Bird Set Free

Disclaimer: This blog explores anxiety. Avoid reading further if you think you will be triggered.


I've had a fair number of people message me to ask when I'm going to write my next blog post and that it has 'been a while'. Noo idea why, but it is appreciated!

I thought I'd write about my experience of cognitive behavioural therapy (CBT).

For those of you that don't know CBT is a treatment which focuses on how your thoughts, beliefs and attitudes affect your feelings and behaviour. It also teaches coping skills for dealing with different problems and strategies to modify negative thoughts, behaviour or attitudes. CBT can be delivered by a psychologist (high intensity CBT) or it can be self taught using online modules (low intensity/moderate CBT).

Unfortunately, due to demands stretching resources in the NHS there is a very long waiting list. I waited 11 months before starting high intensity CBT.

However, the good news is anyone (in most places in the country) can self refer without visiting a GP. This can be done using the IAPT NHS website. Simply google IAPT, the area you are living in and you should find a link. You can receive high intensity CBT much quicker privately, but this can be quite expensive.

So far, I've become more aware of what is going in my head because I am using a 'mood' diary to record my thoughts and feelings. I am now able to objectively analyse/reflect on melt downs after they occur (hurrah!). This helps me recognise the triggers/negative cycles that take place, and hopefully will result in being able to develop strategies to stop/prevent meltdowns in the future.

Apart from finding the psychological principals very interesting to read, CBT is actually an excellent intervention. It is methodological, logical and it creates structure to my internal chaos.

For those of you that are dubious- CBT is very evidence-based. It is one of the few interventions which have been proven to help overcome depression, anxiety disorders, phobias, PTSD, OCD and eating disorders. 

For those of you  interested in the science showing this, a systematic review and meta-analysis (the queen of studies aka 'study of all studies') investigating whether CBT can improve generalised anxiety disorders was undertaken.

Below is a diagram called a forest plot. The blue squares demonstrates the result from each study. Squares to the left of the vertical line (aka line of no significance) demonstrates that the study showed  patients who received CBT had a better chance (aka risk) of improved clinical response to anxiety when compared to patients still on a waiting list or receiving  'usual treatment'. The bigger the square the more patients in the study. The more patients in a study, the stronger the accuracy (weighting) of the result reported.

Figure 1: Forest plot comparing the clinical response post treatment for CBT vs usual treatment/waiting list 

Reference: Hunot V,et al. Psychological therapies for generalised anxiety disorder. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001848. DOI: 10.1002/14651858.CD001848.pub4.

The black diamond at the very bottom of the graph is the overall result from number crunching and combining the results from every study identified (aka meta-analysis or pooling). The diamond result is more reliable then the results reported from individual studies.

The meta-analysis (aka diamond) is a stronger result as it includes more patients (think of using a result from one study which has 10 patients compared to a result of 100 patients from 10 studies). The result from the meta-analysis will have more 'power' (aka strength) and therefore  interpreted as a more robust result.

For the medics, scientists and mathematicians reading this. Yes - I have given a simple explanation, and yes - I've not explored confidence intervals, heterogeneity, risk of bias, confounders etc. But, I've already gone off on a tangent and this isn't a critical appraisal blog :). Hopefully, it is enough to persuade someone reading this blog who is dubious about the benefits of CBT to explore it further.

Anyway, after my humongous tangent, I'm going back to the blog topic. To demonstrate my learning process I've explored 2 scenarios and how I've used CBT to understand and deconstruct what happened:

Example 1

Going for a run with a new friend.

The 'rational me' looked forward to it: I get to combine socialising and running-win win! two things I love doing, running with someone will motivate me to run further/quicker etc, I get to share/learn from someone, this always adds to knowledge, wisdom and life experience. I also get time to be outside- something I love and appreciate.

The irrational me: what if the friend thinks I'm stupidly slow? what if I have to stop mid run? what if I fall over, what if I'm too breathless to talk? why does this friend *actually* want to go for a run with me? are they just being polite? will they judge me for what I'm wearing/ the way I run? why do they *actually* want to be my friend? what have I actually *given* to this person to justify them wanting to be my friend, what if they find the experience terribly boring/awkward/ difficult. Shall I just cancel the run? I'm sure they will be secretly relieved.

This cycle of thinking made me feel more anxious as the day progressed. By the afternoon I was struggling to concentrate on my work. Que run and it transpiring to be exactly what my 'rational' side believed.

Looking at it objectively- I had a lovely run and enjoyed the catch up. The friend was very encouraging and positive regarding my pace (!). We even continued chatting for a while after the run. If this person really disliked my company/pace/etc they could have cut short the run/ or made their excuses to leave asap.

After the run my thoughts wondered to what they actually thought of the run, whether the person actually enjoyed my company or if it was just a 'kind gesture' on their behalf. I usually thank my friends after meeting them. In this scenario I worried if my message of thanks would be seen as too much, too keen or weird. What if they decided after the run they didn't want to be my friend and they were forced to reply. I reasoned with myself, I would definitely send this message to any of my long-term close friends so this is no different. The message was sent, nothing happened and the matter is history.

Example 2

Meeting at work.

The 'rational side' me: It's just a standard meeting. No biggie. I've not done anything wrong (backed up by X/Y/Z). This is part of the motions and to be expected. Get the meeting done and dusted and move on. Learn, reflect, and become wiser and stronger.

The 'irrational side' of me: what if they say I'm a bad doctor/ that i'm not doing/ working hard enough , what if I get in trouble? what if they record negative feedback. What if they suspend me? what if they tell me to stop working? What if they think I'm a rubbish doctor and a burden to their already stretched precious time. What if they dislike me? would this affect my future career? 

The meeting was (obviously) fine and I received good feedback. I tried to process what actually occurred rather then what I was anxious about. Initially, I was happy and relieved.

However, as the day progressed worry crept up on me. By the time I was trying to sleep I felt depressed -why do I even bother/ I should give up/no one cares/everything is a battle/I never seem to do anything right/my life is rubbish/I'm not good enough .

I woke up after 3 hours sleep at 3 am. I felt extremely anxious, and panicky: *That* person at work was definitely off with me the other day, they must have heard something and be annoyed/disappointed with me and dislike me. They all know, they must think I'm potty, impulsive or crazy. They must think I'm a rubbish doctor. I think they've lost respect and will now dread working with me. They'll probably be on the look out to get rid of me. Should I cancel my next shift? should I call in sick? surely they'd be happier if I did. Will people treat me differently? Will life become even more difficult?

I got so worked up I never managed to get back to sleep despite trying breathing techniques, meditation, and getting up to do something to distract me. At 5 am I decided to 'eff it', I got up and proceeded with my day. By this point I still felt sad, stressed and anxious. I had a melt down (thankfully not in public). It was so bad (depressed thoughts) I thought I should reach out to someone (FYI I rarely do). I looked at my phone: Shall I message X? no they have their own issues, shall I reach out to Y? no they will probably think I'm draining. What about Z? I'll put them in an awkward situation in which they will be forced to listen when they don't want to. I don't want them to worry. In the end I didn't call anyone. I just couldn't do it. I decided to contact a friend to see if they were free to hang out (I didn't say why), I was semi-relieved when they said they already had plans because I hate 'emotionally dumping on someone'. I really do struggle 'reaching out'. I felt okay by mid afternoon but I was very tired!.

Tracking my thoughts has made me realise I *probably* have generalised anxiety disorder (i.e. worry about everything) with a social component (.e. worry about what people think of me).

These 'irrational thoughts' reflect my own insecurities about myself. If someone 'consolidates' my insecurity then this triggers a full blown melt down.

I've come to learn my 'irrational thoughts' reflect my core beliefs.

Core beliefs are the very essence of how we see ourselves, other people, the world, and the future. These can be positive i.e. 'I am a fun, attractive caring person' or negative i.e 'that person thinks im dumb/stupid, weird, ugly'.

Having negative core beliefs can affect cognition (the meaning one gives to the events of your life).

Core beliefs represent the 'bottom line' of a person’s mind.  These are the fundamental beliefs about oneself, other people and the world in general. Characteristics of core beliefs include:

  • Not being immediately accessible to consciousness. They may have to be inferred by observation of your character through thoughts and behaviours in different situations.

  • They can manifest as general and absolute statements. For example: I am bad or others are not to be trusted.

  • Not varying significantly across times or situations .

  • They are seen by the person as fundamental truths that apply in all situations.

Core beliefs are usually learned early in life as a result of childhood experiences, but they may sometimes develop or change later in life, e.g., as a result of severe traumatic experience. Negative core beliefs may result in many different types of anxiety and depressive disorders.

The locus of evaluation describes how a person evaluates information and rely on their own judgment and to make conclusions.

Someone with an internal locus of evaluation will have strong self belief. For example someone is told they are lazy. The person will listen to what is said but disregard this feedback because-actually- they disagree. They're not lazy and always work hard. This is backed up using X/Y/Z examples and therefore they are not affected by this feedback.

Someone with an external locus of evaluation will rely on others to evaluate their beliefs. For example when someone is told they are lazy, they will accept and believe the feedback 'it must be true because X said so'. They are more likely to be affected negatively by such comments and this may subsequently alter their core beliefs.

Therefore, I have learnt I have negative core beliefs with an external locus of evaluation. The way I have interpreted this is that my negative core beliefs induces worry. When combined with a 'blow' i.e. a external locus of evaluation it results in a full blown melt down.

I'm actually quite pleased I've managed to psychoanalyse myself (haha!). But- it's all fine and dandy understanding why I react/behave this way, the important thing is how am I going to fix it.

Ultimately, I will have to change my core beliefs, and internalise my locus of evaluation. 

I've been told the first step to changing is challenging the beliefs. When I think 'I am stupid'  to try challenge the belief by objectively analysing the situation.

Really, I feel the crux of my problems is belief. How does one genuinely change the belief of oneself?. I can speak positively to myself e.g. 'I am intelligent' or 'I am attractive' but I know I don't/won't believe it.

Que the next part of the rabbit or bird  hunting....