How to make the most of online CBT therapy

As social distancing looks set to consider for some time, I’m writing to introduce you to the idea of online CBT with a therapist and how to make the most of your online CBT therapy session. Many clients wonder what is it really like to have therapy when you’re not in the same room? Having spent the past few weeks working online with clients, and having attended various workshops on this, I want to outline for you some of what I’ve learnt so you can benefit the most from your session. I work as a CBT therapist, so this article is aimed at online CBT therapy.

Online therapy has been around since long before the coronavirus pandemic, and has been well studied. Studies have shown that online CBT therapy can be as effective as face to face therapy. But understandably you might have questions about this way of working. That’s fine, I did myself to start with! To clue you in, I’ll first outline some of the benefits of online therapy and some of the potential limitations before outlining how to get the most from your session and how you can offset some of the possible disadvantages.

The plus points of online therapy are clear, it’s convenient for you from the comfort of your home, saving on time and costs to travel or park, and is easier to access for clients suffering from social anxiety or currently unable to leave their home for any reason. It is at the moment the safest option in terms of not catching or passing on coronavirus. For those who are working or looking after children, the ability to be able to schedule in a therapy hour without travel time to a different venue may mean the difference between being able to have a therapy session or not at all.

Many of the drawbacks which are often worried about can be offset with good practice, some of which include concerns about confidentiality, not being in the same room as your therapist and unreliability of technology. I’ll cover these below in my tips for making the most of online therapy. In most cases, if you are committed to working towards change through therapy, there is every chance you can get as much from your online therapy session as if it were face to face. Here’s how…

1. Where do I sit? Find a place in your home where you can talk privately and without interruption. If there are other people in your home, if you can, ask them not to disturb you during your session. If necessary, put a note on the outside of your door to ensure you are not interrupted. Helpful family members offering to make you a cup of tea are obviously supportive, but we want you to have this hour to yourself with your therapist, free of distractions, feeling safe that you can say what you want to, as if you were in the confidential environment of a therapy room. Switch notifications and phone ringers off. As much as you can, make your room into your home therapy room. As for those kind offers of cups of tea, perhaps they could be a nice way to prepare for your session (it’s okay to have a refreshment to hand if you choose) or perhaps they would be welcome when come off your call to take a pause before whatever is coming next. At my end, I work in a private room with a notice on the door, so it’s a confidential environment.

2. What do I need? You need a good wifi connection. This is a prerequisite. Without this, I would go so far as to say this is the biggest potential drawback to online therapy. Calls dropping out, time lags with speaking, unsynched voice and pictures make a session tricky. You can minimise this problem by asking others in the home not to overload your network during your therapy hour. Find the best wifi spot in your home and claim it for your therapy hour. If you have poor internet in your home, I probably wouldn’t recommend online work. But it is always worth trying to see.

Making sure that you regularly update system software and apps on your devices is recommended so that virus protection and software privacy is kept up to date on whatever platform you are using. Whilst initially there were privacy problems with Zoom (a popular online meeting app), these problems seem to have been overcome by the developers. Password protection is also recommended for privacy. Nothing is 100% risk free, but my perspective is, even if we were working face to face, we could worry about people theoretically listening at the door or bursting in by accident. This would be highly unlikely, just as the likelihood of someone remotely listening in to your therapy session online is highly unlikely. But by being aware of the risks, you can best manage these.

3. Use headphones and a microphone. This seems to cut back on the tiring nature of online work. First, you can hear better. It also cuts out feedback which can be distracting if you can hear your own voice echoing back. I always wear headphones if this is a problem.

4. If you’re not using a laptop or sat at a desk, I recommend you get a stand for your tablet or your phone. This will mean you can be handsfree to take notes and be more at ease. It also makes me feel less sea-sick than if you are bobbing around with your phone!

5. Think about your position in the screen. You don’t have to be too close-up. Head and upper body in frame is best. In fact, it helps your therapist to be able to see more than just your face, so we can see if you are looking particularly tense in your body or fidgety.

6. Does it feel a bit intense? I think it can sometimes. It’s okay not to stare at the screen the whole time. In real life we are not staring at each other close up like this for an hour, so it’s absolutely okay if while you are talking you want to rest your gaze aside, or look down at your notes.

7. Is the screen a barrier to therapy? There is not a definitive answer to this, it’s more down to personal preference. Many young people are used to chatting and talking online and are comfortable with technology and its ups and downs and comfortably ease into working online. It is also true that some people may have had previous negative experiences of working online. I can’t answer to this, but it may not be the online aspect which was the problem.

8. Working online may make it easier to discuss your problems. In some cases, online therapy is a bonus. Just as some feel that not meeting in person is a barrier, some clients may feel more open to discussing their problems as it feels somehow safer. Perhaps this is you?

9. Will online therapy take longer? This is difficult to say. During the current pandemic, perhaps yes, but this may be down to underlying factors, such as a client’s general stress being higher at this time for multiple reasons, as well as isolation and the difficulties this can bring with it.

One specific factor during this time of coronavirus, is that during social isolation some of the behaviour change work which is necessary for recovery and managing your problems may be held up as there are less opportunities to practise. We can manage this by being more creative about how you might set challenges for yourself online instead of the real world, or by using your time outside the home to engage in challenges as often as is permitted. As lockdown eases, this is less of a problem.

10. Is online CBT as good? Success of therapy is down to many factors, your relationship with your therapist, whether you connect with them and feel they ‘get you’, whether you are prepared to engage and do the hard work required in CBT and having a realistic and achievable goal which you are invested in working towards. Most of the hard work required in therapy, whether you are meeting your therapist in person or online happens in the real world, and has little to do with the ‘online’ part.

For me there is one final proviso about online therapy, and this is only my personal opinion. There are certain situations where someone is at high risk of harm, where I would not recommend it. As a private practice practitioner, I’m not available to offer support outside of sessions. Online therapy may not be advisable for complex and serious problems where crisis situations might arise.

I hope this article has helped to give you some tips and answer some of your queries about online therapy. If I can help, please let me know.

For further information, why not read 5 ways to make the most of your CBT therapy session.

Ali Binns is a CBT therapist based in Bath and now offering online CBT therapy.

How to cope with anxiety about Coronavirus (Covid-19)

At the start of this year, almost no-one could have predicted the current health situation. Within the space of a few weeks, a new coronavirus (Covid-19) has emerged, first in China, and gradually, spreading across countries all around the world. Of course it is part of the human experience to feel concerned when we are faced with an unpredictable threat such as this, but this virus is not only a threat to our health, but also a trigger for many people who have health anxiety or general anxiety. This blog post is to introduce you to a couple of ideas to help you to help yourself and manage the problem more effectively.

To be completely honest, I don’t just have professional experience of health anxiety, it is also a problem I have had difficulty with in the past and do have to pay attention to my own vulnerability to this trigger. I wanted to write this post to support anyone looking for tips to manage their anxiety and prevent it from escalating; particularly anyone who might be struggling with their health anxiety, general anxiety or even OCD being triggered by the threat of Coronavirus (Covid-19).

If you consider the people you know, you will probably notice there is a sliding scale of responses to the virus. At one end of the scale you will notice people experiencing high anxiety and panic, at the other end people sticking their head in the sand and saying, “It’s just flu, move on, what’s the fuss about?”, and also frequently (although not necessarily as obvious) the pragmatic and calm middle ground of realistic concern. You can probably see that there are problems at both extreme ends of the scale and that concern is going to benefit everyone the most.

If you stick your head in the sand and ignore the experts, you are more likely to adopt an “I’m alright Jack” attitude, and be less likely to pay attention to measures to slow down the spread of the illness. This has the downside of making it even harder for our wonderful NHS workers to do their jobs. In a worst case scenario this could mean they can’t help everyone who needs help. At the other end of the scale, if you panic, you will be suffering emotionally, lacking sleep, panic buying supplies you may not even need, and generally heaping distress on yourself. At worst, life could become consumed with the thoughts of the virus.

The sweet spot, you’ve guessed it is, to be appropriately concerned about the spread of the virus. Concern is anxiety at a lower level, but it is behaviourally different and less intense than anxiety. It helps us to be prepared, to keep the threat in perspective and to focus on what we can do to help ourselves, our loved ones and others in our communities. So, how can we stay concerned without tripping over into high anxiety…

What triggers the anxiety

Before I move on to the tips, it might help to understand why anxiety is so triggered by this threat. First off, if we are experiencing anxiety, there is always a threat behind it, and this threat may be real or it may be imagined. With the new coronavirus, the threat is real, but there is uncertainty about how big the threat is. There is uncertainty about whether or not you will get it, how severe it might be. There is uncertainty about whether loved ones, or vulnerable people you know will get it. There is uncertainty over how well they will be able to fight it off. There is uncertainty about how dangerous the virus is. There is uncertainty about how this will impact you and how you live your life. Maybe you are starting to see the crux of the problem? UNCERTAINTY! Anxiety can be driven by a need to be certain. This drive for certainty then locks you in to certain behaviours designed to try to achieve the clarity and certainty you are looking for. It also gets your mind on a quest to gain certainty by worrying. Worrying can be the mind’s way of trying to be more prepared, but unfortunately it’s fuel on the flames of anxiety. A quest for certainty where there is none keeps anxiety going, and is extremely distressing over time.

I’m going to list some of the common behaviours which may suggest you are anxious and how you can manage that. In no particular order, here are some pointers to look out for.

Coronavirus anxiety and what to do about it

Checking the news or social media

Hands up who recognises this? If this is you, then consider yourself caught in the trap of reassurance or certainty seeking. If you’re finding yourself regularly pressing refresh on social media hashtags about the virus, or seeking out constant ‘Live’ news coverage of the virus situation, you’re engaging in action which will keep your focus on the threat and keep your anxiety high. While from time to time you might come across a ‘good’ news story, there will be far more to stoke your anxiety and your doubts about how ‘safe’ you are.

Solution: Try limiting your news addiction to once or twice a day, though certainly not just before bed. Even better, stick to respected sources of information. For example World Health Organisation, Public Health England (if you’re in England) or your local and trusted source of expert information. The press may not be the place to look for keeping anxiety at bay. Journalists, although thorough, are human beings and can make mistakes or misinterpret statistics. Neither are they experts in pandemics, so the facts may be sometimes unfortunately distorted. In some papers the facts may be deliberately misleading to create sensational stories or for political point scoring. Stick with a trustworthy and scientific source and put a limit on how often you look at it. You may need to wean yourself off the checking if you are highly engaged in this activity.

Extensive rabbit hole research

If you, or others, have noticed you are becoming something of a armchair expert in virology or epidemiology, through excessive reading around the virus, then pay attention to how all the knowledge you have been accumulating might be fuelling your anxiety. The purpose of your research is most likely to try to find some vital piece of research to reassure yourself. You’ll know you are severely afflicted as you find yourself trying to download and decipher scientific papers on the coronavirus to see if you can glean the piece of information which might put your mind at ease. Most of these papers, need PhD level scientific knowledge and will be frustrating and lead you down a warren of rabbit holes. For every bit of reassurance you’ll find, you’ll find something else that contradicts it, or places a doubt in your mind.

Solution: Remind yourself that there are people far more qualified than you whose life work it is to make sense of the ongoing information about the virus and its spread. Your activity will only fuel your anxiety and take you away from living your life. This kind of behaviour is highly addictive and you will need to keep an eye on yourself for slipping back into the temptation (as with news/social media above). Hours can be spent down this rabbit hole. Spend this time doing something enjoyable or useful instead. For example, cook a meal for your freezer, catch up or write a note to a friend, spend it with people you care about.

Worrying

Worrying is your mind’s way of trying to protect you, or to prepare you for a worst case scenario. If you can step outside of this persuasive thought for a moment, is it genuinely the worry that protects you from the threat you are facing? Hmm, probably not. Worrying is unproductive and keeps us in a space of overthinking and unable to relax.

Solution: Practice redirecting your attention from worry thoughts which are unhelpful to you. This takes time and practice, acknowledge that your mind has been temporarily hijacked by anxious thinking and a need to achieve certainty about what is going to happen, then refocus on something outside of your mind. Experiment with what works best for you.

If you have a tendency to get stuck in worry mode, why not try The Worry Tree method which can help to put worries to one side and focus instead on what you can reasonably do.

Overpreparing

Overpreparing again keeps your focus in the threat in an unhelpful way. We have no certainty about what will happen over the coming weeks and months. We may have to self isolate, we may not; we may have greater restrictions placed on us regionally or as a whole country, so it’s impossible to plan for every possibility.

Solution: Reasonable planning seems sensible. Panic buying will increase your own anxiety, as well as others’. There’s nothing like an empty supermarket shelf to increase scarcity fears and place an emphasis on risk and danger. Make a proportionate plan in case you need to self isolate. This will be different for everyone, depending on how they live, who they live with, where they live. If you can’t go out and you don’t have reasonable stocks of food in your cupboard to see you through, think about who you could ask to help you out if this was a problem (friend, neighbour), or use online shopping if you don’t usually.

Overcautious actions

This is a tough one. If you have extreme levels of anxiety or OCD around fears of contamination and a highly developed sense of responsibility for preventing harm to your self or others, then you may engage in safety behaviours to prevent the spread of the virus which are above and beyond what is required. If you have had ERP for OCD, you will have heard that to overcome the problem you must tolerate ‘dirty’ hands for example. However, in the case of the current coronavirus, a decent exposure would be to wash your hands once according to World Health Organisation guidelines and resist the urge to go further than that.

Solution: Reasonable hygiene is healthy and helpful. Washing your hands as per NHS or World Health organisation guidelines is effective. Click here to see how to wash your hands. Soap and water is recommended as being as effective as antibacterial gels.

Similarly you can do your bit to prevent the spread by coughing or sneezing into a tissue, binning it and washing your hands after.

That’s just a snapshot of ideas which I hope might help. For further ideas, I highly recommend this video by Ali Matthu on coronavirus anxiety.

Despite the inevitable concern this virus has for many people, I hope that this post can go some way to helping you to keep things in perspective… to find the middle ground between overestimating and underestimating the threat. Stay healthy, stay concerned!

Ali Binns is a CBT therapist based in Bath, UK. Her special interest is in helping people to manage a range of anxiety problems.

Belief change and the tooth fairy

In traditional forms of CBT we often talk about changing our thinking or changing our beliefs. On the surface of it, that might sound easy and the CBT mantra of change the way you think to change the way you feel probably oversimplifies the process. In order to change our beliefs or the way we think, and to really truly feel and buy into new beliefs or attitudes and subsequently experience an emotional shift, certain conditions are important.

To illustrate this idea I’m going to use the analogy of a child’s belief in the tooth fairy. This quaint tradition involves leaving a lost milk tooth under the pillow, by morning it will have been replaced by a small token, a coin, and more latterly perhaps, a note (inflation obviously!). The benefits of such a belief are unclear, although it’s been suggested that it might make small children less fearful of losing a tooth. Or perhaps there’s nothing more to it than a fun and magical game that parents play while children are still young enough to enjoy the magic.

Belief change

In any case, this is a belief which we can use as an example of a belief which can change. This belief involves a way of thinking: the tooth fairy is real and visits with a small coin when a tooth falls out. This belief may fly in the face of all the evidence, how does a tiny fairy carry a pound coin, let alone a £2 coin, but it is still believed, because adults around us told us about it. It has a benefit for us, a surprise under the pillow in the morning. The belief also involves certain behaviour, for example the child may go to bed early and stay in bed to ensure the tooth fairy comes, as well as saving the tooth to put under the pillow. As long as the tooth fairy (ie. mum or dad) keep remembering to deliver the goods, the belief is maintained (at least until an age where the child developmentally has suspicions and questions the whole reality).

The steps of changing beliefs and attitudes

In order for beliefs to change, I’d suggest the first step is that you need to be open to the possibility that there is a different perspective to your belief. That there might be another way of looking at things. In the case of the tooth fairy belief, a child might have suspicions themselves that this belief isn’t entirely true, or perhaps a sibling or friend has let the cat out of the bag. Perhaps unwittingly a parent has been spotted placing coin under pillow… A seed of doubt has been planted, opening up a different way of looking at things.

So far so good. At this point, when we know there might be another way of looking at things, we might still hold tightly to this, because this way of thinking is safe and comfortable. What has to happen next?

Looking for evidence might be the next logical step to changing our beliefs or attitudes. On our own, or with support from others, we might explore the evidence for and against our belief. Tooth fairy example: stay up and pretend to be asleep to prove your theory once and for all; survey other people; google for facts on your mum’s ipad when she’s not looking. Then you could draw a conclusion and come up with a more realistic and balanced belief.

At this point, this may be enough, but if you continued to act as if you still believed in the old belief, then things may happen which keep the old belief going. If you continue to put your tooth under your pillow, the tooth may keep being replaced with a coin (after all, who wouldn’t want that to happen?) So to begin to dismantle an old belief, we need to change the way we act too. A child might stop putting a tooth under their pillow or they might talk to their family and admit that they have a different way of thinking now, that while the story was nice, they’re a big girl or boy now and have a new way outlook now.

Acting in accordance with a new way of thinking will really help to uproot an old belief. The belief in a tooth fairy may have served you well as a child (fun, excitement in this case), but, as is the case, with many beliefs, as you move through life the beliefs may come to no longer serve you well. There may be some sadness associated with this growth and learning, but it’s all for the good, if you have chosen a new set of beliefs and attitudes which help you to move forwards in your life.

So to sum up, what relevance does this have for changing the way we think in CBT? Beliefs can change but changing beliefs takes time, persistence and the following:

Be open to flexible thinking, different perspectives

Look for evidence for and against your beliefs; stick with the facts

Challenge yourself to act in new and helpful ways that support your new beliefs

Over time and with repeated action, you can experience a different outcome in situations where you have experienced difficulties.

Ali Binns is a CBT therapist based in Bath. She enjoys writing about therapy and CBT and hopes these posts can help you in your understanding of yourself.

Am I a failure? What is failure anyway?

What is failure? One thing I like to be clear about is that people aren’t failures. People fail at tasks, people make mistakes, but they themselves are not failures. Sometimes you just don’t have a particular skill yet. Failure is part and parcel of life. All in all, there’s more failure about than success, it’s just that people don’t tend to advertise it. It would be good if they did. Many people become afraid of failure and then miss out or avoid opportunities. If you do fail or mess up, many times people use this as a way to shatter their self belief. Your idea of failure might be different to someone else’s, so we may suffer acutely from pressure driven by ourselves or others to achieve without hiccups along the way. Fortunately, if you change the way you look at failure, then you can change the way you approach the prospect of messing up, making a mistake or not meeting a personal goal and your feelings of failure can change.

My own point of view is that normalising failure would stop people from comparing their insides to other people’s outsides. Daily, we see images of other people’s success and it appears instagram-effortless. With social media and 24 hour news, we have instant access to a world of others to whom we are invited to compare ourselves, so we will always be able to find someone who appears ‘more successful’ than us. This is highly threatening to our brain, our sense of who we are and where we fit in socially. Our brains’ threat systems have not developed the capacity to keep pace with the modern world and this bottomless pool of others. Our brains may have developed well enough to deal with social comparison in smaller social groups in our evolutionary past as hunter gatherers; this was probably in many ways adaptive and kept us on our toes. Today such large scale social comparison in terms of failure or success is probably unhelpful.

Success is given a good press but many times we don’t get to see the struggle involved behind the scenes. The truth is, success is not always what it seems…

One exceptional quote comes from basketball player Michael Jordan:

“I’ve missed more than 9000 shots in my career. I’ve lost almost 300 games, 26 times I’ve been trusted to take the game’s winning shot and missed. I’ve failed over and over and over again in my life. And that is why I succeed.”

You will notice that Mr Jordan is open about his failures and you could notice that he does not label himself a failure. He only defines his actions. This is important. If he were to rate and label himself as a failure this would impact on his confidence and sense of self worth, and this would make it very hard for him to dust himself down from inevitable and frequent failures. This same attitude can help whether you are just making your way through life, or whether you are learning a new skill at work or for leisure, or trying to make progress in therapy.

To fail at something is part of being a living and growing human being. Think of babies…. if a baby cared too much about failure, they’d never learn to crawl or walk. Think of all the effort, the hard work and the tears required for a baby to get up and moving about. There were many failed attempts before the glorious moment they finally found freedom walking on their own for the first time. Their skill (or success) is the result of many failed attempts with a lot of support and encouragement from caregivers along the way. Failure is part of life and ideally not something to avoid or fear.

In order to experience some success or progress, failure is to expected. Failing is part of learning. No-one is born with talent. Even the most ‘gifted’ person you know did not get up one morning and succeed at what they do… chances are they spend many hours messing up, trying and keeping going. There will have been moments of disappointment, frustration, sadness, joy, all the emotions along the way. The application of effort and ability to tolerate the discomfort of failure is key to picking yourself up again, dusting yourself off and standing tall once more. If you berate yourself as a failure when you fail, your confidence will be shattered. Better to accept that you’re a human being and that while you may fail at things along the way, many of which you have limited to no control over, this has no bearing on your worth as a person.

You are not a failure.

The philosophy behind REBT CBT is that you are much more than the sum total of your actions, thoughts and feelings. You are too complex and unique to be summed up with a mere description or label. Human language in the form of labels is just not enough to capture what it is to be human. We are much more than the sum of our parts. All humans are capable of change, and our skills and attributes are ripe for development if we want to change them. We have changed, we will change and will never from moment to moment be the same, so we can never be captured with a single word. To label yourself a ‘failure’ is an unfounded and inaccurate judgment. It’s easy to label yourself (or another) as a failure, but it’s unfair and overly critical, overlooking all your potential and your past.

As a CBT therapist, I want to help you to adopt a new belief about yourself - that all humans are born of equal worth, albeit sometimes into circumstances and a time that may not have been their choice. The only true things you can say about humans are that each is fallible (prone to making mistakes), imperfect, unique, complex and worthwhile. No person is a total failure, no person is perfect or a complete success, nor is it even possible to describe a person as ‘good’ or ‘bad’.

If you want a vivid example of this, I have recently been reflecting on the example of the man who intervened in a terror attack in London and helped to distract and chase the attacker to a location where he was unable to cause further harm. He was claimed a hero. It was later discovered that this same man was on release from prison, having previously committed a murder. So, what is this person? Is he a hero? Or is he totally evil, capable of the worst crime? If we look at it truthfully, he is neither a hero nor is he evil. He’s just a human being, who has on the one hand carried out a heroic act, but he has also committed what most people would consider a terrible crime. When you look at it this way, he’s neither good or bad, though his actions have the potential to be good or bad.

The helpful philosophy of refusing to rate yourself but stay focused on your actions will free you up to do what matters to you. No amount of self-berating when you don’t achieve your goals will help you unless you want to damage your confidence and increase your anxiety. Accept yourself as a fallible human being.

If we can begin to adopt a more balanced and genuinely realistic attitude towards ourselves, then we can accept ourselves for our failings and our mistakes along the way, without shattering any hard-won confidence. We can honestly and fairly rate our actions and accept or improve our skills. But no need to berate ourselves for failures, gentle encouragement and self acceptance will work wonders.

Feel free to keep failing forwards towards your goals and your successes.

Ali Binns is a CBT therapist based in Bath. She works as an integrative CBT therapist using techniques drawn from cognitive behavioural therapies such as REBT, CT, ACT and Compassion Focused Therapy.

CBT therapy for health anxiety

Obsessed with your health? Convinced you are ill, despite getting a clean bill of health? If you’ve arrived here, then it’s likely you (or perhaps someone you know) have health anxiety and you’re interested in finding out more about how CBT therapy and counselling can help health anxiety. I work as a CBT therapist in Bath and help clients to overcome their health anxiety using cognitive behavioural therapy. In this introduction, I hope to give you an understanding of what health anxiety is, some of the ways it is maintained and how we can begin to overcome the problem of health anxiety.

What is health anxiety?

Health anxiety is a preoccupation with becoming ill with a serious illness, or of succumbing to a serious illness, despite medical advice that this is not an issue. Many people worry from time to time about their health, but health anxiety is when this worry becomes persistent, taking up a lot of time and leading to restricted lifestyle choices. Someone with health anxiety might imagine they are ill, or overestimate the likelihood that they will become ill, even in the face of a doctor’s evidence to the contrary.

How does CBT help health anxiety?

Cognitive behavioural therapy is rooted in the theory that our thoughts, feelings, actions and physical symptoms (bodily sensations) are all connected. We assess the problem of your health anxiety by building up a detailed picture of it. Each person with health anxiety is unique, so the first requirement in therapy is to take a detailed look at your worries about your health, how you are thinking and what you are doing about these thoughts. Once a thorough assessment has been made, then with your therapist you can begin to deconstruct the problem…

Health anxiety worries

In health anxiety you might become preoccupied with having a serious illness or getting one. Typically, people tend to focus on serious and catastrophic health events, such as having a stroke, a heart attack or chronic, long term illness with uncertain outcomes, such as multiple sclerosis, or cancer, among others. Often what can happen is when one condition is ruled out, physical sensations can convince you that there is still something wrong. You may become an internet expert in digging out rarer conditions which appear to match the symptoms you are experiencing. It’s not uncommon for people with health anxiety to self-diagnose conditions their GP has rarely encountered in their practice.

The first step in health anxiety is to consider the possibility that you have a problem of worry about health rather than this being a real health problem. This is a huge first step and involves taking a leap of faith, possibly with the help of your therapist. Once this is acknowledged then we can begin to test out the theory that it is your problem of worry rather than an actual illness which is the target of therapy!

‘Real’ symptoms

The belief that you have an illness can be complicated by the existence of compelling and very ‘real’ symptoms. In the past, people with health anxiety were labelled rather dismissively as ‘hypochondriacs’ and told that their problem was all in the mind. The truth is that sensations and symptoms in the body are real and do exist, it’s just that the symptoms (sometimes coming from the anxiety itself) are being misinterpreted in a catastrophic way. If you experience health anxiety you may jump to fast conclusions about bodily sensations. In fact, it’s highly likely you are acutely tuned in to your body and how it feels on a day-to-day basis.

When we experience anxiety, we might attribute our bodily symptoms to serious illness: a tension headache might mean a brain tumour or an imminent stroke; a racing heart may be seen as the onset of a heart attack; tingling sensations may be interpreted as a sign of MS or other neurological disorder. Anxiety itself contributes many physical sensations which are in reality harmless, but which can become a focus of attention. When we focus on the symptoms, they take up more of our attention and a vicious cycle of health anxiety can begin.

Beliefs in health anxiety

Health anxiety is often driven by a need to be sure that you don’t have a particular illness. This need for certainty can compel you to find a certainty that is forever out of reach. It leads to a preoccupation with trying to prove with absolute certainty that you don’t have anything wrong with you.

You may also have beliefs about your worry which motivate you to keep worrying. For example, you may believe that if you don’t worry enough and keep your focus on your health, then you might miss something, and that if you did then you’d sorely regret it. Perhaps you believe it would be irresponsible not to worry, or that worry prepares you for a worst case scenario.

In CBT we really think about our thinking. Your therapist will help you to challenge some of these ways of thinking and to come up with more helpful and balanced thoughts which can help to soothe your anxious mind.

Why do you have health anxiety?

Often clients ask, ‘why do I have health anxiety?’ For this, there’s not a single answer. It can be helpful to explore what has happened to you or around you in your life to understand why you may be predisposed towards anxiety around illness. Factors which come up often are: sudden deaths in the family or among close friends, difficult illnesses in the family when you were growing up, perhaps you’ve had a serious illness in the past yourself, or have experienced a missed diagnosis in the past (either yourself, or others), for example. Often becoming a parent can trigger health anxiety as it becomes especially important to you to stay well and be around for your children. Knowing that we have understandable reasons why we may have a tendency to overestimate the likelihood of illness and perceive this as an ongoing present threat can help to unravel some of the automatic assumptions you might have when you experience a worrying symptom.

Coping in health anxiety

When you are experiencing health anxiety, you likely have developed ways of dealing with this with what therapists call ‘safety seeking behaviours’. Of course, we all strive for peace of mind and contentment, and when you’re anxious about health then you will have come up with ways which help you to feel better (some will be helpful, others not!). In health anxiety, there are some typical ways in which you might try to cope.

A common ‘coping’ method is to consult Dr Google. Dr Google holds a wealth of information for those seeking out symptoms online. The internet certainly has a lot to answer for when it comes to health anxiety. It offers unfiltered, general information and tends to lead to increased doubt and uncertainty, as well as more questions and lines of enquiry to pursue. In case you haven’t realised it yet, the internet is an ‘all you can eat buffet’ as far as health anxiety is concerned.

You might also frequently check out a particular part of your body which is giving you concern by closely monitoring it. If you have health anxiety, do you measure your own blood pressure or heart rate to reassure yourself you are okay? Do you poke and prod at particular areas to check for changes or pain?

Other ways in which you might try to help yourself include frequent visits to the doctor to seek out medical opinions, requesting further tests and visiting different doctors for second opinions. Other ways you might try to cope might be by trying to push aside the thoughts, trying to think positively, or avoiding activities which could, in your mind, put you at risk of something bad happening. You may also avoid talking about illness as if just talking about the illness increases the likelihood of this being true. And lastly, though not exhaustively, you may even avoid TV programmes or newspaper articles where you might come across reference to illness.

What is important to understand in all of the above, is to question how helpful these actions are for you in the short term and in the long term. Do they perhaps have some unintended consequences?

How does CBT help?

Cognitive behavioural therapy counselling for health anxiety helps to break and reverse the cycle which keeps it going. This means addressing thoughts and beliefs about our health. It also means reducing unhelpful coping behaviours which tend to keep our focus on the anxiety. An anxious focus on health unfortunately keeps you on high alert for sensations in the body and at the same time making you more likely to experience sensations which can then be attributed to something other than the anxiety which caused them.

In CBT therapy you learn to face the anxiety and work towards feeling a healthy level of concern for your wellbeing. It’s completely natural to feel concerned about your health, as this will motivate you to look after yourself but without the downsides of pre-occupation and missing out on life because of anxious worry. As an experienced therapist specialising in CBT, I have a wealth of ways to share with you to help you learn to tolerate your uncertainty as you learn to manage your anxiety. We use cognitive methods to soothe your anxious mind, and mindfulness based approaches to increase your resilience and learn to retrain your attention, as you begin to reduce activity which keeps you locked in the grip of health anxiety. It’s hard work, but it’s worth it, so you can get back to the life you value!

Ali Binns is a CBT therapist in Bath offering counselling for health anxiety and other anxiety problems. If you’ve a problem with worry, stress or anxiety, please get in touch if you’d like support in overcoming your difficulties.

CBT for insomnia - solve your sleep problems in a safe and natural way

Have your nights become a nuisance - tossing and turning with a good night’s sleep seemingly out of reach? Perhaps it might be a relief to learn that help is at hand; cognitive behavioural therapy can offer a safe, side-effect free alternative to medication to help you recapture your natural sleeping patterns.

Since, on average, we spend a third of our lives asleep, disrupted sleep can feel very troubling indeed. Insomnia affects an estimated 30-50% of people at some point in their lives, and 10% experience chronic insomnia (technically, sleep disturbance which lasts for longer than three weeks). In short, insomnia is a common problem - you are definitely not alone.

In this post, I’m going to take a look at how we approach insomnia in therapy using a CBT approach. Obviously this is only a snapshot of how we can use techniques from mindfulness, Acceptance and Commitment Therapy (ACT) as well as classic CBT methods to get back to bedtime bliss.

Typically, a series of sessions of CBT for insomnia will cover a range of approaches to help you achieve a realistic sleep goal. To start, you’d be building up an accurate picture of your sleep problem with your therapist. In CBT we look at four distinct areas - thoughts, emotions, behaviours and symptoms. We will be focusing on how all of these areas can be contributing to a difficulty in falling asleep or getting back to sleep when wakened.

How much sleep do you need?

Experts agree that on average an adult requires between 7 and 9 hours of sleep per night. Sleep needs do change during the course of our lives, babies and toddlers sleep far more, for example. If you have a very physical job, you exercise a lot, or perhaps you have recently been poorly, then your needs may change. There’s no gold standard set amount, but the guideline of 7-9 hours holds true for most.

Insomnia is associated with an increased tendency to feel anxious or experience other mood difficulties. Here it can get a little chicken and egg, as sleep disruption can also be part of depression and anxiety, but whichever came first, we know that if we improve the quality of our sleep then we can see all-round benefits.

Benefits of a good night’s sleep

• Improves mood

• Helps with immune system function

• Regulates hormones - including keeping a healthy weight

• Helps with focus and productivity

• Improved energy

• Helps with rational thinking

• Increases our ability to deal with whatever life throws at us

• And last but not least: it’s actually quite nice, to be able to snuggle down at the end of a long day, and appreciate the cosy, safeness of your own comfortable bed

Tracking your sleep

The first steps in therapy for insomnia involve tracking your sleep - the number of hours, what you were doing before bedtime, any remedies you may have used, caffeine or alcohol consumption and so on. There are plenty of apps on the market for this, but we don’t have to get too snazzy… pen and paper will do and probably more easily shared with your therapist. This sleep diary from The Sleep Foundation is comprehensive and will help to establish your current pattern and is a way for you to monitor your progress if you choose to.

What’s sleep hygiene?

Of course, sometimes sleeplessness can be down to modifiable factors, which can be easily remedied, so the next steps in insomnia treatment would be to take a look at your ‘sleep hygiene’. Contrary to how it sounds, this doesn’t mean keeping your sheets clean - although downy duvets and laundry-fresh sheets might assist! Sleep hygiene means taking a look at your bedtime routine, sleeping arrangements and bedroom environment. You can then take practically address areas which are in your control.

When we talk about sleep hygiene, we are ensuring we have some healthy habits in place. eg.

• Reducing alcohol at bedtime (can lead to night wakening)

• Reducing caffeine consumption

• Ensuring your room is a comfortable for sleep: temperature, light levels, comfort, noise

• Reducing over-stimulating activity at bedtime: playing video games, using phone in bed, reading news, going on social media etc

• Eating too late in the evening

• Introducing an effortless healthy wind-down routine

By setting up sleep-welcoming habits, we begin to set the body up for relaxation and sleep. If these simple strategies are still not bringing the progress you would like, then it’s time to move on to look at how your thinking and the very quest itself to get a good night’s sleep can make it increasingly out of reach.

Your sleep beliefs

While a period of interrupted sleep (due to a specific trigger, perhaps illness, a difficult period at work, a loss, relationship problems, having a new baby) might trigger an episode of sleepless nights, when this persists, it can be because our own thoughts about our lack of sleep can keep us locked into sleepless nights of tossing and turning. Paradoxically, the harder we try to get to sleep and the more we might be telling ourselves that we HAVE TO get to sleep, the more we might be getting ourselves stirred up, so preventing sleep from happening when we want it to.

The truth is, sleep will happen whatever we do or don’t do, but in insomnia it ends up happening at the wrong time, perhaps in short snatched bursts. We might find ourselves catching up one night after a sleepless night, or in naps, or at weekends. Just as we can’t force ourselves to stay awake, we can’t truly prevent sleep. Our body has inbuilt sleep regulation - if we’re in a sleep deficit, then we will fall asleep, even if that is during the day when we need to be awake. This isn’t ideal, as not only could it be outright dangerous if we are driving or operating machinery, but it may not suit you to be dozing off at random moments!

Don’t try too hard

Once we find ourselves in a cycle of overnight sleeplessness, we can get into a cycle of behaviours and thought patterns which become fixated on the idea of getting a good night’s sleep. In the case of sleep, there’s a paradox here. The more we try to get to sleep, the more this escapes us. This is called the Law of Reversed Effort. Have you ever tried to stop yourself from laughing where silence was required? Remember when you learnt to swim, how hard you tried and how now, well, really it’s effortless… There are many activities where trying harder does not work, and so it is with sleep. Because sleep comes naturally, we don’t need to be taught how or to strive to do so, it’s more about letting go of everything. It’s all the things we do in our minds and the physical actions we might carry out which keep our body alert, and in a state which isn’t conducive to sleep.

Sleep beliefs

Working out your beliefs about your sleep and challenging these during your waking hours can be helpful and supportive. As can educating yourself about sleep itself. The more you understand about sleep is that you’ll see that it is a natural process, which in reality needs no effort. It is often our thinking about the lack of sleep which keeps insomnia going. Common beliefs might be:

I won’t be able to cope or function without sleep

I have to fall asleep now, I can’t stand not being able to sleep (while watching the clock)

I can’t bear it when I haven’t had a good night’s sleep

I have to ensure my mind is empty before I go to bed, or I won’t fall asleep

I have to have silence to sleep, I can’t bear not having silence

I must have a perfect night’s sleep

If you’re an insomniac, do any of these resonate with you? There are others, but those are some of the typical themes I come across among my clients. These beliefs about your sleep can be addressed and helpful beliefs can be developed which are more conducive to helping your body to wind down for the evening.

A modern CBT approach for insomnia is Acceptance and Commitment Therapy (ACT) which takes a mindful approach towards the thoughts, rather than getting into a bedtime battle. Acceptance and Commitment Therapy is a third wave CBT approach which uses, among other things, mindful awareness to accept thoughts rather than try to wrestle and wrangle with them at the very time we could be drifting off to dreamland. ACT techniques are particularly helpful at bedtime when we don’t want to be getting into increasing mind activity by trying to rationalise thoughts away. Being able to disengage with worry thoughts and let them go, while focusing on the present moment can help. Mindfulness training to accept and allow thoughts, feelings, external distractions to come and go can be of benefit. Imagine your thoughts as clouds in the sky which drift in and out, or as leaves on a stream which bob off into the distance. There’s no need to get into the river with the thoughts, you can learn to allow them to float away without attending to them.

Sleep behaviours to tackle

Aside from the basics of sleep hygiene, unhelpful habitual sleep patterns can be addressed.

There are two tried and tested methods of breaking the sleep pattern called Stimulus Control Therapy and Sleep Restriction Therapy which may be of help. Stimulus Control is for those who may have conditioned themselves to associate their bedtime as something negative. Sleep restriction Therapy aims to improve the ratio of sleep to time spent in bed (sleep efficiency), by restricting your sleep to begin with. It’s not quite as brutal as it sounds, and can get you quickly back on track if you are feeling highly motivated.

Any activities you undertake with the sole purpose of getting to sleep may keep the focus too much on the lack of sleep and give you extra pressure. It’s as if sleep becomes some kind of performance for which you must be ready. Reducing the amount of props or aids to sleep may also take the pressure off.

Helpful behaviours at bedtime might include relaxation techniques, a mindful body scan or simple mindfulness of breath. The key to success here is not to carry them out with an explicit goal, but to practise just accepting and being curious about what you find and what happens, rather than having an expectation that these must work for you. These exercises can be helpful to switch off and to engage the parasympathetic nervous system (our relaxation response) but their effectiveness may be affected by worry about your lack of sleep and focusing on striving for sleep.

Managing general anxiety or stress

Often being able to explore your everyday stressors can go hand-in-hand with insomnia. If you’re at the end of your tether and stressed to the max at the end of the day, it’s no wonder that you’ll find it harder to drift off to sleep. As CBT is a therapy which helps you to help yourself, many of the approaches we use to manage your insomnia can be cross-pollinated into everyday life.

Sleeping beauty. Sounder sleep could be just a few steps away with CBT for insomnia.

As I hope you can see from this introduction to treating insomnia with CBT, we have lots of options to get you back to sounder, more refreshing sleep. If I can be of support, please reach out.

Ali Binns is a CBT therapist in Bath specialising in anxiety problems. Feel free to get in touch using the contact form on the main menu if you’d like support and help in working through your particular problems.

How to manage anxiety: The Worry Tree

When we’re anxious or stressed our mind has a tendency to focus on all the ‘what ifs’ and to steer towards the negative. It’s natural, it’s our friendly mind’s way of trying to seek out threats. Unfortunately the human mind is also very creative so it can take a difficult situation and catastrophise it into something far worse. Many of the worries we have are hypothetical, that’s to say, they are something that hasn’t happened yet, often unlikely to happen and merely stories our mind is feeding us with about future possibilities. If we can recognise our minds tendency to do this, we can learn to address it.

Certainly there will be times when worries are real and valid too, but it’s important to ask yourself whether worry is helping you. Is worrying really the same as problem solving? Is worry the same as taking action? If you can’t do anything about the situation at all and it’s an imagined problem, what are the consequences of continuing to worry about it?

Maybe worry was modeled to you in your family as a way to show you care and that you thought that if you didn’t worry, then maybe this would mean you didn’t care. As a fellow human being, I notice myself doing my fair share of worrying… I often worry about my teenage sons (let’s hope they don’t read this). I find myself worrying if they will get home safely. While my worrying shows that they are two of the people who matter most to me in life, the worrying doesn’t keep them safe and it only harms me. There are other ways to show I care, worry is not one of them! So knowing this, it makes it a little easier for me to begin to put my worries to one side and let them be.

It’s all too easy to get caught up in worry, and those who have anxiety will find themselves trapped in loops of worry. They’re so well practised at it, it’s automatic.

This post is to share with you a practical strategy you can use to begin to break this cycle. Of course this is only one tool but many people find it useful to pin down their worries.

The first step is to notice your worry. It might be pretty nebulous. It really helps to pin it down. Then follow the simple steps. Specify the worry. Is it a real worry or hypothetical - can you realistically do something about this? Then follow the steps in the diagram below.

You can download a full size Worry Tree pdf here. Print it out, hang it on your wall and give it a try, or share it with fellow worriers!

Ali Binns is a CBT counsellor in Bath specialising in anxiety disorders, including GAD, OCD, phobias. If you’re finding it difficult to cope with your worries, then don’t be afraid to seek the help of a professional. If you live in Bath, I offer private counselling sessions using cognitive behavioural therapy. Please don’t hesitate to get in touch if you would like my support.

What is OCD (obsessive compulsive disorder)?

Obsessive compulsive disorder (OCD) is a highly distressing anxiety condition experienced by approximately 1.2% of the UK population. All types of OCD include obsessions and compulsions. Obsessions can include intrusive and distressing thoughts, images and feelings (urges). Compulsions are the actions which are carried out in an attempt to ‘get rid’ of the intrusive thoughts, obsessions and feelings, which are highly distressing to the person with OCD. OCD can eat into a person’s time, taking them away from living the kind of life that they would value. In terms of treatment, CBT for OCD is your best option for managing the condition because it helps you to tackle the thoughts and the behaviours which keep the problem going. Cognitive Behavioural Therapy has been widely researched as the most effective method for overcoming OCD.

Why have I used a ladder to illustrate? This is to draw attention to the fact that as human beings we all have the propensity to think in superstitious ways. eg. Don’t walk under a ladder or you will have bad luck. Superstitious and magical thinking has at its heart a very similar theme to OCD, that of preventing harm and bad things from happening. Magical thinking can play a part in OCD when you may come to believe that by thinking certain things, and not carrying out certain rituals that harm can be caused or prevented.

While superstitious thoughts can be normalised as part of the human experience, OCD is an anxiety problem where you may become stuck in a loop of intrusive thoughts and actions while trying to reduce the potential distress caused by believing that you may be responsible for capable of causing harm to the self or others.

In this short introduction to OCD and CBT for OCD, I am aiming to give a broad overview of what OCD is and what you may expect from CBT for OCD, but there are limitations to such a short piece. Towards the end of the article I’ll recommend a couple of excellent books for you to turn to, should you want to know more.

What is obsessive compulsive disorder?

OCD begins with a trigger situation which is closely followed by an intrusive thought or obsession. To the sufferer this is not merely a passing obsession, but one which is highly distressing or anxiety-provoking. There are certain themes which these thoughts might fall under (contamination fears, obsessions related to perfectionism, religious obsessions, unwanted sexual thoughts, fear of causing harm, or fear of losing control to give a general overview). OCD is not limited to feeling anxious, the emotions experienced as part of the problem can be many: including anxiety, shame, guilt and depression.

OCD compulsions fall into two main camps - visible (overt) and invisible (covert). When most people out there think of OCD, they think of visible actions (such as hand-washing, checking candles are out or electrical plugs off, doors and windows being locked, seeking reassurance) but just as common are invisible compulsions which are carried out in the mind of the person who has OCD. Examples might include counting, memory hoarding, reviewing events to see whether or not something happened, self-reassurance, rationalising intrusive thoughts, neutralising words, or trying to prove the thoughts untrue beyond doubt.

Each person’s OCD takes on its own unique ‘flavour’, but whichever form you have, you can be assured that in all cases, the compulsions keep the OCD going. Yes, temporarily you may feel less emotional distress when you carry out a compulsion, but in the long term these are unhelpful actions. Over time these actions can increase your distress, as they keep you locked into a battle with the OCD, limit the activities you would otherwise choose, and negatively impact close relationships.

The problem with OCD compulsions

Compulsions are behaviours which give your brain the message that the intrusive thought (or urge) you have experienced has something of note to offer you. Responding to the intrusion or the obsession with an activity (covert or overt) gives your brain the message that the thought is important. Correspondingly, your brain, will offer more intrusive thoughts as long as you continue to respond with a compulsion. The brain is so generous like that! You can kindly thank your mind for this, it really does want the best for you, it’s just being an overhelpful friend.

Everyone’s OCD is unique to them so it’s important to be clear what you are doing which might keep the problem fired up. This will be useful material in the treatment of your OCD. Treatment of OCD involves a multi-pronged approach. Understanding what OCD is and how it is maintained, learning about the nature of thoughts, relating differently to the intrusive thoughts, and (most important) learning to tolerate the uncertainty and discomfort which comes when you begin to refrain from responding to your obsession through ERP (Exposure and response prevention) are some of the ways forward.

ERP involves gradual exposure to your intrusive thoughts, so that you can begin to habituate to the discomfort you experience as you learn to refrain from the compulsions. This exposure will be through imaginary exposure and real life exposure; your plan for treatment will be quite specific to your own symptoms and behaviours. To overcome the obsessions you will need to repeatedly expose yourself to situations you fear by whilst not carrying out your compulsions. This is done in a gradual way at a pace you can handle! Over time and with repeated new actions, your obsessions and your fear should start to trouble you less.

Thoughts are just thoughts

Learning not to respond to your intrusive thoughts will be a valuable goal. In studies, we know that 90% of people have odd, strange, unwanted thoughts. (And who really knows for sure whether the remaining 10% had thoughts they didn’t want to admit.) Any thought is possible in any person, and for the most part, these intrusive thoughts don’t cause people problems, but if you have OCD and you have begun to attach layers of meaning to those thoughts, you’ll have begun to get hooked by them. What keeps you getting reeled in is acting to try to alleviate the anxiety, guilt or shame which might accompany those intrusive thoughts or urges.

Cognitive behavioural therapy means working on thoughts and behaviours. With OCD, this means that not only are we tackling the behaviours which maintain obsessive compulsive disorder, but we may also be looking at your beliefs about your thoughts and your feelings, your drive to obtain absolute certainty where you may experience a persistent sense of doubt, and a sense of overdeveloped responsibility for preventing harm. With consistent effort and practice, you can learn to manage OCD and break free of its vicious cycle. You can stop yourself getting reeled in, hook, line and sinker. You can stay on the shore and you don’t need to get into the swirling water with it.

You might also be interested in Courtroom Drama analogy for relating to your OCD in a different way.

As I finish this short intro to CBT for OCD, I’m aware this only scratches the surface of what it means to have obsessive compulsive disorder, but I hope it serves as a brief primer on what keeps this problem going and how you can begin to unravel the problem.

If you want to read more, I highly recommend the following:

Break Free From OCD by Fiona Challacombe, Victoria Bream Oldfield and Paul Salkovskis

Managing OCD with CBT (For Dummies series) by Katie d’Ath and Rob Willson

Overcoming Unwanted Intrusive Thoughts by Sally Winston and Martin Self

Ali Binns is a CBT therapist based in Bath. She helps clients to manage their anxiety and mood using evidence-based cognitive behavioural strategies. Please use the contact form if you would like to get in touch.

OCD: the Courtroom Drama analogy

If you have OCD, learning new ways of managing difficult thoughts, feelings and urges with CBT for OCD is the key to living the life you want rather than the one OCD convinces you to lead. One of the approaches we focus on in overcoming OCD with CBT is to learn to relate differently to your thinking. There are many helpful metaphors which might help you to relate differently to your thoughts, but I particularly like this one…

It might help you to imagine your OCD as something like a very experienced, driven, but flawed prosecutor in a court of law. Think back to watching American courtroom dramas at the movies or on Netflix and picture the most opportunistic prosecutor who will stop at nothing until he can prove you are guilty.

The OCD prosecutor believes you are guilty and responsible for causing harm until proven innocent. You’re in the dock and you’re on trial. You, as the defendant, naturally want to defend yourself and prove the prosecutor wrong beyond all reasonable doubt. However, whenever you do this, you are playing into the hands of the prosecutor. Your problem is that you are trying to obtain proof for something which hasn’t happened. This defence case is going to cost you, and big-time. Hours of worry, guilt, shame, wasted hours putting in the effort of trying to argue your side of the story, proving once and for all, beyond certainty that you weren’t, couldn’t be or are never capable of causing the harm or wreckless abandon you fear. The OCD prosecutor means to win, and will use every doubt-enhancing trick in the book to keep you defending. You might get temporary evidence, but very soon the OCD prosecution will come back for another round, with another witness or another event.

You may even plead the defence that “it’s not me, it’s my OCD”. Often this will create a temporary adjournment in proceedings (to continue the metaphor), but occasionally a particularly crafty prosecutor can even use this against you. “What if you don’t have OCD, and these thoughts are a sign that you are a terrible person?” Forewarned is forearmed, it is true, it’s not you, it is your OCD, but a hotshot lawyer will even try to get you to doubt the diagnosis.

Fortunately, if you watch US courtroom dramas, you’ll know there is a route out of this. You can plead the right to remain silent. By telling the prosecutor that you choose not to respond to their demands for proof that you could not or would not act in the way you fear, be what you fear, or be to blame for what you fear might happen, you give the prosecutor no more material to work with. Over time the case will fall apart. There is no evidence to be found, no certainty to be obtained. You can choose to walk away from the proceedings, knowing that you no longer have to play into the hands of the prosecution.

Of course, this isn’t as easy as it sounds, but the metaphor itself may help to remind you not to play into the hands of your OCD mind. Working alongside a CBT therapist you’ll learn strategies to take you through the changes how you relate to your thoughts and change your behaviours which will help you to manage your difficulties.

You can read a little more here: What is obsessive compulsive disorder?

Ali Binns is a CBT therapist based in Bath. She helps clients to manage their anxiety and mood using evidence-based cognitive behavioural strategies.

What is social anxiety?

Excuse the stupidly cute hamster, he was just to grab your attention… but the wide-eyed gaze, his still body and clasping hands reminded me of how humans look when they are feeling socially anxious. If you’ve arrived here, then this feature is to introduce you to social anxiety and how I approach this in CBT (cognitive behavioural therapy).

What is social anxiety?

Social anxiety is when you experience fear or anxiety in social situations. It can vary in intensity from mild distress to extreme phobia of social or public engagements where the sufferer has come to avoid and retreat from any social situations. It typically begins in the early teens. It seems to me important to make the distinction between shyness and social anxiety. Some people can be shy and yet quite able to engage in a wide variety of social situations. Likewise, if you just prefer small groups and quiet socialising, then this may be your preference and just the way you are. Social anxiety is when (whether you are outgoing or of a quieter disposition) your anxiety gets the better of you and you begin to avoid, and excessively worry before future engagements, and/or spend time after the event going over it in your mind. Social anxiety can affect you before, during and after social interactions. It affects your life, your relationships and how you feel about yourself.

The main characteristic of social anxiety is when you fear negative judgement from others, particularly in your social group (friendships, peers at work or at college/university, groups you attend). If you experience social anxiety, then you worry a lot about people thinking badly of you in some way and even that others may reject you as a consequence of this negative judgement.

While social anxiety sufferers’ worries and anxieties may vary slightly, if you have social anxiety then you will almost certainly be thinking that other people might think you are weird, uncool, stupid, rude, weak, or not good enough, for example.

Where does social anxiety affect people?

The situations which are triggers for social anxiety vary. Common places include meetings at work, social engagements, any situation where you might need to perform in front of others (giving a talk or presentation), parties, going to the pub or a restaurant, making phone calls or even going to the shops. You may experience in small groups or large, or even one to one. When you have social anxiety, other human beings pose a threat.

Why does social anxiety feel so bad?

From an evolutionary standpoint, if through our life experiences we have come to develop beliefs where we see others as threatening (anxiety is always about a perceived threat!), the idea that we may be rejected by others provokes a strong mind and body response. Our fight or flight response is activated and our body and mind go on high alert when it perceives a threat to our survival. Why does it do this when we’re not really at risk? The reason is that our brain reacts in a very primitive way even in today’s modern and relatively comfortable world. Even if our worst fears are true and someone does have a negative opinion of us, then our life is rarely at immediate risk because of this. But, in our evolutionary past, if we were rejected from our social group, our peers, or our tribe, then we probably were at real risk as we might lose our shelter, our food, our means of surviving as a group. Our ancient ancestors depended on living in tribes to survive - cast out of a group and we would risk starvation or predators. Unfortunately our brains respond as if we were still living in this way. That’s the tricky modern brain with its alarm on a highly sensitive setting.

If you’re looking for a simple answer on why your brain might have a more sensitive setting than another’s, then there’s no single answer. Biological and social factors, your temperament, your family upbringing, being around critical people (parents, carers or teachers), as well as your individual experiences in life can all make you more or less vulnerable. A compassionate understanding of these influences can help, but real changes can be made when you are ready to confront and challenge your fears.

When the social anxiety alarm bell has been set off, this will affect how you feel, how you think and how you act.

Social anxiety - what does it feel like?

Social anxiety symptoms can affect any part of the body and all of these sensations are created by your fight or flight response. You may feel hot, experience a racing heart, feel like you want to run away, have sweaty palms, or a tight chest. You might find it hard to find your words.

Things can really up a notch if you are someone who blushes or shakes, because this can become an extra part of the problem, as you may think you will be judged for having anxiety when the signs could be noticed.

Rest assured while these symptoms are uncomfortable, they are actually your body doing its job, preparing itself for survival. It’s just that it’s being a little too helpful for our requirements when it gears up like this in social situations.

Social anxiety - what do you do?

When you’re feeling it, what do you notice you do? If you are in the thick of it, you may feel like running away, leaving places early, or avoiding the situation, or you may find yourself scanning for the nearest exit. You may avoid feared situations entirely or find yourself cancelling plans at the last minute with an excuse.

Your body posture may become ‘smaller’ as you attempt to hide, or perhaps you do hide in the corner or stick only with people you know. If you’re in public, you may often look down rather than make eye contact with others. Maybe you talk very quickly, or you speak very quietly, or perhaps you don’t say a word. You may find yourself overcompensating, trying too hard, or acting in a way that isn’t really you. Perhaps you have a crutch, such as alcohol to get you by.

Social anxiety - where’s your thinking?

You may find yourself analysing what to say, or focusing on how you are coming across. Your focus becomes very much on what others might be thinking of you, in terms of what you say, how you look or how you sound. You may worry before and during the event, and spend time after the event rating how badly it went… When you are worrying you may find yourself catastrophising, labelling yourself, comparing or jumping to conclusions about how others see you.

Wow - I’m even starting to feel quite anxious as I write this, and I’m imagining you might too, especially if you are familiar with any of these symptoms. So what can be done to manage social anxiety?

How does CBT help?

CBT looks at how your thoughts, emotions, behaviours and physical symptoms interact. As a CBT therapist in Bath, I work with my clients to explore how their anxiety is made more intense by their beliefs, thoughts and behaviours. By pulling all of this together, we can work on strategies to offer ways to break the cycle.

Often with social anxiety people can be experiencing a degree of shame and feeling unworthy or not good enough, so some of the therapy may be in learning to be compassionate to yourself in the face of difficulties. Often harsh self-criticism can keep social anxiety going and learning to support yourself in a nurturing way can be so important.

While working through understanding social anxiety, and learning supportive and calming techniques, we would begin to get you approaching situations which you may have previously avoided, and engaging socially while experimenting with new ways of behaving. Although at the start of therapy, this may seem daunting, many clients find this part of the therapy hopeful, even exciting (it’s true!) The aim is to begin to adapt and take on small social challenges as you work towards your chosen goal.

If you have social anxiety and would like support, you can find out more about me by exploring the site.

Ali Binns is a CBT therapist based in Bath. If you have social anxiety and would like support in overcoming this problem, you can find out more by exploring the site. Or feel free to get in touch by hitting the contact button.

Breathing exercise: Box breathing

When emotions run high and we can feel our emotions getting the better of us, it’s not so easy just to think ourselves out of it with immediate effect, so it can be useful to have a variety of techniques at our fingertips to help to soothe our emotions. Then can we step back and see things differently. This post is going to focus on a simple breathing technique called Box Breathing which we can use to help to soothe our emotions when we need to.

Albert Einstein, a clever sort, we can all agree, once said, “We can not solve our problems with the same level of thinking that created them”. This makes a lot of sense when you get into a tricky spot and you find yourself hijacked by your emotions. Please don’t beat yourself up about this, it happens to everyone - it’s just that some people have learned strategies to cope better and some have yet to learn.

When our emotions are triggered, our brain has already begun to send out messages to protect us from imminent threat and has set in motion the body’s fight, flight or freeze reflex. The sympathetic nervous system becomes activated (all systems go!), to fight or to flee the scene, or, if all else fails, to freeze. This is your body’s survival mechanism at work.

The difficulty with being able to think differently when our emotions have been triggered is that the thoughts become threat-focused, with a distinctly negative bias. This would have had a clear benefit to us when our lives depended on it, but in the modern world, the attentional bias causes more problems than it solves. We can’t think differently, as old Albert says, unless we create a slightly different space for ourselves to think in. So what to do?

Fortunately we have our own breath at our disposal to engage the parasympathetic nervous system (a calming response). By breathing in a way that signals safety, you can begin to activate the brain’s soothing systems, and start slowly and surely to reverse the cycle. As you calm your breath, you are in a better position to begin to access your rational thinking and assess how best to proceed in the difficult situation you may have found yourself in.

This post is focusing on the simple technique of Box Breathing. I’d encourage you to give this a try for a week or two and see what benefits it might bring for you.

A guide to box breathing

Begin by imagining you can see a square shape in your mind’s eye - a simple geometric box shape if that’s easiest, or if it helps, imagine a perfectly square window looking out over a relaxing scene of your choice. Now beginning in the top left corner of the box shape, take a deep breath in as you trace your way across the top edge for an approximate count of four, hold for a count of four as you travel down the right hand side of the box shape, breath out for four as you trace along the bottom edge, and hold once more for four, as you head up to the top left corner again and repeat. Repeat for as long as you need.

Don’t try to force the count, if this seems at first unnaturally too long or too short. Feel free to adjust it, but ensuring as best you can to keep the breaths even. Fill your lungs in the in-breath and breathe out all the air on the out-breath. This way you will succeed in slowing down your breathing, enabling your body to begin to relax and slow. Just keep a focus on the idea of the box shape to assist you with keeping the breaths even and smooth.

Other breathing techniques are of course available. You could also practice a beginners mindfulness of breath practice or soothing breathing.

Ali Binns is a CBT therapist based in Bath. She takes an integrative CBT approach, helping you to discover evidence-based approaches which will work for you and your unique situation.

What is awfulising (and the tale of the two arrows)

Awfulising - what a word! It was invented by Albert Ellis to describe a tendency of the mind to catastrophise situations when we meet adversity, especially when things are going against our wishes or our goals. When we are faced with a threat, be it real or imagined, it’s common to ‘awfulise’ or ‘catastrophise’ things not being the way you want them to be, adding an extra layer of distress to an already difficult situation for you.

The tale of the two arrows

Awfulising is the mind’s equivalent of a ‘second arrrow’. What’s the second arrow, you may be wondering? The idea comes from an old Buddhist parable of a man walking through a forest when he is randomly struck by by a hunter’s arrow. The pain of the first is unavoidable, the second arrow is the additional suffering he may add to his experience by going on the ruminate on the event. For example, this shouldn’t have happened, it’s truly the end of the world that this happened. The second arrow is the response to the adversity, which we can learn to manage… Bad things can happen.

In REBT-CBT, we acknowledge that there can be some circumstances beyond our control, but learn that we can manage our response to the second arrow, when we add our own pain to the original injury. Awfulisation is one such arrow we might add to our difficulties. We tell ourselves that something is end of the world bad, that’s it is awful, terrible, specifically that it is off the scale bad. What do you think is the impact of going about your day with a habit of awfulising…?

Here’s an everyday minor example: My printer isn’t working… This is absolutely terrible, how am I going to manage now? How do you think this person is feeling now? Does it help to think these kinds of thoughts? What is a more realistic and helpful way of putting this?

Think of the person above, whose printer wasn’t working. (Okay, I’ll admit, it was me!) What could I have said instead which would be altogether more helpful? Yes, it is true that this is highly inconvenient and a hassle, that this has come at an awkward time, but there are worse things… It is bad that this has happened, but hardly the terrible thing I was leading myself to believe. What is the result of calming oneself with more flexible thinking…? Yes, still some frustration and concern, but a calmer mind means a better ability to problem solve, instead of rooting around switching the printer on and off again with no results.

How to tackle awfulising

It’s always worth stepping back and contemplating your mind chatter when it comes to the everyday habit of awfulising.

Here are some suggestions you could try if you notice you have a habit of awfulising… You could ask yourself, is this situation a truly a horror or just a hassle, an everyday tussle or terrible, impossible or inconvenient?” Any which way you look at it, when we awfulise the everyday adversities, we make life harder than it needs to be. Awfulising sends the message to our brain that the threat is worse than bad, and ramps up our negative emotions, and affects our actions.

It can be helpful to try out a different perspective when it comes to awfulising. You might consider what are the consequences of awfulising or catastrophising your difficulty? You might reflect on the reality of the difficulty - you can practice being genuinely compassionate to yourself about that, because all of us have difficulties one way or another.

Lastly in some situations, you may even be able to cast the net wider and consider three good things which could come about as a result of the problem? (A tough one, but often we can find something unexpected.)

Many times, just acknowledging that you are facing something that is bad and difficult, but reminding yourself of the temporary nature of this challenge and that although it is bad, it’s certainly not end of the world bad, can take the sting out of things. This can alleviate the second arrow.

If there’s an arrow that’s come your way, looking to see whether you are in the habit of awfulising can help to cushion the blow of a second arrow you’ve provided for yourself.

Ali Binns is a CBT therapist working in Bath, UK. Read more about CBT under the tabs above, or delve into the Resources to see if there’s something helpful you can find for yourself.

Compassionate Kitbag

Sometimes, when life is difficult, and we may not have others immediately around to give us the support we need, we need an emotional boost, something to help to soothe us or give us a lift. That’s where the Compassionate Kitbag comes in. This is a homework I sometimes set for clients to support their wellbeing. Read on if you would like to create your own Compassionate Kitbag and reflect on what you might put in yours...

What’s a Compassionate Kitbag? A compassionate kit bag is, put simply, a selection of go-to items for whenever you feel in need of feeling restored. These can be stored in a little box or bag so you know where to find them when you need them. You can create something to keep at home, or even a mini set you can carry with you when you are out and about.

Create your own Compassionate Kitbag

Spend some time gathering and reflecting on a collection of objects which represent soothing and nurturing to you. These can be a mixture of calming or uplifting, depending on what you might need at different times. This is completely personal and unique to you. Focus on selecting things to encourage and experience feelings of soothing, calm, contentment and balance. Spend as much time as you need to ensure you find what works for you.

The items you select for your ‘Kitbag’ can be a work in progress and added to over time as you think of new objects. You can store these in a small bag or a box, or even create a mini go-to bag you can carry with you at all times. Try, if you can, to select a range which might appeal to all of the senses – sight, sound, touch, taste, smell.

For myself, I have some small items I keep by my desk - always a tiny shell, a small holiday souvenir from Thailand, a tiny tube of handcream and a small scented candle. Each of these items appeals to different senses.

If you would like to download these instructions in a printable document, click Compassionate Kitbag.

To get you started here’s a list of suggestions:

o   Smells (eg. essential oils, perfume, hand cream)

o   Soothing objects (eg. Pebble, shell, soft cloth, crystal)

o   Memento connected with safety and calm (eg. souvenir, soft toy)

o   Music/song lyrics (maybe a playlist)

o   Poems / reading (copies of favourite poems, quotations, favourite book)

o   Pictures / photos / postcards

o   Tastes (eg. herbal tea / coffee / hot chocolate sachet, small bar of chocolate)

o   Hobbies you enjoy (portable items or reminders of these); engaging puzzles

o   Imagery or drawings (eg. of compassionate self or other, place of relaxation)

o   Compassionate letter to self

For the purpose of your kitbag, it’s important that the items you choose are associated with nurturing yourself, creating a sense of calm, safeness and contentment. Steer clear of items which may remind you of sad or difficult times as we are aiming for a collection of items to soothe rather than stir up difficult emotions.

Chris Winson (blogger and well known on Twitter for his #365daysofcompassion initiative) writes beautifully about his compassionate kitbag on his blog here. There are some super suggestions which might inspire you further.

Putting together a Compassionate Kitbag is a simple, nurturing and helpful activity which will mean you have a box of meaningful and supportive cues you can turn to as often as you need. I wish you well in putting together your own self care selection. Be sure to dip into it regularly!

Credit for the original idea goes to Kate Lucre, a Compassioned Focused Therapist. I first learnt about this on one of her workshops.

Self acceptance or self esteem?

Would you chop down an orchard if you found one apple that wasn’t perfect? That’s what we do to ourselves when we don’t live up to our own rules about who we think we ought to be or how we should be. When you’re struggling in life, you may find yourself wishing you had ‘better self esteem’ or that you could be more confident. The real answer to this question is not to cut yourself down or pretend that everything is great, but to develop what we call self acceptance in CBT (cognitive behavioural therapy) and REBT (rational emotive behavioural therapy).

Depending on where you are at, the idea of self acceptance can range anywhere from being something that eludes you from time to time, or may at another end of the scale even seem incomprehensible. People often come to therapy with the goal of raising their self esteem. I’ve written this article as it can be tricky to explain that seeking self esteem is not one and the same. I hope to explain why self esteem may not be all it’s cracked up to be, and why self acceptance through a practice of self compassion thinking and acting is a preferable way forward.

What is self esteem?

For many years, self esteem was seen as the positive way to boost feelings of confidence and wellbeing. However, researchers have found there are downsides to the pursuit of self esteem. Self esteem literally means ‘rating the self’. How do we rate the self? Well, naturally, we can and do rate ourselves positively or negatively depending on any given situation. But there are problems with this. When we rate ourselves, we subject ourselves to volatile fluctuations by basing our worth on the back of how well we have achieved or not. What happens when you don’t manage to achieve what you wanted to and you rate yourself as a total failure on the back of this? Your mood and confidence plummet.

Self esteem is conditional therefore as it relies on your performance and this doesn’t entirely add up. As early 20th century philosopher Alfred Korzybski described, “The map is not the territory”. Your performance is not the whole of you. An individual is so much more than the sum of their parts, and so rating our whole selves on the basis of an action, ore even a series of actions, is an unhelpful way of reassuring ourselves that we are worthy and good enough.

We are neither a totally unworthy person because we haven’t done something as well as we had hoped, nor are we a totally good person because we have done something well. We just are.

What’s self acceptance?

If seeking ‘high’ self esteem isn’t the preferred option, what is? The answer is unconditional self acceptance. Self acceptance begins with learning to accept yourself for being you, accepting you for who you are with your unique blend of strengths and weaknesses, your history and experience, the good, the not-so-good and the bad, your thoughts and feelings, and learning to see that in all of this heady mix, you have value, you are worthwhile, you are good enough. In spite of what you may have thought, felt or been led to believe through past experience, you are a complex, worthwhile and unique human being. While your actions may be rate-able, you are not. Unconditional self acceptance is a no-strings attached acceptance of your whole self.

This is a key concept in CBT. It is the expression of compassion towards yourself. It is understanding the human condition of fallibility and deeply acknowledging with compassion where you are at right now, and reaching the conclusion that wherever that is, you have done the best that you can. You have this in common with all human beings, struggling as best you can in the face of adversities in your individual life. Some of it you did not choose.

Acceptance doesn’t mean that you will necessarily like everything that you find, but how does it help you when you struggle against this? Berating yourself for your mistakes or perceived failures keeps your threat levels high, and can lead to ongoing problems with anxiety, anger, depression. By all means you can change and improve on what you do, but essentially rating your self based on your actions is not too sustainable. Even if it works temporarily, it won’t work for long. It’s unstable and, when you think about it, not entirely logical. Rating your whole self in a positive or negative way is too subject to external circumstances which may be out of your control.

Albert Ellis, one of the early front-runners of CBT, describes acceptance as follows, “Accept that acceptance is largely compassion – for you and your self, for others and their self, and for the troubled world and itself.” He advocated compassion in global terms: compassion for self, others and the world. Acceptance of others’ differences or perceived ‘weaknesses’ doesn’t mean we like it, but that we are willing to meet people where they are with a willingness to understand. It leads us to feel emotionally better equipped to talk and resolve differences in a healthy way. But let’s not get ahead of ourselves, we can begin where we are. If we really want to change the world, we can start with ourselves by practising compassionate self acceptance.

How can we develop self acceptance?

What have you got to lose? Certainly if you believe that berating yourself and labelling yourself in a negative way gets you results, then you may fear self acceptance and compassion. But rest assured, self acceptance is not a soft option. Accepting yourself requires compassion. This in turn needs strength and wisdom and a desire to relieve your human suffering. Compassion means allowing yourself to feel difficult emotions and face up to difficult situations. Nobody said this was easy.

Perfectly imperfect, flawed but faultless

Self acceptance is a lifelong attitude to develop. You can make a start perhaps by thinking deeply on the fact that no human is perfect, every human makes mistakes, every baby is born with equal value. No baby is born thinking that they are not worthy or good enough, this is learned and what you come to believe through circumstance. You may begin to learn to accept yourself through remembering this. Perhaps the following thoughts will get you started…

Author, Alice Walker once wrote: “In nature, nothing is perfect and everything is perfect. Trees can be contorted, bent in weird ways and they’re still beautiful.” Imperfection is acceptable, beautiful even.

The Japanese have developed a craft known as ‘Kintsugi’ which means golden joinery or golden repair. Broken ceramics are repaired with a lacquer that is mixed with precious metals. The result is that the flaws in the pots become just a part of the history of the object, rather than something to be discarded or rejected.

My burr oak bowl: beauty in imperfection

There is a type of wood known as ‘Burr oak’. Perhaps you’ve heard of it. The ‘burr’ that you find in this type of wood is actually a flaw in the wood caused by disease, but in reality many people find this imperfection in the grain to be the most attractive. Instead of the expected wood grain, there are unexpected variations in pattern which give unique texture and appearance.

In the end you have a choice. You can choose to develop a compassionate and nurturing relationship with yourself, or you can continue to give yourself a hard time, only conditionally accepting yourself. It takes a concerted effortful approach to changing your attitude to yourself. It may not be a goal you ever reach 100%, but a direction you can choose to take. As long as you are headed in the direction of self acceptance, you will begin to feel better about yourself. What is one small step you could take today towards accepting who you are?

Ali Binns is a CBT therapist based in Bath, UK.

4 beliefs which harm you: Unhelpful beliefs and your emotions

One of the founders of CBT, Albert Ellis had a way with words. His way of explaining things, as a rather brash and forthright New York psychotherapist, was that we would all lead calmer, more contented lives if we were able to stop 'shoulding' on ourselves, and, humorously, he added, not indulge in 'musterbation'. What could he mean?

Ellis' specific branch of CBT (cognitive behaviour therapy), known as REBT (rational emotive behaviour therapy), proposes that much of human suffering is made worse by the demands (the shoulds, musts, shouldn't and must nots) we make on ourselves, others or the world in general. These demands become the window through which we look at our world - past problems and difficulties in life can start to add a level of murkiness to our window. It can help to clean up the glass from time to time... which is where CBT comes in.

Beliefs impact on feelings

In CBT we look at the way inflexible and irrational thinking contributes to our distress. This is not a new way of thinking, in fact it's rooted in wisdom that goes back to the Stoic philosphers almost 2,000 years ago. Epictetus summed it up well when he wrote, "People are not disturbed by events, but by the view they hold of them."

Reality check

Before we start out, this is not to say that there are not situations which are very bad and in an ideal world would not have happened, but we live in an imperfect world. Pain, suffering and bad things happening are the price we pay for being alive. Life isn't always easy, life isn't by nature fair, and people don't always meet our expectations or our needs. The real power in CBT is that if we can learn to address the way we think, we can reduce unnecessary emotional distress which we may be layering on top of what may well be appropriate sadness, concern, healthy anger or regret relating to difficult situations. Negative emotions can be healthy responses to adverse events. These are necessary and human emotions which help to motivate us to take action. CBT is certainly not about putting a sticking plaster on your emotions, but it is about reducing emotional disturbance and experiencing a healthy emotional response.

Danger of demands

One of the main roots of vulnerability to unhealthy negative emotions (eg. anxiety, depression, unhealthy anger, guilt) lies in the irrational beliefs which we may bring to our experience. Let's call these beliefs the window through which we view the world. While we may not be able to change the past, other people, or many situations and things which are outside of our control, we can clean up the window, by addressing irrational and unhelpful beliefs and replacing these with helpful, supportive alternatives. A clearer view will result in a calmer life with more measured responses. And who doesn't want a clearer view? With clarity, we can appreciate where we are with less negative judgement, and we have time to choose our response more wisely.

As human beings we all have wishes, desires, and ideas about how we want things to be... Unfortunately when things are not going our way, we might notice a tendency to absolutely demand that things are different. Often we may not even be aware that we are doing this. These demands might come in the form of unreasonable expectations, inflexible and unrelenting standards or striving to make the impossible possible. Ellis described these demands as being inflexible, unrealistic, and unhelpful. Demands can be easy to spot when you are on the lookout. Listen out for shoulds, musts, ought tos, need to's, have to's or their negative counterparts, mustn't, shouldn't and so on. These demands form an inflexible rulebook which contributes majorly to emotional distress.

Some of our unhelpful demands we may have developed over the course of our lifetime; at some point these may even have served as a way to adapt to difficulties we have experienced. This may have worked at some level in the past, but when we don't address these patterns of thinking, we can be left reacting in the same way we always have to our personal trigger situations. And in this way, we can easily become trapped by our past.

What are your demands?

How often have you considered the demands you place on yourself or others? What arises when your demand isn't met? Have a ponder for a moment. How often do these demands contribute to living your life in a calmer way? How often to they feed helpful behaviour or ways of thinking? How might they even exacerbate symptoms of anxiety or stress?

And it doesn't end there... When a demand about how things ought to be isn't met, we can disturb ourselves in three additional ways. 

Catastrophising: inflating the badness of the demand not being met. Self talk: It's awful, it's a disaster when my demand isn't met.

Low frustration tolerance: an underestimation of our ability to cope with the demand not being met. Self talk: I can't bear it, I can't stand it.

Self / other / world criticism: global negative and damning beliefs about yourself or others. Self talk: I'm a loser, failure, worthess. Or, he's an idiot, a total pain.

Flexible thinking

To remedy this, in CBT we work towards challenging irrational and unhelpful beliefs in order to improve psychological flexibility. This flexibility leads to adaptable supportive behaviour, greater resilience in the face of adversity, emotional wellbeing and improved self worth.

When you can reframe your beliefs with rational, flexible, realistic and helpful beliefs, you can experience a calmer outlook. Adapt your philosophy on life and choose to reframe the way you think with flexible preferences.

To illustrate, here's an example on a sporty theme.

Runner A: I absolutely have to win the race. It would be a disaster if I didn't. I couldn't cope with not being top of my game. I'd be a failure if I didn't win.

Runner B: I really want to win the race but accept that I might not. It would be bad, but not a disaster if I didn't. It would be hard facing up to it, but not impossible. I feel secure that I will have done my best and not winning doesn't mean I am a failure, just that on this occasion there was tough competition.

Which runner experiences the greatest emotional distress? How is runner A likely to feel? What about runner B? Which runner is likely to put in the best performance? Which runner will find it harder to compete next time?

Flexible preferences express what you would like to happen but acknowledge the reality that you may not get it. Even though this situation might be bad, and it might be hard, you can begin to learn to tolerate the difficulty of not getting what you would like.

So for now, I'd like to leave you just to consider your own demandingness. Keep a track and notice the tendency. Once you notice you can begin to relax some of the demands you feel able to let go of.

In summary, beware of the must, shy away from the should.

The other unhelpful beliefs I will deal with in another blog soon and link up to it here.

Ali Binns is a CBT therapist based in Bath. If you're looking for support, please feel free to get in touch using the contact link at the top of the page.

5 ways to make the most of your CBT therapy sessions

Now that you have taken the brave step of reaching out for help and since you are investing time and effort in coming to sessions, I’d like to offer you some tips on making the most of your CBT therapy sessions. Here's how best to navigate the process and  work towards the life you want.

First task. Let's clear up any misconceptions about therapy. Of course CBT is a talking therapy, but it might be more truthful if we called it a talking and doing therapy. Emotional change only comes from thinking and doing things differently. It will never be as effective to only talk about your problems. Talking may help you to understand why you feel the way you feel or think the way you think; of course, this can be helpful. But, if you think of therapy as like playing a musical instrument, such as the guitar, you will never succeed at playing by just talking, thinking or reading about guitars. Progress comes from practice, perseverance and commitment. Making changes are the way to experience the progress you are looking for, and CBT is most effective when approached as an active therapy.

The more you can do between sessions influences the amount of time you may spend in therapy. If at one far end of the scale, you only turn up to sessions to talk with your therapist, then it goes without saying progress will be slower.

Here are 5 tips to make the most of your therapy sessions.

1 Get yourself a therapy notebook
Even though we all carry phones around, and these can be helpful for on-the-fly notes, slowing down and putting pen to paper really does help to clarify the kinds of thoughts we are having, and can even help us to see our thoughts for what they are. We can better identify patterns of thinking which may be contributing to our problems.

To get the most out of therapy it is beneficial to make notes before, during and after sessions.

Before sessions Make a note of anything which would be helpful for you to discuss in your therapy session. However, since CBT is a goal-oriented therapy, if it is on a different topic entirely, you may have to weigh up whether this is something you would like to spend time discussing. 

Perhaps something might occur to you during the week which you wish you had told your therapist and which you think may be relevant to your treatment. If so, make a note, so you don’t forget.

During sessions Keep your pen handy during sessions and be ready to write down anything you find helpful or that you will want to remember. You never know when you might have a lightbulb moment. And it’s a good discipline to get into so that you remember any tasks you might have planned for between sessions… Therapists don’t like to nag, they really don’t.

After sessions Reflecting on a session is a good way to make the most of your latest session. Find some time, ideally while the session is still relatively fresh in your mind, and ask yourself a couple of simple questions. What stood out for you in the session today? How are you feeling now? What did you find helpful today? Did you (even in any small way) experience different feelings or think differently about yourself, others or the world in general? What friendly, compassionate and kind thing could you say to yourself now, which would support you to go about the rest of your day?

2 Learn to journal
During CBT we will cover different ways of journaling your thoughts, feelings, behaviours and physical sensations / symptoms. Practising noticing your own particular patterns is going to be important, because if we would like to change how we think and act, then we first need to notice our own tendencies which may be unhelpful and maintaining any difficulties we might be experiencing.

I’ll often supply different thought records and templates so you can practise noticing, then working towards reframing or managing your thinking in a new and helpful way.

3 Be clear about your goals
Even if your initial therapy goal is quite general, such as learning to manage your anxiety, or to cope better with life’s challenges, as therapy continues, it will be helpful to spend time reflecting on what specifically you want to be doing differently. As the weeks go by, it will help you enormously to have a picture of what you would like to aim for, the more specific the better. As with all goals, it’s important for your goals to be specific, measurable, achievable and to have an idea of when you would like to do this by. Goals help therapy to remain on track, although it is fine to step off the pathway from time to time. Life is like that and we can accept that sometimes life throws curveballs during your time in therapy and these may be more pressing to talk about at times.

4 Be honest
This is important on different levels. I really encourage my clients to understand that they are the expert on themselves and to be as honest as they can about how they think and feel. This will help your therapist to devise the best plan for you. If ever you don’t understand a concept or the rationale for an exercise, point it out, so your therapist can be more helpful. If you have struggled with an exercise, let your therapist know. 

5 Do your homework
Homework, or as some might call it, an action plan, consists of between sessions tasks. You might be working towards managing your thinking in a different way, practising mindfulness or relaxation techniques, or journaling. You might be changing what you do and approaching rather than avoiding difficult situations, places, conversations or people. You might be learning to relate to yourself in a kinder, more compassionate way.

In CBT we focus on using evidence based techniques, but it is only in the practice of these where you will learn what works best for you. Even if you think it might not work for you, can you be willing just to see that as an unhelpful thought which may be standing between you and feeling better.

Many tasks in CBT need to be repeated in order to experience a benefit, so be prepared to practice and repeat a task for at least a week or two to see what benefits you experience. Once you know what works for you, you’ll feel encouraged to keep doing it.

So these were the five things I’d like you to know. If that all sounds like a lot of hard work, you probably already knew that nobody ever said therapy was easy. It isn't, but it can be the most rewarding and valuable experience. It can be emotional and it can (clients say) even be fascinating. I wish you well in your therapy and much courage to try new and helpful ways of thinking and acting.

Ali Binns is a CBT therapist based in Bath, UK. To find out more click on the links at the top of the page.

Mindfulness exercise: 5 senses fruit meditation

Mindfulness awareness has a multitude of benefits, not least becoming aware of our mind's tricky tendencies to time travel to unhelpful destinations. Practising simple mindfulness techniques helps to develop our focus of attention, realise that we have control over where we place our attention and to become more adept at noticing what is helpful or not to us in any given moment.  We can learn to notice when we have zoned out and gone into autopilot where we might easily find ourselves worrying about things that haven't happened yet, or ruminating over things which already have. 

Busy minds need a bit of TLC and you can consider a mindfulness exercise just the kind of care your mind needs. Even if you consider yourself time-poor, you can easily slot mindfulness into your day effortlessly by using snack time as a few minutes where you can practise paying attention and bringing yourself fully into contact with the present moment.

Mindful eating exercise

Here we are going to practise paying attention mindfully with a small orange, satsuma or other piece of fruit. We will use all five senses to observe and take in every aspect of the fruit. The key to this exercise is in setting an intention to bring your awareness fully to the fruit as if it were the first time you had ever seen such an object. No matter how many times you try this exercise, set an intention to be curious and open attitude about what this moment has to offer. I might be asking you a couple of seemingly funny questions which might make you laugh or wonder why, but be assured there's a reason for it which I hope will become clearer to you by the end... Just go with the process of paying attention and see what happens.

Here are the simple steps. Take a read through a couple of times before trying this on your own. I've based the instructions on using a satsuma as the focus, so please adapt as you like.

First take your piece of fruit and weigh it up in your hands. Get a sense of the texture of the skin, the temperature, the weight, how it feels in the palm of your hand, how it feels as you run your fingertips across its surface. What do you notice here? Spend a few moments doing this.

Next we are going to use our sense of smell to breathe in the scent of the satsuma. What do you notice here? Try to stay with just sensing the fruit, perhaps notice if your mind begins to make associations. It may well do, our mind likes to join the dots!

Your mind will likely wander or begin thinking about things as you move through this exercise, so just notice make a note of these thoughts, and come back to paying full attention using your five senses.

Next take a good look at the fruit. Noticing its visual qualities - colour, shape, any irregularities, the stalk, surface texture. Just take it in - looking for details. Keep an eye out for any tendency to make comparisons or judge the fruit! You'd be surprised how often our mind rushes to judgements. 

You could try next bringing the satsuma up to your ear and listening to the sound it makes when you squeeze it or tap it. What sound does a satsuma make? (I'll bet you never wondered that before!)

Next take a few moments to peel your fruit. Noticing how this feels as you carry out this simple everyday task. Bring your awareness to your sense of smell and touch as you go... What is here for you as you do this?

Take your time next to undo a segment from the whole and review the segment using as many of your senses as you wish.

When you are ready, take a piece of satsuma and place it on your lips noticing the sensations of touch before placing it in your mouth. Pay attention to the possibility of an instinctive reaction to bite straightaway and instead linger a moment or two on what you notice. Bite when you are ready but slow this action down so you can pay attention to the process of what happens, noticing sensations and flavour.

Bring the practise to a close when you are ready, extending it for as long as you would like.

When you are finished, it's good to reflect on your findings of mindful eating... what did you notice? Was anything surprising? Where did your mind go? How satisfying was it to eat the orange in this way? What do you miss when you eat on autopilot? How might applying some of your findings help you with any problems you are experiencing?

I hope you've found something helpful in this exercise. As I mentioned, you can try this with any snack or drink and just apply the same principles.

If you'd like to try this exercise with chocolate, there's a similar exercise here: Mindfulness of Chocolate.

Ali Binns is a CBT therapist based in Bath. She uses mindfulness based techniques to support her clients therapeutically. Find out more about how she works by clicking on the links at the top of the website.

Unhelpful thinking style: Labelling

Another in my series of posts on unhelpful thinking styles and this time I'm targeting 'Labelling'. Labelling, or global negative rating of the self or others, is a type of thinking which follows close on the heels of a situation where you or another person has failed to meet your standards or your goal. Typical and common self inflicted labels include: "loser", "failure", "idiot", "stupid", "unworthy" or any number of harsher and even sweary adjectives. Feel free to add your own to this list.

Labels are when you put yourself or others down in an unfairly harsh and critical way. If you label others, it exacerbates any angry feelings you may have towards them. If you down yourself, it only decreases your mood, making you feel disappointed in yourself, angry at yourself, depressed, increasingly anxious, perhaps guilty and ashamed. In short, your emotions will take a big hit. (In this post, I'm going to help you to consider self labels, but many of the same strategies can be applied if you find yourself labelling others too.)

What's your poison?

Consider for a moment how you relate to yourself when things don't go the way you want them to. What do you tell yourself? What is the impact of this? Do you feel this in your body somewhere? What do you feel like doing when this happens? Chances are you can easily imagine a sinking feeling in the pit of your stomach, or feel tense as you consider any of the negative labels you pin on yourself even if you only do this from time to time. If you do this regularly, how do you think this might affect your over the longer term? Maybe the feeling makes you want to run away, hide or lash out? 

None of this would be surprising, as self criticism activates our threat system, which increases levels of cortisol and adrenaline. This, in high doses, is not in our interests if we would like to manage our emotions in a helpful way.

Thinking about your labels

Tackling our tendency to label ourselves is first of all noticing when we do this, and the situations where we might have a tendency to do so. Then we can be ready...

Compassionate questioning can be helpful. You can ask yourselves simple questions. Be mindful to use a kind and caring tone such as you would if you were enquiring to someone you really care about...

What's the impact of relating to yourself in this way? How do you feel? How does it make you want to behave?

Does it make sense to sum yourself up with a single radically damning adjective? 

Are you overlooking some of the many other attributes which make the whole of you? Remember that some of the things that unite us all as human beings are that none of us are perfect, we all struggle, and we all mistakes but we all have an untouchable value that remains unchanged... Can you take some steps towards accepting yourself - all of the good and all of the bad? (There's another perspective on this here: What's not on the label)

That goal you didn't reach? Are you 100% responsible for this? Are there other factors which you might take into account?

That rule you set? Was it fair? Did you set up an impossible demand on yourself?

Are you expecting yourself to be something other than a fallible human being?

What would a very close and caring friend sum you up in this way? If not, why not?

Peel off your labels

Be honest with yourself. There may be a part of you which is reluctant to give up on the negative labeling or that critical inner voice. But going on past experience how has that worked so far? What kind of relationship would you like to have with yourself?

What do you think that your inner critic wants for you deep down? Does it have the same desires as the most compassionate and forgiving part of yourself? If so, what might it be like to talk to yourself in the same tones, with the same kindnesses as you would to someone who was very dear to you? 

These questions can be soul-searching and sometimes you may need the help of a therapist or a loved one you can trust to work these through. But I hope some of these questions go a little way to helping you to identify how you may hurt yourself with your labels and how you can begin to treat yourself in a more supportive and helpful way.

Take a look at the other ranges of unhelpful thinking styles for further tips on managing your thoughts in a new way...

Unhelpful thinking styles: Catastrophising

Unhelpful thinking styles: filtering and emotional reasoning

Unhelpful thinking styles: jumping to conclusions

Unhelpful thinking styles: black and white thinking

Unhelpful thinking styles: compare and despair

Ali Binns is a CBT therapist based in Bath. For further information on how she works, take a browse round the website, or to get in touch, use the contact form on the Contact page above.

Unhelpful thinking styles: Compare and despair

Here's an art form which is unique to human beings: the art of comparison. In fact, it's so prevalent that it has its own heading under the list of unhelpful thinking styles in cognitive behavioural therapy: Compare and Despair.

The danger of Compare and Despair thinking is pervasive. Like a weed, it can quickly become rooted, and a feature which any one of us can do without. Compare and Despair thinking can contribute to anxiety, depression, shame, envy, leading to self criticism, lack of self worth and it rapidly undermines any confidence.

In the evolutionary context of survival, having a cognitive ability to compare our abilities with others', or to suss out whether or not we might be acceptable to another social group, makes a lot of sense, especially if the results of our decision are bound up with live or die scenarios. However, in the present day, this hangover from the past can tip from helpful to survival to unhelpful to daily life. This inherited tendency to judge ourselves in comparison to others would definitely have helped us to succeed in competing for resources such as food or shelter, but in our everyday lives, this ability can cause more problems than it solves. First of all, and perhaps most important, is to recognise that you are not to blame if you have a tendency to think this way - it's how your brain was made. 

When we look around us in this information-saturated age, there are plenty of opportunities for us to compare ourselves to others. We might compare looks, status, partners, children intelligence, individual character traits (how funny or articulate someone else is), possessions, emotions... in fact, it's humanly possible to compare just about anything that something else has with what you have.

How to overcome comparisons

No-one would say it is easy to overcome... as with any thinking style, this can be ingrained. Awareness and catching ourselves in the act of comparing and despairing is our first step. You could begin to write down or capture these thoughts before deciding how you treat them.

Unhelpfully, comparing ourselves to others can can go hand in hand with the unhelpful thinking style of filtering, or, tending to paying attention to what fits our worst fears about ourselves... For example, if we believe we are boring then we have a radar seeking out information to confirm this. This is what Christine Padesky calls 'prejudice against the self' - our brains are wired this way too. Just another of the faults our human brain has to contend with! This means that we pay more attention to what we see as our own weaknesses, than paying attention to everything else about us, and compare and rate ourselves negatively.

Take a more balanced view

If we know that we do have a knack of disqualifying the positives about ourselves, or discounting any praise received, we can choose to make a conscious, yet uncomfortable, attempt to let it in! It is okay (though admittedly not very British!) to take on board compliments and acknowledge the positives about yourself, but take them on board you must. It's just that you may have become accomplished at focusing on the ways in which you think you don't make the grade. You can begin to consider a more balanced view about yourself. 

Learn to let go of unhelpful thoughts

It's very likely that in my attempt to persuade you to think about some of your positive qualities, your mind is already coming up with excuses that some of those good things that you have thought of 'don't count', 'they only said that to be kind', 'they didn't mean it', 'they wanted something'...  Notice that this your mind still trying to defend its own prejudice against itself. These are simply thoughts, and not facts. You can learn to let these go. A simple mindfulness practice can help to learn to just watch you thoughts without getting caught up in them. Try this Beginners Mindfulness Practice. With practice, mindfulness can help you to turn your attention to what is helpful for you.

Build self compassion

Perhaps a better answer yet is to learn to be kind and compassionate to yourself. Yes, there may be things that others have that you would like to have, or you would like to be, but none of these are indicators of your worth as a human being. You are uniquely valuable as you are. What they have and you don't is no indicator of your worth.

There is a Zen saying that, “A flower does not think of competing to the flower next to it. It just blooms.” If we learn to accept ourselves for who we are, each of us our own unique, imperfect (yes, because everyone is!) and wonderful version of a human being, and if we can learn to treat ourselves with self compassion... then maybe just then, we can be like the flower, allowing our own selves to shine regardless of how we think we stand in relation to others. 

If you would like to find out more about other unhelpful thinking styles, please take a wander through the following articles:

Unhelpful thinking styles: Catastrophising

Unhelpful thinking styles: filtering and emotional reasoning

Unhelpful thinking styles: jumping to conclusions

Unhelpful thinking style: Labelling

Ali Binns works as a CBT therapist in Bath. She helps clients to overcome their problems using a range of cognitive behavioural strategies. 

Unhelpful thinking style: catastrophising

One of the strangest words you might come across in cognitive behavioural therapy (CBT) is 'catastrophisation'.  This strange yet necessary word (which spell checkers do not like at all!) was coined to describe what is a common and unhelpful thinking style.

Catastrophising means that when we are experiencing something we don't like, we can develop a tendency to exaggerate the badness of the situation into something far worse than it really is. Have you ever caught yourself describing a situation as 'terrible', 'awful', 'disastrous', 'end of the world'? If so, there you have a type of catastrophising in action. As emotional beings, we all tend to throw words around like this. It becomes a real problem, though, when you come up against difficulties in life. 

Such an unhelpful thinking style is closely linked to anxiety, depression and other unhealthy negative emotions as these types of thoughts feed the badness of a situation which might already be causing you problems. And watch out - we can use this style of thinking to describe current, past or future events, fuelling any emotional storm we may be experiencing.

To help you to understand this in greater detail, it might helpful to consider an example. Then we can go on to think about how to counteract this way of thinking...

Let's imagine someone was anxious about a forthcoming exam situation. They might have a chain of thoughts which goes like this: "I've got an exam coming up... I've not done as much revision as I'd like. If I fail, this is going to be awful. In fact this would be a disaster." This line of thinking then encourages further worry thoughts, and vivid imaginings of how 'terrible' this could be... it might lead a person to picture all their friends at a party celebrating while they remain home alone, their family judging them badly, or even imagining themselves unhappy and working in a job in which they can get no satisfaction for the rest of their lives.

Put simply, we may say that someone is taking a bad situation and magnifiying it into the worst possible outcome. When we have a situation which is meaningful to us and we don't get what we want, we can get into a habit of catastrophising the situation. We can even believe this to be truly awful. And because our minds are ridiculously creative, we can visualise scenarios which go beyond reality. This adds to any original emotional distress and makes it harder and harder to think of things we could do to help ourselves to cope.

Once we start build on the original threat or disappointing situation, and we start to repeatedly tell ourselves how awful a situation could be, we might even begin to believe it. It's not our fault that this happens, it's the way our minds try to deal with threats. Constant worry leads to catastrophising an experience and undesirable life events can lead us to make assumptions about how we expect things to turn out. 

To turn catastrophisation, we first need to become aware of when we are giving ourselves these messages. Your brain is listening to what you say all the time, and it will react as if these words and thoughts are true, switching on stress hormones and increasing your negative emotional reaction. The key to moving away from these unhelpful thinking styles is to practise catching yourself in the act of these thinking habits. Habits can be changed with practice, repetition and effort. 

Once you have spotted that this is something you might be prone to, you can learn to question these thoughts. It can be helpful to ask yourself questions such as the following:

• How helpful is this thought?
• Where does this thought lead?
• If I didn't believe this thought, how would I feel differently or how would I act differently?
• How realistic is this thought? 
• What is the real likelihood that this catastrophic thought will come to pass?
• What is the most likely outcome?
• Have I thought this way before, and what was the outcome then?
• How would you reassure a very good friend or loved one who was thinking this way?
• What is a more helpful, balanced and supportive thought which I could choose instead?

These kinds of questions are the kinds of questions which lead to productive lines of thinking and help you to reverse a tendency towards catastrophising situations.

Being curiously aware of your thoughts will pay off with practice. It will help you to avoid the perils of catastrophisation as well as other unhelpful thinking styles...

You can find other articles about unhelpful thinking styles here:

Unhelpful thinking styles: filtering and emotional reasoning

Unhelpful thinking styles: jumping to conclusions

Unhelpful thinking styles: black and white thinking

Unhelpful thinking style: Labelling

Ali Binns works as a CBT therapist in Bath. She helps clients to become aware of their unhelpful thoughts and beliefs and find ways of challenging or managing these in order to feel better emotionally.