cognitive behaviour therapy « The AI-Therapy Blog

In anticipation of the upcoming “Mental Illness Awareness Week”, today I am going to discuss 5 devastating consequences of mental health problems. Unfortunately, the consequences are exacerbated by stigmas against those who suffer from mental illnesses, and stigmas against seeking treatment. I am hoping to show you that anxiety, depression, eating disorders, etc. are no less real than other “physical” problems, and deserve to be treated in a similar manner. (I put physical in quotes because, of course, mental and physical problems are deeply intertwined. However, that’s a topic for another blog).

There sometimes seems to be an underlying attitude that mental health problems are less serious than other disorders. This is an unhelpful and unsubstantiated viewpoint. Nobody asks cancer victims to “just toughen up”. However, this is often the sort of advice given to those with mental health issues. This is incredibly sad, given that we now have psychological therapies that are well grounded in scientific research. In particular, new psychological treatments go through rigorous, peer-reviewed testing, in a similar manner as new medical treatments.

Let’s consider the points below, and see what we can do to break the silence around mental health.

1) No-help: People who suffer from problems often do not admit to themselves or others that they need help

This is perhaps the biggest problem due to mental disorder stigmas. By seeking help one is admitting that they have a problem. Often people fear that if they are known to have a mental health issue, it will adversely impact their job or personal relationships. Therefore, seeking help can be very difficult. In fact, it has been estimated that two thirds of people with mental health problems never receive proper treatment. This leaves people alone, blaming themselves, and dealing with their problem in silence.

Taking the first step can be very difficult. This is especially true for social anxiety disorder (SAD), where a fear of being negatively evaluated by others is at the core of the problem.

Small steps are fine. Try talking to a trusted friend, family member or GP. Identify trustworthy people in your life and open up to them about your problems. Quite often, this person will already be aware (to some degree) of your mental health concerns. In fact, it may be the “elephant in the room” that everyone knows about, but no one dares speak of.

In time, after becoming more comfortable with speaking and thinking about your problem, you should aim to seek professional help. However, be careful to avoid:

2) Bad-help: Many people get inappropriate, non-evidence based remedies

It can take some people years to build up the courage to seek help for their mental health problem. Unfortunately, not all treatments are created equal. For example, a quick search on YouTube turns up many so called “cures” that have absolutely no scientific backing. When I say “no scientific backing”, that means, despite grand claims, that no one has ever checked to see if the treatment actually works. Mental disorder stigma makes it more difficult to force people to back up their claims. Also, it creates a market of people looking for “quick fixes”.

Non-evidence based treatments usually make problems worse. In some cases, they do nothing to help the situation, so the sufferer may resign them self to a life where nothing can be done about their problem. In other cases, the treatment itself can be actively harmful.

When seeking help for anxiety, depression, eating disorders, etc., make sure to find a trained psychology/psychiatrist/therapist who uses evidence-based techniques (such as CBT). A good therapist will take their practice seriously and have high professional standards. High quality online therapies that deliver CBT are another option, especially for those without easy access to well-trained professionals, or those who would prefer to stay anonymous when seeking help.

3) Suicide: As with physical illnesses, mental illnesses can be fatal

In the most tragic of cases, suicide can be a consequence of an untreated mental health problem. The stigma associated with having a mental illness can make a bad situation even worse – to a point where people see no other way out.

If you have ever thought about suicide, it is very important to seek help immediately. Check out this link to find someone in your country that you can speak to. Otherwise, go see a doctor and ask for a referral.

4) Alcoholism: Drinking to cope with problems

Many people abuse alcohol in an attempt to cope with their mental health problems. For example, people with chronic untreated social anxiety may deal with it by using alcohol and/or drugs to help them perform in social situations. Other people use alcohol or drugs as a temporary escape from depression. In all cases, this coping strategy is (A) dangerous and physically harmful, and (B) making recovery from the underlying problem more difficult.

5) Decrease quality of life: Happiness, health, relationships, etc

Almost by definition, mental health problems impact the happiness of those who suffer from them. People often have a low opinion of themselves, struggle in relationships, experience frequent stress, anger, and anxiety, etc. However, there are wider ranging impacts that should also be taken into consideration. For example, untreated mental health problems are associated with a shorter life span. Furthermore, one must also consider the impact on family members and loved ones.

Summary

The stigma associated with mental illnesses creates an environment where people are reluctant or unable to get the help they need. Untreated mental health problems have a range of follow-on effects, such as those discussed above.

I truly hope that in my life time things will change. I hope that mental disorder stigma will become history. The field of evidence-based clinical psychology is relatively young, so perhaps it is understandable that the world hasn’t caught on yet. However, we can all do our share. One way to start is for us to change our attitudes towards mental health. We need to speak about it more openly, and only advocate evidence-based treatments, as we would with any other illnesses.

Fjola Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

When someone is angry, quite often our immediate reaction is to tell them to calm down. However, have you ever noticed that telling someone to calm down can actually make them angrier?

In this blog, I’m going to discuss the reasons why some people get angry, and share some strategies to help prevent future outbursts.

Many of us have been in this situation:

The anger stimulus could have been many different things: an upsetting email, Microsoft Word’s AutoCorrect feature, Manchester United losing a match you had a bet on, or pictures of an ex-partner on Facebook. Whatever it was, the ancient “fight” response has been activated and blood is pumping through your body. You find yourself in what seems like a uncontrollable rage. However, the belief that anger is uncontrollable in some situations is largely a myth!

One of the most common misconceptions about anger is that it is best to “let it all out”. This comes from the faulty reasoning that pressure builds up inside of us, and screaming, kicking and shouting is necessary to release it. The truth (according to the latest scientific findings) is that screaming, kicking, shouting or acting out in other ways only makes a person’s anger problem worse in the long term! I am now going to discuss one reason why many people get angry, and provide an effective way for dealing with some types of anger.

We all react differently to frustrating and difficult situations. Many of us burst out in anger. A lot of anger outbursts happen due to our internal rules being broken. These rules can be due to moral or ethical reasoning. For example, when you hear about someone being cruel to a child. This anger may be justified, and is therefore difficult to address. However, some of our “rules” are much less clear cut. These are rules that have been created (or learned from family, friends or colleagues) about how we feel the world SHOULD work.

Consider this example: a few weeks ago I was taking a bus from the airport, and the driver was being very rude to me and everyone else. I was little upset, and found myself thinking “the driver SHOULD be more helpful to me and the other passengers”. Another passenger was also upset by the driver’s behaviour, and got in a heated argument. It actually escalated to a point where they were both yelling at each other. Almost certainly, the driver was motivated by SHOULD statements of his own. For example, “everyone SHOULD sit down so I can catch up on my schedule!”. Both parties felt violated, but was it really worth the outbursts?

One of the ideas behind cognitive behaviour therapy (CBT) is to identify and challenge or modify unhelpful thinking patterns, including these SHOULD thoughts.

Let’s look at some more examples of should statements, and consider advantages and disadvantages of believing them:

Everyone should always treat me nicely

Benefit	Cost
I will be happy when I am treated nicely.	A major disadvantage of this ‘should’ is that it is unrealistic. It is a fact that some people are rude and inconsiderate. If I think that all people should treat me nicely, I will become infuriated every single time it doesn’t happen. I will experience anger and frustration regularly. This thought is actually making me upset.

Dropping a belief like this is not an easy task. We all have a sense of justice in our head, encoded by our internal rules. However, unfortunately the world isn’t always a fair place. For example, some people are too entitled, selfish or narcissistic to care about the impact they are having on other people. Therefore, it is inevitable that we will encounter people who do not treat us nicely. In fact, we should actually EXPECT it to happen from time to time. If something happens that we are expecting, we are a lot less likely to get angry because of it, and we can learn to think of better strategies to deal with it.

I should always say “yes” to requests from others

Benefit	Cost
Immediately after I say “yes” to other people’s requests I feel relieved to get them off my back.	I will probably be taken advantage of in my personal and professional relationships. I will end up doing lots of things that I really would prefer to avoid. I will end up feeling overburdened. I will end up bitter and resentful of the demands of others.

Once again, this example shows how an internal rule can end up causing unnecessary distress. On the surface it seems reasonable, but if interpreted too strictly, it can lead to anger. For example, it may lead you to expect everyone else to always say “yes” to you, and may cause distress when this turns out not to be so.

Incidentally, SHOULD statements, and a deeper discussion about their role in your mood, are the topic of Part 5 of the AI-Therapy treatment program. The program also identifies your specific SHOULD thoughts, and formulates a CBT intervention to target them.

Back to the original question regarding anger myths and facts: how can you prevent outbursts? In the short term, try not to allow yourself to “let it loose”, as this can lead to a pattern of learned behaviour that is only supporting the anger response. It is better to step back, and try to remove yourself from the situation until the anger wave has passed. Every time you successfully stop an outburst before it happens, the better you become at it. Practice, practice, practice.

In the long term, you should take a close look at your internal rules (i.e. your SHOULD statements). It is very likely that some of these are underpinning your anger. Once you have identified your SHOULDs, CBT can be used to target them.

The world isn’t always a fair place, and it never will be. We can do our best to make it a better place, but we can’t always control the actions of others. However, you can learn to control your reactions to perceived wrongs.

Launch

Our July/August 2012 launch exceeded our expectations. We’ve had over 3500 visits so far, so thanks to everyone for checking us out and helping spread the word. We’re still actively promoting the site, so please contact us if you have any ideas about how we can reach more people. Any links, blog reviews, etc. would be great.

New free online social anxiety symptom assessment

Shortly after launch we added a free symptom test for social anxiety.

Blog

We will put out a new blog every week (give or take) on a wide range of topics. Some recent entries include:

Anger myths and facts – how to prevent future outbursts

How Excel can help you achieve goals

How to avoid the “Top 5 regrets of the dying”

The problem with self help books – they can make social anxiety worse!

Social phobia vs Spider phobia

Spider phobia (aka arachnophobia)

Future

We’ve got lots of exciting ideas in the works, so please keep an eye on the blog and come back soon!

Thank you for visiting! As always, we’d love to hear from you as our goal is to be constantly improving our site.

The original title of this blog was “How Excel helped me run 4 marathons, climb Mt Kilimanjaro, travel the world, and complete 4 university degrees”, but I thought that was a little wordy. However, there really is some truth to it.

“Really?”, said with an sarcastic undertone, is a common response when I tell people how much I rely on my Excel file. In fact, it’s a running joke with my friends and family. My friend Isgerdur wrote a song for my hen’s night including the line “My Excel file is with you!”. This is true romance in my world. Also, there’s even a crack about this nerdy habit of mine in an article in an Icelandic newspaper, and the Telegraph in the United kingdom here!

Despite the jokes and well meaning mockery, I’ve decided to share my Excel usage with the world. However, before I continue I should point out that there is nothing magical about Excel. You can do this same thing with a pencil and paper, and there’s also lots of iPhone/Android apps for exactly this purpose.

How does Excel planning work to achieve goals?

My Excel file is probably one of the simplest documents you will ever see. Basically, it has three spreadsheets: Now, Finished, and Future.

In the Now part, I write short-term goals, and all my day to day activities. This helps make me feel productive because it feels great to finish a recorded task, no matter how small it is. When a task is complete I move it from the Now page to the Finished page. Nothing is too small. For example, even moving “take clothes to dry cleaner” between tabs gives me a sense of accomplishment.

I find colour coding items useful (adding significantly to the nerdiness of the document). For example, anything related to studies might be purple, work is green, and fun/travel is pink. The colour coding helps me to focus on one thing at the time, and I always have a sense of how much time to allocate to each category, which drives me to get things done and out of the way.

The Future page of the spreadsheet is really the important one. It’s not about your day to day life, but recording what you want to achieve in the medium to long term (e.g. the next 2-30 years). However, by having it in the same file as your day to day activities, it helps to connect the two, and you chip away at your long term goals in small, manageable steps.

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I’ve recorded my goals in my Excel spreadsheet for almost 15 years, and when I look back at early versions, it is amazing how it looks like I “predicted” my own future. For example, I included many things that I’ve now done, such as complete a PhD in psychology, travel to more than 40 countries (I’m now at 65), run my own clinical practice, run a marathon in under 4 hours, climb Mt Kilimanjaro before 30, etc. (To be fair, I didn’t reach all my goals – I still haven’t learned Korean, or attended pizza school in Italy. However, there is still lots of time for those things.) I honestly don’t think I would have done all this without careful planning in advance. Knowing what I want keeps me focused and working towards my goals.

The Future page is basically just a calendar. You set a date for a goal (e.g. run my own business by 2015), and set key milestones along the way (e.g. find partners, create business plan, get investors, etc.). That’s all there is to it – I told you it was simple! However, even though everyone knows how important it is to have goals, many people just seem to have them floating around in their head. This whole blog boils down to one sentence: keep a written record of your goals, and a plan about how to achieve them. It is amazing how powerful this little piece of advice is.

A quick disclaimer: There are many things in life that you cannot plan for, such as health problems, or other things that are out of your control. Furthermore, your priorities will naturally change as you get older. Therefore, it is important to be flexible with your planning, and don’t become a slave to goals that no longer make sense. For me, this means that about 3 times every year I sit down and re-evaluate the Future page, and make sure I’m still on the right track.

I’ve put a copy of my Excel file here if you would like to download it. You can use this as a basis to create your own, customized version. I like to keep it in my Dropbox folder, so I can always access it from home, work, by phone etc. I’ve actually given it to a lot of friends and people I meet who have become “Excel life planning” converts.

I’d like to leave you with a favourite quote of mine:

A dreamer is one who can only find his way by moonlight, and his punishment is that he sees the dawn before the rest of the world.”
-Oscar Wilde.

fdh

There’s definitely, definitely, definitely no logic to human behavior
-BjÖrk

I tend to agree with Björk (my fellow Icelander) — especially when it comes to “common sense” approaches to self help for improving anxiety or mood issues.

Despite having about 1000 trials supporting the efficacy of cognitive behaviour therapy (CBT) in the long term, the average Jane or Joe still has not heard about CBT. CBT has consistently outperformed medication when you look at long term benefits. What you learn through the CBT sticks with you for life! First, it addresses the root of the anxiety by determining what is keeping it going in everyday life. Next, it tackles the underlying cause using experiments and exercises. With CBT you develop strategies that you can use for the rest of your life.

One of the most common ways for individuals to deal with symptoms of anxiety and depression is to purchase self help programs (books, e-books, CD/MP3s audio series, etc.). The quality of these programs varies widely. There are some very good programs out there written by experienced and qualified professionals. Some of the best programs walk the client through the principles behind CBT.

Unfortunately, for every high-quality program, there are many more poor quality programs created by “self-help gurus”. Sometimes these gurus are well meaning people who have managed to cure their own problems, and would sincerely like to help others. Other times they are created by people simply looking for a quick buck. The problem is that some techniques for dealing with mental health issues are counter-intuitive, so without proper training, self-help authors can actually make problems worse. Let’s look at an example.

A typical title for self help books might be: Successful small talk: Learn to be open, interesting and intelligent. The purpose is to advise individuals on how to better manage their impressions on other people in social situations. If only human behavior was that simple! It would be great if we could sit down and read a book that would transform us into interesting and intelligent super-humans. Unfortunately, many of the recommended strategies (e.g. rehearse what you say in advance, make constant eye contact, etc.) can actually maintain anxiety in the long run. I mentioned these processes in my last blog, and referred to them as safety behaviors.

For social anxiety, people often believe that their safety behaviors help prevent negative evaluation in social situations. However, they actually might be preventing them from learning the truth. For example, assume that I deal with my social anxiety by only telling people about the positive aspects of my life (like many of us do on Facebook!). Perhaps I believe that this will stop them from judging me negatively. The problem is that if I never test this hypothesis, I am never comfortable being myself. What is wrong with this?

Firstly, it is unrealistic. People are people, and everyone has their ups and downs. By putting this extra pressure on myself to always look perfect, I might start avoiding social situations, reinforcing the anxiety. Social situations become extremely stressful.

Secondly, this type of safety behavior might make people judge me negatively. For example, people may feel resentful about my “perpetually success”, or suspect that I’m not telling the whole truth. Also, this maintains my social anxiety in the long run since I can never test if people approve of me for who I really am!

On the surface, common sense advice like “people don’t want to hear about your problems — focus on the positive” sounds great. However, as we’ve just seen this isn’t the case. Unfortunately, many self-help books are full of these sorts of recommendations.

There are some great self help books or programs out there. My advice is that if you do follow a self-help program make sure that it is (1) is created by a qualified professional with training in psychology/psychiatry, (2) uses CBT to tackle the core problems, and (3) does not promote behaviors that might end up making the problem worse.

Social phobia vs Spider phobia

In my last blog I talked about my personal “dislike” of spiders and other insects. In this blog we are going to look at the relationship between spider phobia and social phobia.

The major difference between specific phobias and social phobia is that people generally need to be around other people a lot the time. This is a bit similar to my unusual experience of moving from Iceland to Australia. I had to get used to being around spiders and other bugs all the time. After 6 years in the country, my fear of spiders had definitely decreased.

Social phobia and safety behaviours

With social phobia, you have to be around, and communicate with, other people on a daily basis. Therefore, the system that maintains social phobia is somewhat more complicated. People develop highly sophisticated mechanisms to prevent negative evaluation by other people. For example, imagine that I always wore pink socks while in Australia, and never got a serious spider bite. It’s possible that over time, I would begin to attribute my successful spider avoidance to the pink socks. This is known as a ‘safety signal’. As silly as this example sounds, we often learn ‘safety behaviours’ to help us deal with phobias and anxieties in day to day life.

The problem with safety signals is that I cannot always wear pink socks – can I? I would need to wear pink socks at all times to feel relaxed, and that could lead to some awkward social situations. I would feel anxious whenever I didn’t have access to pink socks. This is a little bit what happens with social anxiety – individuals have to be around and interact with other people on daily basis, so they develop ‘safety signals’ which prevent the feared social situation from happening.

Any behaviour can function as a safety signal. For example, both talking more and not talking can potentially function as safety behaviour to prevent the social fear of appearing boring, depending on the individual and the context. The distinction between adaptive coping behaviours and maladaptive safety behaviours is sometimes blurred, as the same behaviour can function as both. The category which the behaviour falls in depends on its intended purpose, the underlying belief, and the consequences from the situation.

Back to my example, wearing pink socks in itself isn’t that unhelpful (maybe a bit childish). However, it is only unhelpful if I think my socks have to be pink for them to protect me from a poisonous spider. If I believe in this “function” of the behaviour, I am preventing myself from learning that people rarely get bitten by poisonous spiders in Australia, regardless of the colour of their socks. Also, it makes me nervous to travel, given that one cannot have access to pink socks at all times. In social anxiety these behaviours have many detrimental effects such as increased self-focused attention and preventing dis-confirmation. In fact, these behaviours can even have the opposite effect, and can end up being the reason why someone would judge someone else negatively (once again, think of the sock example).

Common safety behaviours for social anxiety include:

carrying deodorant around at all times
always saying “yes” to other people’s requests
rehearsing what to say before entering a social situation
only telling other people about positive aspects of your life
laughing at inappropriate times
avoiding eye contact
saying little in group situations
re-reading emails many times before sending them

People may feel their safety behaviours are helping them, but they aren’t. On the contrary, several studies have reported the detrimental effect of such safety behaviours in social situations (Kim, 2005; McManus et al., 2008; Morgan & Raffle, 1999; Wells et al., 1995). Consequently, the current view is that safety behaviours can interfere with standard cognitive behaviour therapy techniques by inhibiting testing of hypotheses for socially anxious individuals.

In our online treatment for social anxiety (www.AI-Therapy.com) we explain these concepts in a lot more detail, and help people understand what their specific safety behaviours are. I hope you can see that social phobia is a much more complex issue than specific phobias, like spiders. You can now answer 10 questions, to see how you score on our free online social phobia symptoms test.

In an upcoming blog I will discuss the relationship between safety behaviours and one of my favourite topics – superstitious behaviours. My latest article on superstition was front page news in Iceland last week!

Internet CBT treatment for social phobia. What is it?

A man [woman] who does not think for himself [herself] does not think at all.
-Oscar Wilde

I added the brackets to remind you, my dear reader, that it is 2012.

Internet CBT treatment for social phobia

I have created a video to help explain Internet CBT treatment for social phobia. One goal of this treatment is finding out what type of thinking people use. The video is designed to help people become more aware of these thoughts. Thinking about thinking is the first step.

Social phobia is characterised by an inflated threat perception in social situations. Sufferers experience intense fear of negative evaluation and see amplified threats in being judged by others. This exaggerated fear response has a marked impact on their relationships with others, in both public (e.g. work) and private life (e.g relationships). Frequently people suffer from low mood and exhaustion due to the distress the problem causes. Sufferers fear, avoid, or endure with significant stress the following: conversations, meeting new people, expressing a controversial opinion or disagreement, being assertive, speaking in front of a group, being the centre of attention, eating, drinking, or making mistakes in front of others.

Our Internet CBT treatment for social phobia (http://www.AI-Therapy.com) is a professional website incorporating a computerised CBT practitioner that we have been building since 2007. CBT, or Cognitive Behaviour Therapy, is a well known treatment approach supported by several hundred controlled experimental trials. Our Internet CBT treatment for social phobia offers you a fully automated computer psychologist that tailors your treatment to the specific symptoms that you report to the system. The database it uses is derived from a wealth of psychological data gathered in major anxiety and mood clinics over the past 20 years.

Your subscription lasts for 6 months, and includes the following online treatment procedures: (1) cognitive restructuring exercises; (2) mindfulness tasks; (3) exposure exercises and behavioural experiments; (4) education about the nature of anxiety and depression; (5) quizzes to test your growing understanding of your condition and its treatment; (6) emails to motivate and remind you to access the program; (7) online assessment tools to measure your improvement; and (8) voice overs by me Fjola and Ross explaining each treatment procedure covered in the program.

AI-Therapy is an Internet-based CBT treatment for social phobia comprising 7 sections. Section 1 helps the user get in the habit of becoming aware of their thoughts and behaviours. Sections 2-6 teach strategies to address unhelpful thinking and behaviours. Section 7 is focused on relapse prevention so that the user can maintain their changes in the long run.