CBT and struggling...

[MyNameIsTerry]

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.

They probably haven't and those that have are faced with reality; it could be a long wait for therapy and a patient suffering or in their surgery constantly. So, they opt for the pills thinking they are doing the best for the patient and can end up getting it very wrong.

In my area before NICE it was a minimum 12 month wait to get help and pills were all their was. IAPT speeded up therapy but they also act as blockers to adequate therapies for those they can't help.

The government always love creating new lists to make things look better

---------- Post added at 02:18 ---------- Previous post was at 02:10 ----------

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).

I would imagine you will find the same issue with all therapies if you look at success rates some CBT is considered a high one.

EMDR works in a very different way that is still not fully understood. It's always been sold more for trauma since it works at with memory processing, which CBT isn't aimed at.

There is a "Trauma Focused" version of CBT used for PTSD. Maybe that's worth a look too?

Schema Therapy has evidence emerging that it is able to treat Personality Disorders where CBT has failed.

They also use DBT to treat personality disorders because it takes CBT but adds further work to deal with accepting emotions.

Maybe some of those could be appropriate in dealing with more deep rooted issues?

[Justanutter]

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.

Stumago, this is EXACTLY how I feel about it. In fact, I am going to quote this word for word this week at my session because I feel I need to be honest with her as she is so lovely and only doing her job. My family are exasperated with me and tell me that they believe 'I don't want anything to work' which is utter poppycock - they just need to walk a day in my shoes but I wouldn't wish this on my worst enemy. I am desperate for it to work as I really don't know how I am ever going to rid myself of this state of mind, and I really do think I am trying hard.

---------- Post added at 10:41 ---------- Previous post was at 10:35 ----------

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

Thanks Terry. You seem so knowledgeable in these things. I have had a look at the download and will give it a go. I had pinned all my hopes on CBT and maybe I am being too impatient and thinking it sounds far too simple to do. I do maybe think though, that as you also found, mindfulness may be a better tool for me and I should get back into that.

[EbonyNightfall]

I'm so sorry to hear CBT hasn't worked for some of you.

I'm in the same predicament - I've had 8 of my allocated 10 sessions and have made no progress whatsoever. I find the idea that over 30 years of fear can be resolved in such a short space of time a bit of an insult really, but thought any help would be better than none at all. I agree with those of you who have suggested that some problems are too complex and deep rooted to be conquered, even partially, in such a short space of time. If it was that easy surely we would have managed it ourselves a long time ago!

While I realise it's down to me to do all the hard work, I've found my therapist to be very lackadaisical and lazy. She's currently trying to treat my emetophobia, (she thought it best to treat that first). 3 of my sessions were wasted looking at 3 pictures of people being sick. It took 23 mins for me to stop crying and shaking over 1 picture!? For session 5 I was supposed to listen to a recording of someone being sick. I don't think I lasted 2 seconds before a panic attack took over. I told her that if I was going to listen to something so upsetting I'd like it to be in the safe environment of my own home first (I'm agoraphobic too), so I'd listen to a copy of the CD I was supposed to be given for homework anyway at home before listening to it together in her office; to date she has still forgotten to bring one! Session 8 was a meditation because I've lost my confidence in going to the sessions.
Also, I'm furious that she wrote to my GP, without my consent, to stop him from prescribing me any more anti-emetics, (they're prescribed for my stomach problems), but I don't take them unless absolutely necessary, which is fortunately very seldom these days). I don't have the confidence to step one foot out the door without them :(

And another thing, I don't know about everybody else, but I've found the print outs I've been given to be so simplified that they're just a useless, patronising a waste of paper! I've learnt more in the last week from this forum and self-help books than 2 months of CBT!

I'm so sorry for the self-indulgent rant, but it's so disheartening, disillusioning and frustrating when you hear how successful CBT's supposed to be and it doesn't work for you. I've no idea what to do now :P

[MyNameIsTerry]

Stumago, this is EXACTLY how I feel about it. In fact, I am going to quote this word for word this week at my session because I feel I need to be honest with her as she is so lovely and only doing her job. My family are exasperated with me and tell me that they believe 'I don't want anything to work' which is utter poppycock - they just need to walk a day in my shoes but I wouldn't wish this on my worst enemy. I am desperate for it to work as I really don't know how I am ever going to rid myself of this state of mind, and I really do think I am trying hard.

---------- Post added at 10:41 ---------- Previous post was at 10:35 ----------



Thanks Terry. You seem so knowledgeable in these things. I have had a look at the download and will give it a go. I had pinned all my hopes on CBT and maybe I am being too impatient and thinking it sounds far too simple to do. I do maybe think though, that as you also found, mindfulness may be a better tool for me and I should get back into that.

What I would suggest is reading about what CBT is supposed to do. I had mine and slowly I started learning things after it had finished. Then I looked more into what CBT contained and found I had hardly any of it!

Any health worker can write a book prescription for you. You then take it to your local library (if you still have one! ) and you can have one of several books. Its all free and the booklist is on NHS Choices and includes CBT ones. So, perhaps you might get some more incite that way.

All my therapist was doing was explaining how thoughts, feelings, emotions, blah blah work in the circular diagram and then I was filling in lists about my compulsions plus lists of things I could try doing. She also spent some time on the whiteboard talking about how I felt about some of these things. We did a couple of Behavioural Experiments but I was just asked to think how it affected me when CBT provides actual monitoring sheets I thought for a while that with the lists of things to try she may have been doing some Behavioural Activation but I later decided it was more about basic exposure work.

I learnt about Cognitive Distortions from a charity I joined as they spent 30 mins each walk-in session reading a CBT based module and talking about how we felt it applied to us. These are a staple in CBT yet my therapist never told me anything about them. This got me started and then I joined here later and looked even further. I found real CBT is nowhere near what I was getting. It is tailored but I look at mine, some people I've seen on NMP including in the thread and see it more as "weakened" or "watered down" so it makes me question whether IAPT are just shaving off the people they can and the service is not really there to help us all. I knew barely anything about CBT before looking into it myself, despite having what I thought was CBT over a year before!

I think we are being shortchanged by IAPT. Its all behavioural work they seem to be doing and that is not CBT, its the Behavioural Therapy element that existed before it. They don't seem to be getting into Cognitive Restructuring which is a big part of CBT. The 2 people on here that had more traditional therapists (non IAPT) that I spoke to did have this in theirs and one of them had a similiar number of sessions to me yet had far more CBT than I had.

There are some good websites out there with free courses and loads of free tools and modules. I would suggest having a look at Davit's threads on the Panic board because we added links in there for various things.

You could always try MBCT, the Mindfulness combination with CBT. Thats NICE approved for treating recurrent depression at the moment but more GP's are sending patients on Mindfulness courses so they are pushing it that way. My therapist started me with Mindfulness but they only had a few exercises at the time. There are courses for MBCT with private therapists too and they tend to be around £60+ for 8 weeks online based on ones I've seen like BeMindful (the Mental Health Foundation, long running charity) and even ones like Breatheworks who offer the MBSR versions which have been around for 40+ years now from the US. (But as a tip, a MBSR therapist trained at the main uni for this in the US has put a full 8 week free course online so I've added it in my thread...follow the link in my signature for all that stuff)

---------- Post added at 04:55 ---------- Previous post was at 04:45 ----------

I'm so sorry to hear CBT hasn't worked for some of you.

I'm in the same predicament - I've had 8 of my allocated 10 sessions and have made no progress whatsoever. I find the idea that over 30 years of fear can be resolved in such a short space of time a bit of an insult really, but thought any help would be better than none at all. I agree with those of you who have suggested that some problems are too complex and deep rooted to be conquered, even partially, in such a short space of time. If it was that easy surely we would have managed it ourselves a long time ago!

While I realise it's down to me to do all the hard work, I've found my therapist to be very lackadaisical and lazy. She's currently trying to treat my emetophobia, (she thought it best to treat that first). 3 of my sessions were wasted looking at 3 pictures of people being sick. It took 23 mins for me to stop crying and shaking over 1 picture!? For session 5 I was supposed to listen to a recording of someone being sick. I don't think I lasted 2 seconds before a panic attack took over. I told her that if I was going to listen to something so upsetting I'd like it to be in the safe environment of my own home first (I'm agoraphobic too), so I'd listen to a copy of the CD I was supposed to be given for homework anyway at home before listening to it together in her office; to date she has still forgotten to bring one! Session 8 was a meditation because I've lost my confidence in going to the sessions.
Also, I'm furious that she wrote to my GP, without my consent, to stop him from prescribing me any more anti-emetics, (they're prescribed for my stomach problems), but I don't take them unless absolutely necessary, which is fortunately very seldom these days). I don't have the confidence to step one foot out the door without them :(

And another thing, I don't know about everybody else, but I've found the print outs I've been given to be so simplified that they're just a useless, patronising a waste of paper! I've learnt more in the last week from this forum and self-help books than 2 months of CBT!

I'm so sorry for the self-indulgent rant, but it's so disheartening, disillusioning and frustrating when you hear how successful CBT's supposed to be and it doesn't work for you. I've no idea what to do now :P

My printouts were not very professional. They also weren't NHS branded which was a bit worrying. I have found online templates which are the spitting image of mine and wondered if they had just downloaded them

I think you are right to be angry with that therapist. One of the big points of mental health care (and there are campaigns stating this) is the ability of the patient to be involved in the decisions about their care. That therapist should have discussed it with you. Your GP won't do something just because a therapist says so anyway, 18 months of training in CBT doesn't make someone knowledgeable about meds. She could have called your GP to discuss it since he/she would have more understanding of what the med is for. Seems like arrogance to me.

Your therapist seems pretty poor. The whole point of using ERP as the exposure treatment (as opposed to the "flooding" methods of ET, or the various other ones aimed at bringing on the worst fears) is to use a hierarchy from least scary to worst (plus one extra step beyond usually). If you can't habituate to a step i.e. your anxiety doesn't decrease by 50%, you shouldn't progress of any further and should go back to the previous step or insert a stepping stone to build you up closer the the one you can't habituate to. So, there was no point taking it a step further with that recording when you hadn't progressed to being able to tolerate the images.

Bad therapist, I would say. IAPT again?

Something else that annoys me about this current system is how they can choose to treat one element, spend your whole therapy on it and then send you back to your GP when they haven't even addressed the others. What's the point of that? They wouldn't do that in physical health.

So, perhaps deadlines are more important than patient care? They can say there isn't enough money, which there isn't, but its hardly a justifcation for half-arsed attempts.

[Justanutter]

Thanks Terry, as usual, very informative and helpful. I will have a look during my lunch break.

By the way, I think you would make a great counsellor yourself - have you every considered training for something like that as counsellor training involves lots of therapy for the counsellor along the way I believe and may be turning the tables on the anxiety into doing it for others, which you do on here anyway, may prove something worthwhile. Forgive me, if I'm way off in my thoughts...

[EbonyNightfall]

Thank you so much for reading my message and for taking the time to reply Terry, I really appreciate it You're so knowledgeable!

That's so true - you'd think for treatment to be completely or optimally successful it'd have to be more holistic!

I think perhaps I was deemed a write-off from the offset and not worth the effort lol I have wondered how other people's experiences of CBT for emetophobia have differed to my own. I thought I'd be taught how to cope better with my phobia and to see things in a new insightful manner, but my sessions have involved almost no discussion!? Also, while I understand the theory of desensitisation, and it makes some sense, I find it hard to see how looking at pictures and recordings of people being sick can cure a phobia of being sick yourself..

Ah well, it was worth a shot!

[MyNameIsTerry]

Thank you so much for reading my message and for taking the time to reply Terry, I really appreciate it You're so knowledgeable!

That's so true - you'd think for treatment to be completely or optimally successful it'd have to be more holistic!

I think perhaps I was deemed a write-off from the offset and not worth the effort lol I have wondered how other people's experiences of CBT for emetophobia have differed to my own. I thought I'd be taught how to cope better with my phobia and to see things in a new insightful manner, but my sessions have involved almost no discussion!? Also, while I understand the theory of desensitisation, and it makes some sense, I find it hard to see how looking at pictures and recordings of people being sick can cure a phobia of being sick yourself..

Ah well, it was worth a shot!

Thanks, I appreciate that.

Here is some info that matches what my therapist gave to me.

http://beyondocd.org/expert-perspect...bituation-mean

This explains habituation in exposure exercises. Please read about the scoring for anxiety reduction over X time. It says it needs to be long enough in order to feel a reduction. I know in the diagrams my therapist showed me that it was a bit longer, more 20 minutes which can be shown on this diagram:



The wbsite explaining this can be seen here:

http://www.cognitive-behaviour-thera...rs_anxiety.htm

ERP is also used in shorter timeframes as its impossible for some issues. I don't know as much about how they handle this and allow for time to habituate although I would guess at it being later in therapy so you have more control to be able to move yourself towards habituation quicker.

This is a really good example on NHS Choices:

For example, if you have a fear of snakes (ophidiophobia), your therapist may start by asking you to read about snakes. They may later show you a picture of a snake. They may then arrange for you to visit the reptile house of your local zoo to look at some real snakes. The final step would be for you to hold a snake.

You didn't get that from what you explained. Your therapist barged straight in with pictures and when he/she was faced with a patient unable to habituate, they did nothing to reduce the intensity of the exposure and work back up again. They even went up a step to the recording when there is no chance you should do that if you are unable to handle a previous step. Thats not how the ERP model works at all.

Another problem is that it has not been explained to you either. These exercises are just part of the hierarchy but like in the NHS Choices example above, there would need to be further steps that involve you e.g. using imagery where they talk you through feeling sick or imagery of being sick. This probablt sounds horrific to you right now but when you reached those steps you would already be desensitised to triggers like other being sick so you would have much more confidence & trust in yourself and greater control over your reactions.

Thats just a bad therapist so I wouldn't judge CBT or the ERP component based on your experience alone. I sort of did for a while but I have later come back around to the benefits of it.

The fact your therapist didn't spend time educating you about the core principles is another indicator of poor quality for me. CBT is supposed to be about education and to provide the patient/client with the tools to manage prevention of future relapse so how can you do that if you don't know any of it?

I posted a thread with a link to a report about how ERP can fail and what a therapist should do. Its aimed at OCD but it has a lot of useful information in that should give you can idea of what the aim should be at a deeper level i.e. changing your beliefs. You will see references to "treating the core fear" which is useful because it explains where therapists go wrong in treating the wrong fear. For instance, if one of your symptoms of Agoraphobia was nausea, it will bring on your Emetophobia thus in treating the Agoraphobia it can deal with both at the same time where your Emetophobia is limited to those symptoms in that scenario and you end up desensitised to both in the process.

---------- Post added at 05:18 ---------- Previous post was at 05:01 ----------

Thanks Terry, as usual, very informative and helpful. I will have a look during my lunch break.

By the way, I think you would make a great counsellor yourself - have you every considered training for something like that as counsellor training involves lots of therapy for the counsellor along the way I believe and may be turning the tables on the anxiety into doing it for others, which you do on here anyway, may prove something worthwhile. Forgive me, if I'm way off in my thoughts...

Thanks, I appreciate that.

Its something I've thought of but I've always said I would prefer to get to a better place myself first rather than risk the outlay. I was asked if I wanted to train as a coorindator for a charity but I was worse back then and didn't want any extra pressure.

Thank you for your confidence.

---------- Post added at 05:31 ---------- Previous post was at 05:18 ----------

I wanted to check something on CBT and did a quick Wiki for it and in the criticisms section it states:

Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners

The UK's National Health Service announced in 2008 that more therapists would be trained to provide CBT at government expense as part of an initiative called Improving Access to Psychological Therapies (IAPT). NICE said that CBT would become the mainstay of treatment for non-severe depression, with medication used only in cases where CBT had failed. Therapists complained that the data does not fully support the attention and funding CBT receives. Psychotherapist and professor Andrew Samuels stated that this constitutes "a coup, a power play by a community that has suddenly found itself on the brink of corralling an enormous amount of money ... Everyone has been seduced by CBT's apparent cheapness." The UK Council for Psychotherapy issued a press release in 2012 saying that the IAPT's policies were undermining traditional psychotherapy and criticized proposals that would limit some approved therapies to CBT, claiming that they restricted patients to "a watered down version of cognitive behavioural therapy (CBT), often delivered by very lightly trained staff"

I don't generally read beyond the real information of how you use a therapy in such articles but this is something that is showing in peoples posts on this forum more & more. Some still say it helps them greatly though but you don't always know which service provided this and if you get to Level 4 with the community mental health teams you are accessing a better trained person with a lot more skill & experience of even more complex interventions.

[ricardo]

I appreciate that you have spent so much time studying the pros and cons of CBT, Terry.

All in all I think the success rate is nothing outstanding. I mentioned a while back that my therapist said her success rate was 60% which one can argue is good that 6 out of 10 people have been cured, but when I looked into it further with her these were for specific phobias not deep rooted multiple problems that mant of us have.

One pill for all just doesn't work.

I believe psychodynamic therapy might be a better option for many.

[MyNameIsTerry]

Yes, I think the same, Ricardo. Even the NHS make a point of saying this and part of me wonders whether its because we have to deal with IAPT. Its interesting that their is a short version of CBT at around 12 hours of therapy. IAPT provide typically 12-15 hours. So, sounds like a stripdown to me and not real CBT.

So, perhaps if we had the real deal, we would see better success rates. If a doctor said 60% success we can repair your leg after an accident, it would be brown trousers time!

I've seen 50-60% but I've also seen 80% (which I don't think is accurate).

Its interesting that CBT has become an umbrella term too and therapies such as ACT can be considered part of it. I think these newer forms might be useful given they use techniques that are proven to change brain structure and I'm not sure of CBT has that behind it.

I know for OCD, psychodynamic approaches aren't seen as more effective. The trouble is, we tend to have a lot more issues than just one disorder and CBT seems to struggle with this. Psychodynamic typically takes place over a much longer time so its hard to make a comparison without ruling out the effect of a longer therapy.

The strange thing is that in the NICE guidleines for GAD it say for high intensity therapies (CBT level) give the patient a choice of CBT or Applied Relaxation. I've never seen anyone on here discussing that AR other than when I mentioned it on a thread and Kimberley said he CBT therapist gave her a CD for it. Her therapist being a fully trained community mental health service one, not IAPT because she is in Scotland. I had no choice, I never heard of choice. Do these AR therapists even exist? I can see that being useful to people because it teaches you how to relax and bring on relaxation quicker & quicker until you are practicing it in vivo. It has some CBT influence and can be combined too.

[pulisa]

My preferred method of relaxation would always be a general anaesthetic

I thought "CBT" as it is offered on the NHS was only suitable for mild to moderate cases. Anything more long term-apart from psychotherapy-would of necessity have to be privately funded by the individual as it's not really practical financially for people to have limitless sessions with an NHS practitioner. Just imagine the waiting lists! I had to wait over 2 years for my CBT 10 years ago and I think I got 16 sessions which barely scratched the surface. I was offered psychotherapy but turned it down as I couldn't commit to long term therapy as I'm a carer and I was very frightened as to how it would affect my day-to-day caring for my daughter.

I think that there's too much fancy terminology used today for mental health services when a lot of it is just common sense. Also far too many "therapists" jumping on the bandwagon taking advantage of vulnerable people.