When we think about the effects that a condition such as MS can have on people's lives, it is not surprising that mood problems are common. A team in Surrey set up a psychology service offering two frequently used approaches (CBT and MBCT) that research has shown can improve mood and help people adapt to and cope with living with MS. Lorraine Maher-Edwards (counselling psychologist), Liz Wilkinson (MS nurse) and Annette F Schwartz (consultant clinical neuropsychologist) describe these two approaches and include some of the comments made by clients who took part.
What is cognitive behavioural therapy (CBT)?
Cognitive behavioural therapy (CBT) is a short-term talking therapy where the client and therapist work together to help the client to overcome their difficulties by changing thoughts (cognitive) and what they do (behaviour). The central idea is that the way a given situation affects us emotionally will be influenced by how we think about it and what we do in response to it. Our behaviour and thoughts will influence our body.
Take the following example:
Imagine you wake up feeling tired and a little low. You walk to the shops and pass someone you know, who apparently ignores you (situation). Imagine how you might feel.
If you were to think 'how dare she/he, how rude!' (thoughts), you might feel angry and irritated (emotions), you might notice your shoulders hunch and jaw clench (physical), and you might avoid contacting this person (behaviour). But this is only one possible interpretation. You could instead think, 'she must be in her own world, how funny!', which of course will lead to different feelings, physical sensations and behaviours.
When we are distressed or low we may not think clearly. We probably all know someone who tends to see the glass as half full, or someone who makes a mountain out a molehill. Importantly, the more we think in a given way, the more likely we are to think this way in the future. Ways of thinking can become habits. Moreover, the more we think a certain way, the less aware we become of these thinking patterns. It is similar to when we learn a new skill like driving. We start off all too aware of the complex sequence of actions we need to coordinate in order to drive but the more skilled we become the more automatic this becomes.
Importantly, it has become clear that we can change these thinking patterns with a bit of practice. In CBT, you can look at your thinking patterns with your therapist and learn to challenge unhelpful thoughts. Seeing situations from a number of perspectives can lead to a shift in how you look at yourself and the world.
I went from being someone who beat themselves up over things I couldn't do, believing that nobody thought I had any worth, to someone who realises this is not the case. I was being unfair on myself and others by making these assumptions. I feel like I have gone from focussing on what I cannot do to what I can. I feel better in myself, less tired, less emotional.
The CBT approach also focuses on problem solving, experimenting with how you act or respond in situations, and how you communicate in relationships. We aim to teach people skills to manage their mood in the future and clients undertake (a little) real life homework outside sessions.
I could not believe how far I have come. I now feel I have the tools and knowledge to cope with the future even when life gets stressful. I once again feel I have self worth and look at things in a positive way not a negative way.
What is mindfulness-based cognitive therapy (MBCT)?
Have you ever pulled up outside your house only to realise you were supposed to be somewhere else? Or arrived at your destination and found you have no recollection of the journey? When mood is low, it's easy to get absorbed in brooding about the past or worrying about the future. This tendency to get pulled into our heads is called automatic pilot. Existing in automatic pilot robs us of the present moment, the sound of birds singing, a moment of connection with a loved one. Moreover, we don't notice our mood becoming low.
MBCT marries mindfulness meditative practice with cognitive therapy principles. Mindfulness is a means to get back in touch with the experience of being fully alive. We learn to pay full attention to our experience, moment to moment, without judging it. As for our thoughts, we learn to recognise them for what they are, mental events. We can observe negative thoughts and feelings without getting sucked in to them.
I was very tearful before I started the course and my thoughts controlled me. By using the meditation techniques I am now in control. I still have negative thoughts, but I can see thoughts as thoughts, not facts.
Becoming more aware of the patterns of the mind, we are much better placed to recognise when mood is becoming lower and hence nip these patterns in the bud.
I have found I am in a lighter mood more often than a low mood now. It has changed my sleeping pattern for the better. I can now laugh or ignore things that used to make me tense or stressed.
In mindfulness we bring awareness to our experience, whatever it is - we can apply mindfulness to any moment of our daily lives.
Take the following example
Make a cup of tea
As the tea steeps, watch the colour of the water change, perhaps to green, light brown, or red (depending on your choice of tea). Explore the tea as if for the first time. What do you notice about the changing colour? Add the milk (if you wish) and again observe, as it mixes with the tea. Now pick up the cup and feel the warmth in your hands. Bring the cup to your nostrils and inhale deeply the smell of the tea. Feel the warmth of the steam against your face, watch it rise from the cup. When you are ready, slowly bring the cup to your lips. Feel the hot liquid as it contacts your lips. Is it too hot or just right? What does it taste like? When your mind wanders (as it surely will), don't tell yourself off, just gently notice where it has gone and escort it back to the tea. If you don't like tea, notice this dislike, its strength and quality. Try to note your experiences without judging them.
Adapted from Smith & Hayes. Get out of your mind and into your life. Oakland: New Harbinger Publications; 2012
So does it work?
Of 28 people with MS who took part in CBT or MBCT in our service, 76% rated their mental health as either 'much better' or 'very much better' (from a range of options ranging from very much worse to very much better). People reported a range of benefits from improvements in sleep and more energy, to less stress at work and better relationships. When we looked at how people changed as a result of therapy, we found that people tended to show lower levels of anxiety and depression, less fatigue and improved quality of life.
Confronting mood problems and getting help is a positive step and we like to see the therapy as a first step in a journey that continues long after.
How can I access these therapies?
Contact your GP or MS nurse to find out what's available on the NHS in your area. Your local library should be able to advise you on charities that might offer therapy, or look on the British Psychological Society's website for registered psychologists near you. For MBCT courses, visit www.bemindful.co.uk
Written by Lorraine Maher-Edwards, counselling psychologist, Liz Wilkinson, MS nurse and Annette F Schwartz, consultant clinical neuropsychologist, Central Surrey Health for Open Door - November 2012