In my previous blog I have described some of the ways we can get stuck in eternal roundabouts of things we feel, think and do. Anxiety feeds avoidance – and in turn avoidance feeds anxiety. Feeling low, sad and unmotivated feeds a flat attitude of “I can’t be bothered to do much” – which of course, feeds feeling low, unfocused and sad. Our attentional bias – in other words, finding things in the environment that actually confirm our beliefs – can make us go round and round in a negative spiral if the building blocks of our beliefs are dark, sad or angry. In short: believing is seeing, and then seeing becomes an even stronger belief.
I have ended the last blog with the million dollar question: How do we exit these self-defeating roundabouts?
In this follow-up musing, I will talk about different approaches to this problem, mainly focusing on the three therapy modalities I use the most in my work with my clients: CBT (cognitive behavioural therapy), ACT (acceptance and commitment therapy – pronounced like the verb “act”) and Narrative therapy.
I often chuckle at how pompous “cognitive behavioural therapy” sounds – it certainly sounds a bit ivory-tower-ish in my mind! In actual fact, it really is a quite simple “think-do” intervention with the basic premise that by changing what we think and what we do, can really change our feelings and general perception of life and ourselves. Through many decades CBT has been widely hailed as the “gold standard” of treatment for most mental ailments. Some of the newer therapies, like ACT and narrative therapy, are not that dissimilar to traditional CBT, even if they feel a bit more creative, gentle and a bit less caught up in the medical model. The bottom line is still that embracing another perspective on a problem, re-negotiating the relationship with the problem, re-writing a dominant story line, or doing things differently, will affect a person’s mood, actions and quality of life.
Back to CBT: As the name suggests, thoughts (or cognitions)and behaviours are at the heart of who we are, and the problems we experience. Therefore, in order to exit troublesome roundabouts, we need to change these two major role players. Traditionally, if we very roughly divide “mental disorders” (which is a thorny term in itself!) into two bunches we find ourselves with all the anxious disorders on one end, and the depressive disorders on the other. The rule of thumb would be, to try and find an exit out of the negative spiral.
For depressive disorders, we first address behaviour. This means that, if we can get someone who struggles with depression out of the behavioural slump by getting them to do more of the things that would have invigorated them in better days, it would also change their thoughts. For example, going for a short walk (the behavioural intervention) will have the effect to bring about a change of thoughts (“This was a terrible day, I did nothing and it was completely worthless” changes to “I actually did go for that walk, it felt pretty good”). This change in thoughts will hopefully lead to an increase in behaviour that helps lift the person’s mood even further (“Now that I am feeling ok after the walk, I can maybe fold the laundry too or call my friend to say hello”). Therefore, for depressive disorders, we would first help clients take those first behavioural steps to open their curtains, get some sunshine on their skin, go for a walk, go have tea with a friend, plant something in the garden, make themselves a lovely meal. Once the client gets going with the “do” intervention, we can turn the attention to the “think” intervention. In traditional CBT this will mean identifying faulty thinking patterns (e.g. over-generalising, black-and-white thinking, mindreading and catastrophising) and changing these patterns into healthier, more true and more helpful thoughts. This will be the exit out of the anxious or depressed roundabout.
In a similar way, but the other way round, CBT interventions will target thoughts first, and then behaviour, when tackling anxiety disorders. The rationale is that in anxiety disorders it is the thoughts that are the real culprits (e.g. “something terrible is going to happen” / “everyone is going to think I am stupid” / “there is no way I can do this”). Therefore, the best place to try and stop the unhealthy cycle is to change the thoughts to be more realistic, more balanced, and less anxiety-provoking. Once the thoughts have gotten less highly strung, it is usually a bit easier for the client to focus on changing their avoidant behaviour to try and do the things that usually would send them running for the hills. This means that the socially anxious man would actually say yes if invited to a dinner party. The phobic girl will confront her fear of enclosed spaces by gradually exposing herself to longer and longer elevator rides. The women with OCD will resist the urge to check that the stove is off (again) but rather go for a walk. The hope is that the changed behaviour will lead to new healthier thoughts (“I was actually ok in the elevator”) which in turn will lead to healthier behaviour.
In ACT the strategy is a bit different. Rather than putting up a struggle with the thought, desperately trying to change it because it is “wrong” or “bad”. ACT says that a mindful noticing of the thought or feeling, an acceptance of it, a dropping of the struggle, and authentic self-compassion would be a far better long term strategy to deal with tricky emotions. Rather than judging our thoughts, we learn to notice it, name it, expand around it, and “unhook” from it. We learn to connect to our deepest values, which are the paintbrushes with which we create a picture of our preferred, more fulfilled futures. In this sense, ACT helps us to commit ourselves to the things that really matter to us… despite the anxiety, the depression, the guilt, the fear, the worry, the grief. The exit of the roundabout therefore does not lie in getting rid of tricky thoughts or feelings, but rather in shining the spotlight on re-aligning ourselves to what is important to us, and learning to be connected to these values, even in the presence of difficult thoughts and feelings.
In a similar way Narrative Therapy helps clients to bring some distance between the person and the problem. The problem is externalised, in other words, “the person is not the problem – the problem is the problem”. We curiously explore the story of the problem’s presence in the person’s life, investigating its cheeky tricks in ensnaring the person’s identity. In our quest to re-negotiate a new relationship to the problem, our exit of the roundabout often lies in looking for “news of difference” or “unique outcomes”. This means that we will certainly take our time when we ask: Tell me about a time when Anxiety was not so strong in your life. Think of a time when you were less affected by Depression. What was different in the time when Disrupted Sleep wasn’t so much of an issue? What do we learn of your character in these times when Fear was smaller than now? And more importantly, how can we connect to that personal strength, courage, ability to push through, find joy, or find rest once again?
Thus our intervention is not so much about nipping “bad” thoughts in the bud and replacing them with “better” thoughts. Rather it is about connecting to other narratives rather than being stuck in what is the current dominant narrative in our client’s life. For example, we will tamper with the problem-saturated narrative of “I cannot speak to people I do not know” and find evidence of courage, ability and strength in other stories in the client’s life. Thus we build towards a different perception of the self, which will lead to different self-talk, different expectations, different thoughts and actions.
One of my favourite ways to do this with children is to use the technique of the “wonderfulness interview”. Parents often bring a child whose life has been dominated by some sort of difficulty to therapy, and this often leads to the child believing “I am the problem” or “There is something wrong with me”. During the wonderfulness interview we get Mum, Dad and anyone else to describe the “wonderfulnesses” of their child. For a moment the light shines not on what is wrong, but on what is right. This in itself is highly therapeutic and often signifies a major shift in the therapy. The child starts seeing him- or herself with new eyes, noticing the courage and the strength, and drawing on that to propel himself/herself into a life that is not defined by the problem alone.
In conclusion: even though CBT, ACT and Narrative Therapy are distinctly different therapy modalities, they share an emphasis on exiting problem-saturated disabling roundabouts. The beauty of it all is that not only do we leave the negative cycle, we also actively move towards something new. We don’t simply exit my Croydon or Mooroolbark roundabouts and then just stop at the side of the road. No, we re-align, we find our direction and then start moving in the direction we wanted to go in the first place: a healthier, more balanced, more connected, more fulfilling and more meaningful way of traveling on our life journeys.
Felix & Sage Psychology