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Programme 5. - CBT
RADIO 4
THURSDAY 21/12/06 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
PROFESSOR PAUL SALKOVSKIS
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
MYERS
Hello. Here's a surprising statistic - 50% of people with anxiety or depression, they're the two most common mental health problems, could be cured simply by talking with a health professional trained in CBT, that's cognitive behavioural therapy. It's a relatively new psychological technique that works by challenging negative ways of thinking and unhelpful ways of behaving, as well as helping with anxiety and depression it's also being used for phobias, obsessions and other psychiatric disorders. Can it really be that good, is it really that simple? Well CBT is now recommended as the treatment of choice by the influential National Institute for Health and Clinical Excellence and it's found many champions including our guest today. Professor Paul Salkovskis is clinical director of the Centre for Anxiety Disorders at the Maudsley Hospital in London. And you may have seen him treating people with panic attacks in The House of Agoraphobics on television last night.
So if you would like to know how this treatment might help you call us now with your questions. The number 08700 100 444 or you can e-mail checkup@bbc.co.uk.
And our first caller is another advocate of CBT I believe, Jane this has worked for you?
JANE
Yes, well not for me but for my daughter.
MYERS
Right, tell us more.
JANE
She was diagnosed about 12 months ago with clinical depression. She lived 200 miles away, all we were aware of, because we don't see her very often, is that she didn't respond to telephone calls and e-mails at the same amount of time and we were concerned she was unwell. She rang us at the beginning of the year to tell us. The doctor had said that she should go on antidepressants and have therapy but unfortunately it was a several months wait in her area. So dad said I'll pay. She found a very good therapist close to her who has taught her some fantastic coping strategies. She was off work about six weeks, she has learned to cope and also to recognise when she needs to up the ante a bit and be a little more careful with herself.
MYERS
So is she one of the one in two then who then might say they're cured now of obviously quite a serious issue - depression?
JANE
I would not say cured because I'm not certain you can ever say you're cured ...
MYERS
But she's much better?
JANE
She is much, much better, she can cope, she's bright, she's cheerful, she is well aware it could come back, she's had one or two instances over the last two months when she thought she was going downhill again ...
MYERS
Let me get a comment then from the professor, obviously that's a good news story and really good to hear that Jane. So the success rate can be very good, obviously it sounds as though Jane's daughter got on this quite quickly, albeit having to pay for treatment, and feeling a lot better, although one wouldn't want to say necessarily cured.
SALKOVSKIS
I would want to say cured actually in some cases, cured is possible because anybody who's been through that experience is going to be sensitive to the idea that it's going to go down again. The issue - I mean what it shows is that she's learned new things, she learned - this thing that people say, you know, pull yourself together, well she's learned how to and of course the reason people don't pull themselves together is they don't know how to. And what's she's learned is to pull herself together and the research shows us that people will stay pulled together because if they go down again they can reactivate what they've learned.
MYERS
What are the coping techniques do you think that help her now to sort of feel better and cope better?
JANE
Well when she first saw her therapist he got her to list all her actions and then to score the mood and how well she did it and how happy she felt. That worked very well, especially as she got a new puppy and had to get up to him and might not have got up if she hadn't. Also she learned to give herself regular breaks from any one task, especially once she'd returned to work. Looking at the small picture and not the big one, which can be overwhelming for anybody.
MYERS
Interesting simple ideas there, Paul is this the nature of CBT then, run us through it, the sort of things you would be asked to do and engage in that might just make the difference?
SALKOVSKIS
Well CBT's applied common sense to a degree but it's scientifically based applied common sense. So people when they're depressed don't feel up to doing things, they feel, as Jane said, feel overwhelmed. So you break things into small pieces, you help the person work towards the thing but you also choose things which matter, I mean the other thing is that people when they're depressed lose their dreams and so it's not just a matter of doing things, it's a matter of doing things which take you towards things that you need to do. Helping people deal with the pattern of distorted thinking which turns everything which is actually multicoloured black and helping people with that unhelpful pattern of thinking, helping them find a different way of tackling the world and finding out that the world is not necessarily as they're seeing it, that it works in a different way.
MYERS
Jane thank you very much for calling from Wrexham with that information at the beginning of our programme. I'd like to go to Stuart in Yorkshire, who's wondering whether CBT might help him with sleeping disorders. Stuart, what's the problem for you exactly?
STUART
Hello yes. Well briefly, going back some time now, in March 2000 I had a fever and then I didn't sleep for a week and gradually nature's brought back the sleep. But during this time my GP really hasn't been able to help nor send me anywhere. But in July I did visit the GP again on a different matter because I'd lost weight quite independent of this and I did ask him again and press him a little and he contacted the local mental health people and they, after many, many months, they did eventually see me and they put forward the idea of CBT...
MYERS
Had you heard of it before - had you heard of it?
STUART
It was mentioned a couple of years ago because I was sent for counselling, which didn't do any good for me...
MYERS
And are you now trying it or are you just wondering whether it could help?
STUART
So - well I'm anticipating when I do obtain an appointment that I will be starting CBT but I'm not depressed and I'm not anxious, I mean obviously I'm not happy because I was an electronic engineer and I'm in my late 50s and the longer it takes the harder it will be for me to find employment again. But I'm not depressed but I mean anybody would not be happy with the situation which goes on and on. But I wondered if your ...
MYERS
Expert has any advice.
STUART
... this expert could advise on CBT, if it would help me.
MYERS
You've got the right man to ask, so what would you say Paul?
SALKOVSKIS
Yes CBT is actually highly effective, it's actually more effective than any medication in helping sleep. The effect size is about twice the size you get with medication, it doesn't have the side effects that medication has. And again it teaches simply coping strategies, it doesn't assume there's any - necessarily any deep cause, sometimes there are deep causes but it helps people break some of the bad habits that they've got into. A lot of sleep problems are related to people trying to cope with it and then doing things which are actually counterproductive. So it teaches people new habits and it depends a bit on what the pattern is, what a good therapist will do is help you identify where you're going wrong in what you're doing, identify any distortions in your thinking, which may not be there but if they are help you correct those, and then actually try a range of different things. It's kind of like doing an experiment really, your therapist will work with you to try different ways of tackling it and then look at the results and then what works is what works.
MYERS
And thinking about the very name CBT - cognitive behavioural therapy - is quite a mouthful so I can see why it's shortened but what does it tell us about the treatment?
SALKOVSKIS
Well it says basically there is a combination of the pattern of thinking which then motivates particular behaviours....
MYERS
That's the cognitive side of things?
SALKOVSKIS
Cognitive is thinking, then behavioural is the behaviours that are motivated which are often counterproductive, so it's things like if you have panic attacks in a supermarket where you think you're going to die - that's the thinking, the cognitive part - you then run out and instead of thinking well I didn't die, you then think well good job I ran out because I would have died had I not been there. What therapy does is help people change those beliefs, question the beliefs, loosen them up to the point where they can actually stay in the supermarket long enough for example to discover that they don't die. So we're tackling it at both levels - the beliefs, the negative thinking, which is motivating the particular behaviours and then giving people real assistance in actually changing those behaviours and sleep is just a good example of that I think.
MYERS
But thinking about people starting CBT if they have to change the way they've thought perhaps for many years and the sort of beliefs they have and then they've got to act very differently, that's quite a big piece of work for people to do. Presumably if they could do differently they would do differently wouldn't they?
SALKOVSKIS
Well they would but they don't know how. I mean the thing about it is it's not - cognitive behaviour therapy is not some sort of the old [Indistinct word] thing, you know wake up and look in the mirror and think well every day in every way I'm better or whatever or doing the pantomime - I'm feeling depressed oh no I'm not. What it's actually doing is helping the person make sense of the problem and very often in terms of the way people understand their depression or anxiety there are missing pieces of information. What a therapist does is help them fill in the gaps and people see it in a completely different way, they're almost having a high experience, say that's how it works. And so now if that's true I can test it out. So as a therapist, a good cognitive behavioural therapist doesn't say trust me, I'm a doctor, they say well don't trust me, work with me, we'll find out what's going on, we'll find out where the missing pieces are and then when we've identified those we'll help you test it out. And again it's this idea of helping find out how the world really works and how your own mind really works as well.
MYERS
So just pushing a little bit further on behalf of Stuart then, he has trouble either getting to sleep or staying asleep and so on and so forth with his insomnia, how are you going to help him think differently about that and act differently?
SALKOVSKIS
It depends on the pattern but typically many people with sleeping problems it's worry which is keeping them awake and sometimes it's worry about not sleeping. And so it becomes circular, so we worry about not sleeping and so on. So actually one of the missing pieces is often understanding sleep itself, understanding that lack of sleep doesn't drive you mad, that although it might make you feel rather tired it doesn't actually mean you're going to crash your car, unless you drop asleep at the wheel. And then trying to do different things, so for example people often will toss and turn and it's actually better to pick up a book and read then your body gets the rest and actually if you've got a boring enough book it might help you to drop off and there's a series of procedures that therapists work with with a patient to actually deal with that. One of the things that we've discovered recently is that people with chronic pain that's added to - the really nasty things that happen in chronic pain are added to by the difficulty in sleeping and actually improving sleep almost certainly improves the chronic pain as well. So there's all kinds of little wrinkles on this. Everybody's different as well, the other thing that it isn't kind of a cook book thing, there are particular things that we know and we apply but they have to apply to the individual and good cognitive therapy's not ABC but is actually helping the person make sense of things then use the strategies themselves.
MYERS
Let me take you to an e-mail in that case from Denise who says that her nephew, in his early 20s, is suffering severe palpitations and has trouble with his breathing. His GP has done the normal tests, nothing actually wrong, and she says the problem is psychological, he rather agrees that it may be in his head but he says the symptoms are so real that he can't rid himself of the fear that he's really ill. So he's definitely struggling. Would CBT help him with that?
SALKOVSKIS
Yes it's probably one of the few things that would in fact. This sounds like it's either health anxiety, a thing that doctors sometimes called hypochondriasis or panic attacks, probably both. And of course the typical way that people try to deal with that is to reassure people and so the doctor, your family doctor, will say these palpitations aren't a sign that you're dying of a heart attack or whatever, which is kind of nice to know, but then raises the question which I think is rather nicely raised here which is well what is it then? And what a therapist will help the person see how, for example, that if they notice a skipped beat or a palpitation if they think that might be a sign they're having a heart attack that then frightens them, terrifies them, it's a terrifying idea, you've got a heart attack, and then that terror increases the symptoms, the increase in symptoms confirms the idea and round they go in a vicious circle. Breaking that vicious circle is part of the story but also helping the person understand that you do get strong physical sensations from psychological reasons and anybody - I'm not sure I should mention this - but when people, for example, get very excited when they're having sex their heart pounds, they get dizzy, they get short of breath and so on. When people are very excited, very happy, very angry they get flooded with physical sensations, it doesn't make them feel anxious unless they misinterpret those, so what you're seeing is a misinterpretation of physical sensations causing panic and anxiety.
MYERS
And you wouldn't need to explore with Denise's nephew his sort of past history, I mean actually she tells us he's had a very normal happy childhood, got a happy life in every way, so you wouldn't be interested one way or the other in the detail about the sort of personality type he might be or the family history and so on, it's dealing with the palpitations that he's got now and actually thinking differently about them and not panicking about them?
SALKOVSKIS
It's starting with that, it's not necessarily irrelevant. For most people it is irrelevant but for others it isn't. So we start with the here and now. Think of it as being like say if someone breaks their leg, you don't have to send a team of detectives out to found out which stairs they fell down if they don't remember. On the other hand when they've dealt with the problem it might be kind of nice to know that you have a lose piece of stair carpet so you can nail it down and of course sometimes people's past experience makes them vulnerable to having anxiety or depression, in other instances it's just bad luck, I mean the main cause of most depression and anxiety and other problems is bad luck, you know, you were in the wrong place at the wrong time and you react in the wrong way.
MYERS
Let's go to a caller, Alexander is waiting to speak to us, interested in CBT and how to get it. Is that the case Alexander?
ALEXANDER
Yes that's correct. I was wondering what availability there was on the NHS to get CBT.
SALKOVSKIS
Well depends where you live, the availability is poor, I have to say that most people who seek evidenced based psychological therapies are often offered something else. And that's understandable because of the poor availability. There are directives that if you are referred, that you're supposed to be assessed at least within 13 weeks but again it doesn't always happen that way. So it's a bit hit and miss. Typically you should be going to departments of clinical psychology within the health service but sometimes the waiting list is terrible. Our own waiting list and we're not a direct referral centre, we're a sort of tertiary to a hospital based service, has at times become embarrassingly long. So there's a huge demand and there really isn't the supply of therapists.
MYERS
So what's the answer because Jane said she sought I think treatment privately, obviously not everyone can afford to, not everyone would want to, is that a route if you are really keen to get on with this and get the help you need?
SALKOVSKIS
Yeah I dislike the idea that people have to pay to live a decent life but yes it is a route that people can go down and they should in that case look for accredited therapists through something like the British Association of Behavioural and Cognitive Psychotherapy. But typically I think putting pressure to be referred to a health service centre that actually provides this would be appropriate. There is a move at the moment to increase the accessibility of evidenced based psychological therapies and we may see a massive change in that over the next five years and there's talk of 8,000 to 10,000 new therapists and 250 specialist centres. If that happens that will make a huge difference and the evidence is that it will actually not only make people happier and so on but would actually save us money because people will hopefully come off disability and be able to be more productive in their lives.
MYERS
Alexander I hope you do get the treatment that and that it works for you. We'll go to Elinor, if I may, and she has tried CBT after panic attacks. Didn't entirely work for you I believe Elinor.
ELINOR
Yes hi. Unfortunately not but I wouldn't say that it doesn't work for everyone, I was in a group situation and I did see it work on very specific phobias and I thought I had gone there for a specific phobia but worked out that actually it wasn't the phobia that made me panicky and in fact we're still working on it. It did reinforce coping strategies I'd learnt before, so I wouldn't say it was a total waste of time, but unfortunately it didn't work for me and it did in the end make me feel like a bit of a failure because it was suggested that CBT was the main treatment nowadays, it should work and that it obviously wasn't the treatment that wasn't working it was me.
MYERS
Would do you say to that? So it can work for some and it's good that you saw it working for some people Elinor but wasn't quite as effective as it might have been in your own case. Where does that leave Elinor?
SALKOVSKIS
Well, you know, well it makes me feel that I want to go and kill someone but not Elinor. CBT for things like panic and so on is best treated - is the best treatment but not delivered in groups and essentially it's kind of mixing up, you don't get the individual kind of attention that you need, you don't - you aren't helped to make sense of the problem. So Elinor don't give up on this one, ask for individual CBT with an experienced cognitive behaviour therapist. Very often what's happening these days is we're having this thing called Stepped Care, which is where you have to go through different steps, you're perhaps given a book or a leaflet to read, some people are given computerised - access to computerised therapy, then a group and then eventually hopefully a skilled therapist. I would persevere and one of the problems is it may be that you didn't actually have the CBT that was appropriate to your problem because it's not - it's not a uniform thing, CBT for panic, CBT for specific phobias, and even within panic, it needs to be tailored to your individual needs.
MYERS
And just picking up on that idea that perhaps either if the problem is not so severe or you'll get on to it quite quickly, the idea that you can perhaps learn from books or from using computer programs, you'd say that was quite a good way forward for people who perhaps can't get on to a list of some kind to get it as a professional bit of advice?
SALKOVSKIS
Oh it's a great way to start. I mean as I said earlier cognitive behaviour therapy is about understanding how the world really works and getting good information about your own problem, yourself, beginning to make sense of it is a great way to start and for some people that's enough. There are many people out there in the world who've had panic attacks and depression and who have been successful in pulling themselves together because they have the tools. It's only when you don't have the tools to hand that you then need to find them and you can find them in books, for some people, but others they're going to need to sit down with somebody and be helped to make sense of things. And you know all of these things are appropriate, people should, in a sense, pull themselves together but with the right - with the right equipment.
MYERS
Now often as not people are offered medication when they go to their doctor with anxiety or depression. Helen writes to us saying that her fiancé was diagnosed with depression. Since taking antidepressant tablets his extreme lows have been less frequent, however, he does tend to worry and she's worrying that if he comes off the antidepressants what will happen then - would CBT be useful at that point?
SALKOVSKIS
There's a very complicated story about medication and CBT and it's become more complicated in the last couple of years. Essentially people who are suffering from depression it's appropriate to combine medication with CBT. There is an issue of relapse after discontinuing - discontinuing medication and CBT probably reduces the relapse rate. However, in anxiety it's different. So there's no evidence that people who combine cognitive behaviour therapy with things like the Prozac type drugs, the serotonin active antidepressants, that the combination is much worse than the individual treatment with CBT in the longer term. So when you discontinue the medication as many people relapse as people who actually just have the medication alone, so it damages the impact of the CBT. So you're looking at differences say between 10% relapse and 60% relapse. So taking the medication increases the relapse rate when combined with CBT by 50% which is appalling. And it's a real surprise to us all actually.
MYERS
We'll go to Maria, she's in Essex, has recurring depression, I don't know whether you've had antidepressants for that but I think you've also - you have anyway tried CBT, what's been the upshot Maria?
MARIA
Well I've had recurring depression over about seven years and each time I've come off the medication I've had recurrences and I was in hospital for a period of time and this was probably a couple of years ago when they were just introducing CBT and I found that because of the whole thing with depression, everything seems out of control, the CBT did actually give me, as you say, some tools so I can take back some of the control for myself and then start to build my confidence again. But I am hoping to have a long term course on a more structured basis to help get over this awful illness.
MYERS
Do you want to comment on that Paul?
SALKOVSKIS
Yes I mean there are some - again exciting new developments, I mean one of the things about CBT is it's kind of romping forward, it doesn't really stay very still. With people - for people with recurrent depression there's a variant of CBT called Mindfulness Based CBT, which rather surprisingly is offered to people when they're not feeling depressed. It actually involves a range of techniques but it's focused on things like meditation, helping people make sense of their own thinking in a different way and it prevents the recurrence of depression at really quite spectacular rates in people who've had more than three episodes of prior depression. So it might be worth talking to your therapist about that as an option.
MYERS
And we'll take a final quick call if we may from Gail, has had depression and breakdowns but has found CBT helpful?
GAIL
Very much. Having the CBT has given me the control over my life. I now choose what I want to do not what the depression makes me feel I shouldn't do. It was just the thing I needed. I'd been on antidepressants for so long that you get to know when you start getting lower and I just didn't want to take anymore antidepressants. And asking the doctor if I could be referred to somebody was the best thing I could have done.
MYERS
Well that's a good news story to end with Paul and you hear that a lot do you?
SALKOVSKIS
Hear that a lot and I hear the two things there which are choices, empowering people and dreams, people actually being able to reach for the things that they've dreamed of. And that's in a sense why I would say recovery is possible because then you can reach for your dreams - having children, having a better job and so on.
MYERS
So you see some really exciting recoveries?
SALKOVSKIS
Yes.
MYERS
Thank you very much indeed. Well we hope we've given you a lot to think about there. Thank you very much to my guest today Professor Paul Salkovskis for his expertise and to you for all of your questions of course and your comments. If you wish and if you have the opportunity you can listen to this programme again, go to our website, that's www.bbc.co.uk/radio4/checkup. You can get more information by calling our free help line, that's 0800 044 044. And if you will join me again at the same time next week when with Christmas over by then and New Year's resolutions in mind we'll be finding out how 2007 might be the year you finally quit smoking.
Ends
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