“How does that make you feel?” “How do you cope with that?” “What is it that makes you anxious?” “Are you Catastrophising?” “Have you tried mentalizing?” “Where do those negative thoughts come from?” “Are you avoiding?” “What is unhelpful about those coping mechanisms?” “Do you remember to breath?” “How about setting goals?”
After several years of dabbling in Cognitive Behavioural Therapy (CBT) one’s brain starts to chuck out these predictable mantras at opportune moments. Going to get on the tube – “what is the anxiety about!?” Worried about the Ebola virus – “is this catastrophising!?” CBT has often been described as a sticking plaster, useful for the worried well but just a scratch on the surface for anyone with deeper or more stubborn difficulties. The early research seemed to suggest this was the new miracle cure, more effective than Prozac, cheaper than psychotherapy. Everyone was leaving their Drs office cured of their depression and/or anxiety, adding to a growing nation of cognitively intelligent beings. Even hardened Builder’s started identifying their anxiety, learning relaxation techniques. What the health service and those pro CBT failed to tell you, was that the majority of those with actual depression or an anxiety disorder ended up returning to their Drs with recurring complaints; the techniques were wearing off. A revolving door has become a good analogy for these patients. Perhaps this is better than before the CBT era, where patients may have found themselves stuck in long term psychiatric outpatient care, or even in inpatient care, with little ambition of leaving in the near future. Most Psychologists (mostly those not associated with the NHS) do not consider CBT worthy of all this glory however, and studies have been produced showing these flaws and suggesting better therapies and more effective long term solutions. So this week I was surprised to learn that with severe cuts to the mental health service, and with the provision of new care pathways which places patients into neatly labelled boxes, the only therapy being commissioned in the NHS for those with depression or anxiety is CBT. Gone is the art and music therapy, the counsellors and the psychotherapists. Drugs and CBT can cure it all.
For those with little knowledge of what CBT entails and are new to this world, CBT is a ‘psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviours and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures’ (thank you Wikipedia). The language used to describe CBT is quite reflective of what the therapy is actually like to experience; cold, robotic and a little confusing. Goals are often set to overcome specific problems, such as a fear or busy places. Your therapist will talk through what makes you feel anxious, what sort of thoughts you are having, how those thoughts affect how you feel and what you do. You will fill in sheet after sheet with these sorts of questions, doing ‘homework’ outside of sessions to achieve an ultimate goal, such as going to a busy shopping centre.
So sounds like it might be helpful for some people? ‘Some’ being the operative word. For some others it can actually be more damaging, like for some people with autism. How can you give someone the tools to help themselves when they don’t have the mechanisms in place to actually use them? In fact research has found that this group struggles in particular with this sort of therapy, but why?
During my own periods of CBT I found the course too short, too much was expected in such a short period of time. I could not pin point my difficulties to goals, several I could and did achieve, but the deeper ones lay stuck in my autistically developed mind. My therapist would frustratingly and impatiently keep asking me why I felt a certain way, and I could never say. Why do I feel anxious today? I don’t know I just do, well I think I do. One of the impairments of having autism is that there is a sort of block between emotion and cognition. It is why many perceive us to have a lack of empathy, which we categorically do not we just sometimes having difficulty showing it or processing it. So you can see why teaching us ways to think less catastrophically isn’t going to really cut the mustard (odd phrase I will spend the next few minutes working out the literal meaning of).
The problem also lies in the unpredictability of emotions. I generally feel anxious in busy shops, but not always. Sometimes I feel empty in small empty shops. For my homework I could achieve the goal of shopping somewhere busy fine, a week later I might have a panic attack doing it again. Sometimes I might have a panic attack just sat at home watching TV. It is hard to understand where these emotions come from, and sometimes it is easier and best to just accept them as they are. If we cannot understand these things ourselves, how can we communicate them to others? With great difficulty, especially in a talking therapy with a stranger.
The frustration that comes with trying to understand oneself in a ‘neurotypical’ way can be pretty intense. I have admittedly needed further therapy to get over therapy that has exhausted my brain’s processing capacity! If something is going to help anxiety and depression related to autism then it needs to be gentle and compassionate. Two things with the NHS unfortunately cannot provide, making support for adults with autism extremely hard, if not impossible, to find. There is no pathway for individuals with autism spectrum disorders. Those at the high functioning end fall between the gap of learning disability and mental health difficulty, neither quite attending to specific needs. Fortunately there are some great private counsellors around who specialise in these areas, contact your local NAS centre to find out more.
I would like to hear more about your experiences if you have had any with CBT or with NHS mental health services, please leave a comment =]