68 COGNITIVE THERAPY IN CLINICAL PRACTICE

The next phase of the discussion about locus of control focused more specifically on her illness. Margaret did not feel she had much control over this in general, e.g. she could not control whether secondaries occurred. However, she stated spontaneously that her compliance with the radio-therapy treatment had been an attempt to reduce this risk as much as possible. We defined Margaret’s role in controlling her illness as taking responsibility for being as healthy as possible. The elements of this are listed in Table 5.2.

Table 5.2 Margaret’s action list for reducing her anxieties related to her health

Sessions 5 to 7

These sessions predominantly focused on working on Margaret’s list. Her mood was improving and she appeared more relaxed. We reviewed her visit to the hospital to discuss her illness. We examined her automatic thoughts and feelings before and after the visit. Margaret concluded that her depression, anxiety, and hopelessness were all reduced by seeking out information and dealing with the realities of her illness and her prognosis rather than focusing on her fantasies about the situation.

She had started to exercise by walking a mile a day through some fields near her home. Ultimately, she decided she would like to join a health club she had previously been a member of, but she would work towards this in a graded way. In the past, she had managed to give up smoking, but had lapsed and now smoked more than twenty cigarettes a day. To try to aid reducing this, she was shown how to make a ‘flash card’. This was a small card that she carried around with her. On it she listed the key reasons for not smoking, e.g. to be healthy, you have to make some effort; think of the money you save; how could you smoke after treatment! This card was available to her to re-read at appropriate moments to maintain her motivation to give up. Margaret managed to stop smoking, and derived considerable pleasure from this success experience. She was worried, however, that she would gain weight. This in fact reinforced her desire to get fit and eat a healthy diet.

During the sessions Margaret learned anxiety management techniques and incorporated these into her assignments. In session 7 we also discussed the possibility of joining a support group. Margaret showed some ambivalence towards this. As a homework assignment she generated a list of the pros and cons of joining.

Session 8

The list of pros and cons seemed to favour making a commitment to a support group. On further exploring her reluctance to take this step it came out that Margaret felt going to such a group might be seen as a sign of personal weakness. (Again, this issue of Margaret’s view of a strong person came to the fore.) In addition, Margaret felt she would rather receive support from relatives and friends than from ‘strangers’. A theme that came out, however, was that Margaret’s behaviour (attempting to be strong and coping) did not allow her friends to offer the response she would like (i.e. caring and supportive). Since her operation, she had become rather withdrawn socially and was feeling lonely. Also she had not spoken in any detail to her daughter or mother about her problems. The agenda for this session was to look at her support network and to examine if she should change her approach.

T: It seems that what you’re saying is that you feel you should put on a brave face for your friends? P: Yeh, I think they expect it from me. People don’t want to listen to my moans.

T: Do you listen to theirs?

Instead of taking the stated automatic thought that ‘people don’t want to listen to my moans’ and then going through all the evidence, the therapist decided to check out whether Margaret was applying double standards, a tendency that had been obvious on many occasions previously.

P: Yeh, I’m regarded as a good listener. I never turn people away.

T: Do you mind that you do that for them, but they don’t reciprocate?

P:No…well, I guess that’s not entirely true. [Margaret smiles, an acknowledgement that she knows there is a problem for her here.] Sometimes I feel a bit annoyed….

CANCER PATIENTS 69

This line of enquiry proved to be very fruitful and through further questioning we were able to elicit a number of underlying assumptions. Margaret had grown up in an environment (both family and school) where open expression of distress was perceived as weakness. Since then she had been reluctant to confide in people. On one occasion after her husband’s death she had talked at length to Rosemary, a close friend. It was later reported back to Margaret that Rosemary had then remarked to someone else that being with Margaret was depressing. This incident confirmed for Margaret her belief that ‘weak people are unlovable’. From then on Margaret had avoided expressing any difficulties to others. She acknowledged that she would like more support, but resisted approaching anyone for fear of rejection. (She also demonstrated the belief that ‘good people are selfless, bad people are selfish’. According to her definition, however, even talking about her own problems would be selfish.) In addition, Margaret promoted a false self-image of being totally coping and would not accept even tentative offers of support. She constantly failed to assert her own needs in her friendships, she always put others first. The outcome tended to be that failing to assert herself left her feeling frustrated and ultimately angry that people did not support her more, i.e. this rigid pattern of behaviour left Margaret feeling uncomfortable with herself. More importantly, she found her friendships unfulfilling as she concluded that she cared about her friends more than they cared about her.

As a homework assignment Margaret agreed to try to be more open about her difficulties. She agreed to re-establish contact with two of her closest friends and, if the opportunity arose, to tell them about some of her anxieties. With encouragement she also agreed to talk to one of them about her mother’s mental health problems. Margaret had never disclosed this to anyone, but was getting worried about her mother’s impending return visit to her. These conversations would be used as experiments to:

1.see the effect on Margaret’s self-image of allowing people to know about her true anxieties and feelings; and

2.to look for evidence that expressing these anxieties would lead to rejection.

A further assumption came to light in these discussions, namely that Margaret also held the belief that ‘I cannot be happy if I am independent of others’, i.e. she desired a close network of supportive friends. Again, she was encouraged to make contact with her friends. This statement was also explored by asking her several key questions. Could she identify people without close personal relationships who were happy? Were there people who were in a close relationship who were unhappy? Were there activities that she did or could enjoy alone? Could she only feel happy in other people’s company? Lastly, could we distinguish between what she wanted (i.e. was desirable) and what was needed (i.e. fundamental to survival). We established that, whilst she desired close relationships and gained many positive benefits from them, they were not absolutely essential to her.

We also looked at Margaret’s relationship with her daughter and mother. Her daughter had apparently withdrawn from her. The discussion suggested that Margaret’s daughter was probably scared about her mother’s illness and was uncertain about what the future held. Margaret (in an attempt to be strong and coping and to try to protect her daughter) had not shared her anxieties with her, nor had she shared any of the information she had about her illness and prognosis. She decided to tell her daughter the information she had gained from her visit to the clinic and from the educational booklets she had been reading. Margaret also agreed to ring her mother and try to talk through her recent difficulties.

Sessions 9 and 10

The very positive feedback and support that Margaret received from relatives and friends surprised her and helped her adapt her coping strategies. She no longer felt she had to be invincible to keep her friends. Margaret and her daughter started exercising at home to ‘workout’ tapes. This gave them a joint activity that they both enjoyed that allowed them to spend some time together and work on their relationship. Over the next few weeks we repeatedly tested out her rigid schemata and tried to develop more flexible, adaptive assumptions.

The last few sessions focused on helping Margaret identify stress-provoking situations and thoughts. We included her perfectionism, her difficulty in asserting herself and her difficulty in asking for help or confiding in friends as stressors, again reinforcing the advantages of relinquishing these ideas and patterns of behaviour. Many of these issues overlapped with other aspects of Margaret’s problems and had been dealt with in previous sessions. However, she also read some self-help material on perfectionism, e.g. Feeling Good (Burns 1980), and on assertiveness training, e.g. Your Perfect Right (Alberti and Emmons 1975).

Finally, we spent time dealing with Margaret’s anxieties about leaving therapy and being her own cognitive therapist. She was still debating whether to join a support group but on balance was now in favour as she felt that anxieties about her health and how to cope would never fully disappear. What seemed important, however, was that she no longer suffered from incapacitating anxiety and depression.