Cognitive Behaviour Therapy: A Practical Guide to Helping People Take Control

Danny C. K. Lam

• Publisher: Routledge
• Year: 2008
• Print ISBN: 9780415398114
• eBook ISBN: 9781134151233
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Cognitive Behaviour Therapy: A Practical Guide to Helping People Take Control explores the premise that negative beliefs play an important role in the development and continuation of mental health problems. The book offers a new integrative model of causality for instigating change, based on giving clients control and choice over these beliefs, and therefore over their mood and behaviour.

This practical guide also focuses on the stigmas often attached to people with 'mental illness'. Danny C. K. Lam suggests that by providing both the client and the general public with a more accurate understanding of the nature and causes of mental health problems it is possible to de-stigmatise the 'mental illness' label. This will help the client improve self-esteem and the ability to manage personal and interpersonal difficulties and take control of their problems and responsibility for recovery.

Divided into six parts, this book covers:

• stigma, prejudice and discrimination from societal perspectives
• the nature and cause of emotional upsets
• a therapeutic framework for change
• self-prejudice, personal and interpersonal issues
• good and bad methods of communication
• practical approaches to assessing problems
• methods of taking control.

This cognitive behavioural approach to mental health problems is an innovative contribution to the field. Illustrated throughout with clinical examples and practical advice, the book is essential reading for all of those involved in mental health, from nurses to counsellors, and from medical practitioners and social workers to ministers of religion.

Part I
Societal perspective

Stigma, prejudice and discrimination

Chapter 1
Mental illness stigma

Stigma has its roots in differences. For example, society or the majority of society perceives individuals with a physical disability, HIV and AIDS as different. These individuals may also feel different. People are in reality different from each other, whether that difference is one of personality, physical appearance, illness and disability, age, gender or sexuality. Thus, it can be argued that it is not the difference itself (or a particular type of difference) that causes the stigmatisation, prejudice and discrimination; it is about how acceptable the difference is to society or the majority of society. People with ‘mental illness’ are, unfortunately, seen as one of the most unacceptable groups in society because of their perceived character.

The Oxford Dictionary defines stigma as a ‘mark of shame, a stain on a person’s good reputation’. When the difference is a mark of shame in the person’s attributes or character, it discredits the person in the eyes of others (Franzoi 1996). People with ‘mental illness’ are discredited because they are wrongly perceived as having attributes of unpredictability and danger as part of their character. These attributes portray them as having little or no control over their mind and behaviour and as such they are not responsible for their aggressive and violent behaviour. The public may therefore be fearful of coming into contact with them; prefer to have as little to do with them as possible and view them as inferior, flawed, unworthy, and so on. These attributes are forms of labelling, signifying them as being different from the majority of society and the difference is emphasised through the process of discrimination and prejudice. There are forms of discrimination and prejudice which can be identified in the interaction between the ‘normal’ and the ‘discredited’ or the public and the mentally ill (Goffman 1990). Discrimination and prejudice in any form serve to separate and socially exclude individuals from society and from many of the benefits of society, such as equitable access to services like housing, education, health and social support. Prejudice and discrimination in this way thus serve as a form of social exclusion.

The public perception of people with ‘mental illness’

Research shows that ‘mental illness’ is one of the most stigmatised conditions, and is more stigmatising than conditions such as homelessness, epilepsy, homosexuality, HIV and AIDS. There is little or no sign of stigmatisation being reduced, despite a range of health initiatives being used to de-stigmatise the condition since the late 1950s and the advancement of effective treatments such as drugs and psychotherapy.

Numerous surveys of the public’s attitude towards ‘mental illness’ have revealed strikingly negative views of psychiatric and psychological disorders and the people who suffer from them. In one early attitude study involving four hundred individuals representative of the general population, Nunnally (1950) asked the participants to rate a number of different groups with respect to a list of bipolar objectives (e.g. good-bad, safe-dangerous, predictable-unpredictable). The objectives most commonly used to rate people with ‘mental illness’ were dangerous, dirty, unpredictable and worthless. Tringo (1970) conducted a survey to assess the relative acceptability of people with ‘mental illnesses’. In the survey, the public was asked to rate twenty-one different disability groups with respect to their social acceptability. People with ‘mental illness’ were rated at the very bottom, just below alcoholism, mental retardation and a former convict. Gussow and Tracy (1968) showed that the two most horrible diagnoses that can happen to someone are leprosy and insanity; insanity (or mental illness) is viewed as the worse of the two. In other words, someone with leprosy is viewed more favourably than a person with mental illness.

Even now, people who are mentally ill are consistently portrayed as dangerous, unpredictable, dependent, unsociable, unemployable, unproductive, transient, flawed, unworthy, incompetent, irresponsible and socially undesirable (Day and Page 1986). There has been little change in public perception of people with ‘mental illness’ and recent research suggests that the stigmatising attitude is actually worsening (Sayce 2000). This inaccurate portrayal of clients’ characteristics thus maintains the stigmatising attitudes of the public and influences their prejudiced and discriminatory reactions towards people with ‘mental illness’. The impact of stigma and social exclusion can be devastating, leading to low self-esteem, poor social relationships, isolation, depression and self-harm.

Enacted and perceived stigma

Stigma can be categorised into enacted and perceived. Enacted stigma is the result of a person being stigmatised for certain attributes (e.g. dangerous, dishonest or flawed) or certain conditions (e.g. unmarried mother, HIV/ AIDS or homeless), whereas perceived stigma is a fear of being stigmatised because of these attributes or conditions. Scambler (1989) believes that people with epilepsy were much more likely to experience perceived (or self-perceived) than enacted stigma. There is evidence that, due to a better understanding of and more effective management or treatment of epilepsy, stigmatising attitudes towards the sufferers are diminishing (enacted stigma). However, people with epilepsy are still anxious about and fearful of being stigmatised, probably because of feeling ashamed of having this condition (perceived stigma).

There is mounting evidence that people with ‘mental illness’ stigmatise themselves because of enacted stigma. Social scientists are interested in the likely impact of stigma on their thinking and behaviour. One common observation is that stigma may become internalised, whereby stigmatised individuals may come to share the same beliefs as the majority of society and have a low opinion of themselves. They may believe that they are inferior, flawed, unworthy, incompetent, and so on. Some clients may accept that there is nothing they can do to change and get better because their condition is ‘genetic, a disease of the brain, or the result of chemical imbalances’. What follows becomes a kind of self-fulfilling prophecy. They may act in unmotivated and pathological ways that confirm the expectations that they and society have of them. It is believed that societal expectations place subtle pressure on mentally ill clients to live up to those role expectations.

Through the stigmatising process, the ‘mental illness/psychiatric label’ has the unwanted effect of taking away clients’ self-belief, undermining self-confidence, lowering self-esteem and increasing pessimism about recovery and the future. This is particularly so with clients not responding or not responding satisfactorily to drug treatment. It is believed that the stigmatising process may include clients either receiving professional diagnoses (e.g. you suffer from bipolar disorder), seeking psychiatric treatment, receiving drug treatment, or displaying behaviour consistent with the stereotyped image of people with mental health problems. For example, Christian, described below, could not quite shake off the stigma of ‘mental illness’ and often felt inferior to others because of the psychiatric diagnosis.

The case of Christian

Christian, aged 32, was a computer programmer. He did not go to university, but was quite good at computer programming and web design, largely through reading books and magazines and a lot of learning by trial and error. His friends thought he was good at what he did, started to give him some work to do for them, and also recommended him to others. His girlfriend, with whom he had been going out for almost two years, was caring and supportive and encouraged him to study for a degree in computer science. The course was beneficial not just to help him expand his interest and expertise in this area, but also for his self-esteem. Self-esteem had always been a problem, right from his early years. He was a shy and introverted person, did not have much self-confidence and this was particularly the case in social situations. He avoided going to parties where there were a lot of people and he did not like talking to people he did not know. Holding a conversation with people had always been a problem, as he felt that he needed to be interesting and to be able to come up with topics that would interest people. He monitored his performance and the behaviour of others he was talking to. If there were signs of him not meeting the standards he set himself or if others didn’t seem to be interested in what he was saying, he would go quiet and withdrawn. His body just tensed up and he felt uncomfortable, his heart started pounding and he would eventually leave. However, he was determined to make a change for the better, as he knew avoidance and escape were not the way forward. His social circle was small, but he had a number of good friends and some outside interests such as swimming, walking, reading and tennis. He had been coping reasonably well since his discharge from hospital two years previously for the treatment of depression, low self-esteem and alcoholism. However, Christian had also struggled with the stigma of ‘mental illness’, both enacted and perceived stigma, for most of his life.

His parents divorced when he was 10 years old. He was so traumatised by this experience that it seemed to have negatively affected his self-confidence and self-esteem throughout his life. Not only did he blame himself for the divorce, believing that he was the cause of frequent rows between his parents, but he also believed that he was not good enough as a son. Following the divorce, he stayed with his mother and attended a local school, but his mother was diagnosed as suffering from depression, which made it difficult for her to care for him and his sister, Helen, who was two years younger. Christian said that his mother was ‘a caring and supportive person with a nice personality and I love her’. She went downhill when she heard that her ex-husband was soon to be married as this dashed her hopes of their getting back together. The news hit her quite hard. She became quiet, tearful and withdrawn and found getting out of bed difficult. Sometimes she stayed in bed for days without going out of the house. She was diagnosed with depression and admitted to a psychiatric hospital as there were increasing concerns for her safety and that of her children. Christian did not have a close relationship with his father, who was described as a hard-working and successful businessman. However, he was also a cool and emotionally detached person who hardly spent any time with Christian and Helen. Christian believed he had been abandoned by his father and there must be something wrong with him. He was not good enough.

Helen went to stay with their father and stepmother and Christian was placed in a boarding school. Christian did not understand the reason for this and this made him believe even more that there must be something wrong with him: he was a reject. His experience at boarding school was painful and traumatic and he did not like it. He went to three different boarding schools, until he left when he was 18. He hated it and started to withdraw. He isolated himself from others and stayed in his room as much as he possibly could. The other children teased and bullied him and called him all sorts of names. In order to survive and try to be accepted he learnt to please others by conforming to their expectations. He smoked, drank and took drugs, as some in the school did, in the hope that he would be accepted and could become one of them. However, making friends was hard, as he found it difficult to get close to anyone and he didn’t allow people to get too close to him, in case they found out something ‘bad’ about him. Rejection was always a fear and a problem that he found difficult to handle. Alcohol and drugs allowed him to escape from the pain of reality and they seemed to boost his confidence and improve his mood. He found it increasingly difficult to cope with life and turned to alcohol and drugs more and more. On hearing that his mother was going to marry again, his mood went down and he cried, saying, ‘I am rejected again’. He was taken to a psychiatric hospital at the age of 16 and was diagnosed with depression with an addictive personality disorder. Since then, he had been in and out of hospital on many occasions. He was initially relieved to know the diagnoses, believing that drug treatments would ‘cure’ him in the same way medication does a physical illness. Despite being given a cocktail of drugs of various dosages over the years and a course of electro-convulsive therapy (ECT), his problems remained. He struggled with the stigmatising thoughts of ‘I am insane, I am mental and I have a personality disorder’, believing that there was no ‘cure’ for his ‘mental illness’.

Since leaving school with six GCSE and two A levels, he had had a number of short-term low-paid jobs, as a labourer with construction firms, a filing clerk and a postman. With the support of his girlfriend and a therapist, his life was starting to improve, as was his relationship with his mother and his stepfather. He joined his mother’s mail order company on a part-time basis as a web-designer. The company sold jewellery and employed four part-time staff. ‘For the first time in my life, I started to feel that I had a future,’ said Christian. He could not quite shake off the stigma of ‘mental illness’, however, and continued to encounter, from time to time, hurtful and offensive attitudes and behaviour. This impeded his recovery by adding stress and undermining his already fragile self-esteem.

Cognitive behaviour therapy approach to stigma

Stigma is due to an inaccurate belief that people with ‘mental illness’ are dangerous and unpredictable and are not in control of their mind and behaviour, thereby creating fear in the mind of the public. Violence and unpredictability are two stigmatising factors that have constantly emerged in attitude surveys since the 1950s. Such a belief is popularised by the unproven idea of ‘mental illness’ being ‘a disease of the brain, genetic, or caused by chemical imbalances in the brain’. As such, there is little or nothing clients can do to change the way they feel (e.g. anger, depression or anxiety) or their behaviour (e.g. violence, aggression or unpredictability). The idea of drug treatment as the main mechanism in the treatment of ‘mental illness’ may not be helpful in combating stigma and in changing how mentally ill clients are perceived. In addition, clients may become passive in the treatment process (e.g. taking medication as prescribed) rather than being proactive in learning how to resolve their emotional difficulties or problems.

To reduce stigma, the CBT approach is to enrich clients with an understanding that feelings or moods (e.g. anger, guilt or depression) are closely related to the thinking process (e.g. ‘I am no good’, ‘I will not get through the probation’, or ‘People think that I am stupid’) and to the way in which emotional difficulties or problems are dealt with (e.g. procrastination, self-criticism or perfectionism). It is important for clients to understand that mental health problems (e.g. depression, anxiety disorders) are not the result of a biogenetic cause, but are due to a combination of interacting factors such as psychological, social, environmental and genetic. CBT empowers clients with a tool to handle these difficulties or problems in a different, more realistic and adaptive way. The idea is to give clients a feeling of being in control and the public a reassuring message that people with ‘mental illness’ are not mad and insane.

Technique: ABC model

Rationale and focus

Clients often believe that their feelings are beyond their control and there is nothing they can do about it. Some attribute it to external causes (e.g. ‘People...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• About the author
• Foreword—Cognitive behaviour therapy: counteracting the poison of stigma and prejudice by Paul M.Salkovskis
• Preface
• Acknowledgements
• A personal experience by Danny C.K.Lam
• PART I Societal perspective: stigma, prejudice and discrimination
• PART II Therapist’s perspective: a therapeutic framework
• PART III Client’s perspective: self-prejudice and personal issues
• PART IV Client’s perspective: self-prejudice and interpersonal difficulties
• PART V Therapeutic approach: skills and techniques
• PART VI Taking control: new models for helping change
• References