Introducing Cognitive Behavioural Therapy (Introducing...) (2 page)

2. The ABC of CBT

The ABC of CBT:

Antecedents – Beliefs – Consequences

A
= the
A
ntecedent, trigger event or occurrence which appears to lead to an emotional reaction.

B
= our
B
eliefs, thoughts, interpretation or evaluation of that event and its possible causes or meaning.

C
= the
C
onsequences of that way of viewing the event – our emotional or behavioural reaction to it.

Imagine you are in bed at night, alone in the house and you hear a sudden noise downstairs. This is the antecedent, the triggering event – an
A
.

You might think you’d know immediately how you’d react or feel in this situation. Actually, our feelings and reactions depend entirely on how we interpret the
A
. Look at the three possibilities below:

1. You might think: ‘Oh gosh there have been several burglaries in this area recently, I bet it’s them’. This would be a belief, or thought – a
   B
   . It might follow that you’d feel scared or even angry. This would be a consequence, or reaction – a
   C
   . Your behavioural reaction (another
   C
   ) might be to hide under the covers or to call the police.
   
2. You might think: ‘That’s my son coming home late again and crashing around waking me up – third time this week – he’s always so thoughtless!’ – a very different
   B
   . In this case your reaction (
   C
   ) might also be quite different. Now you might feel very angry and frustrated and your behavioural
   C
   might be to shout at him or try to impose some kind of sanction.
   
3. But you might think: ‘Ahh! That’s my lovely partner returning earlier than expected to surprise me because I was feeling a bit low today. How very sweet!’ Then your feelings (
   C
   ) might be loving and positive and your behavioural reactions (more
   C
   s) equally so!
   

So, in each of these scenarios the
A
is exactly the same. The
C
s are all completely different. What makes the difference? The
B
s, our beliefs! The way in which we think about the situation determines the way we feel about it and react to it.

Of course in real life things are more complicated. Our beliefs are influenced by myriad factors including our upbringing, education and past experiences. Behavioural and emotional Cs in one situation feed into the As and Bs of other situations, and so on. However, bearing in mind these simple principles can help us understand and then make changes in many areas of difficulty.

Throughout this book we’ll be illustrating how it’s our Bs (beliefs) that largely cause the stressful Cs (consequences), not necessarily the actual situation itself. So, if someone isn’t stressed about meeting important deadlines, giving a presentation or meeting new people it’s because they
believe
they’ll cope well and therefore don’t predict any awful consequences. The fact that they’re not stressed in this way can then become a self-fulfilling prophecy, in that it will cause them to behave and react in positive ways which might actually make a successful outcome more likely. When we hold overly negative beliefs the opposite can happen.

A key part in the process of challenging negative beliefs is to question the commands which say you
must
,
ought
,
should
, or even
have to
achieve a particular outcome.

Where do these commands come from? Do they just pop automatically into your head, or are others telling you these things? If they’re from others, is there a reason you have to agree? Are others necessarily infallible? What would happen if you did fail? Would it really be that unbearably awful? Could you be exaggerating the outcome? And if it did happen, is there a way you
could
bear it, even if you didn’t like it? After all, there’s no law which says you
have
to like it! Challenge those previously unquestioned assumptions. Ask yourself how one missed deadline means you are a complete waste of space at work. Isn’t that a bit unfair on yourself? Would you judge others like this?

In becoming more aware of the beliefs that are driving your reactions and behaviours you can then make those beliefs more balanced, realistic and flexible, less demanding and no longer so absolute. When beliefs are modified you usually find that you feel emotionally and physically different. This actually enables you to evict ‘catastrophizing’ and his companion, procrastination, and get on with the task in hand. The consequence? You normally find yourself feeling ever so much better than before.

Have another look at the quotation from Epictetus at the start of the introduction. Amazing how it’s absolutely spot on, encapsulating the latest developments in CBT, despite being said over 2,000 years ago.

But identifying the
A
ntecedents, and the
B
eliefs, and then actually
C
hallenging them, both in your mind and your behaviour, like so many things, is much easier said than done.

It’s very important to tell yourself that like any new skill, learning your ABC takes a while. It will take time before you know it by rote, and can incorporate it automatically into your daily routine.

Think of this book as your mental workout – after all, you are ‘working it out’, aren’t you? You really can sharpen, tone up and keep your mind fit by regular workouts at the mental gym. When you go to this space, your private mental gym, that’s when you practice challenging unhelpful, mood-disturbing, distorted thinking. Your workout strengthens you, as you develop new qualities and performance-enhancing, stress-reducing, life-improving beliefs.

3. Improving your sleep

A good laugh and a long sleep are the best cures in the doctor’s book
.

Irish Proverb

Take rest; a field that has rested gives a bountiful crop
.

Ovid, Roman Poet

‘Tick! Tock! Tick! Tock! What time is it? How on earth will I get up in the morning if I can’t get to sleep? No! Surely it’s more than five minutes since I last looked at the clock!’

When we sleep badly life can seem so much more difficult. Being tired can make worries seem bigger and more overwhelming. Relationships can become strained because we are irritable or miserable and everyday chores and challenges feel far more difficult to cope with. If you are someone who is having problems with sleep, you certainly aren’t alone. Most of us will experience brief periods of sleeplessness at times when we are distressed, worried or under pressure.

How can I tell if I may have a sleep problem?

Here’s an easy way to see whether you could be suffering from a sleep disorder. Just answer YES or NO to the questions below:

Do you:

1. Have trouble falling asleep at night?
   
2. Take more than half an hour before you fall asleep?
   
3. Find that your mind just won’t shut up and thoughts keep rushing through your head?
   
4. Worry about all sorts of things and find you just can’t switch off, relax and fall asleep.
   
5. Have trouble getting back to sleep if something wakes you?
   
6. Usually wake several times a night, in the very early morning?
   
7. Wake up very early no matter how late you get to bed?
   
8. Suffer from depression?
   

Scoring your results

If you answered YES to three or more statements, you could be showing signs of insomnia (sleep disorder). It is always useful to talk to your doctor about this problem in the first instance, as sometimes there can be a medical cause, which your doctor can help you to deal with and to overcome. However, let’s assume there’s nothing physically wrong with you, and take it from there.

How CBT can help us to understand sleeplessness

The diagram above shows the way in which CBT can help us to understand what maintains a problem with sleep. A period of sleeplessness can be caused by many things and, in most cases, will last a few nights and then pass without you needing to do anything different from normal. However, the thoughts, emotions, behaviours and physical reactions of people who have ongoing problems with sleep can all interact to keep the difficulty going. In fact it becomes a vicious cycle – the more we worry about sleep, the less likely we are to sleep well. If we nap during the day because we are tired, we are again less likely to sleep at night.

Case study – Robert

Robert is really worried. He has always been a bit of a worrier and finds that this becomes particularly bad when he faces important deadlines at work. This affects his sleep. Whereas he normally sleeps well and feels refreshed in the morning, currently he finds it takes him several hours to get to sleep. He lies awake and worries. In his head he plays out all the things that could go wrong if he does not meet his deadline. The scenarios get more and more alarming. Within the space of 10 minutes of thinking he has failed to meet his deadline, been sacked, lost his home and he and his family are on the breadline. ‘This is just too awful for words! I’ve got to stop thinking like this!’ Robert looks at the clock ‘2am! I have to be up in 5 hours … I’ll be so tired tomorrow I’ll never get anything done … I have to get some sleep NOW! But I just can’t.’ And so now he starts worrying about worrying … and the worrying begins all over again …

Case study – Simon

Simon has recently been made redundant from his job. He is struggling to find a new job and this is taking its toll on his mood. At first he relished having some extra time to do things around the house and to catch up with friends but now he is finding it hard to get motivated to do anything. He has stopped seeing people as he feels embarrassed about being unemployed, and spends ages sitting in front of his television. He often falls asleep on the sofa during the day. He feels lethargic and drained of energy. Sometimes he falls asleep on the sofa late at night, after having a few drinks, and goes to bed very late. He falls back to sleep easily but then wakes frequently and sleeps badly. He often wakes at about 3 or 4 am and just can’t get back to sleep again. During the day he is tired and irritable.

Simon and Robert both have very common types of problems with sleep. We will look at how they can use techniques from CBT to help them later on in this chapter. For now let’s think a little more about sleep and sleep patterns.

The most common types of sleep disturbance are:

• Difficulty falling asleep
  
• Difficulty staying asleep
  
• Early waking
  
• Poor quality sleep.
  

All these mean we feel physically and mentally tired during the day.

There is good evidence that one or two bad nights’ sleep don’t do us much harm other than leaving us feeling tired. Research shows people who have had very little sleep for one night can still carry out tasks almost as successfully as when they had slept normally. This means that one sleepless night, say before an exam or an interview, is unlikely to significantly affect our performance. We might not feel our best but we can still do things about as well as normal.

However, long periods of disturbed sleep can affect our concentration, our ability to solve problems or to make decisions. If people are driving or operating machinery, then it can actually be dangerous. It can also mean we feel depressed, anxious or irritable. And of course these mood changes often have an impact on both our work and our relationships.

It is very difficult to accurately assess the amount of sleep we have had. When people have their sleep measured in a clinic, they are often surprised that they actually sleep more than they have predicted.

How much sleep do we need?

There is huge variance in how much sleep one person needs compared to another. Popular wisdom suggests what the average person needs is … 5 minutes more! 5 minutes more than what, however, is the question. Our sleep requirements change at different times in our life. A baby sleeps for 17 hours a day on average. A child usually needs 9 or 10 hours of sleep per night, while most adults need around 8 hours. All of us are different. Some people need more than 8 hours, and others may need considerably less. In later life we do not necessarily need less sleep, but the type of sleep we have changes. Our sleep becomes lighter as we get older and we wake more frequently and easily. Contrary to popular belief, it does not matter when during the night we sleep, one hour before midnight is worth exactly the same as one hour after midnight. However much sleep an individual needs, the important thing is that our sleep should leave us feeling refreshed and able to get on with our lives during the day.

What are the different stages of sleep?

Exactly why we sleep is still a mystery to us, although scientists have many theories about this. All animals sleep in some way and it appears to provide some kind of restorative, reparative function for our bodies and brains. We know that we go through several different stages when we sleep. There are four main stages of sleep and we may move through these several times during the night. At different stages we may wake more or less easily. These stages are:

• ‘Pre’ sleep
  – when we move between sleeping and waking, our muscles relax and heart beat and breathing slow down
  
• Light sleep
  – when we are truly asleep but can still wake easily
  
• ‘Slow wave’
  or
  deep sleep
  – the largest proportion of our sleep. We’re deeply asleep and it is hard to wake. We can feel confused or disorientated if woken. We may sleep talk or walk during this stage
  
• REM (rapid eye movement) sleep
  – our brains are active although our muscles remain relaxed. Our eyes move rapidly and we dream. REM makes up about a fifth of our sleep.
  

Most people wake approximately every couple of hours for a few seconds. Usually we go straight back to sleep again and may not even be aware that we have woken. Occasionally these wakeful periods can make us feel as if we have slept for less time than we actually have.

Studies have shown that all people dream. However, some people are more likely to remember their dreams. We do not fully understand the function of dreams. There is some evidence that if you deprive someone of REM sleep then their next sleep will contain a higher proportion of REM sleep. It looks like the body needs this type of sleep and so if you miss out on it, your body makes up for it later.

So, what can I do to help myself sleep better?

Way back in ancient times the Greeks and Egyptians used opium to help themselves sleep. Pictures of Hypnos, Greek god of sleep, usually show him holding a poppy flower. Today it certainly wouldn’t be recommended as we are far more aware of the dangers of using opium, and in fact it is a banned substance. Other sleep aids used in ancient times were lettuce juice, mandrake bark, a herb called henbane and alcohol. While we certainly don’t recommend any of these, do not despair as there are many things you can do to improve your sleep.