CBT and struggling...

[Justanutter]

Had my 5th session of CBT last night but the homework this week is proving really difficult and this is one of those times were I am not quite sure about the benefits of it. Basically have to spend 30 mins each day writing about my main worry (heart problem) in this instance...and go into great detail about how it would feel if the worst happened and detail all scenarios, emotions and fear etc. I have tried to put pen to paper but just can't do it and to think I would have to write the same scenario each day for a week is winding me up. I know it is supposed to desensitise the fear eventually but I just can't see that happening. It feels stupid and pointless and is making me cross. Is this all part of the process? Anybody been here with CBT? I really want it to work but I am so sceptical.

[nomorepanic]

Hi

This is just a courtesy reply to let you know that your post was moved from its original place to a sub-forum that is more relevant to your problem.

This is nothing personal - it just enables us to keep posts about the same problems in the relevant forums so other members with any experience with the issues can find them more easily.

[MyNameIsTerry]

This is often the case when it comes to methods such as CBT, it needs to be a repetitive behaviour because your subconscious needs to create new associations between neurons in the brain and it won't do this by the odd time something it done, its needs to be influenced over time. This way it creates new neural pathways. Its called neuroplasticity which is the process used to embed behaviour in the brain - its how we learn anything.

So, when you do some of these things, they can seem like they aren't helping at all but thats because we are viewing it in the short term whereas the therapist is viewing it more long term because he/she knows that to change our core beliefs about our fears is going to take time and repetition.

I struggled with some of it, often affirmations. They did nothing for me. I later found that on more positive days, they did a lot for me and but nothing on the bad ones. Over more time, I had more control and could influence with affirmations. So, its one for patience really.

Its never what we want to hear with all this anxiety and frustration but its sadly the case that we need to influence our subconscious towards the positive and away from the negative so that it starts to create new pathways and core beliefs and the old ones get mothballed in the process.

How about starting the ball rolling with a question to yourself? Then create a series of questions of it? Like in a "5-Why's" used in business improvement. If you can get your mind working on the problem, you might ease into it more and be able to scrap this and write something more comprehensive.

It can be useful to use a format, like a table. Has your therapist given you a format?

For instance, something like this might be used in some circumstances such as a fear about an event or thought and how it affects you:

http://psychology.tools/belief-driven-formulation.html

[ricardo]

A fairly simple question Terry.

I have tried CBT and had about 12/14 sessions and the psychiatrist in charge of the unit stopped the CBT therapist as I wasn't responding.

I have read up quite a lot about it and it is sometimes explained that for CBT to work one should be medication free whilst I have also read that it doesn't matter.

Who is right ?

[stumagoo]

I'm on my 8th session of CBT for depression/anxiety.

I understand the logic of CBT but don't feel it's benefitting me at all. To me it's like putting spin on everything - seeing good when there's not good. I've found the homework tedious and unrewarding. If I'm having bad thoughts or I'm in a low mood it tries to teach me to distract myself by spending time on something I like - problem is I like nothing at the moment and find no joy/pleasure in anything so can't concentrate on any distractions.

CBT blames my thought process for my depression/anxiety whereas I blame my circumstances/experiences on my depression. Simply pointing out why a thought is irrational, doesn’t really alleviate the emotional attachment to a more irrational thought. I often end up challenging my own thoughts and replacing them with more rational ones without really believing in what they are telling me.

When I explain an issue to my therapist - rather than her delve deeper into the issue, she just ignores it and goes into a filing cabinet to pull out a spreadsheet for me to read and tells me if I follow the spreadsheet the issue will eventually go away.

She told me after 6 sessions I would probably start noticing a difference but there hasn't been any so I'm about to pull the plug on CBT as for me it's too superficial and totally ignores deep routed emotional/psychological issues.

[Phill2]

I'm on my 8th session of CBT for depression/anxiety.

I understand the logic of CBT but don't feel it's benefitting me at all. To me it's like putting spin on everything - seeing good when there's not good. I've found the homework tedious and unrewarding. If I'm having bad thoughts or I'm in a low mood it tries to teach me to distract myself by spending time on something I like - problem is I like nothing at the moment and find no joy/pleasure in anything so can't concentrate on any distractions.

CBT blames my thought process for my depression/anxiety whereas I blame my circumstances/experiences on my depression. Simply pointing out why a thought is irrational, doesn’t really alleviate the emotional attachment to a more irrational thought. I often end up challenging my own thoughts and replacing them with more rational ones without really believing in what they are telling me.

When I explain an issue to my therapist - rather than her delve deeper into the issue, she just ignores it and goes into a filing cabinet to pull out a spreadsheet for me to read and tells me if I follow the spreadsheet the issue will eventually go away.

She told me after 6 sessions I would probably start noticing a difference but there hasn't been any so I'm about to pull the plug on CBT as for me it's too superficial and totally ignores deep routed emotional/psychological issues.

I'm much the same as you
It just doesn't work for me

[stumagoo]

I know 2 other people that did CBT and they're still on meds after doing CBT counselling. It obviously didn't do much for them.

To me it's too easily a way for a "counsellor" to practice a therapy from a text book in a business like manner and avoid the hassle/effort/time of proper individual therapy.

[MyNameIsTerry]

I'm on my 8th session of CBT for depression/anxiety.

I understand the logic of CBT but don't feel it's benefitting me at all. To me it's like putting spin on everything - seeing good when there's not good. I've found the homework tedious and unrewarding. If I'm having bad thoughts or I'm in a low mood it tries to teach me to distract myself by spending time on something I like - problem is I like nothing at the moment and find no joy/pleasure in anything so can't concentrate on any distractions.

CBT blames my thought process for my depression/anxiety whereas I blame my circumstances/experiences on my depression. Simply pointing out why a thought is irrational, doesn’t really alleviate the emotional attachment to a more irrational thought. I often end up challenging my own thoughts and replacing them with more rational ones without really believing in what they are telling me.

When I explain an issue to my therapist - rather than her delve deeper into the issue, she just ignores it and goes into a filing cabinet to pull out a spreadsheet for me to read and tells me if I follow the spreadsheet the issue will eventually go away.

She told me after 6 sessions I would probably start noticing a difference but there hasn't been any so I'm about to pull the plug on CBT as for me it's too superficial and totally ignores deep routed emotional/psychological issues.

CBT isn't for deep rooted issues, thats the more traditional psychotherapy styles such as psychodynamic or psychoanalytical. CBT is the best evidenced one for anxiety & depression, however even the NHS state it is not sufficient for complex issues. The trouble is, if you present with these disorders they will simply push you to CBT without considering whether you are too complex. So, for me this is about a failing in the system than it is the therapy itself. Bascially, the NHS are using it as a filter between the GP and traditional psychiatric services. Get past Level 3 (CBT) and into Level 4 and they will provide a whole range of other therapies if they believe they are required (however, you may still have CBT if they believe it to be the best for you)

I think we have some major issues with CBT under this new IAPT network. Talk to people on here about their CBT by the Level 4's and they will tell you a whole load of stuff you've never heard of that was delivered as fundamental to them.

What you said about environmental factors, my CBT therapist (IAPT) said to me WAS a cause. I was told I could try to retrain how I view them from a more positive angle but it was accepted that they exist and can be the root cause. So, maybe we have some issues with the standard of therapists under IAPT? It takes quite some years to deliver the Level 4 services whereas for Level 3 CBT you can be qualified in 18 months.

I found that CBT did very little for me. Mindfulness did far more. I did find myself improving more after my CBT ended and was tackling things I couldn't even start in therapy so this tells me its just too short or second courses are needed.

IAPT have recently created a stripped down version of psychodynamic therapy for depression called DIT. They have decided it only needs the same number of sessions as CBT. Does that sound a little fishy? Making the therapy fit the business model, maybe?

It would be a good idea to get a resource for CBT, whether online or a book and see just how much you have been shown. I left CBT thinking 'is that all? Big deal' to later do my research and find I had little better than guided self help!

---------- Post added at 04:50 ---------- Previous post was at 04:40 ----------

A fairly simple question Terry.

I have tried CBT and had about 12/14 sessions and the psychiatrist in charge of the unit stopped the CBT therapist as I wasn't responding.

I have read up quite a lot about it and it is sometimes explained that for CBT to work one should be medication free whilst I have also read that it doesn't matter.

Who is right ?

CBT doesn't need to have or not have medication involved, Aaron Beck didn't devise it based on either of those. The earlier model by Albert Ellis is the same. They can work alongside it or without it.

If you look at NICE guidance, they state psychological therapy OR drug treatment. They only state both where there has been a partial improvement from drug therapy:

https://www.nice.org.uk/guidance/cg113/chapter/guidance

Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions

Treatment options

1.2.16 For people with GAD and marked functional impairment, or those whose symptoms have not responded adequately to step 2 interventions:

Offer either

an individual high-intensity psychological intervention (see 1.2.17–1.2.21) or

drug treatment (see 1.2.22–1.2.32).

Provide verbal and written information on the likely benefits and disadvantages of each mode of treatment, including the tendency of drug treatments to be associated with side effects and withdrawal syndromes.

Base the choice of treatment on the person's preference as there is no evidence that either mode of treatment (individual high-intensity psychological intervention or drug treatment) is better. [new 2011]

High-intensity psychological interventions

1.2.17 If a person with GAD chooses a high-intensity psychological intervention, offer either CBT or applied relaxation. [new 2011]

1.2.18 CBT for people with GAD should:

be based on the treatment manuals used in the clinical trials of CBT for GAD

be delivered by trained and competent practitioners

usually consist of 12–15 weekly sessions (fewer if the person recovers sooner; more if clinically required), each lasting 1 hour. [new 2011]

1.2.19 Applied relaxation for people with GAD should:

be based on the treatment manuals used in the clinical trials of applied relaxation for GAD

be delivered by trained and competent practitioners

usually consist of 12–15 weekly sessions (fewer if the person recovers sooner; more if clinically required), each lasting 1 hour. [new 2011]

1.2.20 Practitioners providing high-intensity psychological interventions for GAD should:

have regular supervision to monitor fidelity to the treatment model, using audio or video recording of treatment sessions if possible and if the person consents

use routine outcome measures and ensure that the person with GAD is involved in reviewing the efficacy of the treatment. [new 2011]

1.2.21 Consider providing all interventions in the preferred language of the person with GAD if possible. [new 2011]

Drug treatment

1.2.22 If a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI). Consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions. [new 2011]

1.2.23 If sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI), taking into account the following factors:

tendency to produce a withdrawal syndrome (especially with paroxetine and venlafaxine)

the side-effect profile and the potential for drug interactions

the risk of suicide and likelihood of toxicity in overdose (especially with venlafaxine)

the person's prior experience of treatment with individual drugs (particularly adherence, effectiveness, side effects, experience of withdrawal syndrome and the person's preference). [new 2011]

1.2.24 If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin. [new 2011]

1.2.25 Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the 'British national formulary' on the use of a benzodiazepine in this context. [new 2011]

1.2.26 Do not offer an antipsychotic for the treatment of GAD in primary care. [new 2011]

1.2.27 Before prescribing any medication, discuss the treatment options and any concerns the person with GAD has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on:

the likely benefits of different treatments

the different propensities of each drug for side effects, withdrawal syndromes and drug interactions

the risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping

the gradual development, over 1 week or more, of the full anxiolytic effect

the importance of taking medication as prescribed and the need to continue treatment after remission to avoid relapse. [new 2011]

1.2.28 Take into account the increased risk of bleeding associated with SSRIs, particularly for older people or people taking other drugs that can damage the gastrointestinal mucosa or interfere with clotting (for example, NSAIDS or aspirin). Consider prescribing a gastroprotective drug in these circumstances. [new 2011]

1.2.29 For people aged under 30 who are offered an SSRI or SNRI:

warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and

see them within 1 week of first prescribing and

monitor the risk of suicidal thinking and self-harm weekly for the first month. [new 2011]

1.2.30 For people who develop side effects soon after starting drug treatment, provide information and consider one of the following strategies:

monitoring the person's symptoms closely (if the side effects are mild and acceptable to the person) or

reducing the dose of the drug or

stopping the drug and, according to the person's preference, offering either

an alternative drug (see 1.2.23–1.2.24) or

a high-intensity psychological intervention (see 1.2.17–1.2.21). [new 2011]

1.2.31 Review the effectiveness and side effects of the drug every 2–4 weeks during the first 3 months of treatment and every 3 months thereafter. [new 2011]

1.2.32 If the drug is effective, advise the person to continue taking it for at least a year as the likelihood of relapse is high. [new 2011]

Inadequate response to step 3 interventions

1.2.33 If a person's GAD has not responded to a full course of a high-intensity psychological intervention, offer a drug treatment (see 1.2.22–1.2.32). [new 2011]

1.2.34 If a person's GAD has not responded to drug treatment, offer either a high-intensity psychological intervention (see 1.2.17–1.2.21) or an alternative drug treatment (see 1.2.23–1.2.24). [new 2011]

1.2.35 If a person's GAD has partially responded to drug treatment, consider offering a high-intensity psychological intervention in addition to drug treatment. [new 2011]

1.2.36 Consider referral to step 4 if the person with GAD has severe anxiety with marked functional impairment in conjunction with:

a risk of self-harm or suicide or

significant comorbidity, such as substance misuse, personality disorder or complex physical health problems or

self-neglect or

an inadequate response to step 3 interventions. [new 2011]

The problem we have, as ever, is a lack of therapists (and cash to get them) and GP's chucking pills out like they are desperate to get rid of them. Pills are incredibly cheap and a course of Citalopram for 12 months would likely cost around 2 therapy sessions. So, whilst we have guidance, whether GP's follow it is another story and we all know that GP's overhere operate without little governance and checking of their quality practices.

Basically, its a left hand right hand situation.

What can be a problem is that meds can mask symptoms. So, you come off them thinking you are fine and snowball. Your CBT skills can be used to control this as relapse prevention is part of the model (not that I ever had this in my CBT!) but whether you manage that is a different story altogether.

Meds can also cause a lot more symptoms than you had before, something I've had problems with ever since going on Duloxetine. So, they can also mean that meds can make things worse, but thats all about switching really.

[pulisa]

Sounds fine in theory but we all know the realities of the 10 minute GP slot-or 5 mins if the appointment falls after a Bank Holiday.

I doubt whether many GPs have read this directive more than once. It's more a question of switching drugs rapidly and failing to be aware of challenging and long-lasting withdrawal symptoms from the powerful drugs they are playing around with.

[stumagoo]

Thanks Terry, my issues are deep routed going back to my childhood which is probably why CBT was never going to make much difference to me.

My counsellor also wanted me to do a therapy called EMDR, but when I read up on it it was said to be as effective as CBT so I decided not to bother.

It's much cheaper and probably just as effective to buy a CBT self help book and practice the tasks from the book rather than pay for it privately (which is what I did).