"Cognitive Behavioural Therapy"

I've recently completed a course of six cognitive behavioural therapy sessions at the Oxford Street branch of Let's Talk Wellbeing in Nottingham. 

Since attempting suicide during university in 2013 I have been struggling with depression, anxiety and suicidal thoughts and have sought help in the form of both medication, and talking therapy/counselling, both of which have had no effect in treating my depression and as a result I haven't  been able to pursue my goals and live a fulfilling life. Throughout this time CBT has been recommended by mental health workers and doctors, but I have struggled to access it due to waiting lists and being transferred between different mental health teams and services. In November 2019 I self referred myself to Let's Talk about a month later had a telephone assessment and a CBT appointment in January, at a date, time and location that I could choose.

I constantly found the sessions to be unstructured, sparse (in content) and inconsistent. For example, a homework would be set one week, and treated of little importance the next (not linking it to any particular goal, skill etc.) and wouldn't be brought up until I mentioned it, but at other times when I struggled to complete the homework I would be made to feel guilty, and the therapist would continue assigning the same homework rather than trying something different. From the homework that I was assigned, I did not acquire any new skills that were effective coping strategies or techniques that lead to an improved behavioural outcome.

When I did communicate my negative thoughts, the therapist didn't challenge them, but enabled them in many cases. For example, when I explained that I was anxious about making an academic appeal with the university "because I feel like I have let down the university and wasted the opportunities that they have given me, even though they have already made plenty of allowances for me", I thought to myself that I had finally said something that might be "usable" and that we would start doing the cognitive behavioural thing I was hoping for , but they didn't do anything to challenge that particular thought pattern and the avoidance that it leads to but instead treated it as if it was a casual conversation and expressed sympathy for that view point.

The therapist didn't support me in a long-term goal that I have been struggling with for a number of years (it is one which I have previously made successful initial steps in but struggled after that). When we discussed the problem, there was absolutely no challenging of the negative thinking that surrounds it.

I often struggled to express myself during the sessions and felt judged for this. It may have been partly due to the fact that I wasn't able to establish a relationship of trust with the therapist in the small number of sessions, but I think that this was contributed to by ineffective use of questioning by the therapist. Whilst I understand that open-ended questions probably have an important role in avoiding dictating to patients and giving them freedom to express themselves, the reliance on that particular style of questioning didn't work for me. As somebody who is introverted and has difficulty when talking about emotive and sensitive subjects I have an instinct to give the least that is possible when asked general, open-ended questions (not sure if they were technically open-ended questions as I'm not an expert on questions but that is how I perceived them as they seemed to lack precision). To me it seems clear how this open question style might disadvantage a range of personality traits, behaviour patterns (i.e. avoidance), people with differing abilities to express themselves for a variety of reasons and I feel that this where I struggled with counselling/talking therapy and was hoping that CBT would offer a more structured and investigative approach so that I would feel supported in communicating more of my thoughts.

I'm not saying that as a patient I should take  a passive role in the CBT, but asking the right questions in order to gain an understanding and insight is surely the bread and butter of being able to help to find a solution to any problem. I've had a quick browse through some of the other stories on this website about Nottingham IAPT and at least one other person describes the sense of the therapist "not getting to the root cause" of an issue. 

Being asked "What can I do for you?", "what would you like to get out of this session?" etc. at the beginning of each session contributed to a sense of non-continuity, and that we weren't working towards goals and developing skills and made me question whether they remembered what was said in the previous session or whether they had taken adequate notes.

During the sessions they would ask how they were doing as I'm sure they could sense that I was struggling to communicate but this just added an additional role that I had to carry out when I was already struggling with trying to "perform" what seems to be required as a patient (I've written more about this idea later). I should add that I wasn't deliberately withholding information from the therapist, it's only after a period a reflection that I have some sense of why I acted in a certain way and what could have helped. It's disappointing that the therapist didn't seem to have the skills or framework to analyse the situation and find potential solutions for my lack of communication and instead seemed to judge me for it. 

When a discussion did manage to arise in the dialogue that we had did not contribute to any new understanding on my part. I didn't learn anything insightful about my mental state or thought process from the therapist, and often it felt like the responses were rehearsed rather than being relevant to my situation - I would agree with the assessments but they were quite general and something that I had already recognised in myself, and these assessments weren't really linked to anything else, I wasn't given the skills or techniques to challenge these particular thought or behaviour patterns.

They kept telling me that "CBT wasn't suitable for me" or that "I wasn't ready", without explaining why or what the alternatives might be. They would often contradict himself and retract things that were said in a previous session. The therapist complained that they were "doing too much work", adding to my feelings of guilt and the sense that I can never be helped, and if they were doing any work I didn't feel like I was benefiting from it. The sessions would often leave me in tears (which I expected to happen as it was advised that this might be a possibility on the appointment letter) but I wasn't given any techniques to deal with this and it wasn't used as an opportunity for learning.

There wasn't anywhere I could go to collect myself and calm down when I left the sessions in tears, apart from the only bathroom which was a single-stalled bathroom which opened directly into the hallway. I was lead to believe that I could potentially have more sessions if I wasn't making any progress, but was discharged because I didn't make any progress. 

After each of the interactions I've had with mental health workers I come away with a sense that there seems to be some specific performance that they are looking for, even though I am unable to quite put my finger on what that performance might be, my ability to carry out this performance seems to be a necessary condition attached to the quality of care provided. I was finally given a clue to what this might look like at the end of the final session (I was trying to make sense of all of the contradictions being made  so was losing focus of what they were saying) but the therapist talked about me re-referring myself in several months time and had ideas about what those therapy sessions might look like - saying something to the effect of "You're going to learn things about yourself which you won't like/ you will learn that you think things about yourself and won't understand why you think that way/ it will be difficult but when you are ready you will share with other people". I found it fascinating how they didn't seem to have planned the next week's session but was able to glimpse months into the future to tell me what my therapy would look like. It seems to be at odds with the sense of flexibility which I suspect they were trying to create (depending on which week it was), but which was ultimately an illusion.

Even as someone who suffers from persistent negative thoughts, I would never have thought of my self as helpless and usually retain a sense of hope that things will improve, which is what leads me to seek help from mental health services and self-refer for CBT. But unfortunately the repeated, unsuccessful interactions with mental health "professionals" is increasingly engendering this mindset - I'm starting to get the sense that I am trapped in a web and the more that I do to try and escape, the more tangled I am becoming and it is has added a new element to suicidal ideation. Increasingly I am thinking that I am in the wrong for hoping or believing that anyone can help me and the deleterious effects on my mental health that I am experiencing are a natural outcome of such a foolish assumption.

The service which was supposed to alleviate my long-term mental health issues and has caused more harm than benefit, and I am left with little to no support in the aftermath. I went into the treatment with an open mind and determined to make the most of the opportunity only to be completely disappointed and let down by the service. I have wasted time which I can never get back and feel like I've drifted further from my goals than I have ever been during the course of these sessions. 

Whether it's an institutional problem, an academic problem or simply one of quality assurance it's safe to say that until there is a (visible) system of accountability for mental health workers then I believe little has changed since the time when lobotomies were a common treatment for mental health patients.