One of my youngest patients was referred by her distraught mother who had desperately tried to manage her daughter’s depression, refusal to go to school and suicidal thoughts.
She had been referred to the local CAMHS service and placed on a 4-month waiting list, but needed immediate intervention to prevent her mental health condition deteriorating further.
At the first appointment she was very miserable and withdrawn but after my taking the time to get to know her and share interests, she relaxed. By the end of the session, we had talked about a very difficult few months when she felt lonely and judged by others on social media.
She had good family support and was encouraged to do things she enjoyed like baking, taking the dog for a walk and spending time with her family, instead of being alone in her bedroom.
She was also given information about social anxiety and depression, advised to keep a daily diary of her mood, and encouraged to take some fresh air and exercise (not an easy ask of a teenager).
This was the easy bit. Doing these things helped her feel more positive, and then she worked with me on changing her perception of how she thought and valued other people’s opinions. This involved reducing exposure to social media, trying to be more face to face with her friends, and not critically judging herself.
She returned to school, found things easier with some coping strategies developed in the sessions and made the decision to continue with her University applications which she had put on hold over the summer. The negative thoughts were much reduced, and her confidence began to rise. Her family felt they had their daughter back.
I’m delighted to say she has since been accepted at the two universities she wants to study at. She is better equipped to manage the stress of her mock exams and is now having bi-monthly sessions to maintain her progress until after A levels. Friendships are now a source of support rather than sorrow and the future looks very different to 7 months ago.
Stress-related anxiety in the workplace is one of the biggest contributing factors for people signing off sick or seeking alternative employment. When I first met my patient, he was suffering very high levels of stress and anxiety, triggered by a fear of giving highly scrutinised presentations at work.
His anxiety affected his concentration and he often experienced palpitations, sweating and stomach pains for days prior to the presentation.
Although he was able to deliver the presentation, he felt his productivity and happiness at work was being affected and his anxiety also impacted his personal life.
His natural reaction was to resign, however the nature of his work meant that presentations would still be a significant part of it, so he needed a way to control his anxiety and move forward.
The first step in his treatment plan was to understand and recognise the symptoms of anxiety and to learn effective ways to self-manage his symptoms.
CBT encouraged him to reflect on how he felt about delivering presentations and to document thoughts, emotions, and behaviours he experienced. The process helped rewire his thinking and develop a more productive and positive mindset towards presentation day.
He is a keen cyclist, so an increase in weekly exercise was advised. Gradually he created a new work routine, with a fresh perspective towards colleagues.
Becoming more aware of his symptoms and implementing self-help measures at home, in-between sessions, helped my patient stay on track.
After 8 CBT sessions my patient reported much lower feelings of anxiety in build up to, and on presentation day. And, although he still experiences a level of anxiousness, he now understands this is normal for the situation and he can better control his thoughts and prevent any escalation of anxiety.
His annual appraisal was very positive, and he is now considering promotion rather than resigning. He continues to practice CBT and mindfulness techniques and has kept up with the cycling.
This patient had been signed off work for 3 months before contacting me using her work private medical insurance. At this point she scored highly for depression and anxiety and coped only with very basic daily tasks. Both her adult children had recently left home and were coping well with their life changes, which made her feel redundant, rather than delighted that she had brought them up to cope with life. Her partner was also depressed due to family issues in his family, and she felt that she was supporting him. Overall, she could not imagine returning to her demanding job (which she used to enjoy).
The early sessions focused on finding out how the depression had developed and helping restore her motivation. Her children leaving home, the problems her partner was experiencing, a debilitating physical illness and a work reorganization, had all made her feel unvalued, as she got her identity from helping others.
I focused initially on providing psycho education about depression and the effect the illness has on people. People who are depressed stop doing things they enjoy, reduce their social life, and generally think negatively. They also experience tiredness and have no regular routine. Some people stay in bed during the day and then spend time on their devices through the night.
She was encouraged to return to a routine of getting up at a regular time and going to bed at a regular time. Our deal was she had to walk her dog, do some exercise, have a shower and get dressed every morning. After that she could do what she wanted. At the end of each day, she had to list two good things that had happened. I also encouraged her to get back in touch with people she would like to meet up with again.
Initially getting the exercise routine established proved problematic, but in discussion about past family issues it was clear this mirrored an unpleasant aspect of her youth, so we reframed the whole thing and she then made more progress and felt better about herself.
Six sessions in, the depressive mood was still high scoring, and in talking about her previous job before the work reorganization, I realized how much she had changed. I also discovered she used to enjoy cooking. So, homework was beginning to do more healthy cooking and plan healthy meals and writing about how she was three years ago in the previous role. This narrative provided a wonderful baseline to help her generate some ideas of what she now wanted to do for herself, and an action plan. She was working on self-help manuals for depression and anxiety, and we agreed that she would now focus on a manual to help improve self-esteem.
This coincided with a return-to-work program, as her work financial support was running out. We devised a plan, which was agreed at a meeting with the work Occupational Health Team. She said that she had never thought she could ‘dictate’ what was going to be helpful for her about returning to work, and that discussing this in the session was helpful.
The partial return to work was successful, and she continued to develop a routine that combined her daily activities and work. Initially she worked shorter hours from home, but after a few weeks we agreed she could try one day in the office. This helped her socialisation and to be more assertive in her job role. It also coincided with company policy changing on WFH (encouraging 2 days minimum in the office for all employees). I indicated that she would be ‘in favour’ as she had included being in the office as part of her RTW program. Three months on, she has increased her working days per week and hours of work per day and is looking to work full time hours in September with two days in the office (possibly three by Christmas).
The work on improving self-esteem maintained her progress and she is doing more outdoor activities for herself. She is developing some plans relating to her future career and is able to recognise which problem is ‘hers’ and which problem is not for her to solve. This has proved challenging both at home and at work for people around her.
She still attends CBT sessions with me. She is feeling more confident and has developed new ways of thinking and behaving and the future looks more enticing than a year ago. The cheerful, bright, and resourceful woman I see now is a million miles from the person I met at the start of her treatment.
The Covid pandemic and its aftereffects showed how devastating anxiety disorders can be. Most employers assisted their employees with mental health issues, both during the pandemic and in the aftermath. Sadly, some tolerated increased harassment of employees on Zoom and Teams platforms and employees already feeling isolated felt very much at risk.
In May 2021 my patient (60 years of age) held a successful senior position in a major retail business, with a long successful career. The arrival of a new director in September 2019 changed everything. He found himself under constant attack and criticism, and then in more public attacks via internet meetings when working from home during the lockdowns. Our first Zoom session in May 2021 showed he was valiantly working to his best ability, with ever increasing demands from his director for one-to-one remote meetings. My patient’s work was being micromanaged. I was concerned by his high level of anxiety and depression. Understandably the previous three years had taken their toll.
My patient had constant physical feelings of anxiety, which he misinterpreted as being something more sinister. He felt anxious and unmotivated, and his personal relationships were suffering. Conducting meetings and one-to-one sessions with his director via Zoom made him feel his work was not as it should be. He felt isolated and unable to contact HR for support or advice on harassment from his director. His home which he loved now felt a prison due to the strain and having no clear boundary between work and home life.
Early CBT sessions provided support and education about anxiety, to allay his fears about the physical symptoms. Also, I monitored risk as his scores were very high and I was responsible for his mental health. He was encouraged to take daily walks and do some brisk exercise, and to write down two good experiences daily. The initial focus was twofold; to educate him about anxiety and to help him cope better with the work pressures. Despite this my patient was not making progress and I urged him to contact his GP and get signed off from work, with the specific instruction that it was stress caused by work pressure.
The GP signed him off for a month initially and prescribed a low dose of an antidepressant to improve his mood. My patient and partner hired a Personal Trainer which helped stimulate his general mood. With encouragement he contacted HR and indicated how he had been treated over the previous three years, and why he was now off work.
He was undertaking specific CBT work for generalised anxiety, and now free of work demands, the techniques enabled him to think more rationally about the work issues. His sleep improved and he was enjoying the personal training. He also received encouraging support from his team members.
As he progressed with a structured programme to manage his anxiety, he felt more able to challenge his anxious thoughts and more rational when thinking about work pressures. He was now positively thinking about a change of career direction along with moving to a cheaper housing area.
In July 2021 his anxiety and depression increased as he had discussions with HR about a return-to-work programme which appeared to have little regard for the issues that had led to him to be off work. He sought legal advice from a solicitor specialising in employment issues.
In therapy we continued to use CBT to help his thinking and help his confidence. His solicitor asked me to provide a report regarding his generalised anxiety and depression and indicate how harassment and undue pressures at work had caused his mental health issues.
The plans to move and develop a new career had progressed, and my patient now understood and accepted that the director was at fault. Once a solicitor was representing my patient, the company adopted a more reasonable attitude to helping him leave the organisation with proper compensation and references. When the agreements were signed off, it was encouraging to see my patient’s improved overall mood and the scores finally reducing.
As he and his partner planned to move to a ‘dream’ house he could see how badly he had been treated by his director and was grateful that my support and CBT enabled him to fight back.
We had a follow up Zoom session in October 2021 where he talked about continuing his daily recording of two good things. Occasionally he referred to the materials that we had used to maintain his control of his anxiety. His new career was going well and as I expected his industry reputation had stood him in good stead to develop new avenues. He was also delighted with the move and enjoying his new home environment.
This case shows that CBT and appropriate support can help in times of crisis.
Footnote: over the past three years I have dealt with a large increase in anxiety disorders arising from the pandemic and harassment at work through Zoom during lockdown.
Most companies are helping employees to manage mental health issues in the workplace appropriately and encouraging openness regarding mental health.
My patient was referred to me after a breakdown at work. Her GP had signed her off from work and she was suffering with social anxiety and depression.
Despite having done well in her job for over 10 years, she described feeling overcome with tiredness and very little willingness to do much, except the school run and basic errands.
She had been feeling low for a while prior to her breakdown and worried that she would never be able to return to work.
As part of her treatment, I recommended regular walks after the school run, ideally with a friend, and encouraged her to keep a journal of all her positive feelings and experiences.
Over time, she felt more confident talking to friends and family about her feelings and gradually increased her daily exercise and began enjoying her life and spending time with her family again.
As her depression started to subside, she reflected on her social anxiety and low self-esteem and realised she had suffered with the symptoms for a long time.
The CBT treatment focussed on gradually building up her confidence and self-esteem. She followed a tailored programme designed to challenge her social anxiety and started to plan her return to work with her employer.
She returned to work on reduced hours and her manager changed her attitude towards mental health, restoring trust in my patient.
Developing assertiveness was a key part of her recovery, enabling her to manage the demands of work and feel confident saying ‘no’ whenever she felt overwhelmed with the volume of work. After her initial 15 BCT sessions, BUPA agreed an extension of treatment, enabling further progress. She continued to exercise regularly and developed new social contacts and interests.
GJ is now back at work on her original hours. Despite some organisation hiccups she has coped well and says “saying no” (politely) when necessary is part of her new persona. She maintains her daily journal, and regularly reviews my material and notes to keep focussed on the present and the future. She is now the mental health ambassador for her organisation, promoting mental health issues to managers and employees.
My patient’s anxiety about contamination and cleanliness had affected both her home and work life so much that when we first met, she had been signed-off from work.
She was keen to return to work and gain control over her OCD, so we examined her intrusive thoughts and over 10 sessions, she identified the triggers for her anxiety.
CBT helped her understand how her anxiety had developed into OCD. Her road to recovery started when she began to test out her ‘false’ predictions that “something awful would happen” if she did not clean and do her rituals and discovered that despite her misgivings nothing happened.
She created a pyramid of her anxieties and began to challenge the lowest ones first, gradually working up to the hardest, using CBT to challenge her thinking and behaviour. Over time she found that her anxious feelings diminished.
She returned to work, received the required support from her employer with a ‘return to work’ programme and did not resume her cleaning rituals in the workplace.
Within 6 months she had been promoted to a more senior role.
This patient is a 33-year-old with a 2-year-old son. She has experienced generalised anxiety for most of her life, with bouts of OCD starting in her teenage years, not helped by difficulties during secondary school and the death of her father. With support from her family, she was able to manage the OCD so it was not disruptive, and successfully trained in her chosen profession, starting her own business which has gone from strength to strength.
Prior to Covid she became depressed, and her OCD worsened, but she managed to control her intrusive thoughts. She got married and had a son. Working on and off through Covid lockdowns made the worry and anxiety worse and her intrusive thoughts became increasingly destructive, leading to her husband needing to constantly reassure her. The OCD reduced when she was working, as she was distracted by focussing on what she needed to do.
At the first session with me, both the patient and her husband attended as she was frightened of saying the ‘wrong’ things or forgetting something. One of her immediate fears was using certain words, and if she used them something terrible would happen to her son or other close family members. This is very common amongst people with OCD. Her main fear was that if she touched a knife she would cause serious harm to those around her. Consequently, knives were placed out of reach, and only her husband could handle them, which made anything around meal or snack preparation by her impossible. Even more disabling were the constant intrusive thoughts about knives or words.
At the end of the first session, for her homework she had to write down two good things that happened every day and make a list of the dominant intrusive thoughts, and the words she did not want to speak out loud. She was provided with information about general anxiety and OCD. Her husband was tasked with only reassuring her once when she wanted reassurance, and after that not to reassure her. He was to continue to be the ‘knife handler.’
At the next session, she reported feeling better, and although she was scared when her husband was not providing reassurance, she saw that nothing happened and became more confident in distracting herself from the thoughts. We also looked at some patterns of these thoughts and behaviour and how they developed from past incidents. She was clearer about how her OCD was disabling her and that she was not going mad. Again, many people have this fear if they have OCD.
At the third session, I felt we could try some Emotional Response Prevention (ERP) around knives. This involved her seeing a knife, touching it, and not acting on what she predicted her thought would be. To her surprise by the end of the session she was holding a long bladed knife, picking it up and putting it down, and realising that there was a difference between a thought and an action. Homework was to continue with this at home. The smile on her face as she left was reward for the work.
Next session, she reported that she was now using knives with no problem. She said her husband did not believe what she had done in the previous session until she demonstrated it. Now she is cooking for him when he comes in from work.
In this session we addressed the ‘anxiety’ words using some ERP techniques. This proved successful. For homework she was asked to practice saying the words out loud each day, and watch TV programmes that she avoided in the past.
She was also using a manual to work on her anxiety between sessions, which she felt was helpful.
Prior to our final session, she had experienced some family trauma, but coped well when the intrusive thoughts returned, and used distraction techniques and thought stopping, so things did not get out of control. She had remembered a thought is not an action and was still handling knives. She felt that she could now manage her thoughts and feelings, and they did not manage her.
They are now planning on having a second child, which had been postponed because of her anxiety and OCD. Her business is flourishing, as she is relaxed, and the OCD is at a low level which she knows she can control.