John sought cognitive behavioural therapy (CBT) after his wife urged him to seek help with low mood, poor motivation, lack of confidence, social withdrawal and poor sleep. He also had thoughts of "not wanting to be here anymore". His relationship with his wife had deteriorated and he was increasingly frustrated and irritable.
When I first met john he was hesitant and a little sceptical to how CBT could help lift him from his depressed mood. I listened to John and how his thoughts towards himself and his situation were adding to his low mood. Although he retained employment, he felt that "life was passing him by" and that "he had not achieved what he could have done", although he was in a senior managerial role. John was self-critical and compared himself to others, mainly his brother whom was doing well in his career and seemed happy. John was on anti-depressant medication but did not feel that it was helping in the way he wanted. Although John did have dark thoughts re-ending his life, these remained thoughts and he had no intentions or desire to end his life. We agreed that we would continue to check on these thoughts regularly.
Although John had a relative that had depression he didn't really understand it. I provided him with information so that he could learn more about depression so that he was informed about the symptoms and and numbers of people experiencing it. I wanted John to realise that there was not a "flaw" in him. Working together we identified activities that John had given up and that he could start to re-engage with. Although John was sceptical that he had the motivation to re-engage in interests and sports he had stopped doing, he was able to identify some steps that would enable his to re-connect socially. We also looked at improving his sleep pattern using sleep hygiene and behavioural techniques.
One of the key steps of CBT is to "map out" the links between thoughts, emotions and behaviour, this would then help John to see what was maintaining his depression. John expressed many thoughts of a self-critical nature and we was able to see that he felt himself to be a "failure" and "not good enough". We agreed that his thoughts were not based on facts and that these were maintaining his depressive mood. John was able to challenge his self-critical and depressive thoughts to generate ones based on evidence. Over time John was able to modify his thoughts and realise there was limited or no evidence supporting these. He was also able to see alternatives to his thoughts of being a failure and not being good enough, though the strength of these were acknowledged and approaches put into place to reduce the intensity of these further. John was able to recognise that lots of his thoughts, were indeed that, thoughts and not facts.
John was able to identify behaviours that were not helping, eating too much and drinking a little too much alcohol to numb his low mood. He was able to change these dysfunctional behaviours based on the goals he had set at the start of CBT therapy.
John made good progress in CBT had although his depression had not entirely gone away he was in a much better place, his relationship had improved, he no longer had thoughts of "not being here" and was equipped to being "his own therapist". Importantly John achieved the realistic goals he had identified at the start. John ended therapy with a plan to maintain progress and reduce the chances of him retuning to the level of depression he had experienced.
Anxiety in social situations
Jane first attended CBT after deciding she was becoming increasingly isolated and alone. Other than going to work, where she was quiet and tended to keep "herself to herself". Jane remained at home and avoided invites to social gatherings.
Jane sought remote CBT. Initially, Jane was quiet and avoided eye contact, but at our second session she started to feel more comfortable and offered more information as to her problems. Jane said that she had always felt shy and unsure what to say to people. She had become self-conscious and believed she would say the "wrong thing", blush and that everyone would would either laugh at her or avoid her completely. When asked, she could not identify any times when this had actually happened.
After providing information on CBT and social phobia Jane had a much better understanding of what was driving her anxiety. A key learning point was that Jane realised that avoidance was actually adding to the problem as she was never able to learn that her fears would not occur. Jane was able to explore her thoughts and unhelpful thinking styles such as "catastrophising" that were driving her anxiety leading to stomach "butterflies", racing heart, and sweaty palms, head and neck. In turn, her thoughts and anxiety symptoms resulted in a behavioural response of avoidance and social isolation.
Jane started to realise that to overcome her anxiety she would have to stop avoiding social situations, and we were able to discuss the additional anxieties that this generated. Jane was able to identify behaviours that enabled her to face situations where she had no choice at work i.e. avoiding eye contact. A key treatment approach for social anxiety is to shift focus from "ones self " (Internal) to what is going on externally such as what others are actually saying or wearing.
After developing an overview of the components of Jane's anxiety we agreed a number of goals and key aims. These were graded in terms of what Jane considered achievable, with the most anxiety provoking goal left until last. We also discussed ways that Jane could manage her symptoms of anxiety both before and during the planned exercises.
Although the first exercise was difficult, Jane was able to learn that no one laughed at or avoided her. Jane found the external focus work very beneficial as well as being able to challenge her initial catastrophic thoughts to balanced and helpful ones.
Jane made good progress in CBT and she was able to have a much better understanding of her social anxiety and ways to overcome it and take control. Jane was able to recognise that the problem was an unhelpful anxiety cycle and not her as a person. At the end of therapy we developed plans to ensure learning was maintained and that Jane was able to continue with the progress she had made.
