Cbt Based Self Help

Seek help from the NHS for depression or an anxiety disorder and it's likely that, sooner or later, you'll be offered some form of CBT-based self-help. There are face-to-face classes. There are online programmes. There are books on prescription. Then there's group or individual cognitive behavioural therapy, but in my experience, on the NHS this is still likely to be heavily focused on self-help. Typically, you are taught techniques, set homework, then discharged once you're making progress with the expectation that you can 'become your own therapist' and continue the work by yourself.

When I founded Sirius Project back in 2003, I was a passionate advocate of this type of CBT. It was empowering to take charge of my own recovery and some of the techniques really did seem to make a difference to the way I felt. However, as time has gone by I've become increasingly disillusioned with the approach. Although CBT thought records do provide some temporary relief from the symptoms of depression and have been a useful coping skill for me, they haven't been able to help me recover or stop me from relapsing. Worse, I've come to realise that the CBT I've had was actually feeding into some of the factors which were making me ill in the first place, such as perfectionism, pushing myself too hard and difficulty turning to others for support.

In this post, I'm going to share some of the CBT information and resources from the old Sirius Project website, but also inject a note of caution and talk a little about when CBT-based self-help might and might not be appropriate.

THE THEORY

Cognitive behavioural therapy is a practical treatment based on the theory that our thoughts, behaviours, emotions (mood) and some physical symptoms all influence each other. It is therefore possible to change the way you feel by changing your thoughts and behaviours.

For example, if you feel depressed, you're likely to have all sorts of negative thoughts about yourself and other people. These make you feel even worse. Then you might stay in bed all day because you can't face the world, and you hate yourself because you didn't do any of the things you were supposed to do. Physical symptoms like trouble sleeping and loss of appetite (so not eating properly) can also feed into the cycle. You're trapped in a vicious circle where you just go on feeling worse and worse.

Similarly, if you're afraid of public speaking, you're likely to feel very anxious or even panicky at the thought of doing this. You might find yourself thinking, "I'll mess it up. Everyone will laugh at me." Then you might get physical symptoms like shaking hands or trouble concentrating, and these make it more likely that you "will" make a mistake, deepening your fear. You might start avoiding situations where you have to speak in public, but the longer you put it off, the more terrified you feel - and you never have an opportunity to build up your confidence or learn how to cope. Again, you're trapped in a cycle.

However, if you can break the cycle at any point, you can start to feel better. CBT teaches you to identify the thoughts and behaviours that feed into the cycle and change these so that your mood and other symptoms will improve.

THE REALITY

In my experience, the way we think and how we behave absolutely do affect our mood and can feed into the symptoms of mental health problems such as depression and anxiety disorders. I have experienced it myself that when I challenge the negative, distorted thoughts that are part and parcel of depression, and come up with more rational, balanced alternatives, my mood does lift - temporarily.

The problem I have with CBT-based self-help is that it often takes a fairly simplistic view of mental health problems and focuses on addressing symptoms rather than the underlying causes. At best, this means a lot of hard work constantly having to practise CBT skills because - as one popular self-help book admits - you are doing the equivalent of trimming back weeds rather than pulling them out at the root. (This is particularly frustrating when you have been promised by the NHS that CBT will cure you.) At worst, you might find that the programme doesn't work or even makes your symptoms worse because the factors that make you depressed or anxious and keep you that way are different from the ones assumed by whoever designed the programme. For example, most CBT-based self-help for depression encourages you to become more active, yet my depression tends to be triggered by pushing myself too hard and I find that spending a lot of time resting is actually what I need.

You might think that having individual CBT would help to avoid these pitfalls. Yet even when I was referred to an NHS CBT service providing individual therapy for "complex and difficult-to-treat" patients, I got little more than formulaic, guided self-help that failed to acknowledge the complexity of my issues. It's important to acknowledge, however, that CBT doesn't have to be like this. I have it on good authority (from a friend who is training to be a therapist) that in its full form, CBT works on the root causes of mental health problems and is very different to the 'sticking plaster' version typical of the NHS.

One final potential issue with CBT-based self-help is that it places a lot of responsibility on the patient (or client, or service user - whatever you like to be called). This can be empowering, but I feel the idea of 'becoming your own therapist' is often abused by the NHS as an excuse for not providing appropriate help and support. Similarly, some CBT-based resources seem to imply that 'twisted thinking' and unhealthy behaviours are the cause of any emotional or mental health problem, ignoring the effect our emotions have on how we think and act, as well as the roles of biology, life experiences and other factors. In my opinion, 'good' CBT should always acknowledge the way these factors feed into one another, and be focusing on thoughts and behaviours because these are the things we can change directly; it should never imply that the patient is to blame for all their problems.

WHEN IS CBT-BASED SELF-HELP APPROPRIATE?

I think CBT-based self-help is worth a try if:

* Your mental health problems are mild and not particularly complex OR you'd just like to learn some coping skills. (I personally feel that CBT thought records saved my life when I had no other healthy ways of coping with depression, so I'm not knocking it as a self-help technique - I just have problems with the way the NHS uses and abuses it.)
* The theory behind the CBT makes sense to you and seems to correspond with your own experiences. (Some CBT-based self-help resources, such as the books in the Overcoming series, start off with a lot of information about the problem they're designed to treat and this is really worth reading to see whether your particular flavour of depression/anxiety/whatever is likely to be helped.)
* You're willing to change the way you think and behave, and won't feel overly invalidated or triggered by an approach that asks you to do this. (See also my comments above about resources that imply if you feel crap it's all your own fault!)

It's also worth looking out for CBT resources that seem to target your underlying problems rather than the surface symptoms. For example, I'm finding a CBT-based guide to overcoming perfectionism far more helpful than one about beating depression. Resources which target 'core beliefs' - the longstanding views we hold about ourselves, the world and other people - are definitely worth a look, although I've personally found that I need professional help with this.

CBT-BASED SELF-HELP RESOURCES

If you haven't been put off by all of the above ;) and would still like to give CBT-based self-help a go, here's some further information and resources.

"Challenging Thoughts"

This part of CBT is very similar no matter what your problem is. It involves identifying thoughts that are causing you distress or feeding into your issues, and then challenging them with an alternative, more balanced way of looking at things. There are two main ways of doing this that I've come across. One involves writing out all the factual evidence for and against your most distressing thought in a 'thought record'. I've written a post about how to do this, with examples from one of my own thought records, here. The other involves learning about common types of distorted thoughts and how to spot these in your own thinking. This is covered in detail by David Burns in his book The Feeling Good Handbook, and his 'ten forms of twisted thinking' are available online at BPDRecovery.com.

"Changing Behaviour"

The behavioural side of CBT-based self-help varies depending on what your problems are. It involves identifying the behaviours that feed into your cycle and finding ways to change them. For example, for a phobia, it could involve gradual exposure to the things that make you anxious. For BPD, it could involve learning healthier and more effective ways of coping, so that you don't swing from crisis to crisis and end up feeling more and more distressed (that's what DBT aims to do, although it takes a more validating approach than CBT). If your main problem is primarily a behaviour, for example an eating disorder or self-harm, CBT-based self-help will of course involve tackling this.

Here are a few resources that focus on changing behaviours for specific problems:

CBT for Depression

An example of the approach that does NOT work for me! :P

Using Rational Emotive Therapy to Control Anger

Good for all forms of freak-out - anger, panic or just feeling like you can't cope.

The Five Steps

A simple coping technique for people who tend to make impulsive decisions.

"Thoughts and Behaviour: Comprehensive Resources"

Living Life to the Full

An online, CBT-based life skills course that aims to help people suffering with depression and/or anxiety among other issues.

Self-Help Leaflets

CBT-based booklets covering a range of specific problems from depression and anxiety to self-harm and hearing voices. Available in PDF or audio format.

SOURCES

My understanding of the theory behind CBT-based self-help is drawn from the books Mind Over Mood by Greenberger and Padesky and Feeling Good by David Burns.

"(Image: Graur Codrin / FreeDigitalPhotos.net)"