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.

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.

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.

A tale of self acceptance: The Two Waves

Ever summed yourself up as a failure, not good enough, worthless or other sweeping negative description? You’re not alone. This tendency to downgrade ourselves if things aren’t going the way we want in life is common place. Self esteem can come crashing down when we do this. In CBT, we call this a global negative evaluation of ourself, and it’s helpful if we can learn to notice when we are doing this and work towards an understanding of the self as far too complex to rate and sum ourselves up with unhelpful all-encompassing evaluations. All too commonly, people suffering from depression, anxiety or stress can sum themselves up as ‘a failure,’ ‘not good enough’, ‘useless’ and so on, when the truth is that none of these can be proved to be 100% true.

Ever noticed yourself doing this? Some of us label ourselves down when things have gone badly in a particular area of our life, but then proceed to sum our whole self up as a result of one mistake or failing. Each person on the planet has a unique and interesting combination of strengths, weaknesses, traits, roles, history, attributes, thoughts, beliefs, emotional responses, so when we explore a ‘global negative rating’, it’s just never true. Each person is so much more than the sum of their parts.

I recently heard this story of the two waves, which I think explains in a vivid way how we are much more than we imagine we are.

There are two waves racing towards the shore, one large and one small. The larger wave is frightened and he says to the little wave, “Oh no, this is it, it’s all over for us. I can see the shore and the cliffs and we are doomed.” The little wave looks back at him and says, “No, we’re fine. I can’t see what the problem is.” The big wave replies, “Look, I am bigger than you, I can see over the top of you and I can see the foam and the shore – I can see that our journey is over.” The little wave looks back and replies, and says, “The end? Not at all you’re not just a wave, you’re the ocean.” The big wave has given himself a self-limiting label, just as we often do, and that has increased his distress as he chases in to shore. Consider for a moment how you might limit your own progress with your own negative labels.

Perhaps you can work on this idea for yourself? Grab a pencil and note down everything you can think of that makes up you. For example, make a note of all your strengths, weaknesses, neutral points, roles in life, beliefs, ideas, attributes, thoughts, likes, dislikes, and feelings.  If it’s hard, you can ask a close friend or family member to get you started. When you’re done, take a look. Now does it make sense to ever sum yourself up in global terms? Can it also be true that you are so much more than any label you give yourself?

Can you begin to learn to accept yourself for who you are – this wonderful one-off and complex human being. There will never be another like you! Sure, you make mistakes, from which you are welcome to learn, or you have weaknesses you'd rather you didn't, but that’s where you’re not alone. Welcome to being human!

I work as an accredited CBT therapist in Bath (MNCS Accred, National Counselling Society) and see self acceptance as one of the keys to improved mental health. If I can help you, please feel free to get in touch via my Contact page or email info@alibinns.co.uk