For more information visit his website at www.relatedminds.com
Below is an outline of what you can expect in treatment for anxiety or depression with CBT, as well as a comprehensive list of online resourses and self-help books.
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Anxiety 101
An Introduction to Interventions for Anxiety
Dr. Jim Roche, PhD JD CAGS
relatedminds@gmail.com
This short introduction is to help individuals I see in my practice deal with the common issues associated with anxiety. You might be diagnosed with an anxiety disorder, or just have everyday anxiety like many others have in their day to day life's.
Anxiety itself is not a bad thing. It serves some useful purposes. It warns us about danger, calls on us to rethink things before taking actions we might regret, and it helps us focus in situations we need to ignore stimuli around us. It’s also, in some situations, is something we want and seek. No roller coaster ride, movie, television show or book would be enjoyable without a certain amount of anxiety.
Regretfully anxiety can get out of control, and can sometimes fill our day. Usually this is due to ongoing "automatic thoughts" we are having, sometimes beneath the level of consciousness, that we just can't get control of. Many people who see me take a long time to accept the idea that they are controlled not by the stimuli they are experiencing, but instead by automatic thoughts about those things. When your on a roller coaster, and you just finished one downhill ride and your going up and up and up you are having automatic thoughts about what's coming next. Your not hearing words, no voice is telling you to “hold on it's going to be scary”...but you are having thoughts that's you cannot control. You might start yelling, talking to yourself (No! No! No!) or scream, and when you do this your using a simple behavioural technique to control your thoughts, ”self talk." That's the sort of skill you need to learn in order to deal with your anxiety. Understanding and learning to use self-talk is one of several things that go on in therapy for anxiety.
Cognitive Behaviour Therapy (CBT)
The primary intervention we use in psychology to address anxiety is Cognitive Behaviour Therapy or CBT. Even if you make the choice to take medication, sooner or later you need to learn skills to deal with anxiety. CBT, along with behavioural techniques, are the evidence based methods we use.
CBT involves psychoeducation, reading or talking about the way CBT works, its theory and techniques, and practicing these techniques. A lot of what you will practice is a variation on a much older method called "exposure therapy." Albert Ellis and Aaron Beck, the two clinicians who developed CBT (Ellis called it Rational Emotive Behaviour Therapy or REBT) understood that exposure therapy often wasn't enough to successfully combat anxiety because sometimes symptoms transfer to new situations once you have them under control in one area of your life. They also understood that at the heart of anxiety that gets beyond your control is the fact that you have developed a way of thinking that encourages anxiety, negative automatic thoughts, and behaviours that reinforce it, avoidance or panic. During the psychoeducational part of therapy we discuss these issues because you need to learn to recognize when these things are happening before you can do something about them.
As you can see, in CBT we don’t talk about your past, but we do a lot of talking.
There are several books and websites that discuss all of this. I will suggest some books for adults, and a structured intervention process for children. Online there is already a wonderful, brief, and direct resource here in British Columbia called "AnxietyBC." This website has all of the materials you need. Sometimes the website can be a little difficult to navigate, so I will suggest specific searches to enter into your search engine (google) that will lead you right to a PDF that addresses each topic or skill. If you can't find them, email me or look for the list on my website. They are all listed at the end of this short introduction.
Another source that might seem silly at first, but really is helpful, is looking these names, topics and techniques up on Wikipedia. There is a lot of strange and frankly wrong things out there on the web about mental health, but looking up topics like cognitive behaviour therapy, Albert Ellis, Aaron Beck, exposure therapy or relaxation methods leads you to some pretty simple and clear explanations. The UK and Australia also have a multitude of resources for CBT and have adopted it as their primary method of addressing anxiety and depression.
"I've done CBT before and it wasn't helpful!"
Regretfully Cognitive Behaviour Therapy is taught by a lot of people with insufficient training, using only manuals and often mixed in with a lot of other therapeutic interventions that contradict the theory and practice of CBT. CBT is highly effective a good part of the time. Sometimes it is combined with medication. Sometimes it needs to be practiced for a long time. Look up Albert Ellis, Aaron Beck or his daughter Judith Beck and find a video of them talking or actually doing CBT with patients. It's a direct therapy. It's about questioning what you believe and think. It's somewhat confrontational because it's based on the Socratic method - a trained CBT therapist will ask you a lot of uncomfortable questions. And it asks you to participate in exposure therapy - which is inherently uncomfortable. Most people I see who have completed CBT with someone else can't explain the method to me, they don't understand the theory and can't tell me about any exercises they engaged in or describe the process of therapy in a logical manner. You need to be able to do these things for CBT to work. CBT isn’t just about addressing your anxiety or depression, it’s about changing the way you think.
What about Relaxation?
The AnxietyBC site teaches you a complex relaxation method. It's similar to what I was taught, but more complicated. You do need to learn how to relax, and that means learning to control your breathing, muscles and what is going on in your head. I'll teach you a very simple method to PRACTICE. You will practice, practice and practice some more, and then you will try using it on minor issues in your life before using it in a crisis situation where it is least likely to work. We want you to use skills first in situations where they are more likely than not to work. THEN you will use them in a variety of situations, and after that you can try the skills in more complex and difficult places. One of the exercises is developing a “Fear Ladder,” which we then use for you to learn how to use these techniques in an increasingly set of situations.
My last therapist taught me Mindfulness, do you teach that?
Honestly, "Mindfulness" is not very useful in situations where people are having serious difficulty with anxious thoughts. I know therapists and counsellors tell people this is "research based,” but there really isn't much research on using "mindfulness techniques" with individuals having significant anxiety problems. Yes, there are literally hundreds of books on mindfulness, there are school based programs, on-line programs and iPad apps. That's not research, that’s sales. Using an inappropriate techniques such as mindfulness to address serious anxiety problems, situations where you are having panic attacks, near panic attacks, have intrusive negative thoughts or your mind becomes confused and you are having physical symptoms of anxiety, makes little sense to me. It is more likely going to lead to repeated failure, and reinforce the very negative thinking patterns we are trying to avoid. It will prove to you that "there seems to be nothing that works..." There is a time and place for mindfulness, but not until you know techniques to control your intrusive thoughts and symptoms.
The research for mindfulness was originally done at the University of Massachusetts in Worcester Mass, and a great resource on doing "Mindfulness" is anything written by Jon Kabat-Zinn. My advice on mindfulness is to read Full Catastrophe Living (Revised Edition): Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. Here is something from the latest edition's book review:
"Stress. It can sap our energy, undermine our health if we let it, even shorten our lives. It makes us more vulnerable to anxiety and depression, disconnection and disease. Based on Jon Kabat-Zinn’s renowned mindfulness-based stress reduction program (MDSR), this classic, groundbreaking work—which gave rise to a whole new field in medicine and psychology—shows you how to use medically proven mind-body approaches derived from meditation and yoga to counteract stress, establish greater balance of body and mind, and stimulate well-being and healing. By engaging in these mindfulness practices and integrating them into your life from moment to moment and from day to day, you can learn to manage chronic pain, promote optimal healing, reduce anxiety and feelings of panic, and improve the overall quality of your life, relationships, and social networks. This second edition features results from recent studies on the science of mindfulness, a new Introduction, up-to-date statistics, and an extensive updated reading list. Full Catastrophe Living is a book for the young and the old, the well and the ill, and anyone trying to live a healthier and saner life in our fast-paced world."
Sounds great? It is over 700 pages long! People who get through it, love it. There are shorter workbooks, but as far as mindfulness goes, this is THE book. You can also get the book on CD or download it through audible.com. I will also suggest some shorter books during our sessions.
What I think is critical is to note that mindfulness is a technique use to avoid relapse AFTER you have used other techniques to get your racing thoughts and anxiety under control. It's a long-term project for everyone. It is not a technique for those in crisis seeking professional psychological help, and I am often very disillusioned when I see individuals who have serious problems with anxiety and are advised to use mindfulness as a first line of intervention.
Alternatively I suggest these books (also available on audible.com):
1. Feeling Good The New Mood Therapy (also a fairly long read) by Dr. David Burns
I have done several trainings with Dr. Burns, and his methods are clear and evidence based. He taught at the Albert Ellis Institute in New York when I received my advanced certification in Cognitive Behaviour Therapy. This book is an excellent choice for those interested in self-help material. Here is a link to a short audio clip from Dr. Burns: https://youtu.be/33G1Aue4cP8
2. Mastery Your Anxiety Worry: Treatments That Work by Dr. David Barlow
This is a much shorted treatment guide by one of the most well know clinicians alive today. Dr. Barlow has written many treatment guides that are evidence based, and this one has a short set of interventions broken down into a series of discrete lessons. I often use this in treatment in my office. There is a separate clinician guide and training book to help organize the week by week sessions. Here is a brief video with Dr. Barlow: https://youtu.be/HHjnG5fFPYg
3. Mind Over Mood: Change How You Feel by Changing the Way You Think (Get the SECOND EDITION )by Dennis Greenberger and Christine Padesky.
Again, this is a workbook, and it covers all the necessary topics for not just panic and anxiety disorders, but also how to use these same techniques to address depression and related issues. Again, this is a workbook I often use in my practice. It is highly recommended, and if you are going to work on anxiety by yourself (self-help), this might be a better workbook than the David Barlow book.
There are many more books out there, but these are the ones I would recommend.
For children and teens: We often use a curriculum called “The Incredible 5-Point Scale.” This is a great series of books, workbooks, posters and classroom lessons appropriate for all children. Additionally you will find that AnxietyBC has a complete set of materials for working with children and teens. This includes videos and workbooks. AnxietyBC has some really great videos which you can get at the public library or watch on their website. I sometimes suggest these to my adult patients, as it provides a great example of how anxiety works on others that is easily understood.
Where do we start and what does a treatment series look like?
Here is a brief outline of where we usually go.
If we decide to use a workbook such as the Mastery Your Anxiety Worry: Treatments That Work by Dr. David Barlow, we would follow that book. The second most likely workbook I would use is “Mind Over Mood.” Usually each session consist of about 50% of the time spend reviewing the curriculum in the workbook and 50% talking about particular problems you are having at home, in relationships or at work. Usually weekly sessions are advised for 6-8 weeks. After that patients come back after a month, and then periodically as needed. Trying out methods and getting on-going coaching is the key to success.
First Topic Set: We will talk with the aim of understanding you and your symptoms. We talk, explore what’s going on, and address how we would use CBT on one problem you are having. Also, during the first session you are usually assigned readings about CBT. I would ask you to read some of the PDFs below: What is Anxiety? What is CBT? etc. Finally, usually during the first session, we practice a short relaxation method. This topic set might be completed in one or two sessions.
Second Topic Set: We review the readings and the concepts behind CBT, and make sure you understand them. We practice using CBT on a problem. We practice the relaxation method again and I ask you to again read the PDF on relaxation methods. Next we review the Realistic Thinking Form and Challenging Negative Thinking. Calm Breathing is then reviewed and we discuss how to use self-talk, and may or may not address using an “Dealing with Intrusive Thoughts” card, a technique to address serious and seemingly overwhelming intrusive thoughts. Finally, we review materials from the first week and discuss which techniques are most appropriate for you. From this we develop a brief anxiety plan.
Third Topic Set: We review the previous two weeks lessons and skills. We usually practice calm breathing and the relaxation methods we agreed upon and review the behavioural prompt aspects of the method. We then develop a long term plan for addressing your most serious problems. At this point some patients make a choice to start to follow a self-help workbook like “Mind Over Mood” and that workbook guides our process.
ADULT Helpful "How To" Documents for Self-Help (AnxietyBC)
Here is a list of the PDF documents from AnxietyBC that I often use in sessions. If you are reading this list online or as a PDF on your computer you will be able to click these documents and get the PDF. If not, type into your search engine “AnxietyBC, PFD, (then the name of the document).” The list is also available on my website at www.relatedminds.com. Look for the page of forms and handouts. It’s at the bottom of the page.
CHILDREN AND TEENS: Helpful "How To" Documents for Parents
Home Management Tips for Parents
I hope this brief outline if helpful to you in understanding the therapy process. The process itself is often followed by individuals in a self-help manner, but there are a lot of technical issues that come up that require coaching. What you need to remember is that cognitive behaviour therapy isn’t just learning a quick and easy procedure such as a breathing exercise. CBT is about a way of thinking. Your anxiety or depression is caused by the automatic thoughts you come to problems with. CBT doesn’t seek to teach you that everything is great and you need to be happy. It teaches you to think REASONABLY, rationally. Read the PDF on Realistic Thinking to fully understand this. Life is still difficult at times. CBT is a technique to help you approach problems and issues in your life in a realistic, reasonable and rational manner. And that kind of thinking can help everyone in their relationships, at school or work. If you decide to learn CBT you will be learning a method to approach all of life in a more successful manner.
I hope this short introduction is helpful.
Dr. Jim Roche
Registered Psychologist
Registered Marriage and Family Therapist
relatedminds@gmail.com
