Written by Dr. Daniela Steyn
I was first introduced to Cognitive Behavioral Therapy (CBT) in 2010. I was a Family Physician in Westlock, Alberta in Canada—a beautiful tiny rural town in a farming community with a population of 5000 people. We didn't have easy access to a Psychiatrist, Psychologist or Counseling Services.
Patients came to me regarding their mental health, and I didn't have the tools to help them, so I registered for a course geared specifically toward psychotherapy and counselling skills. This was when I got introduced to CBT. Research clearly showed that people didn't have a significantly better outcome after years of psychotherapy. However, after only 12 weeks of CBT, people had substantially better results with major depression, anxiety, and post-traumatic stress disorder.
CBT differs from psychotherapy in that a lot of time and energy during conventional psychotherapy is spent on understanding why you are depressed and how trauma you experienced as a child is now causing your current symptoms, feelings and behaviour. With CBT, the emphasis is not as much on the therapist as on you and how you take ownership of your future.
How it works
CBT involves taking ownership of your future and deciding where you want to be ten years from now. Deciding who you want to be ten years from now and setting goals. Your therapist will help you navigate through this process, acknowledging the past but then moving on and identifying the narrative in your head, identifying your thoughts, emotions and beliefs about yourself and your problems. Even just realizing that a problem is not a stagnant thing but our thoughts, emotions and beliefs about our problems can make these problems bigger or smaller.
1. Identify the problem
Once you've identified the problems to work on, your therapist will encourage you to share your thoughts about them. This may include observing what you tell yourself about an experience (self-talk), your interpretation of the meaning of a situation, and your beliefs about yourself, other people and events.
2. Identify negative thinking
The next step is to identify harmful or inaccurate thinking. To help you recognize patterns of thought and behaviour contributing to your problem, you can pay attention to your physical, emotional and behavioural responses in different situations.
3. Reframe negative thinking patterns
A considerable part of CBT is to reshape negative or inaccurate thinking. Over time you will develop the skill to ask yourself whether your view of a situation is based on fact or on an inaccurate perception of what's going on. This is tricky to do on your own and helpful if you go through this process with a therapist you trust. You may have long-standing ways of thinking about your life and yourself. With practice, helpful thinking and behaviour patterns will become a habit and take less effort.
Success in Menopause
After I saw the significant improvement CBT had in my patients with depression, PTSD, anxiety and sleep disorders, I started using CBT to help my patients with other conditions such as chronic pain syndrome, fibromyalgia and weight loss.
It honestly never crossed my mind that menopausal/ perimenopausal patients would benefit from CBT. The first time I attended a menopause conference and heard the research and statistics of how beneficial women have found CBT during menopause, it made so much sense.
Katherine was the first patient to whom I applied CBT for a patient with menopause. Katherine was 56yrs old. She had a bilateral mastectomy done for breast cancer. She also had a deep venous thrombosis (blood clot) in her leg after her surgery and had to be on blood thinners for a year. When Katherine came to me regarding severe hot flushes impairing her sleep and quality of life, we both knew HRT would not be a safe option for her. The breast cancer treatment she used lowered her natural estrogen rapidly. Hormone levels affect our body temperature control mechanisms. The threshold for flushing also narrows when we are under stress, so when we implement CBT, our primary focus is to reduce stress and increase relaxation to help manage hot flushes.
CBT and hot flushes
1. Breathing exercises
The first thing I taught Katherine was paced breathing to calm her body's physical and emotional reactions. Paced breathing is slow, even breathing from your stomach.
Deep breathing from your stomach stretches your diaphragm, which stimulates the Vagus nerve and then, in turn, stimulates your parasympathetic nervous system, your relaxation response. Breathing deep breaths increases lung capacity to get more oxygen, and it has a significant calming effect. If practiced regularly, (a couple of times a day every day), diaphragmatic breathing can help you to relax. You can practice deep breathing by putting your hands on your chest while taking deep breaths and then later on your belly while taking deep breaths. Watch my YouTube video on Breathing exercises here.
2. Reframe your thoughts
Next, we looked at how the physical symptom, a hot flush, being hot, red in the face, sweating and having palpitations, led to a thought. It will often sound like this "Everyone is looking at me." "I can't cope!" This leads to feeling anxious, embarrassed or out of control, leading to behaviours such as leaving the room.
CBT addresses what each individual thinks about their situation and provides cognitive strategies. Hot flushes are typically harder for people who tend to 'catastrophize' their hot flush and are more self-critical in nature. These women typically think the worst: "This is out of control, I can't cope with this, I look terrible, Everyone is looking at me, I can't sleep with this hot flush, I will never fall back asleep, I will feel terrible tomorrow."
With CBT, women recognize their own thought patterns and alter them to become calmer self-supporting responses. For instance, "This will pass soon." "Let's see how well I can deal with this one, one hot flush at a time." "I realize I notice my hot flushes more than the people around me." "I know this will get better over time." "What is in my control to cope better with the next flush"? This conversation in your mind, setting goals and strategies help to gain more control of the situation.
I have been implementing CBT or certain aspects with each menopausal patient or menopausal client I have worked with since. The most significant benefit they have found from CBT in implementing these cognitive behavioural strategies is that it helps you to remain calm irrespective of the symptom.
It teaches the ability to separate your thoughts and emotions from yourself and recognize them for what they are, only an opinion, only an emotion. Once you recognize an unhelpful thought, you can quickly jot it down in a journal. Once a day, you can sit down with your journal and address these thoughts. It is easier to deal with the content of your worrying thoughts the following day when you are removed from your stressful situation. It is easier to fall back asleep when you know you will have time and capacity to deal with worrying thoughts the next day calmly.
I have more resources on my website at www.wellnessmdhealth.com, and the Women's Health Concern, part of the British Menopause Society, also has excellent patient resources.