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Depression with Anxiety

Robyn decided to try CBT after being signed off work. She was a middle manager in a public sector job and life had recently been particularly stressful following restructuring. She had also recently separated from her husband, her youngest son had left for University, and she was worried about how she would manage financially. In a nutshell, she felt that her life was falling apart. After a visit to her GP, she had been diagnosed with depression and put on a low dose of Citalopram; in conversation with her GP, they agreed that CBT might be an option as she also reported feeling anxious about everything and unable to relax.

In her first session, Robyn's cognitive behavioural therapist took a brief history of what Robyn believed had led to her becoming depressed and anxious, and gathered from her as much information as possible about how she was currently feeling. The therapist also spent some time explaining how they might work together using CBT and answering any questions Robyn had. One of the things the therapist explained is that, once they had some grasp of what was happening in Robyn's life, they would draw up a formulation, or a pictorial representation of how Robyn's thoughts, feelings, physical sensations and behaviour interacted. The purpose of this was to identify unhelpful patterns, perhaps fuelled by persistent negative thoughts, which might cause Robyn to get stuck in a cycle of depression and anxiety. In this initial session, Robyn and her therapist agreed that they would meet for 8 sessions, at the end of which they would review her progress.

This was a process which Robyn and her therapist went through more than once in the course of 8 sessions, and the formulation evolved as they looked at different areas of her life which were causing her distress. Here is an idea of what Robyn's initial formulation looked like.


If you look at Robyn's personal formulation, it is not hard to see how each part of the 'system' interacts with the others, preventing her from moving forward.

In simple terms, the way Robyn's therapy progressed was by addressing the areas in which it was easiest to make changes. Obviously, it's not easy to change feelings or physical states, and it takes time to work on our negative thoughts and beliefs. However, it is possible to make changes very quickly in our behaviour. Even small adjustments to what we do can have a big effect on what we think and how we feel. Each week, Robyn agreed to commit to homework. Sometimes this involved simply keeping a record of her negative thoughts and how she responded to them. On other occasions, she would decide with her therapist that she would arrange to go out twice with friends, or go for a cycle ride every other day, or to make sure that she planned decent meals for herself, and maybe invite someone else to eat with her.

She was also encouraged to look at her negative beliefs and to ask herself what evidence she actually had for those beliefs, or if there were other ways of looking at her situation in a more realistic light. [It is important to emphasise that CBT is not about looking at life through rose-tinted spectacles, or thinking positively about sad or bad things. It simply invites us to do a reality check, as we often get caught in inaccurate and unhealthily negative belief systems about our lives which compound real life challenges.]

Throughout her CBT, Robyn and her therapist also monitored her progress in various ways to make sure that she was benefitting from her therapy.

After her 8th session, Robyn reported feeling quite a lot better. She had got into a rhythm of exercise and social activity and found that her sleep was less disturbed and that she felt less angry and resentful. Although there were still practical challenges in her life, she had developed the ability to recognise when she was engaging in distorted thinking: catastrophising, minimising the positives, maximising the negatives, thinking in 'all-or-nothing' terms, and so on.

There was still a way to go, but she now had some techniques up her sleeve to put into practice by herself if she felt she was sinking into her previous patterns. A year later, her therapist received an email to say that she had started a degree through the Open University which she was greatly enjoying and even dipping her toe into 'dating' again.



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