Running the gamut of CBT
Reprinted from "CBT" issue of Visions Journal, 2009, 6 (1), p. 12
I had a serious motor vehicle accident nine years ago while working for a very high-paced software company. I was in Ottawa—far from my home in Vancouver—driving to a client’s suburban location. Another driver wasn’t paying attention when changing lanes and rear-ended me at high speed. I ended up in a multi-car accident involving nine vehicles. Numerous ambulances and fire trucks were called. I had to wait on the side of the road in the minus 40 degree weather, hearing sirens wail and wail as they tried to get through the backed-up traffic.
I continued to work after the accident, even though I had shooting pain and numbness in my right forearm and hand as well as poor concentration. The pain increasingly affected my work output, so the Workers’ Compensation Board (WCB) [now called WorkSafeBC] sent me to a psychologist for pain management techniques. That was the start of my cognitive-behavioural therapy (CBT) treatments.
From CBT for pain...
CBT deals with changing a person’s thought patterns so they have a better and more positive understanding of things that have happened to them. In these sessions, the psychologist and I looked at behaviour, physical symptoms and thoughts. We talked about how there is a psychological aspect to pain and that we can change our experience of the pain by changing our thoughts and behaviours in response to the pain.
For homework, I had to log my experience of pain so we could see what the flare-up patterns might be. The psychologist also trained me to do imaging; that is, make mental images to call up when my pain is severe. I bring up an image of a beach I visit in Maui; this mental ‘retreat’ helps ease the pain. The psychologist also taught me breathing exercises to do when the pain is strong. So, for instance, in a meeting at work, I could deal with a surge in the intensity of my constant pain by changing my breathing pattern.
In talking about my pain, it became apparent to the psychologist that something more than physical pain was going on. I told him I was quite uncomfortable driving my car. I stayed off highways and took side streets to avoid busy thoroughfares, as these reminded me of my accident. He mentioned this in his case report to WCB, and I was moved to another psychologist who specializes in CBT for post-traumatic stress disorder (PTSD).
to CBT for PTSD...
The new psychologist diagnosed me with PTSD; this was about one and a half years post-accident. Not only was I anxious about driving my car, but by now I was having insomnia and nightmares—images of my accident constantly replayed in my mind. I also had intrusive thoughts during the day, where I felt like I was back there, reliving the accident. I felt angry at the world and had a low tolerance for other people (whereas before I’d been a super people person). Another thing that had progressively gotten worse was that my arms and hands would involuntarily wave and clap whenever I saw fire trucks, heard sirens or was put in a position of increasing stress. I had to stop driving altogether.
The CBT for PTSD was really intense. It involved exercises like visualizing the accident, writing down the details of the accident, tape recording myself telling the story of my accident and watching tapes of other accidents—over and over. This is called exposure therapy. These exercises were done both within the safe environment of the psychologist’s office and at home afterwards.
These tasks are not easy to do; they bring up bad memories of the accident. Working with the brain to change the memory patterns is a long, exhausting process. However, with repeated exposure to the stories of the accident, the incidence of these images and memories has very slowly decreased in frequency.
We also incorporated the imaging and breathing I had previously learned. Plus, the psychologist grounded me, bringing me back to the present when I’d get lost in the memories of my accident (i.e., was triggered). I then learned to ground myself, by rubbing my legs or the handles of a chair, or running my hands over the keys of my laptop. (This was actually a first taste of mindfulness-based CBT).
to CBT for depression...
In spite of two years of therapy, my PTSD had become chronic (it lasted more than six months). And after being a highly regarded employee for nine years, I suddenly lost my job in March 2003. Major depression ensued. I ended up in Vancouver General Hospital (VGH) before finally being moved to the UBC Hospital mood disorders ward.
While in the hospital, I was considered too fragile for the rigours of CBT. I did a little swimming and walking. This may have been helpful for the depression, but my hospital stay was not good for the PTSD. I wasn’t allowed to stay in the hallway at night when I retreated there from nightmares. And another patient in the semi-private room kept startling me at night, which made my insomnia worse.
But we did have group therapy meetings, which was great for me. I had lost contact with people and felt very alone, so it was wonderful to have people to talk with. I was able to realize that I wasn’t alone in my depression.
UBC Hospital staff recommended that I take Changeways, an outpatient program for depression offered by the hospital at that time. So, after I was discharged, I took the eight-week, once-a-week program.
We did CBT in a group environment. I learned how to organize my time to reduce my stress. I was accustomed to the high-paced, multi-tasking environment of my former workplace, but learned to look at one task at a time and just one day at a time.
I was still alone in my PTSD, however. No one else in the group had this diagnosis and I was constantly being triggered by comments made in the group. I only found comfort with my psychologist, because it’s clear that the PTSD drives my depression. He continued to work with me on exposure analysis. As homework, I practised increasing my tolerance for walking outside where I was near cars. He also worked with me on the depression in sessions by having me write a task list for the coming week, then having me revise it to be more reasonable.
to mindful CBT for anxiety...
Once my depression was under control, a neuropsychiatrist (UBC Hospital had referred me to him for my arm-waving movement disorder) referred me to VGH’s PTSD program. There was a year-and-a-half wait for the program, so the intake psychologist referred me to the VGH outpatient group for generalized anxiety disorder (GAD).
The GAD group was also in a CBT format; however, they were using a technique called mindfulness-based cognitive-behavioural therapy (M-CBT). Mindfulness is about being in the present moment, the here-and-now. Through mindfulness, I was able to start changing my negative self-talk by observing my behaviour and thoughts, and then coaxing the negative behaviours and thoughts to become positive ones. This also helped me deal with my anger.
For example, at home I sometimes find myself getting angry at noise from outside—such as roofers working—and have an impulse to storm out and express that anger. With mindfulness, I will take a moment, bring myself into the present by feeling where I’m sitting and then maybe draw on imaging to feel myself in Maui so that I relax.
I also started knitting, which I learned as a child. This is a form of relaxation I can do anywhere—on the bus, in a car or waiting for appointments.
Another very important tool learned in this group was an anxiety scale from zero to 100, used to self-assess our anxiety levels. A reasonable range was from 30 to 60. If we thought ourselves higher, then we would draw on our CBT skills to bring our anxiety into a more acceptable range.
Finally, in the VGH PTSD outpatient group, all the therapy I’d done over the previous seven years came together. I got a grasp on PTSD and began to work with it to enable me to get going with my life.
There were three parts to this program. The first part consisted of one-on-one sessions with a psychiatric nurse to ensure I had the necessary skills for the next phase. The anxiety scale, for example, was one of the tools that was needed, as well as imaging, breathing and basic information about PTSD. Because of my years of CBT therapy, I only needed a few sessions to be ready for the next phase.
The second part of the program was a 28-week group session led by the nurse and a psychiatrist. The group was in M-CBT format like the anxiety group and included relaxation at the end of each session. Stress reduction is very important in PTSD. They compared it to a car engine, which can go from zero to 4,500 revs a minute. A person without PTSD generally idles at about 1,500 rpm, but someone with PTSD idles at 2,500. When a person with PTSD is stressed, they have less room to deal with the stress before reaching 4,500 rpm.
The really powerful aspect of the group session was that, starting about week 12, each group member had to explain their traumatic experience. The facilitators asked us questions so that we’d be triggered and relive the traumatic event—I found out that red car tail lights were a major trigger for me. When I began to dissociate (not to be present mentally), the psychiatrist coached me to apply the M-CBT techniques.
Doing this process actually caused me to be hospitalized at VGH for a couple of weeks during the group due to depression from the PTSD. However, experiencing the trauma in the group setting, the recovery, the sharing, using the anxiety scale—it all did me wonders.
The third part of the program was 40 weeks of a support group led by the nurse. Sometimes we focused on particular topics. But we always shared and explored our experiences of working with the M-CBT tools in our day-to-day lives.
I’m now back to one-on-one therapy, seeing a new psychologist for return-to-work issues. We do less cognitive-behavioural work—though I do monitor and log my pain, anxiety and mood—and do more talk about socialization. But the theory behind CBT and M-CBT is really strong. You have to take time daily to practise it, but for those who do, it works to reduce the stress of living with PTSD.
While going through the therapy process, I never thought CBT would work for me. Back when I was recording stories of my accident, I felt I was getting worse rather than better. But now I feel that it’s been a success. When triggered, I can acknowledge the PTSD images, rather than pushing them away. This has lessened my arm movements, as I’m managing my stress better. I can walk more often on a busy street and am more at ease in cars, though I’m still not driving. I volunteer, go to appointments, run errands and work at living a stress-free life. My next steps: getting back to work and getting my degree!
About the author
Lynda worked in hotel management and the software industry before she had a workplace accident. She’s been diagnosed with post-traumatic stress disorder, major depression, a spinal injury and myofacial pain. Lynda studies part-time at BCIT and UBC. She aims to earn a BAdmin before she’s 50