CBT for anxiety, depression, relationships, and much more
Welcome to the second part of my new Open Access course “Cognitive Behavioural Therapy with a Twist”. This is aimed at anyone struggling with psychological difficulties who would like and could benefit from a self-help course*. People who search for anxiety therapy, depression therapy, or are interested to learn more about anxiety disorders, low mood and trauma could start here.
In the first part, I asked you to start noticing your thoughts in emotionally charged situations (we describe situations with the 4Ws) and to play back these thoughts to yourself as a way creating some distance from them: they are, to begin with, thoughts, not facts.
Melissa** is interested in how to deal with anxiety and overcome depression. She has jotted down a few thoughts when she was feeling anxious and low:
“My boss criticised me”, “Few people want to come over at mine for dinner and drinks”, “I will never find a partner”.
Dev** is struggling with anger management, and depression. He noted:
“My wife forgot my birthday”, “I am a failure”, “I can’t provide for my family”.
As promised, today we are going to look deeper into negative automatic thoughts and how they evoke the emotion that alerts us to their presence. In therapy, it takes time to develop both the skill of noticing thoughts and of “mining” them to understand their emotional significance.
Analysing negative thoughts The downward arrow technique
Quite often, the answer to “what am I thinking” will be a description of the situation. This will often be in the form of a description of others’ thoughts, emotions, and behaviour. It can also be a description of our own thoughts, emotions or behaviour. For example:
“My boss criticised me” (others’ behaviour). “My husband is angry with me” (0thers’ emotion). “She thinks I’m not up to it” (others’ thoughts).
“I’ bore people (my behaviour), “I am anxious” (my emotion), “I could harm my child” (my own thought -this is a thought about a thought!).
Let’s look at the first thought that Melissa noted when she was feeling anxious, “My boss criticised me”.
Let’s get you thinking like a therapist. If Melissa tells me that her boss criticised her and she felt anxious, I want to know more. Of course, I can imagine that this is not a pleasant situation, but I want to know why this particular person feels anxious in relation to this thought (I could imagine they could have also felt sad, or angry). So I’d like to help Melissa (and you) to get to this information.
The next stage involves in analysing is the so called “downward arrow” technique. Ask yourself:
“What does this mean about me”?
For example, if “my boss gave me critical feedback what does this mean about me”? This may lead to a new thought.
“My boss doesn’t value me”.
That’s great, but this is still in terms of the behaviours of others: “They do not like me”. “They disrespect me”. “They prefer A to me”. A lot of us may stop at this point. Who doesn’t want to be liked? What is there more to say? As a therapist I often find that people may resist going further, because it starts to get more personal at this point. What do I mean?
Most of the times people’s preoccupation tends to be about being loved (liked, appreciated, respected, admired, wanted, valued) or about being competent/good enough. Even the second, probably, is about being loved again.
So let’s carry on:
“What does it mean about me if my boss doesn’t value me”? It means I may lose my job”.
Now we are thinking about ourselves so we are getting closer.
“And what would it mean if I lost my job?” It would mean I would be poor and vulnerable.
“And what would it mean if I was poor and vulnerable?It would mean that I will lose other people’s respect and love. It means no one will want me or love me.
At this point, you probably have reached a plateau because this thought explains why Melissa really is anxious.
She is anxious NOT because she thought that her boss criticised her, but because she believes she is at risk of being alone and unloved. Does this make sense?
Let’s call this a “root thought”. The root thought fits the emotion of anxiety.
Let’s try another one:
Dev felt angry and noted: “My wife forgot my birthday”?
“My wife forgot my birthday”? What does this mean about me?
“It means she doesn’t hold me in mind” (that’s about her attitude). And what does that mean?
“It means that she is an uncaring person”. But what does it mean about you?
“Nothing, just that I make stupid choices and my wife tops these!”
OK, I’ve put that one in to show you how this process can run into trouble. Dev is protecting himself from something. He may need more help to find the root thought. Sometimes, it’s a bit of an art to get things moving and it can be helpful to recruit a trusted ally and have an outside view.
Chris: Dev, I know you’re being sarcastic when you hold yourself responsible for choosing a silly wife. I wondered if you really do feel responsible in a different way. Like there is something about you that is to “blame” for being forgotten.
Given Chris’ artful comment and the fact that Dev can tolerate appearing vulnerable in front of Chris, Dev goes a step further.
“I suppose it means I am not important”. And what does this mean?
“It means I am not lovable” (now feels sad rather than angry).
Anger. This is usually a secondary emotion that conceals other emotions like anxiety and sadness.
The process of the downward arrow is not always easy. Most of us have an innate resistance to accessing the implications of our thoughts because we do not really want to know. But not knowing means we cannot do much about our pain.
Now, this is also important IMHO. Although this is a self-help course, like Dev, you cannot always help yourself. We need other people in our lives to help us think when we get stuck. So I invite your to recruit allies to help you. Thinking buddies!
I do know that many of us either do not have access to people, or do not trust others enough, or do not want to burden them. If that is the case you may want to speak to your GP to get CBT or other therapy in the NHS. This can really help with connecting to others and making thinking buddies.
Week 3 and 4 plan
Weeks 3 and 4:
Like last week, keep an eye out for a strong emotion, and as close as possible to when you feel it, note down your thought about and the 4Ws.
This time around, I’d like you to try the “downward arrow technique”, as well. Once you have identified the thought (e.g. “I will fail my exam”), start asking yourself:
“If this thought is true, what does it mean about me?”
“If this thought is true, what is the worse that could happen?”
“And if that is true then what does that say about me?”
“And if that is true then what is the worse that could happen then?”
Keep at it and keep noticing your emotions. You may experience an increase in anxiety as you are exploring the deeper layers of the thought. When you are trying the downward technique, you are trying to arrive at a thought/idea/meaning about yourself and your place in the world of people. It’s likely to be an idea that is linked to your legibility to be part of the tribe, to remain connected to others and therefore alive and happy! I believe that everything that we struggle with utlimately boils down to relationships which is why I named my clinic Relationships in Mind!
At the end, you will hopefully have a chart with the 4Ws, the emotion you felt and the “root” thought you have discovered. In part 3 we will look at your behaviour, what you do in response to the thought and emotion, and start building what psychologists call a “formulation”. This is a psychological snapshot that brings together thoughts, emotions, & behaviours and tells you where you can intervene to make changes.
*Please note that this course is not meant to be a substitute for professional help from a registered psychologist. I also cannot respond to any concerns you raise about yourself either in the comments section or conveyed to me by email or any other means . If you need more help, speak to your GP who can direct you to your local NHS service and you can get CBT for free. If you have some really scary thoughts about hurting yourself or someone else, please speak to your GP or, if you cannot wait, call Samaritans (call 116 23), go to your local A and E, or call 999 to request an ambulance. If you are already under NHS care reach out to your service and ask to speak to a duty worker if they have crisis options available. If you would like to see me for a course of CBT or another psychological therapy you are welcome to email me at Nikos.firstname.lastname@example.org. We can then sit down together and look at what you struggle with in depth.
**Melissa and Dev are not real people, but representatives of clients I have seen in the last 10+ years.