11 Working with people who are anxious or low in mood
Introduction
The interventions and clinical skills described in this chapter are informed by a cognitive behavioural therapy (CBT) approach (see Ch. 3). There is a growing evidence base for the effectiveness of these interventions when working with people who are anxious or low in mood. Additionally there has been strong political support to increase access to psychological interventions in the UK which has led to investment in specific training and service programmes (Department of Health 2008). Efforts have been made to identify the positive elements of a CBT approach and adapt them so that a greater number of practitioners can feel confident using them in mainstream mental health practice. The interventions described here utilise these adaptations and are reflective of the contemporary ways in which CBT is delivered in mainstream services. More information and resources on this approach can be found at http://www.fiveareas.com/resourcearea/ (accessed June 2011). Specialist services do still exist where experienced CBT therapists adopt more traditional approaches and work with people with complex problems.
The Five Areas assessment model
The Five Areas assessment model recognises that when people are feeling anxious or low in mood their thinking can become extreme and unhelpful. For example, people may see themselves as worthless or incompetent which then leads to reduced or avoidant behaviours. The model identifies five domains within which a person’s problematic thinking and behaviour can be examined, and the links between each area can be established (Williams & Garland 2002a):
Focused and specific questions are asked to explore the problematic life situation and ascertain how it is impacting on or being maintained by the remaining four areas. For example:
Area 5: altered behaviour
• What things have you stopped doing since you have been feeling this way?
• What things have you started doing to help you cope with the way you have been feeling?
(For a more extensive list of example questions, see Williams & Garland 2002a.)
The information gathered from the assessment process is summarised under the five domains in a diagram which identifies the relationship between the areas. This can be used to feed back to the multidisciplinary team so that the whole team can gain an understanding of the person’s problems and adopt a consistent approach to interventions. An example of when this could be particularly helpful would be if a service user is coping with anxiety through seeking constant reassurance. You may be working with them to change this behaviour and will require other members of the team to support this intervention by not giving reassurance when the service user requests it.
Once the assessment is complete, a plan for intervention is agreed by identifying the area which is likely to have the most significant impact on the defined problem. The following interventions are examples of approaches which are commonly adopted in mental health practice.
Challenging unhelpful thinking styles
The thinking style associated with a problem or behaviour will often become extreme or unhelpful if a person is experiencing anxiety or low mood. You may hear this referred to as negative automatic thoughts, thinking errors or cognitive distortions. They tend to be consistent and lead to misinterpretation of everyday situations. There are common unhelpful thinking styles which lead people to blow issues out of proportion or downplay their ability to cope with a problem. These could include the following:
• A high level of self-criticism.
• A negative attitude towards past and current events.
• Negative predictions about the future.
• Presuming others think badly of them without evidence to suggest that this is the case.
• Feeling responsible for poor outcomes.
• Taking feedback as criticism and personalising criticism which is not directly related to them.
• Holding high standards for self which are likely to be impossible to meet.
It is important to recognise that we all hold some unhelpful thinking styles and you may be able to apply some of the examples given above to yourself at times. These tend to become problematic when these thoughts become frequent and hard to dismiss which then leads to significant levels of distress.
In the following scenario, try to identify the unhelpful thinking styles which are present.
Jane is a 38-year-old single woman who lives alone in a small flat and works as a legal secretary. She has been seeing her doctor for several months complaining of lack of appetite, feeling listless and no longer enjoying her work. After extensive tests revealed no physical health problems, her GP referred her to a psychiatrist for assessment. Although initially reluctant, Jane eventually agreed. The psychiatrist diagnosed Jane with mild depression and prescribed a course of antidepressant medication. Jane was reluctant to take the tablets and enquired whether there was any alternative. She was told about cognitive behavioural therapy which she chose to take up.
During the first meetings, Jane spoke about always feeling different and isolated from other people but things had become worse over the past few months following a date with a work colleague. Jane had never got on well with men and could see nothing in herself that men would find attractive. She had therefore resigned herself to remaining single and had arranged her life accordingly. When a colleague asked her out for a meal, she was flattered and immediately agreed. However, on reflection, she felt her decision had been hasty and was convinced he had only asked her out of pity. Her doubts were confirmed on the date when she acted clumsily and could think of nothing interesting to say. The next day at work her colleague made no attempt to ask her out again. Since that time Jane had found it difficult to talk to men and women. She felt her work colleagues were talking about her behind her back and that she was completely unlikable. She had also lost her desire to play her piano in the local church which was her main hobby.
While on placement you should try to identify these thinking styles among the service users you are working with. You may also be able to recognise them within yourself and friends and family.
Stage 1: recognising unhelpful thinking styles
Interventions which aim to challenge unhelpful thinking styles start with helping the service user to recognise them, identify the impact they have on how they feel and what they do as a response. The follow steps will guide you through this process:
1. Use the list above (p. 165) to talk about if and when the service user has noticed adopting any of these thinking styles.
2. Ask the person to describe the general situations or events when they noticed the thinking style was present. Examples might include:
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