Introducing Cognitive Behavioural Therapy (Introducing...) (10 page)

However, a note of caution: there is good research evidence suggesting that using medication alone to deal with anxiety doesn’t prevent anxiety recurring in the future. Learning new ways to cope is usually very helpful, as the chances are the anxiety will return at times. There is also evidence that in certain cases using medication whilst undergoing CBT can in fact reduce the effectiveness of the therapy. Why should this be? The theory is that in order to learn to cope with anxiety and panic, you have to actually
experience
those feelings and develop ways to overcome them. Medication reduces the experience of anxiety in the short-term and so can prevent effective learning taking place. The only way to truly conquer anxiety is to learn strategies to manage it.

Finally …

Let’s see how putting into practice some of the things in this chapter helped our three case studies:

Case study – Jane (GAD)

Jane starts to put into practice the idea that ‘good enough is good enough’. She keeps to her paid hours, and when she’s unclear how to prioritize her work (too much to do in the available time) she asks her boss, and is told what she can drop. To her amazement, she becomes much faster at her work, and nothing’s returned with errors identified. Her confidence increases, and within 6 months she’s offered a promotion. Jane discusses it with family and friends, concluding that her present level of stress is about right. She tells her manager that she’s keen to reassess the option in 6-months time, and this is agreed. At home, her sleep improves; she has more energy, and is less snappy with the family. When Jane has thoughts about not being good enough, she puts into practice thought balancing techniques, finding to her surprise that her self-esteem dramatically improves. The family start going on fortnightly outings, sometimes just to the local park, and all feel closer to each other. Jane and her husband also put aside time for themselves, as well as time together, and both are much happier with themselves and with their relationship.

Case study – Billy (panic disorder with agoraphobia)

As we have seen, Billy makes really good use of behavioural experiments to start testing out the fears he has about going out. He also reads about panic attacks and now understands more about the interaction between his thoughts, feelings, physical sensations and behaviours. He finds that once he recognizes what’s happening, it’s easier for him to control the panic. He still experiences it, but it gradually becomes less intense and he’s less frightened that he’ll completely lose control. He gradually starts to go out more and more. He makes arrangements with friends and asks them to support him to carry them through. Billy designs behavioural experiments to get back into using public transport and travelling on his own by train. He notices the safety behaviours he’s using, such as sitting close to the door, and gradually reduces these so he really tests out whether the things he fears actually happen. He discovers that they don’t. He is now seeking work outside of his home again and is enjoying his social life.

Case study – Mamta (health anxiety)

Mamta understands the role that focusing on symptoms and seeking reassurance is having in maintaining her health anxiety. She enlists the help of her family and her GP to no longer provide her with reassurance but to encourage her to challenge her fears herself. She writes out a plan to cope when she notices what she regards as symptoms. Mamta now weighs up the evidence that the apparent symptoms are actually just passing, normal sensations. She postpones thinking about them and gets involved in alternative activities, as well as using relaxation to move her mind away from them. Mamta uses thought balancing to help reduce her fear. She promises herself to only go to the doctor if something she regards as a symptom persists for longer than a week. Gradually Mamta begins to feel better. As her anxiety and physical tension decrease, she notices that in fact she experiences far fewer ‘symptoms’. She asks others about their physical sensations and is amazed to find that everyone occasionally experiences the things she was worrying about. The only difference is that they consider this to be normal. Mamta talks with her family about her grief over losing her friend. She still fears getting cancer, but slowly finds it no longer dominates her life and that she can get back to normal. However, Mamta regularly does a monthly breast check, and always goes for screening tests when invited by her GP.

And finally …

Facing up to your fears can be one of the hardest things you’ll ever do. Remember these words:

The greatest victory of all is victory over oneself
.

5. Beating bad habits and building better ones

The unfortunate thing about this world is that good habits are so much easier to give up than bad ones
.

Somerset Maugham

Practice, it is said, makes perfect. When we deliberately keep repeating an activity, it may be in order to improve our skill and get to the point where we can do it with minimal thought. Habits are also things we do regularly, often without even thinking about them. This ability to do things almost on autopilot, with minimal conscious thought or control, is very important to the way we live our lives.

Consider learned skills – imagine trying to walk up a flight of stairs, tie your shoelaces or drive a car if you had to think through and plan each stage of the process every time you did it. Learning a new, complex skill like driving is really tough at first, requiring serious concentration. Every stage has to be thought about and you can feel overwhelmed by how many things you have to do at once. However, once you have developed the skill, you no longer need to think about each step – you can carry them out automatically, freeing you to concentrate on other things such as where you are going or avoiding the neighbour’s cat that runs into the road!

Likewise, being able to develop habits is very useful. For example, if you consciously practice putting your clothes in the wash-basket when you undress, rather than on the floor, and deliberately ensure you put an object back where you found it after using it, you are well on the way to developing the habit of tidiness. However, the downside to this is that we can equally develop some habits which aren’t so useful. There are many different types of ‘bad’ habit, which may be bad in different ways. Some relate to how we treat our bodies – such as using addictive substances which are bad for us, eating the wrong foods, not drinking enough water or taking too little exercise. We might bite our nails, pull our hair out or pick at our skin. Others may be interpersonal habits. Think for a moment about how you treat other people. Are you highly critical? Do you irritate your partner by being thoughtless about particular things around the house? Maybe you are always late or untidy. All of these involve patterns of behaviour which can become habitual. The bad news is that it takes effort to change those patterns. The good news is that it can be done, often with great success.

Now let’s get personal! Think about your bad habits. Write them down in the table below.

A word about addiction

Habits that involve addictive substances such as nicotine (found in all forms of tobacco), alcohol and other drugs can be overcome using many of the techniques we discuss in this chapter, which are effective for changing all habits. However, substance misuse can be more than a habit. It can lead to addiction and if you are addicted to a substance you may need additional help to give up, besides learning how to change your habit.

Take smoking. There are various alternative ways of getting nicotine other than via tobacco. Many people find it helpful to stop their tobacco habit by initially still having nicotine, for example in chewing gum or patches. They then gradually reduce their intake of nicotine, withdrawing slowly from the drug, having first broken the habit of smoking, or any other form of tobacco use. If you do want to give up tobacco, in the first instance perhaps you might try out the options we provide and not take nicotine in another form, to test out whether you actually need to slowly withdraw from the nicotine. The actual effects of nicotine addiction are usually relatively short-lived and the physical cravings pass within a few days – it is then the habit itself of using tobacco which needs to be broken.

Be aware that drug use of any sort can be quite difficult to change in the initial stages. You need to break both the addiction and the habit at the same time – and you are having to do this at the point where you are least confident in your ability to succeed. Withdrawal from addiction to alcohol or other drugs can be so difficult that some people need professional help managing the process. Consider seeing your doctor or an addictions specialist. There are many sources of help out there (see
Chapter 9
). So, if you find it impossible to give up a substance by using only the techniques described here, do go and ask for help. Once your body overcomes the physical addiction to a substance you can then concentrate on breaking the habits, both behavioural and cognitive (what you do and what you think), which you have built up around your addiction.

How much is too much? How can I tell if I’m drinking too much?

Many people actually know that alcohol abuse is a problem for them, but have difficulty admitting it to themselves or others. Keeping an eye on whether you are regularly drinking more than the recommended number of units for your gender is important, but so is examining your drinking behaviour. It is estimated that 1 in 25 adults in the UK is alcohol-dependent.

Answer the following questions. Do be honest – it’s private to you, and can highlight whether you might need to do something about your drinking:

1. Do you find it very hard to stop drinking?
   
2. Do you get physical reactions when you abstain from alcohol?
   
3. Has anyone around expressed concern about your drinking?
   
4. Do you always drink when stressed?
   
5. Do you avoid events or situations where you know you won’t be able to have a drink?
   
6. Do you regularly do things whilst drinking that you regret when sober?
   
7. Do you find it hard to go for ‘just a half’, or stick to one glass of wine?
   
8. Do you almost prefer to drink alone?
   
9. Do you ever feel you absolutely must have a drink to get through certain situations?
   
10. Do you or anyone else have to actively set limits on your drinking?
    
11. Do you regularly drink in order to get rid of a hangover?
    

If you have answered ‘yes’ to any of these questions then you may have a problem with alcohol. If you think you do fall into this category then we recommend you get advice from your doctor.

Step 1: deciding to change

Habits are difficult to change. As we have seen there is a good reason for this. They need to be firmly established and quite resilient to enable us to do things automatically. However, this means that though we may make a change, it’s oh so easy to slip back into our old ways if we are not on our guard. In order to make a difficult change, and maintain it, we need to be motivated to do so – if we are not then we are never going to be able to undertake the hard work required.

Weighing up the costs and benefits of habit change

Taking some time to really think about and explore your motivation for changing a habit will make it much more likely that you will succeed. Think through all the advantages and disadvantages of changing. This table can help:

Filling in each section of this table can help you to think through your reasons for changing. Make sure you work out the benefits (pros) and costs (cons) both of staying the same and of making a change in your habit – these may often be direct opposites of each other but aren’t always. If you miss out a section you might miss some important factor in helping you to change. The smiley faces are in those sections which may contain the factors most likely to motivate you to change. If there are lots of strong benefits to changing, and high costs to staying the same, then you are more likely to be able to make this change. Do some work on this – ask other people around you what they think as they may identify some areas which you haven’t considered.

Of course whether you feel motivated to change won’t just depend on having lots of things written in the ‘benefits of changing’ and ‘costs of staying the same’ boxes. The
weight
of the individual things will count too. You might only have one benefit to staying the same, but if this is something that is hugely important for you then changing will be hard no matter how many things you have in the other boxes. Think about the weight of each identified pro and con. Are there ways in which you could change them? What information do you need to gather to help increase the weight of the things that might help you to change this habit?

Here’s an example of how this might work.

Case study – Anna-Maria

Anna-Maria is a smoker, aged 31. She started smoking at school and has continued for many years. She generally smokes around 20 cigarettes a day. She actually enjoys smoking and believes that it relaxes her. Many of her friends smoke, although these days more and more are giving up. Anna-Maria knows smoking is bad for her. This was brought home very strongly when a family member who had been a life-long smoker was recently diagnosed with lung cancer. Anna-Maria wants to stop smoking and has tried before but found it too hard. When she tried previously she found that, though the cravings passed quite quickly, it was actually the habit of smoking which seemed impossible to give up. Anna-Maria is married with two young children. Let’s look at how Anna-Maria used the pros and cons exercise:

Anna-Maria works through this exercise. She notices that there are several things that are very motivating in both the benefits of changing and the costs of staying the same. The most important are those relating to her children. She finds it helpful to look up information on the dangers to children of parents smoking and on the health risks of cigarettes. This information greatly adds to the weight of those factors in motivating her to change.

She also notices, however, that there are some quite powerful things in the boxes on benefits of staying the same and the costs of changing. In particular she believes strongly that smoking relaxes her and that she’d become very stressed if she stopped smoking. She looks more deeply into this, and examines the evidence that this is true. Her reading helps her to question this assumption.