Therapy? Experiences of Cognitive Behavioral Therapy

Ok. Time to hold my hands up - I'm in therapy. I'm nearing the end of a course of Cognitive Behavioral Therapy to help me deal with anxiety. Up to now there were only three people who knew this: me, my wife and my closest friend.

Cognitive Behavioral Therapy (CBT) is a therapy that is designed to teach new ways of thinking, to provide the client with new ways of dealing with problems that they face in their lives. It is very important to bear in mind that it does not promise any cure: in my case it will not stop me feeling anxious in certain situations. What it will do (I believe and I've not yet experienced anything to contradict this) is give me tools to manage my anxiety.

One thing that has struck me throughout the course is how obvious it all seems. In short, the steps have been to identify the causes of anxiety and rank them in order of severity, start at the bottom and develop ways to handle them. It's that simple! But there's something significant about the fact that the advice comes from somebody who has no emotional connection, who is impartial and nonthreatening. I feel that they have no "hidden agenda", that they are not trying to manipulate me (even though in fact they are - that is the purpose of the sessions). It comes down to trust: I feel that I can trust my therapist and consequently I am very accepting of her advice.

The thing about CBT is that it is a learning experience like any training course. If you are not engaged then you will not learn. Period. I believe that if you don't want to learn something then you won't. You can sit through lesson after lesson but if you don't apply and practice what you are taught then you won't learn. I think this is why CBT gets some negative reviews - people come into it expecting some silver bullet that will cure them of their problems, but it doesn't work like that. The sessions with the therapist are just to provide the foundations. It is up to the client to build upon them by practicing the coping techniques learned. It's difficult to begin with - you have to expose yourself to the challenging situation before you can try to apply the lessons.

I guess people fail because they don't put the effort into this part. But as I said to my friend earlier tonight, I wouldn't have brought this up with my GP if I didn't want to try to fix my problem. And if that means I have to do "homework" then I'm going to put the effort in because the end result will be worth it.

I did some research about CBT before I started the course - that's my way - and the key fact I learned about it is that it does not claim to be a cure. In may case it will not stop me feeling anxious. I believe it is important to go into this kind of therapy with realistic expectations of the outcome, and in my case it was that it would not stop me feeling anxious - it might not even make me less anxious - but it would provide me with ways to handle that anxiety, to function despite the feeling.

In many ways the success of the treatment depends on how much effort the client is willing to put in. The key to graduated exposure (which is the type of CBT I am receiving) is that you make the effort to expose yourself to the situations.

I've found that one of the hardest aspects of this for me has been to remember that I have to attempt to interact with people differently. Remembering this instead of falling back on ingrained habits has been very taxing mentally. I've discussed this with my therapist and she agrees that being on the autism spectrum poses particular problems for this type of therapy: resistance to change, ingrained habits (routines), co-morbid conditions such as social phobia and sensory hypo- or hyper-sensitivity, and difficulties interpreting non-verbal communication.

To this end I've been set tasks including listening to the radio (interpreting conversational voices) and summarizing what I've heard, observing other people's conversations (which is one of the most difficult tasks - trying to derive rules for conversation based on observation, because it involves trying to interpret the non-verbal signals), and making phone calls (to my friends initially - it's starting small but if that's where I want to end up then I'll have to build my way up to it.

I reckon I've made progress, even if it's not easily quantifiable by the simplistic measures recorded by the questionnaire I complete before every session. And that's the most important part - as long as I feel that I've progressed and I feel more able to tackle these anxiety-provoking situations then I think I'm gaining a benefit from the therapy.

So, in summary, I believe it's only effective if the client is prepared to put the effort in to practice the skills being imparted. If one doesn't have a realistic view of the aims and purposes of the therapy and isn't prepared to put in the work involved in learning the skills presented, then it simply won't work. In this type of therapy the therapist is the pilot guiding the course but the client is the engine room providing the momentum.

Unintended Consequences

It's very difficult to admit that you are in the wrong. Especially if the misdeed was not an intentional act but a consequence of natural behavior.

With impeccable timing under the circumstances I read this blog post over the weekend. It was like looking into a mirror - and I don't mean that everything appeared back-to-front! It was as if the writer had looked into my mind, seen inside as if it were crystal. I'm no stranger to recognizing aspects of myself in other Aspie blog posts: that goes with the territory. But occasionally I read something that could have been written about me. Which is kind of why I'm writing this now.

It doesn't matter exactly what happened over the weekend. But what made it worse was my failure to apologize in a timely manner. You see, I started out thinking that because I hadn't intentionally done anything to cause hurt then I couldn't have done anything wrong and the other person must be behaving irrationally. I'd forgotten about unintended consequences.

To truly be responsible for one's actions means accepting responsibility for all the effects, both intentional and unintentional, expected and unexpected, desirable and undesirable. And realizing that even unconscious, unplanned, unavoidable acts are included in this - accidents do happen.

"I never meant to..." is an excuse. It's a valid excuse as far as it goes, but that's not far enough. "It's my fault" is better. I might not have been able to foresee the results of my actions, or even avoid doing it, but that doesn't mean I don't regret what happened. Accidents have causes. In this case I didn't communicate early or clearly enough that I was approaching a crisis. It's like being too busy defusing a ticking bomb to evacuate the surroundings in time. I had too narrow a focus on what was happening internally to think about anybody outside. And that was a mistake. There were consequences that meant the problems were more severe and lasted longer.

And so to the apology. I'm sure some people can say sorry and convey the appropriate sincerity regardless of whether or not they feel remorse. I can't. If I'm going to apologize then I've got to understand that I did something wrong and regret it. Admit to myself first that I was wrong. That's hard.

In some ways I had an easy life growing up. I had a natural gift for the subjects I studied in school and regularly achieved top marks with little effort. I got the "gifted" label early and it stuck. I enjoyed the plaudits. But the down side is that the more used you get to success, the worse failure appears. It makes you risk-averse: you avoid choosing the path of uncertainty because you have become afraid of the possibility of failure, of getting something wrong. In some ways being labelled as gifted is a curse: you're only as good as your last [excellent] result. It made me happy, sure, but it made me awfully insecure at the same time. I identified with the label to such an extent that I felt that losing it would destroy who I was.

Admitting I got something wrong equates to admitting I failed. To accept being less than perfect. (Yes, I know intellectually I'm not perfect and I make mistakes but I don't feel it - there's still that belief that I have to achieve perfection just to keep on being myself.) I try so hard to get past this but it's always there, like rails preventing me from changing direction. I still look for praise in what I do and dread censure: it's made me a perfectionist, never satisfied with what I create because I concentrate on the flaws. It's a never-ending school report with just the comment "could do better".

So... it takes me time to get to the point where I feel able to admit that I've done wrong and apologize. Please bear with me and be patient.

I'm doing my best.

Anxiety: Learning to Cope

Nobody Home?

It's the strangest feeling, or it would be if it weren't so familiar. I catch myself playing the part, acting "normal", carrying on without conscious intervention while all the time I'm there, watching. I feel like a spectator in my own body, a mere passenger.

I remain aware of everything around me, fully linked to my senses, but my mind is free-wheeling, pursuing lines of thought unrelated to what my body is doing. And every so often I notice that my body has been walking around, even talking to people, while I've been occupied with my thoughts.

Role Playing

I guess it's a form of acting: I'm performing a role that I've rehearsed so thoroughly I don't need to think about what I'm doing, leaving my mind free to wander. This is the state in which I'm most at ease: there is a comfortable familiarity as I run along the rails of routine.

Am I a Stereotype?

The trouble is... as I watch myself I wonder whether I am being myself or whether I am merely exhibiting a set of learned behaviors with the aim of fitting in. What makes me suspect this? I get little nudges from my conscience - a feeling that I should be, say, flapping my hands or talking at length and in detail about some topic of personal interest. Things I used to do as a child but have suppressed as I've grown.

Since discovering that I have Aspergers I have become more aware that a number of things I used to do instinctively were characteristic of the condition. I see my innate Aspie traits on one side of a balance with my acquired "normal" traits on the other, and as one side rises into prominence the other side sinks from view. I've been feeling more and more that I am out of balance and I need to take corrective action to restore the equilibrium.

I've found that whereas in the past I had been led into thinking of my differences as aberrant behaviors to be corrected, I now consider them to be natural aspects of the way I am. I have accepted that I'm different - and the reasons underlying that - and I try to be more myself rather than struggling to "act normal". That said, there are some areas where my instinctive reactions are a hindrance to living independently: it's not possible to go through life without interacting with strangers at some point.

Identity and Self-confidence

My sense of self - my identity - is moderately strong: I know who I am and my core values are well-established in my mind. I might not always have the strength or confidence to actively uphold them but I find that I am incapable of acting against them. My self-confidence on the other hand varies according to the situation from bulletproof to non-existent. And that's where my anxiety creeps in.

The Sum of All Fears

First a bit of background: there is a psychological theory of learning usually referred to as "The Four Stages of Competence". Briefly, the four stages are:

1. Unconscious incompetence where you are not aware of your lack of a skill.
2. Conscious incompetence in which you become aware that you do not understand or know the skill.
3. Conscious competence which is having the knowledge but not grokking it: knowing a sequence of steps and able to follow the sequence but without fluency. One still has to think heavily about the task.
4. Unconscious competence where practice - rehearsal - has made the skill so familiar that it has become habit and little or no conscious effort is required to perform it.

What I described at the start is stage 4: I'm doing things that are so familiar I don't have to think about them and my conscious thoughts can drift off. Problems arise for me at stages 2 and 3 where I come face to face with the unknown.

When I am faced with a situation that is unfamiliar or where I can't predict what turns events may take I become anxious. I lack self-confidence in my ability to perform the task, whether it is making a phone call or interacting with strangers. I know I can manage well-defined, structured interactions such as ordering a pizza or going to the doctor because I have become familiar with the routines involved: I am around stages 3-4 in those cases. But with something that is off-the-wall where I would have to react according to the context I find myself back at stage 2 where I am all too aware that I don't really know what to do.

Breaking the Circle

At the moment I find myself trapped in a vicious circle where I have evolved strategies of avoidance when faced with anxiety-inducing situations. This prevents me gaining the experience to deal with similar situations in the future, and results in greater anxiety if I can't avoid them. I recently raised this problem with my GP and I've started a course of therapy to try to manage my fears so that they don't continue to be an obstacle to me doing things.

Square One

One of the first tasks has been to analyze the roots of my anxiety: what triggers it, what is it I am afraid of? Many people have a fear of judgement: what will the other person think of them? But that's not it for me. My core fear is of failure, of not being able to complete the task. Fears of this kind in particular can affect people who grew up with a "gifted" label as I did. A lack of experience of failing makes any failure, however small, appear catastrophic. This leads to risk aversion, a strong drive to avoid the possibility of failure. Perhaps if I can learn to accept failure than I will be able to attempt things where I lack confidence. I can hope.

Going Back

There's a saying that might appear familiar to readers of Terry Pratchett: "You can't cross the same river twice". If it wasn't for the clue in his books that the obvious interpretation is not the intended one then I don't think I'd have worked it out. I'm too literal a thinker to have realized, unaided, that the river here refers to the water rather than its course. I'm not going to take the metaphor too far and start considering the water cycle through evaporation and rainfall by which the same water molecules could be crossed again. For the purposes of this metaphor, once the water has flowed downstream it must be considered "lost" as different water flows down, replacing it. The river crossing in this instance is an event in space-time: the time coordinate is key to understanding.

So far, so what? Is any of this relevant? Well,... yes. You see, I sometimes get nostalgic. I recall places in terms of past events and some of those events evoke memories of happiness. I feel a longing to experience a particular event again that going back to the same place in the present can't satisfy: it's not the same river.

This unsatisfied longing to go back to an event - a situation - in the past can be so overwhelmingly powerful that I feel a profound sense of loss because there is no way to return, wind back the clock. This can be a problem when I find myself in the same place doing the same thing, whether it's socializing, playing darts or watching a band. Association triggers memories of the historical event and I can be left feeling that there is something missing, some vital piece of the puzzle that would complete the picture.

So I'm left with my memories, replaying the experiences, going back in my mind instead of in time. Maybe I can't cross that river again, but it will always be there.

Wish You Were Here

Outside the Wall

To be a fly on the wall, an unseen observer. How many people have wished that at some point? Usually because of curiosity: they want to be in on private events that they would normally have no access to. It's a normal human feeling... and I don't experience it; I don't have that curiosity about the minutia of other people's lives.

Eclipse

What I do experience is a desire to be unnoticed, to fade into the background, to become invisible, hidden. Not so that I can observe others but so that they can't observe me as I go about my daily activities.

Paranoid Eyes

Obviously I'm not the invisible man. But is what people see really me or am I hiding behind this fleshy facade? Looking out through the eye-holes in my mask? Like a mask, my face doesn't show much of what I'm thinking or feeling: this is a common autistic trait. And I like it that way. I'm not comfortable with the idea of my private thoughts being broadcast involuntarily by a traitorous subconscious via facial expressions or other body language. I want to have full conscious control over every aspect of my communication.

In the Flesh

That's an aspiration; the reality falls short and I find that people are able to "read" me in a limited way. But I find I get misread almost as often, so I guess I'm sending mixed signals. I've been wearing this body for nearly 40 years and I still don't have effortless control over its motor functions: it doesn't always move in the way I want so I can be physically awkward and clumsy. And this also applies to facial expressions and even speech: it takes me a degree of concentration if I'm not to speak indistinctly, mumble or slur my words.

Speak to Me

I normally speak softly, only raising my voice when I'm overloaded or in meltdown when I don't have much control. Sometimes too softly and I get asked to repeat myself, which is fair enough given the number of times I have to ask people to repeat themselves. That or I just stand there for a spell while I try to decipher what I just heard into meaningful words. Chinese whispers has got nothing on what I think I've heard at times! It can be quite amusing but mostly it's just confusing and distracting.

Us and Them

What is behind this desire to be apart rather than to be a part in social situations? It's partly a lack of affinity with in-groups: I have never identified with any group or class. Most people maintain an identity based on attributes shared with others, whether they support the same football team, listen to the same bands, go to the same church. I am, and always have been, just me. While I am well aware that my interests and activities overlap with those of other people I know, I don't feel that this makes me part of any social group.

I'm just me, on my own, always on the periphery. Not so much a fly on the wall as outside the wall, looking in through the windows. The eternal outsider.

Abstract Pictures

I've written before about being a strongly visual thinker. While this can involve the obvious triggering of mental pictures - snapshots if you like - as a direct result of words and phrases, sounds, smells or other sensations, my experience goes far beyond this simple interpretation.

C is for Cat

cat

Aside from being a gratuitous cat picture (scores high for cuteness), this image serves to illustrate the simplistic view of visual thinking: akin to a child's picture book that associates a concrete noun with a visual representation of that entity. This is indeed the most basic level of visual thinking: hear or read the word - "cat" in this case - and see a picture of a cat in the mind's eye.

This is all very well as far as it goes, and it does introduce the concept to those people who don't think in the same way. But there is much more to thought than just a collection of concrete entities, and so I will move on to another aspect: visualization of movement.

"And Yet it Moves!"

The first step beyond static pictures is to introduce motion. This is straightforward: in the real world things move and change over time. Continuing with my cat theme; unless it has had an unfortunate meeting with a taxidermist, a real cat does not sit motionless 24x7. So we need to imagine it doing "cat things": stretching, washing, playing with a fluffy ball, lapping water from its bowl, scratching at a post and so on. With all this in mind we move from thinking about one instance - a cat - to a more abstract notion of catness that may be applied more generally. If you'll forgive the pun, we've gone from a cat to a category.

My Own Private Street View

Another aspect of motion involves travel, moving from one place to another. Google Street View is a great analogy for how I see it, but years before that kind of thing was even possible using technology, I would visualize a journey such as "going to the shop" as if I had filmed it on a previous occasion and was now watching it back. This kind of visualization coupled with a good visual memory - for places if not other things - is a great help if I'm heading someplace I've only been to once before. I just correlate what I'm seeing in front of me with what I can see in my mind. Of course since Street View came along I have been able to make use of it to see routes before I ever go there in the flesh, which saves a lot of effort trying to navigate from a map while driving.

In terms of visualization, going somewhere is not so different from doing something such as making a sandwich: again it is like playing back a recording. So now we are visualizing processes - things are getting more abstract.

"It's Worse Than That, It's Geometry Jim!"

Simply relying on memory to furnish images would be rather limiting. What we need if we are to step beyond this slide show/VCR model of visual thinking is the ability to create new images: something like a sketchbook or whiteboard. And this is exactly what a visual imagination can provide.

Let's imagine something simple: a square. Picture it drawn on a sheet of paper. Now add another square next to it so that the edges join like squares on a chess board. Add another two so you have a row of four adjacent squares. Now add two more squares, one on each side of a square at one end of the row so you end up with a T shape. Cut away the paper around the edges of the T and then fold the shape up at a right-angle along the edges of each original square so that it forms a cube: if you've got this far then you've got some ability for thinking visually. I find this kind of thing easy to do; so easy in fact that 2- or 3-dimensional geometry becomes as straightforward as mental arithmetic.

I use geometrical visualization to understand mathematics and associated concepts. Solving equations is equivalent to finding intersections on a graph; complex numbers become points in 2D space. In computing, my "special interest" and day job, data structures and algorithms become animated diagrams, like flow charts on steroids: visual models of processes. Software as flowing shapes.

You Can't Get There From Here

It's all been positive so far, but there is a rather large elephant in the room. Everything abstract is derived from or analogous to concrete entities. It all comes back to things that can be seen. But what about truly abstract concepts? Things that cause physical sensations such as heat, roughness or sourness elicit images of situations that cause those sensations, so heat could be standing in sunshine on a summer's day, or being close to a fire. My problem is when there are no physical effects and no real-life situations in which I have experienced the concept. Emotions are a particular problem area for me: I am aware that there are far more distinctions, shades of emotion according to the dictionary definitions, than I am able to relate to my own experiences.

Consider the spectrum of meanings in words relating to happiness. I've colored these to illustrate that they can be thought of as sitting at different points along a scale:

at peace, content, cheerful, happy, elated, blissful, ecstatic

I know intellectually that these words describe different degrees of feeling but I can't distinguish them in relation to my own emotional states. I don't identify nearly as many points on the scale:

at peace, content, cheerful, happy, elated, blissful, ecstatic

The effect of this is that I get the same mental response when I consider "happy" as I do when I consider "elated". I get the same images, imagine the same situations. It is analogous to color-blindness. I also suspect that this is connected to my difficulty reading emotional states in other people.

Beyond Words

There's just one final facet of visual thinking that I need to explain. Because I've been presenting everything in this written medium, I've been giving the impression that words are of primary importance. This is not the case: when I say that I think in pictures it is literally true. I start with the visual representation and then translate that into words (or the equivalent mathematical expressions, programming language, diagrams or whatever else depending on the domain). I sometimes have a problem, especially when speaking, where I struggle to find the words for what I am thinking - and because I'm not thinking in words I find it difficult to describe in alternative terms.

I hope this has given a flavor of what it is like to have a strongly visual-oriented mode of thinking. I'd be interested to know how other people's experiences match up to mine.

Emptiness

There comes a point when it stops hurting. When the pain is replaced by numbness. When all that remains is emptiness.

And in a way that's a good thing - there might be no joy, no happiness but there is no hurt either. Only a silent void. Absence of feeling, deathly serenity.

They say ignorance is bliss and they might well be right - insulation from feelings brings a certain clarity to my mind, in which state I may contemplate choice of actions rationally.

Except...

I am faced with hard choices that bear the seeds of possible futures. I could continue on my present course in the expectation that further hurt lies ahead or I could turn aside onto a new, unknown path. I fear the unknown but can hardly bear the life I have. Is my despair enough to drive me over the barrier of my fears?