Introducing Cognitive Behavioural Therapy (Introducing...) (9 page)

Why is this story amusing? The man really believes that his clapping is keeping tigers away. He believes this because while he does it there are no tigers. However, what he doesn’t know, but the boy does, is that there are no tigers in the first place. The only way for the man to discover this would be to stop clapping and test out his belief – but this is very scary to do if he really believes the clapping is keeping tigers away. The clapping is what we call in CBT a
safety behaviour
. People with anxiety frequently use safety behaviours to try to help them cope better. For example, they may:

• Carry a bottle of water when they are out in case they get hot and start to panic
  
• Sit close to the door on a train so that they can escape if something bad happens
  
• Try to control their breathing
  
• Use headphones to block out the sounds of other people talking (if those sounds increase their anxiety)
  
• Bury their head in a newspaper if they imagine people are looking at them.
  

All of these things may help them to tackle things they wouldn’t otherwise do. The problem is that, like the man clapping they continue to believe that the feared outcome – the ‘something bad’ – would definitely have happened if they had not carried the water, used the headphones, sat by the door, controlled their breathing and all the rest. In this way these behaviours prevent the person from really testing out if they can cope with their fear, and finding out if the thing they are afraid of really happens. So, the anxiety never really goes away.

While you are doing your exposure work, watch out for safety behaviours. If you need to use one to do the exposure at first, that’s fine. But remember it’s a safety behaviour. You need to drop it as soon as possible and carry out the exposure without using this crutch – only then will you really conquer your fear.

Behavioural experiments – stepping up the pace

Taking things a step beyond graded exposure, you can become a scientist, testing out your anxious thoughts and fears. A scientist designs experiments to test out theories and hypotheses about the way the world works. In CBT we do the same thing.

Courage is resistance to fear, mastery of fear – not absence of fear
.

Mark Twain

Step 1

Think of a situation which you avoid because you are afraid something bad will happen. What is it you are afraid of? What is the worst thing that could happen? What is your most anxious prediction about what might happen if you were to put yourself in this situation? Write down this fear or prediction. Remember that your prediction should not simply be that you will get anxious in the situation – we already know that to be true. There would be no point in doing this experiment if the situation didn’t make you anxious. Your fear is likely to be more than that – what is it that you think will be the consequences of getting anxious? Losing control? Not coping? Falling apart? Becoming dangerously ill? Making a fool of yourself? Use your imagination – what are you really terrified will happen?

Step 2

Design an experiment to test out that prediction. What do you need to do? How would you measure whether the prediction was true or not? Write all this down. Rate out of 10 how much you believe your prediction will come true. Also think about what might stop you carrying out your experiment – how could you overcome such obstacles to ensure you do complete it?

Step 3

Carry out the experiment. Remember to use whatever way you have decided on to measure what happens. Write down what happens.

Step 4

Okay. What did happen? Did your most feared prediction come true? What did you learn? Write all this down – this can then help you to design your next experiment.

Case study – Billy (panic disorder and agoraphobia)

Remember Billy, our panic and agoraphobia case study? Here is an experiment that Billy did to help test out his fears, and what he learned from it.

Billy’s experiment

Step 1

Anxious Prediction:
If I go to the local shop I’ll have a panic attack and I won’t cope with it. I’ll faint or lose control in some way and make a total fool of myself. I believe 80% that I’ll lose control if I get anxious.

Step 2

Experiment:
To walk to the local shop and go inside. To spend a few minutes looking at the magazines. To stay for at least 5 minutes and then to come home.

What might stop me?
I might get overwhelmed with fear and not be able to go through with it.

How can I overcome this?
I’ll write down the rationale for this experiment and use it to remind me why I am doing this. Remembering this will help. I’ll get a friend to encourage me to leave the house. I’ll arrange to do something nice afterwards as a reward.

Step 3

What happened?
I did it! It was really tough and I did feel pretty bad. My heart raced and I felt very wobbly. I was exhausted afterwards. But I didn’t freak out or pass out and I don’t think anyone really noticed how awful I was feeling.

Step 4

What did I learn?
That although I feel awful it is not as terrible as I thought. People don’t seem to notice my anxiety as much as I think they will – perhaps it is not as obvious as I assumed. I do panic a bit, but I don’t lose control. I now believe only 40% that I will lose control if I get anxious.

What next?
I’m going to try this in different situations – test out what I fear.

Activity scheduling and planning

Very often we feel anxious and panicky because we have taken on too much or not planned our time effectively. Effective planning is a very important life skill which many of us (including Elaine and Clair, your authors) need to work on.

When we have a lot on, we often get anxious and the anxiety can paralyse us – stopping us being able to tackle the many things we have to do. There are a few rules which we can follow to prevent us from getting overwhelmed and stuck in this way.

1. Be more like a hummingbird than a butterfly

Watch a butterfly. It seems to flit from one place to the next, and when it stops you can’t really see it doing anything before it flits off again. When we are anxious we tend to behave like that butterfly – dashing from one task to the next, trying to do too much at once and ultimately not doing anything properly or completely. A hummingbird, on the other hand stays in one spot, hovering despite the pull of gravity, drinking the nectar out of one flower before proceeding to the next. The rule is, however much you have to do,
do one thing at a time
and focus on just that one thing until it is finished and you can move on.

2. Break things down into manageable steps

Have you ever looked at all you have to do and felt overwhelmed, not knowing where to start? It’s so tempting to abandon any attempt to start your task and to just bury your head in the sand. Instead,
break tasks down into small steps
. What’s the first thing you need to do? Then just do that first step without worrying about the next. Now move on to the next small step and before you know it you will have completed what felt like a mammoth task. Use the 5-minute rule we discuss in
Chapter 6
. If something feels too overwhelming, just do it for five minutes. Don’t think any further ahead than that.

3. Write out an activity plan

Each day, list out the tasks you intend to do.
Ensure your choices are realistic
(this probably means crossing out a few), then prioritize them. Which absolutely have to be done today? Which could wait a little? Decide what you want to do, when, and how much time you need for each task. Then add a bit of extra time for good measure. Draw up a timetable for the day. Build in ‘bio breaks’ (coffee and tea, meals and toilet stops), and even allow for brief day-dreaming periods! Then follow your timetable. As you work your way through, visualize yourself as that hummingbird, hovering away steadily until the task is complete, then heading for the next one.

4. Problem solve

If you are not sure how to deal with a certain task,
take some time to work it out instead of panicking
. Are there any sources of support you could use? Who could help? There’s no shame in asking for help if you are stuck – how else would anyone learn anything? What would someone else say about this?

Write down the problem clearly. Now spend some time brainstorming all the possible solutions there might be. Really go for it – imagine as many as possible. Write them all down. Now go through each solution. Identify the pros and cons. Write them down. Give each solution a mark out of 10 after you have balanced the pros and cons. Then select the solution with the best scores. You could even get a friend to help you with this task. Not every problem will have an instant solution but breaking things down into small steps can often help us to see what we can do first or identify what information we need to gather to be able to come up with a solution.

Finally, test out the solution. Did it work? If not, why not? Go back to your problem solving with the new information and try something else.

Learning to say ‘no’ can be very important. Do one thing at a time and try to avoid taking on too much in the first place

Medication

There are certain medications available, both on prescription and over the counter, which can help anxiety in the short-term. Beta-blocker medicine can ease anxiety and some physical symptoms such as trembling. It can be helpful for certain situational anxiety, like a performer wanting to reduce symptoms of shakiness before a concert. Beta-blockers are not addictive, are not tranquilizers, and do not cause drowsiness or affect performance, so you can take them as required. Sometimes your GP might prescribe diazepam (a benzodiazepine) as a short course for 2–4 weeks, if the cause of the stress is likely to last a short time, and if the symptoms are particularly acute and severe. You are unlikely to be prescribed diazepam for longer given the potential problem of addiction.