He got on well with his father and step mother, but felt like an outsider in their house and had disengaged from them and other people. A recent relationship had ended after he was treated badly, and he felt angry with his ex. This had triggered feelings of abandonment and he had been doing things to try to connect with his ex, although this made him feel worse. He felt low in mood and said he had been drinking too much and using drugs when he was out drinking with friends. He had already recognised that while he felt better in the short term, this was making his mood and feelings of anxiety worse. He was also avoiding social invites from work friends because he didn’t feel like being with people. He made excuses or delayed replying until it was too late because he couldn’t stand the feeling of letting people down and felt he couldn’t be honest with them.
Steven wanted to worry less, be more positive, stop over-analysing things and be more honest and open with friends and family. His goals were to spend more time with his family, do things with his friends that weren’t focused on drinking. He also wanted to try some new things, including getting out in the outdoors.
Using ACT, we explored how Steven wanted to be living his life and how he wanted to be treating himself and the people in his life. He learned new skills for handling difficult thoughts and feelings. After deciding that he wanted to stop using cocaine, we identified his relapse cycle, and he learned CBT skills to manage the temptation to take drugs when he was out with certain friends. Steven discovered that he had been operating based on some hidden rules and reasons, and once he could spot these and manage them, he could more effectively manage these situations and stick to his guns.
Steven worked hard between our sessions practicing what he learned, and he also brought a good sense of humour into our work. He started spending and enjoying time with his family. After 11 sessions, we agreed that he had met the goals he had set. He said he could handle emotions better and these did not get in the way of everyday life. He said he was more honest with people, felt comfortable being on his own and was no longer depending on other people to feel happy. He also started setting and working towards bigger life goals.
Treatment for OCD with a young woman who wanted to keep everyone safe
Amy had several rituals to keep her family safe and to manage “bad” thoughts. She had had these for nearly 3 years, but they got a lot worse after she went for a routine medical check and then thought that she had contracted an infectious disease.
She was preoccupied with this thought, which was enormously distressing. She described imagining ‘the worst-case scenario’, which made her tearful and she felt totally overwhelmed and unable to cope. She described knowing rationally that it was highly unlikely that she had contracted a disease, but this thought still showed up and bothered her in a lot of situations.
Amy was spending up to 30 minutes checking things many times before going to bed at night. This included checking that doors were locked and that switches and sockets were off in case they were burgled or in case there was a house fire. She also checked that her father had taken his medication to bed with him, and that the rest was safely put away. She also had a compulsion to ‘touch wood’ or touch her head when she thought something “bad”. “Bad” thoughts included worrying that her boyfriend or a member of her family might die or get ill with cancer, or thinking that she had contracted (or might contract) an infectious disease from someone. She had been starting to feel embarrassed that other people might notice her touching her head to neutralise difficult thoughts, and her health worries were starting to affect her physical relationship with her boyfriend.
In early sessions, Amy clearly found it very difficult to articulate her thoughts out loud and she touched the wooden coffee table a lot while we discussed and made sense of these. Using ACT, Amy learned skills to manage difficult thoughts and feelings of worry, anxiety and distress. We clarified that it was important to her to be loving and fun in her important relationships.
At session 5, we began developing a hierarchy for exposure work, which is a technique from traditional CBT. With clear discomfort, Amy wrote her most feared thoughts right at the top of this list, and added other thoughts in the middle and lower down. With encouragement, she developed a thought that was a clear prediction to put at the start of the hierarchy. Then we ran an experiment live in session so that she could use ACT skills to manage her anxiety without resorting to previously used responses that only brought temporary relief from anxiety. After more experiments to test out negative predictions in sessions, she then had some success at home without neutralising difficult thoughts. Additional ACT skills helped her to work up her fear hierarchy, and she became able to tolerate seeing news articles about health concerns without using neutralising behaviours.
After 11 sessions, Amy was no longer neutralising difficult thoughts and she was checking doors and sockets by only looking or touching once. She could also tolerate difficult feelings of anxiety and disgust that arose when she saw things or heard conversations about difficult topics.
CBT for trauma symptoms and binge eating with a man who had been reminded of the past.
Philip described a history of comfort eating since he was a child. He had had this under control for a few years, but it had re-emerged as a problem over the previous 12 months.
He reported problems with self-esteem and described a pattern of always trying to please other people. He said he needed to be able to say ‘no’ to people because he either felt guilty if he did or angry if he didn’t. Philip also reported having flashbacks. He said he had previously buried memories and disclosed that he had been abused as a child. Media attention to a prolific historic abuse case had re-triggered trauma symptoms, and his flashbacks were readily triggered by a noise or a smell.
Philip had lost trust in people and had withdrawn. He had a worry about his work productivity, and he dismissed positive feedback as people being patronising because of his physical disability. When we explored his thoughts, he was getting caught up in some truly horrible critical thoughts about himself as a person. He wanted to feel that what he was doing was worthwhile, wanted to manage stress without binge eating, and wanted to feel less angry, less stressed, be out more, doing more and meeting people.
Intervention using ACT involved skills to help Philip ‘unhook’ from some very difficult thoughts, grounding techniques to manage flashbacks, and skills to manage strong emotions such as anger. He uncovered rules for his work behaviour that he had been adhering to, but which were very unhelpful to him. Philip had a good understanding of his cycle of binging and identified that the original function of this behaviour was to increase feelings of safety. He was binge eating several times a day when he felt stressed or worried. Together with ACT skills, mindfulness increased his awareness of emotional triggers and allowed him to savour and enjoy food. He learned how to look after himself better and felt more in control.
Philip worked hard between sessions practising what he had learned. At session 8, he decided that he had taken things as far as he wanted to in therapy. He reported that he could manage unhelpful thoughts, particularly at work, and he was feeling less stressed in work. Flashbacks were much less frequent and he said he could intervene to interrupt them nearly every time they showed up. He had a range of new skills to manage triggers to different emotional responses, and he had significantly reduced binge eating and was enjoying food again.