list of things that the client is doing ok on or receiving love for
    • Ask them for contrary evidence continually
    • When they are displaying positive behaviours ask what that means about them and what it is about them which makes this happen
    • Give positive feedback about their skills and behaviours
    • Ask them to gather evidence too (they might need a reminder to do this; a bracelet, a post it, reminder in phone)

    Of course there are ways of doing this and I’d like to explain this in a bit more detail.

    We might get the client to fill out a Core Belief worksheet which comprises the evidence supporting the new core belief of (for example) “I’m competent but human” and also the evidence supporting the old core belief of (for example)“I’m incompetent” BUT with a reframe afterwards which allows them to broaden the perspective.

    I would also use an extreme example of an incompetent (for example) person that they know and ask what that person is doing. I would then ask how they are different from that person.

    I might use a story or an example of someone famous to illustrate similarities between them and elicit how the wouldn’t judge the example unfavourably so illustrating how it is not logical why they should judge themselves in such a way i.e. Cinderella wasn’t bad just because she got abused.

    It is also possible to use the emotion a client displays in session. So when the client is emotional, we might explore why and what the core belief is behind it and then ask about where they feel it in the body. Then we might ask them to remember a time when they were younger when they experienced this same feeling. Then we would discuss it and ask about how the other people in the situation were behaving and whether their actions were right. We might also ask why they and others might have acted that way. Then we might role play the situation with you, the therapist, as the young client and the client as the other person in the memory.

    We could also do the same as above but using imagery instead. I might interview the younger client, getting them to imagine the scene when they were young, asking for details and ask for thoughts, feelings and behaviours, so that it intensifies the effect. Then I would ask if the older version of them can come into the scene to talk to them. I would get them to choose where they should stand and whether they’re holding hands etc. Then I might get the client to talk to themselves as the old client to young client, talking them through the conversation, i.e. saying older client, ask the younger client what’s wrong, now what would young client say? etc.

    I would stop when the client is feeling a bit better and ask them to rate how believable (emotionally and intellectually) the old belief is and now the new belief. I would then take them back to the present day exercise and ask them how the same principle applies.

    More Techniques

    There are other CBT techniques which can also be used alongside this to help the client both manage real problems,and  help them cope with core beliefs and overcome some core beliefs:

    • Problem solving
    • Making decisions using a decisional matrix
    • Asking them how they refocus away from their core beliefs and onto their daily life
    • Distraction (such as walk, tv, newspaper, music, call someone, email someone, clean, do finances, go to the shop, bath, prayer)
    • Complete thought records
    • Measure mood intensity during activities to find patterns and to show that things do fluctuate
    • Relaxation
    • Mindfulness
    • Graded tasks of overcoming fears bit by bit
    • Role playing to learn social skills and practice beforehand
    • Draw a pie chart to show the imbalance of time spent on things they don’t want to be doing vs ideally what they’d like to be doing (in arenas of fun, social, work, hobbies etc) and then ask how they feel about adjusting, then asking them to test their prediction.
    • Determining their responsibility for success, i.e. Get them to identify other reasons for failure (such as luck, other people’s actions, weather, lack of resources and training) and put this in a pie chart and then re-evaluate the core belief after this
    • Ask them to compare themself to themself at their worst rather than comparing themselves to others (by explaining that it’s not reasonable to compare to others without depression for example)
    • Get them to write a credit list through the week of positive activities or things which were hard but ‘I pushed through anyway’

    Imagery

    Clients might not relate to the idea of core beliefs as thoughts but might call them memories, mental pictures, imaginings, fantasies, images, visual ideas.

    Techniques which we use with images differ slightly:

    • Completion: I would explain that the image normally stops at the worst point, and get the client to imagine what happens next and after that and again and so on and try to guide them to see themselves coping, can say “what do you want to imagine happens next?”. If it ends in catastrophe, then we might ask for the meaning of this and this might highlight another core belief.
    • Jumping ahead: I would ask them to jump to the completion of the event they are imagining and imagine the detail of it and ask how it feels once they’ve done this
    • Coping: I might ask them to go through the image again and imagine themselves coping the next time
    • Changing the image: I would explain they’re the director of the upsetting scene and ask them to imagine how they wish it would happen next. I would then discuss what they could do behaviourally to make this more likely.
    • Reality test the image, using evidence to critique it
    • Repeat the image and ask how it changes every time
    • Substitute the image, as if it was on TV and then change the channel or volume or colour

    We can also induce images to help us challenge a thought, for example:

    • Imagine a year from now what will you be doing, ask them for details from when they wake up and notice how the thought doesn’t often appear
    • Imagine the prediction and then ask them to imagine what they will do to help themselves cope
    • Imagine the consequences or what life will be like in 6m, a year, 5 years
    • Get them to imagine more encouraging surroundings and faces and equipment around them

    Hopefully, this article will have given you more of an understanding of core beliefs within a CBT framework, but more importantly how, as therapists or individuals, we can challenge the unhelpful ones to help us live happier lives.

    www.happii.uk is a website providing information about mental health and wellbeing.

    Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region. You can contact her here.

    CBT – Intermediate Beliefs

    Intermediate Beliefs are different from core beliefs and encorporate rules, attitudes and assumptions. We formulate these gradually through treatment, not right from the start. 

    It can help to explain that different people have different beliefs because of different personalities and experiences, and that they may make things hard for us but that we can unlearn them. 

    Examples are:

    Rule: I should do things myself

    Attitude: it’s terrible to ask for help

    Assumption: if i ask for help I’m incompetent”

    To uncover them, we would normally start with the Hot Cross Bun or Five Areas model but would also start to ask ‘what does this mean’  when we’re exploring a clients negative thoughts.

    We might ask what childhood events might be related to the core beliefs ? What events might have initiated and maintained the core belief?

    Then we might ask “how did you cope with this painful core belief?” i.e. which intermediate beliefs such as assumptions,  rules and attitudes have you developed in response to the painful core beliefs? 

    When thinking of how to elicit intermediate beliefs we can:

    • Ask outright “what is your belief about X?”or do you have a rule about that?

    • Look for themes and ask them if their belief is X

    • Use the downward arrow technique to dig further into the issue by repeating similar questions such as ‘what does that mean?’ / ‘what does that mean about you?’  / ‘what’s the worst part about X?’ / ‘what’s so bad about X?’   / ‘if that’s true so what?’ 

    • Start first half of a sentence and ask the client to finish it, such as “ if I haven’t done this properly then it means I am…”

    • They might come in the form of Negative Automatic Thoughts (NATS) 

    It’s important only to work on beliefs that are distressing and believable by client, and so in order to uncover those out can help to get them to rate its distress level. 

    Easier to challenge intermediate beliefs

    Typical coping strategies for dealing with these core beliefs are detailed below and are paired together to illustrate how we might use the extreme opposite coping strategy:

    • Avoid negative emotion, or display high levels of emotions

    • Be perfectionist, appear helpless

    • Be responsible, avoid responsibility

    • Avoid intimacy, seek intimacy

    • Seek validation, avoid attention

    • Avoid conflict, provoke it

    • Control situations, abdicate

    • Be childlike, authoritarian

    • Please others, distance self, be selfish

    It is worth looking at the advantages and disadvantages of holding the belief, before challenging them. 

    Then, when the client decides to work on then it can help for the clinician to plan it first by writing some new alternative beliefs for the client before they start doing their own. The clinician can be more persuasive than collaborative now than with challenging NATS. 

    When challenging beliefs, clinicians should ask patients how much they believe it on an intellectual and then on an emotional / gut level.

    Ways of challenging beliefs:

    1. Socratic questioning:

    Is there another way of viewing X?

    If I did X in this (similar situation) would I still be Y?

    Is it possible that in doing X I can be z?

    If we have 2 people, 1 does X and one does y but the consequence is z, which is more positive?

    2. Behavioural Experiments 

    3. Cognitive continuum:

    Useful for all or nothing thinking. Put things on a scale from 0% to 100%,  i.e I’m a failure. So put self at 0% initially. Then ask if there’s anyone doing worse than you. Put them at 0. Then ask whether there’s someone doing even worse than them, or who doesn’t try or who doesn’t turn up or who couldn’t be bothered to enrol at uni even and add those onto the scale then reevaluate where client sits on scale.
    4. Intellectual / emotional role plays:

    They play part of emotional brain, you play part of intellectual and argue both sides of the belief. Then swap over so hey have to be the intellectual side of things
    5. Using others as a reference point:

    A)Talk about someone else who doesn’t mind for example if they don’t get all As. Ask what client thinks their belief is. Ask if the client agrees with this belief about the other person. Ask whether the belief could apply to the client too. Ask if there is anything different about the other person vs client that makes the rule inapplicable?

    B) talk about someone who has the same belief and whether the client would agree with their belief about themselves and how they would guide them to think differently

    C) role play where client has to convince someone else that the belief isn’t right

    D) imagine they had a child or are speaking to a child, what would they want the child to believe? How does that apply to them?

    6. Acting as if:

    Ask the client what they would do if they didn’t believe it at all, what would they do differently. Ask them to act as if they didn’t believe and then report back.
    7. Self disclosure:

    Say,  “ X happened to me but I don’t think that makes me y, do you?”

    As homework, ask them to read the beliefs and new beliefs and re-rate them for believability every day. Get them to stop when they’re below 30%. 
    www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

    CBT – Negative Automatic Thoughts and Thought Challenging 

    We all have negative thoughts from time to time; they are often what make us feel low or anxious. 

    The thoughts themselves can be distorted or the conclusion from the thoughts may also be distorted i.e. I didn’t remember calling my friend back therefore I am a nasty person.  Or our thoughts may simply be unhelpful, i.e. ‘this will take me til 3am to finish’ might be accurate, but focussing on it makes us feel worse.

    To identify the negative thoughts, simply ask yourself “what was going through my mind?”. Clinicians might ask this when there is an emotion change and this can help us get to the unhelpful thinking patterns. 

    If stuck identifying them, a therapist might:

    • Suggest opposite thoughts to the ones they think you might predict so that you become clear on what you’re not thinking 
    • Ask for the meaning of the situation
    • Ask for an image that you might be imagining 
    • Ask for more detail of the situation as this might get more thoughts to come out
    • Ask you to role play it with you to do the same
    • Ask you to identify where in the body you were feeling it and that can get you in the feeling again and then they may ask again what was going through your mind

    If there is a discrepancy between your emotions and your thoughts then they might help you dig deeper into it to find out what other thoughts occur and whether there are other emotions involved. 

    In addition, labelling the intensity of our emotions can help us prioritise which situations to focus on. Asking how intense that feeling feels now / later can help us understand whether it’s worth focussing on now or whether you’re over it, and if you’re over it then we can look at what behaviours or tools you used to do this as they might be useful in the future. 

    Once we’ve identified the negative thoughts it can then help lift our mood to challenge them. 

    How to challenge thoughts:

    • When challenging thoughts, imagine how taking your thoughts to court; look at evidence (not opinions) on both sides
    • You might be given a testing thoughts worksheet to use
    • ask “is there an alternative explanation for what has happened?”
    • If (the worst) happened, ask how would you cope? What else could you do?
    • Ask what the impact of the negative automatic thought is on your emotion
    • Ask what you’d advise a friend to do

    Other questions can help us flush out practical, alternative ways of thinking about the situation. 

    This can be illustrated with an example:

    • How bad is it in the grand scheme of things if your mother is upset?
    • How hurt is she?
    • How long was she hurt for?
    • Has she been hurt before and got over it?
    • Is she hurt now?
    • Is it possible for you to spare her hurting all the time?
    • If she wants to see you all the time, is it possible to ever do something for you and it not result in her hurting?
    • What would you have to give up yourself in order to do that? 

    Sometimes or negative thoughts aren’t biased or inaccurate, they’re true.  In this case it can help to:

    • Problem solve
    • Challenge the meaning of them
    • Work toward acceptance

    After a while you may be able to come up with an alternative more helpful way of thinking without going through the evidence.

    Your clinician may ask you to read your therapy notes every day and when needed,  and it helps if you have your revised thoughts written down on card for later, to look at and repeat in order for the message to sink in. 

    Of course,  you don’t have to challenge your thoughts, you can:

    • Problem solve
    • Distract yourself 
    • Use relaxation techniques 
    • Label the situation for what it is and accept it

    If you want to do this then you can use the acronym AWARE: 

    • Accept emotion
    • Watch without judgement
    • Act as if not anxious
    • Repeat
    • Expect the best

    Thought challenging may not work if there are core beliefs in the way, or if not all evidence is brought to the fore. 
    In addition,  your clinician might not always challenge your thoughts if you’re too distressed, if they think that you don’t feel supported by them or aren’t on your side or if there are other important matters to focus on.
    www.happii.uk is a website providing  about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

    Asking Powerful Questions

    Asking the right thing,  at the right time, and listening to that answer is one of the most important skills any of us can ever learn.  But it’s an art, not a science so here I’ve tried to look at how we can ask better questions which will in turn help therapists (and anyone trying to support a friend or family member) to create meaningful,  constructive and positive conversations.

    Most of us have heard of Socrates, he was a philosopher, born in Ancient Greece about 470BC.  A lot of people think of him as the father of Western Philosophy.

    Many of us will have heard of Socratic questioning too, as a way of asking ourselves about things in a structured way, so that it narrows our focus in (eventually), towards the truth. It’s used in order to gain further insight into a topic, often when we already know a little bit about it.

    But when is Socratic questioning useful and why is is used so often in therapy?

    In the therapy world, it’s important for a client to understand what they’re going through themselves. So, Socratic questioning it is a way we can guide our client’s  discovery of their own difficulties. It’s not trick questioning where we lead the client to discover what we always knew, it’s a joint discovery where the new information provides fresh perspectives on problems and solutions.

    It can be defined by:

    1. Asking the client questions about something they already know something about
    2. Drawing focus towards relevant topics but topics which may have not previously been considered
    3. Moving from a concrete issue toward a more abstract view of it
    4. Encouraging the client, at the end, to use this new information to come to a new perspective in the issue which can help them move forward

    A great example of some Socratic questioning in therapy is provided below (taken from Christine Padesky’s speech to the European Congress of Behavioural and Cognitive Therapies in London in 1993):

    Client: I’m a failure in every way

    Therapist: You look defeated when you said that. Do you feel defeated?

    C: Yes, I’m no good

    T: What do you mean by that?

    C: I’ve completely screwed up my life, I haven’t done anything right

    T: Has something happened which led you to this conclusion or have you felt like this for a long time?

    C: I think I see myself more clearly now

    T: So this is a change in your thinking?

    C: Yes. I went to that family reunion and saw my bother and his kids and wife. They all looked so happy. And idealised that my family’s not happy. And it’s all my fault because of my depression. If they were in my brother’s family they would be better off.

    T: And so, because you care about your family you then decided you were a complete failure, that you’ve let them down.

    C: Thats right.

    T: You also indicated that this was a change in your thinking. You’ve been depressed many times. And you’ve seen your brother and his family many times. How did you think about this in the past?

    C: I guess I always used to think I was ok because I tried to be a good father and husband, but I see now that trying isn’t enough.

    T: Why is trying not enough?

    C: Because no matter how hard I try, they are still not as happy as they’d be with someone else

    T: Is that what they say to you?

    C: No, but I can see how happy my brother’s kids are.

    T: And you’d like your kids to be happier…

    C: Yes

    T: What things could you do differently if you were less depressed or a better father in your own eyes?

    C: I think I’d like to talk to them more, laugh more, encourage them like I see my brother do

    T: Are these things you could do even when you are depressed?

    C: Well, yes, I think I could

    T: Would that feel better to you- trying some new things as a father, rather than simply doing the same things?

    C: Yes, I think it would. but I’m not sure it would be enough if I’m still depressed.

    T: How would you find that out?

    C: I guess I could try it out for a week or so.

    I’ve also come across a few really powerful therapeutic questions that my colleagues in the therapy world use regularly to help clients explore the meaning of what they’re going through. I’ve listed a few of the best therapeutic questions below :

    • If I could wave a magic wand and you were happier, what would you be doing differently?
    • If you weren’t scared what would you do?
    • If the person you loved most in the world was thinking the way you are what would you say to them?
    • In five years from now will this situation matter?
    • What is the worst that can happen in this situation? (don’t use this as a stock phrase,  but ask this genuinely, out of interest)
    • What would your best friend say to you right now?
    • What does this say about you?
    • What does this say about others?
    • What does this say about the world we live in?
    • If someone observed you for a week, without taking to you,  what would they say you cared about most in the world?
    • What would they be surprised you care about?

    Knowing the right question to ask at the right time takes skill and experience, but I believe the two most important aspects of these questions, are to ask these questions without expecting a certain answer and then to listen and react to the answer itself, not some pre-prepared structure. Then we are truly working empirically, as scientists, testing hypotheses and evaluating the results, but together with our clients.

    www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.

    You can contact her here.

    Post Traumatic Stress Disorder – what is it and how to treat it

    What is Post Traumatic Stress Disorder (PTSD)?

    PTSD is when, following a traumatic incident, individuals experience distressing symptoms such as flashbacks, nightmares and intrusive thoughts about the incident. This can mean that they re-experience the event, they might avoid any memories of the event or even small triggers which bring on memories of the event and they often exhibit symptoms of low mood, anxiety and depression and negative thoughts about themselves, others or the future. Individuals with PTSD are often very sensitive to things around them; this might manifest itself in being on guard more than other people, maybe jumpy or quick to react to small things. They might also come across as more aggressive or reckless because small things might make them more stressed than usual and they therefore react in a more extreme way than they would have normally.

    What kinds of traumas cause PTSD?

    Normally the events are ones where the individual feared for their life or someone else’s life. Individuals can develop PTSD if they were victim to the event, saw the event or even if they heard about it happening to someone who was important to them.

    Events such as road traffic accidents or assaults of any nature may bring on these symptoms, burglary and rape too. Sometimes repeated exposure to the details of an event through work can cause the same effects.

    Why does it happen?

    Shapiro said that when we experience a threatening event, our brain’s memory systems don’t work as well as normal. When it’s processing the traumatic event it can be too upsetting to process and so it simply doesn’t turn it into a memory. This means it remains a current event in our minds so that our body reacts as if it is in that event again, and so it can feel like it’s happening now (rather than in the past) and right here (rather than where the event happened).

    How do they treat it?

    Government guidelines recommend CBT therapy, EMDR or anti-anxiety and anti-depressants as a treatment for PTSD.

    What is EMDR?

    Do you know the saying, ‘sleep on it’? Or ‘everything feels better after a good night’s sleep’? This is because when we sleep, and enter REM (Rapid Eye Movement) sleep, the brain starts to process what happened the day before, and to make sense and store the memories of it in a helpful, useful way. This way, when we wake up, we can access the information from the day before in an easier and more accessible way. EMDR is said to work in a similar way but for traumatic events.

    EMDR stands for Eye Movement Desensitisation and Reprocessing Therapy.

    EMDR is complex, thorough and goes through 8 phases of treatment including History and Treatment Planning, Preparation (where trust between the client and the practitioner is established), Assessment, Desensitisation, Installation (of a new positive belief), Body Scan and Closure.

    It is perhaps the Desensitisation stage for which the treatment is most known. In it, the therapist will encourage the client to identify some of the disturbing emotions they are experiencing and asks them to move their eyes through different sets of structured movements as they focus on different aspects of the trauma. This movement, which is thought to mimic that of REM, desensitises them to the trauma.

    If you think that you or someone you know are suffering from PTSD and would like to receive therapy for PTSD then I would encourage you to refer yourself to your local IAPT service which is part of the NHS and which provides free treatment for this disorder. Your GP can provide this number. In Buckinghamshire please google Healthy Minds Bucks. If you do not wish to have to wait for treatment then please search for EMDR therapist in your local area.

    www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.

    You can contact her here.

    Why Depression Happens

    In this article I’d like to explain a way of looking at and understanding depression which has just been published and which I feel pulls together a lot of what we know about depression from the fields of genetics, neurochemistry, neuroscience, behavioural psychology and social psychology.  I think that, if you can understand where depression might come from and why it happens, it may help you find a way out of it.

    Brief summary
    Depression is the body adapting in order to conserve energy after we perceive that we’ve lost out on something important like a relationship, something which forms part of our identity (like a job) or a personal asset (such as our home, health or mobility) after we’ve invested in it. It does this, because from an evolutionary perspective, if we conserve energy then we are more likely to survive.
    Below, I explain in more detail how this comes about and how it might help us to understand depression from this angle.

    Predisposition
    Some things can pre-dispose us to depression as follows:
    Traumatic Experiences
    If we’ve had early traumatic experiences – i.e. loss of a parent, abuse or a difficult childhood it an affect our brain’s development, affecting learning and memory areas of the brain which in turn makes us more vulnerable to depression.

    Genetics
    Genetics can play a part too. If we carry the 5-HTTPLR genetic variant (linked with serotonin which helps us maintain a good mood) or some variants of the FKBP5 gene or the BDNF gene we are more likely to experience depression following a stressful life event.  Ultimately, if our family had depression, we are more likely to develop it.

    Negative Thinking Biases
    Whilst we know that people who are depressed tend to notice negative information more than others, they are more sensitive to negative feedback, and remember negative information more readily, we often think it’s a symptom of depression, but actually, it may be the reverse.  If our brain works in these more biased ways, we are actually more prone to depression. This might be because certain parts of the brain simply function differently.  It might also be because the genetics we talked about above are in some way impacting on the way we process information.  Equally, the childhood trauma we spoke about may impact on these processing abilities too.

    Body Sensitivity
    In addition, the way our body reacts to stress may have an effect on our susceptibility to depression. If our stress regulation system (the HPA) is out of balance, then we are more prone to depression.  We’ve found that stress hormone levels are higher in depressed people when they are exposed to stressful situations.  This may even cause cells in our brain to die off which in turn can impact on the way we think and remembers things and again makes our stress reaction in the HPA even more out of balance.  The part of the brain which processes emotion (the amygdala) is activated to a higher level in individuals with both the gene variations which we spoke of earlier, and those with childhood trauma, meaning that the stress response is higher and thus linked to depression in these individuals.  This hyper-activated emotional processing means we remember things in a biased way and our emotions are more unstable too.


    Low Self Esteem

    The way we develop can influence our predisposition too.  If at an early age we develop low self-esteem, or develop a tendency for our self-esteem to drop when things go badly, then this can predict depression later on in life.  People with depression also tend to blame themselves and predict that things go badly and these negative beliefs keep the cycle of depression going.

    Triggers
    If we’re predisposed however, we normally still need something to trigger off this depression.  This theory suggests that the trigger is when we think we’ve lost something in which we’ve invested resources. This might be rejection by a lover, death of a child, and decline in productivity at work. It doesn’t have to be a singular event though, it can be a gradual build up in say, stress at work.

    Depressive Belief
    However, the important thing to recognise is that the things which trigger depression only have an effect when we think that we have no control over them and believe it’s irreversible.  This negative appraisal of the situation is key.
    Over time, if we’re experiencing more and more stress, unfortunately we develop a lower and lower tolerance of stressful situations, because our brain is trying to protect us from the same again, so it becomes more sensitive.  Our brain has developed a ‘depressive belief’ or attitude to these situations and so small events re-ignite the distress we felt at previous situations; it then tries to solve it with depression.
    How predisposition + trigger + despressive belief  = depression
    So, some of us might have a pre-disposition and there may be a trigger as well as a despressive belief too.  But why does that bring on all the symptoms of depression?

    How we survive
    Three systems within our personality help us work towards survival – they are our emotions, our behaviours and our cognitive systems.
    Our behavioural system ensures that we do things which meet our needs, our urges and cravings.
    Our emotional system provides the positive and negative reinforcement which gives us feedback along the way of how we’re doing.
    The cognitive system – our thoughts – is in control, coordinating the other two.

    In depression we can end up doing less, thinking negatively and feeling emotionally low, sad, flat, so how does this help towards survival?  We can understand how below.

    Conserving energy
    Depression can be understood as a means of conserving energy.
    For example, relationships allow us to achieve the evolutionary goal of survival because being in a couple gives us more protection and security, is likely to mean more resources because two people are providing an income, food, skills, resources and support.  So when a relationship stops or gets bad,  we feel the need to compensate for this loss of resources by stopping or the limiting activity which doesn’t help us survive. So we are programmed to reduce libido (because we don’t need another mouth to feed), appetite (if I eat less then I can save food for later and it will last longer),  sleep too much (to replenish energy)  and even reduce parenting skills (I need to survive, not others).
    In a similar way, we can sometimes react to environmental turns for the worse such as winter weather because we see it as there being fewer resources and thus we need to spend less energy and do less.
    The problem comes from the fact that this response was more useful previously, when lack of resources really would endanger our lives, and now, this isn’t the case; our depressive response might be a bit excessive. It depends on whether you’re experiencing mild or severe symptoms.
    Social withdrawal, slow movements and slowing down or simplifying the way we think also help our energy conservation. This might also be the reason why we have less enjoyment when we’re feeling depressed, because our body decides to reduce the reward (or pleasure) were receive when expending energy in an aim to discourage us from doing things which will expend energy.

    Maintaining Vigilance
    Keeping our guard up is important for survival as we can pre-empt any threats which might endanger us.  The areas of the brain which do this are more active in depression.  Feeling restless, difficulty concentrating and insomnia may have all developed to increase our ability to notice danger, in the same way that anxiety and irritability may work – they aim to protect us from danger. Equally, social withdrawal may also help us avoid risks.

    In Summary
    Depression is activated by a combination of an external event and a ‘perceived loss of a vital investment’. If the individual is predisposed then there is even more likelihood that they will develop more severe adaptations and thus symptoms.
    If we think of depression in evolutionary terms it acts by mobilising the behavioural, emotional and thought systems of our personality. Stress alone doesn’t make this happen but a stressful event plus a depressive belief often make us appraise a situation negatively. Thus when we think that we’ve lost something vital in which we’ve invested resources (time, effort, vulnerability) the evolutionary depressive system kicks in to help us conserve energy.
    The extent to which it occurs depends on how much we feel we’ve lost. This depressive reaction can be helpful, but if we have developed feelings of hopelessness or helplessness alongside this, then the depression can become unhelpful and thus we experience severe symptoms.

    There is Hope
    Whilst we can’t change our genetic makeup, or our childhood, or sometimes even the stressful events themselves, there are ways forward.
    Medication can of course impact on the chemical imbalance regarding serotonin, cortisol, adrenalin and other hormones for some. But the fact that this ‘depressive belief’ is part of the formula for depression is what can help us.
    Ultimately, this conservation of energy (or depression) has been influenced by the way we think about a stressful situation.
    We know that when our beliefs change back again the depressive response stops and this change in perspective can happen spontaneously or with our own effort.
    Because this is often hard (because some of us may have had years of thinking in these depressive ways) that is where therapies can help; by helping you challenge these long-standing beliefs and attitudes and helping to re-train your brain out of the negative bias, and into a more balanced way of looking at things.

    Taken from:
    Beck, A. T., & Bredemeier, K. (2016). A unified model of depression integrating clinical, cognitive, biological, and evolutionary perspectives.Clinical Psychological Science, 2167702616628523.
    Full article here: http://cpx.sagepub.com/content/early/2016/03/26/2167702616628523.abstract

    www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.
    You can contact her here.

    The best Cognitive Behavioural Therapy apps / CBT apps

    There’s lots of evidence that Cognitive Behavioural Therapy (CBT) is effective at treating anxiety, depression, phobias, hypochondria, PTSD and eating disorders.

    Trouble is…whilst it’s free on the NHS, the waiting lists are huge; where I work, clients have to wait up to 6 months for treatment in some cases! Of course you can pay, but it’s pricey, sometimes up to £80 per hour session.

    So?  How can you access CBT quickly and affordably?  The answer? CBT apps!

    Below I’ve reviewed a few of the key apps for various disorders to help you find the best CBT apps on the market.

    CBT-i coach – click here for free sleep app

    The best insomnia app, built by Stanford University in the US and the National Centre for PTSD, so some good credentials. Features a sleep assessment, psycho-education about what to do to boost your sleep, a sleep diary to help you track your progress, alarms and reminders to encourage you to adhere to your prescribed sleep times and sleep prep behaviours, check lists for preparing your environment for sleep, caffeine management tool, motivational tools to help you get out of bed and go to at the prescribed time, relaxation exercises and tracks.

    Mind Shift – click here for free anxiety app

    Great app for managing anxiety, packed with some really useful techniques.  Features psycho education on anxiety, mindfulness exercises, relaxation audio tracks where you can choose from a female voice or male, visualisation exercises.  There are also tailored modules on managing test or exam anxiety, social anxiety, dealing with conflict, managing panic, dealing with perfectionism and performance anxiety.   Each of these modules includes a page to measure your own anxiety, a choice of  more helpful / rational thoughts to guide your thinking away from negative thoughts and towards realistic thoughts, the chill out tools listed above, but probably the most powerful advice is the Active Steps which provide lists of really effective worry management, panic management, graded exposure tips, behavioural experiments and preparing for big events.  The app also includes limited inspirational quotes.

    Mood Tools – click here for free depression app / therapy app

    This app has so much information on depression, the causes, types, but more importantly it has potted guides on how to treat depression, including guides on how to use the following evidence -based therapies on yourself, without a therapist.  Just pick one!

    • Cognitive Behavioural Therapy -although it focuses on challenging thoughts rather than modifying the behavioural side of things which is in a different section for some odd reason
    • Acceptance and Commitment Therapy – how to learn to live with difficulties
    • Dialectical Behaviour Therapy – this is more useful for more complex difficulties like personality  and attachment disorders so I’m surprised it’s in here for depression but the information is great to apply to many disorders
    • Suicide Prevention – quite extensive plan to help keep yourself safe from self harm and suicide and a crisi plan for if things get too much
    • Lifestyle Changes – not a recognised ‘therapy’, more of an intervention but nevertheless very powerful, including suggested activities on socialising, exercise, nutrition, sleep and sunlight

    The app also includes a depression test so you can measure how severe / frequent your depressive  symptoms are, videos on mental health, guided meditation tracks, relaxing tracks, an interactive thought diary (basically the one below) and suggested activities to boost your mood and interactive rating tasks.  It even helps you find a therapist from the BABCP website which is the accreditation organisation for therapists.

    The app isn’t as interactive as some others however, which is a bit of a shortcoming, although it is so jam packed full of information that you’d be mad to not download it.

    SAM app – click here for free stress and anxiety management app

    A very interactive app written by the University of West of England so some smart cookies.  Includes an anxiety tracker, a social media ‘cloud’ where you can network with others, a space to list your anxiety provoking situations, but best of all lots of relaxation exercises, psycho-education about anxiety, some great interactive anxiety reduction exercises and tips, an app to audio-record your thoughts and listen to them back again.  Takes a while to find your way around but you can create your own ‘tool kit’ of your favourite techniques.

    Thought Diary – click here for free thought challenging app

    Very simple cognitive restructuring app which will be useful with most disorders. The app asks you to write down the situation you’re in, the emotions you’re experiencing and the level of distress they are causing, it then prompts you to identify the negative thought you have, and then to pinpoint the way in which the thought may be distorted.  It then gives you a choice of statements which can challenge the distorted though and then  prompts you to re-write an alternative point of view and reassess how distressed you then feel as a result.

    Hope these free CBT apps help you, if there are any issues with the links, please let me know.

    www.happii.uk is a website providing information about mental health and wellbeing.
    Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.
    You can contact her here.

    Different Therapy Types

    There are so many different types of therapies, but what do they each do? Here I’ve written a comprehensive (but not exhaustive) list of the different kinds of therapies on offer, what the different therapies treat, how they work and what to expect from each therapy.  If I’ve missed one, then let me know and I’ll add it to the list!

    ACT / Acceptance & Commitment Therapy

    Theory: What we think and do can have a negative impact on how we feel, but also some situations are difficult and will not improve so we must learn psychological flexibility to accept what is out of our control and commit to living life to the fullest within such limitations
    Works on: long-term conditions such as pain and fatigue, depression and anxiety
    What will they do? Behaviour change, mindfulness

    Behavioural Therapy

    Theory: The things we do are often a learnt response to certain situations and we can stop doing unhelpful things once we retrain ourselves.
    Works on: phobias, compulsions, obsessions, brain injury, addiction
    What will they do?
    Exposure to feared situations, analysis of past behaviours, repetition of new behaviours, behavioural experiments

    CAT / Cognitive Analytic Therapy

    Looks at the way a person thinks, feels and acts, and the events and relationships that underlie these experiences (often from childhood or earlier in life). It brings together ideas and understanding from different therapies into one.

    It is a time-limited therapy – between 4 and 24 weeks, but typically 16. It is available in many parts of the NHS.

    CBT / Cognitive Behavioural Therapy

    Cognitive behavioural therapy (CBT) is a talking therapy that can help you manage your problems by changing the way you think and behave.

    It is most commonly used to treat anxiety and depression, but can be useful for other mental and physical health problems.

    CBT cannot remove your problems, but it can help you deal with them in a more positive way. It is based on the concept that your thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can trap you in a vicious cycle.

    CBT aims to help you crack this cycle by breaking down overwhelming problems into smaller parts and showing you how to change these negative patterns to improve the way you feel.

    Unlike some other talking treatments, CBT deals with your current problems, rather than focusing on issues from your past. It looks for practical ways to improve your state of mind on a daily basis.

    Couples Therapy / Relationship Therapy

    Relationship counseling is the process of counseling the parties of a human relationship in an effort to recognize, and to better manage or reconcile, troublesome differences and repeating patterns of stress upon the relationship. The relationship involved may be between members of a family or a couple, employees or employers in a workplace, or between a professional and a client.

    Couple’s therapy (or relationship therapy) is a subset of relationship therapy. It may differ from other forms of relationship counseling in various regards including its duration. Short term counseling may be between 1 to 3 sessions whereas long-term couples may be between 12 and 24 sessions. An exception is “Solution focused brief therapy” couples therapy. In addition, counseling tends to be more ‘here and now’ and new coping strategies the outcome. Couples therapy is more about seemingly intractable problems with a relationship history, where emotions are the target and the agent of change.

    Marriage counseling or marital therapy can refer to either or some combination of the above.

    Cognitive Hypnotherapy

    Trance states are part of everyday life, and include daydreaming and fantasising. Science indicates that we are in these kinds of states 90% of the time. For example, have you ever driven somewhere and not remembered anything of the journey?

    Cognitive Hypnotherapy also suggests that all behaviours have a positive purpose, so the problems we experience are just the result of unconscious thought processes based on miscalculations, like misinterpretations of childhood experiences, or significant emotional events which lead to actions designed to bring a benefit, even though they often don’t.

    Cognitive Hypnotherapy is about waking the person up so they remain in control of their actions, not hijacked into smoking, eating or running from spiders.

    Counselling

    Counselling is a type of talking therapy that allows a person to talk about their problems and feelings in a confidential and dependable environment.

    A counsellor is trained to listen with empathy (by putting themselves in your shoes). They can help you deal with any negative thoughts and feelings you have.

    Sometimes the term “counselling” is used to refer to talking therapies in general, but counselling is also a type of therapy in its own right.

    Counselling aims to help you deal with and overcome issues that are causing emotional pain or making you feel uncomfortable.

    It can provide a safe and regular space for you to talk and explore difficult feelings. The counsellor is there to support you and respect your views. They won’t usually give advice, but will help you find your own insights into and understanding of your problems.

    DBT / Dialectal Behaviour Therapy

    A specific type of cognitive-behavioral psychotherapy developed to help better treat borderline personality disorder. Since its development, it has also been used for the treatment of other kinds of mental health disorders. Dialectical behavior therapy (DBT) treatment is a cognitive-behavioral approach that emphasizes the psychosocial aspects of treatment. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels. Because few people understand such reactions, most of all their own family and a childhood that emphasized invalidation, they don’t have any methods for coping with these sudden, intense surges of emotion. DBT is a method for teaching skills that will help in this task.

    ECT / Electro-Convulsive Therapy

    A procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses.

    EMDR / Eye Movement Desensitisation & Reprocessing

    If something traumatic has happened to you (whether it be a car accident, abuse or something seemingly less significant like being humiliated), the memory of your experience may come crashing back into your mind, forcing you to relive the original event with the same intensity of feeling – like it is taking place in the present moment.

    These experiences that pop into your awareness may present themselves as either flashbacks or nightmares, and are thought to occur because the mind was simply too overwhelmed during the event to process what was going on.

    As a result, these unprocessed memories and the accompanying sights, sounds, thoughts and feelings are stored in the brain in ‘raw’ form, where they can be accessed each time we experience something that triggers a recollection of the original event.

    While it isn’t possible to erase these memories, the process of Eye Movement Desensitisation Reprocessing (EMDR) can alter the way these traumatic memories are stored within the brain – making them easier to manage and causing you less distress.

    During EMDR therapy the client attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus. Therapist directed lateral eye movements are the most commonly used external stimulus but a variety of other stimuli including hand-tapping and audio stimulation are often used

    Family therapy

    Is also referred to as systemic therapy, is an approach that works with families and those who are in close relationships to foster change. These changes are viewed in terms of the systems of interaction between each person in the family or relationship

    Humanistic Therapy

    In humanistic therapy, there are two widely practiced techniques: gestalt therapy (which focuses on thoughts and feelings here and now, instead of root causes) and client-centered therapy (which provides a supportive environment in which clients can reestablish their true identity).

    Interpersonal therapy

    A time limited treatment that encourages the patient to regain control of mood and functioning typically lasting 12 – 16 weeks. IPT is based on the principle that there is a relationship between the way people communicate and interact with others and their mental health.

    Life coach

    A life coach is someone who aims to help and empower others to make, meet and exceed personal and professional goals – including excelling in the workplace, becoming happy and fulfilled in the home, exploring the self and the world, and achieving ambitions.

    Mindfulness Therapy

    Mindfulness-based cognitive therapy (MBCT) is a psychological therapy designed to aid in preventing the relapse of depression, specifically in individuals with major depressive disorder (MDD).  Cognitive methods can include educating the participant about depression. Mindfulness and mindfulness meditation, focus on becoming aware of all incoming thoughts and feelings and accepting them, but not attaching or reacting to them. The goal of MBCT is to interrupt these automatic processes and teach the participants to focus less on reacting to incoming stimuli, and instead accepting and observing them without judgment.

    NLP / Neurolinguistic Programming

    Encompasses three components involved in producing human experience: neurology, language and programing. The neurological system regulates how our bodies function, language determines how we interface and communicate with other people and our programming determines the kinds of models of the world we create. Neuro-Linguistic Programming describes the fundamental dynamics between mind (neuro) and language (linguistic) and how their interplay affects our body and behavior (programming).  In the belief system of NLP it is not possible for human beings to know objective reality. Wisdom, ethics and ecology do not derive from having the one ‘right’ or ‘correct’ map of the world, because human beings would not be capable of making one. Rather, the goal is to create the richest map possible that respects the systemic nature and ecology of ourselves and the world we live in. The people who are most effective are the ones who have a map of the world that allows them to perceive the greatest number of available choices and perspectives. NLP is a way of enriching the choices that you have and perceive as available in the world around you. Excellence comes from having many choices. Wisdom comes from having multiple perspectives.

    Person-Centred or Client-Centred Therapy

    Person-centred therapy – also known as person-centred counselling or client-centred counselling – is a humanistic approach that deals with the ways in which individuals perceive themselves consciously rather than how a counsellor can interpret their unconscious thoughts or ideas.  If there are any techniques they are listening, accepting, understanding and sharing, which seem more attitude-orientated than skills-orientated.

    Psychoanalysis / Psychodynamic Therapy

    Psychodynamic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client’s psyche in an effort to alleviate psychic tension. In this way, it is similar to psychoanalysis. It is a therapeutic process which helps patients understand and resolve their problems by increasing awareness of their inner world and its influence over relationships both past and present. It differs from most other therapies in aiming for deep seated change in personality and emotional development. Psychoanalytic and psychodynamic psychotherapy aim to help people with serious psychological disorders to understand and change complex, deep-seated and often unconsciously based emotional and relationship problems thereby reducing symptoms and alleviating distress. However, their role is not limited only to those with mental health problems. Many people who experience a loss of meaning in their lives or who are seeking a greater sense of fulfilment may be helped by psychoanalytic or psychodynamic psychotherapy.

    Psychotherapy

    Psychotherapy is a type of therapy used to treat emotional problems and mental health conditions.

    It involves talking to a trained therapist, either one-to-one, in a group or with your wife, husband or partner. It allows you to look deeper into your problems and worries, and deal with troublesome habits and a wide range of mental disorders, such as schizophrenia .

    Psychotherapy usually involves talking, but sometimes other methods may be used for example, art, music, drama and movement.

    Psychotherapy can help you discuss feelings you have about yourself and other people, particularly family and those close to you. In some cases, couples or families are offered joint therapy sessions together.

    Re-birth Therapy

    Not something we’d recommend but if you’d like more info http://www.rebirthingbreathwork.co.uk/

    Solution Focussed Brief Therapy

    A goal-directed collaborative approach to psychotherapeutic change that is conducted through direct observation of clients’ responses to a series of precisely constructed questions. Based upon social constructionist thinking and philosophy. SFBT focuses on addressing what clients want to achieve exploring the history and provenance of problem(s). Therapy sessions typically focus on the present and future, focusing on the past only to the degree necessary for communicating empathy and accurate understanding of the client’s concerns

    Systemic Therapy

    Family therapy, also referred to as systemic therapy, is an approach that works with families and those who are in close relationships to foster change. These changes are viewed in terms of the systems of interaction between each person in the family or relationship

    Once you’ve chosen your therapy, use this post to help you choose which therapist.

    www.happii.uk is a website providing information about mental health and wellbeing.
    Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.
    You can contact her here.

    Panic Disorder Management – a problem based learning case study

    Often, when we are presented with a case it can be difficult to find a way forward. To aid clinical decisions, it is sometimes necessary to break down the decision making process into stages. The problem based learning task below does just that. Here I was given a case study and we methodically worked through the problem to get to a solution.

    Reena fears that she is experiencing the precursors to a heart attack. Reena avoids going to the gym, or out of the house alone, other than to work. Reena carries out safety behaviours whilst driving. Her GP feels that physical symptoms are due to panic attacks and as such has recommended that Reena seek IAPT support. She has been assigned a PWP trainee which she is concerned about. She presents with mild depression and moderate anxiety symptoms.

    Identify what you already know to work toward resolving the problem

    • Heart palpitations, racing and pounding are all symptoms of panic disorder (DSM-5, 2013)
    • Physical exertion (i.e. exercising at the gym) can bring on symptoms similar to those experienced when anxious or panicking
    • Avoidance of situations which may increase physical symptoms is common in clients who suffer from panic disorder (Richards & Whyte, 2011)
    • Seeking reassurance is common when facing an anxiety provoking situation
    • Reena has a supportive friend who she listens to, who may be able to support her in treatment if needed
    • It is a GP’s responsibility to investigate and ascertain whether the client’s heart is sound; a PWP, qualified or otherwise, is not able to make judgements regarding this
    • The recommended medications for panic disorder are SSRI and TCA antidepressants but psychotherapy should be he first port of call (NICE, 2011)

    Identify what you need to know in order to work towards resolving the problems.

    I would want to do a full assessment including:

    • Assessing risk
    • client’s history including triggers and previous incidences
    • how long symptoms have occurred
    • how quickly they peak and subside
    • nature of thoughts during palpitations
    • thoughts, emotions, physical sensations and behaviours during last instance of panic and whether this is typical
    • whether she worries about other health difficulties to assess for health anxiety
    • what thoughts go through her mind before going to go out to assess for agoraphobia
    • client’s goals and barriers to working towards those goals
    • the client’s attitude to starting to go to the gym, and going out alone again

    I would also want a discussion with GP to understand extent of the investigations he has made, and also to collect a brief history to see if illness anxiety disorder could be evident

    How and where you can access new information to lead towards the resolution of problems

    • Discussion with client
    • Discussion with GP
    • Mobile use when driving https://www.gov.uk/using-mobile-phones-when-driving-the-law

    Treatment plan

    • Phone work initially if she felt unable to leave home
    • Full assessment
    • Psycho-education about the qualifications of PWP trainee and what they are trained for, education about tendency for catastrophisation, hyper-vigilance, avoidance and safety behaviours
    • Graded exposure to gym / going out alone / driving without safety behaviour
    • Behavioural Experiments if assessment indicated that self-monitoring or avoidance of gym was due to fear of symptoms
    • Cognitive Restructuring of catastrophic thoughts if detailed assessment indicated this would be necessary
    • Give educational material to housemate if permission given

    Signposting

    • Education about law regarding mobile use while driving