After nearly two hours’ driving, Keith arrives at the hospital.
If you don’t know who Keith is, you’d better start from Part I of this series.
Victor was highly recommended by the psychiatrist who assessed Keith at the hospital three weeks ago. He’s a CBT specialist who has written two textbooks and a lot of research papers.
Keith is now used to the idea that therapists accept and understand the strange feelings of anxiety he suffers from, so he can explain what happens much more freely than he could at first. But Victor is interested in the details of Keith’s thoughts. His approach seems analytical, scientific. Keith feels he is under a magnifying glass.
Like Keith’s previous therapist, Victor seems genuinely concerned, thoughtful and confident. When Keith explains how his previous therapist only wanted to address superficial practical difficulties, Victor is dismissive of that approach. CBT, he says, should deal with thoughts in great detail. When the thoughts have been put right, the practical difficulties will sort themselves out.
Keith is convinced. He trusts Victor and his detailed, methodical approach.
Victor explains that certain thoughts are negative and harmful, yet they come into mind automatically. This is what causes a mental health problem. To solve the problem it is only necessary to counteract these negative automatic thoughts.
Yet it is pointless just trying not to think these thoughts. That only makes things worse. What’s needed is a system for identifying negative automatic thoughts and using reasoned argument to reject them. Victor will teach Keith to use the system. Once Keith has learned the system, he can apply it for himself whenever he needs to.
Six sessions later, Keith has learned the system. When he feels his anxiety coming on, he identifies the negative automatic thoughts and uses reasoned argument to counter them.
He finds that he is able to feel anxious and fearful, for his mind to race just as it always did, and also to argue with his own thoughts in the way Victor taught him, all at the same time. Having arguments with himself has had no effect on his anxiety. It’s just a slight distraction from it. The whole thing, all that driving up and down the motorway, has been a complete waste of time.
What happened was that Victor only managed part of a formulation. He got the second part mixed up with something else entirely. The three parts of a CBT formulation (the common sense explanation of what’s going on) are:
Victor got part 1 right. He understood that the faulty thought process was Keith’s feeling of something very bad about to happen.
Then he got part 2 wrong. Keith’s feeling of something very bad about to happen makes Keith’s mind race as he tries to think of what the bad thing might be. But Victor got this the wrong way round. Victor thought that Keith’s racing mind causes the feeling of something very bad about to happen.
Victor’s mistake arose because he was badly taught. In CBT theory there is a thing called an “automatic thought”. It is a fleeting thought that people are mostly unaware of, because it is almost immediately replaced by an emotion. Victor had heard of automatic thoughts, but he has never really understood what they are. So he assumed that the thoughts Keith has when his mind races must be automatic thoughts.
As a result, Victor never really answered the second question, and he didn’t even attempt the third. He tried to make Keith change his thoughts without any common sense explanation of where those thoughts came from.
Keith is angry and despairing when he gets together with his brother and tells him how therapy went, but his brother comes up with one last thing to try. A neighbour of his was treated by a local CBT therapist who doesn’t seem to advertise and who is not listed on any of the websites, but this neighbour swears she gets amazing results.
“Why not?” Keith thinks to himself. Una will be the sixth therapist he has seen.
Una doesn’t have the intensity of the other therapists Keith has seen. She’s just kind of quiet. He finds himself more upset about the way all these therapists have failed him than about his anxiety, which he has started to think is just the way he will always be.
Una asks some unusual questions. Maybe she doesn’t really know what she’s doing. It would not be at all surprising.
“When did this start to become a problem? What was happening in your life around that time?” It was three years ago — just over, early summer. Keith’s father had just had a small stroke. Keith had cancelled his holiday, but the stroke had turned out not to be very serious and his father had got over it quickly.
“And before that? Did you ever have a similar feeling before? Perhaps when you were much younger?” No, it had never happened at all before that. The nearest thing Keith can remember is when he was a small boy. His grandfather had been taken ill, and in fact he died. There had been no one to take Keith to school, and no one had told him what was going on. Now that Keith thinks about it, the feeling he had had then as a small boy of something fearsome but unknown, his mind racing trying to work out what was going on, the routine of his life frozen in time, it had all been quite similar. Odd, that.
“And the latest episode? Tell me about that.” It had been in the supermarket. He had been heading towards the coffee and suddenly out of the blue the feeling came on.
“What do you remember about the moments just before it came on?” Nothing special. Looking for any offers in the coffee section. At the end of the aisle a young girl at the till, and old man trying to put his card in the machine. The old man’s hand had been shaking, so the girl took the card and put it in for him.
“And the time before that? Was there an old man?”
Keith has five more sessions with Una, although after that very first session his anxiety attacks never recur. His homework tasks between sessions involve talking to his father about that day long ago when there was no one to take him to school, about his grandfather, about his father’s stroke, and about the inevitability of death.
Although Keith understands Una’s formulation from within, so to speak, not as an intellectual exercise, she would have spelled it out to him if she had needed to:
1. The faulty thought process is Keith’s thought that something terrible is about to happen. It’s faulty because nothing terrible is about to happen, and there’s no reason to think there is.
2. Faulty pattern-recognition in Keith’s mind links anything suggestive of old age or death with the thought that his father might die, but instead of this being a conscious thought it’s a fleeting automatic thought that triggers a feeling from childhood.
3. Unresolved memories of the time of his grandfather’s death caused the fault in the first place.
Una’s treatment plan is to work backwards. First resolve Keith’s childhood memories. Then resolve Keith’s feelings about his father’s eventual death. Finally, if necessary, desensitize Keith to triggers like seeing an old man in a supermarket or the Compliance manager (who looks a little like a photo Keith has of his grandfather) at work. In Keith’s case it wasn’t necessary.