Cognitive Behavioural Therapy for the emotional symptoms of menopause
By Dr Anita Goraya
In my first blog, I explained the principles and evidence base for how CBT works. In this article, I will tell the (anonymised) story of Ayesha to outline some insights and strategies for self-managing low mood and anxiety. Ayesha is not troubled unduly by the physical symptoms of menopause, but finds her mood has dipped significantly. The third blog will look at how Suzy, another menopausal woman, uses CBT skills to help manage her troublesome physical symptoms of tiredness, hot flushes, night sweats and sleep problems.
CBT is based on the observation that there are close connections between the way that we think, the way that we behave and the way that we feel emotionally and physically. In addition, these components work together in a single system, with each component maintaining the others. CBT works like any system, the most important characteristic being that only one component has to be tweaked for impact to be felt across them all.
The CBT cycle
Anxiety and low mood in menopause should not be seen as ‘normal’ or ‘to be expected’ and ‘put up with’. However menopause occurs midlife when women are often simultaneously dealing with other life challenges, so the overall burden can feel overwhelming or too demanding. Around 10% of women are more likely to have depressed mood during the menopause transition. The main predictor of menopausal depression is a previous history of depression. Some women may experience mainly a state of anxiety and others a mixed picture of both low mood and anxiety together.
Ayesha is a 53 year old woman who has been feeling depressed and anxious for around six months, coinciding with her son leaving home for university and her father becoming increasingly frail and dependent. She is now post-menopausal but she is not sleeping well despite minimal flushes and sweats. She previously experienced depression when she got divorced three years ago. She describes herself as ‘a worrier’.
Her cycle of thoughts, feelings and behaviours is shown below.
Ayesha’s vicious cycle
Ayesha’s low mood and anxiety are being maintained by her thoughts about her life in general. Her thoughts are themed around hopelessness for the future and worry about her ability to cope. Her physical sensations are more suggestive of co-existing depression and anxiety rather than specifically menopausal symptoms. It’s not surprising that her behaviour is to withdraw from a world that feels threatening and unrewarding and to distract herself with food. She spends most of her time brooding about the past and worrying about the future. The more she does this, the lower her mood becomes and the less she can see a good life for herself. This is a vicious cycle.
Ayesha uses some cognitive and behavioural techniques to develop a more balanced and accepting view of her situation.
She recognises that she has reduced her overall activities and so she starts to structure her day by scheduling in a few activities that she finds pleasant, as in the past. These activities range from tiny things, like rubbing a favourite, perfumed cream into her hands, to slightly bigger things, like walking to the cafe specifically to buy a special coffee and resuming her embroidery hobby. She also schedules in small tasks that give her a sense of achievement or reward, even if they’re not especially enjoyable, such as clearing out one kitchen cupboard, or making a phone call to her father. She selects these particular activities because they align with her values and aspirations for her life e.g. ‘I value looking after myself; I value my creativity; I like to keep my home tidy; I want to look after my Dad as best I can.’ She notes that her mood lifts a little after each of these activities and she prioritises scheduling in and carrying out some of these activities every day.
At the end of each day, she writes a note to herself about three things that went well that day, however small. She recalls how she felt during or after each activity, and allows herself to relive the sense of wellbeing.
Ayesha asks herself ‘Is it really true that there’s nothing good for me in life now and that my life is useless –what’s the evidence for this? And against this? What would I say to a friend in my situation? Are my thoughts ‘facts’ or are they just thoughts?’ She is able to identify some alternative perspectives, rather than taking her original, automatically occurring, mood-lowering thoughts as ‘facts’.
Ayesha also begins to recognise that she is asking herself a lot of ‘what if…?’ type questions – ‘What if I can’t cope by myself?’, ‘What if I never meet another man?’, ‘What will I do if Dad’s health gets even worse?’ All of these questions make her feel very worried and her response is to keep worrying on and on, without any solutions or practical steps appearing. Worrying just makes her feel exhausted and demoralised, without actually achieving anything. She takes the radical decision to try out ‘walking away from worrying’. When she next has a ‘What if…?’ thought, she identifies it as ‘worrying’ and ‘walks away’ from it. To give her mind something else to do instead of ‘worrying’, she immediately does something pleasant (as in point 1) or she brings her mind away from the world of thinking and into the world of direct experience. She does this by tuning in to what she can see, hear, smell, touch or taste right now. She can sit quietly for a couple of minutes and actively listen to all the sounds around her, being in the soundscape and gently bringing her mind back to it unreproachfully whenever it inevitably wanders off into thinking again. This is an example of a mindfulness exercise.
As her mood starts to lift, Ayesha also notices that some of her thoughts do have a practical component to them, such that she can do something about them. For example, she thinks ‘Dad can’t clean his house any more.’ Ayesha recognises that she could end up simply worrying endlessly about this thought but also, that there is an actual, real-world problem that needs addressing here. So she ‘walks away from worrying’ and does some problem-solving. She lists all the possible solutions to this problem, considers the pros and cons of each option, rules out the less feasible/desirable options and comes up with two possible solutions. She then enlists the help of her sister and they discuss the options with Dad, deciding upon and implementing their action plan. While problem-solving may seem obvious and a bit like teaching your grandmother to suck eggs, it can be very difficult to sequence actions and enact them if your mood is persistently low.
After some weeks of using these techniques, Ayesha’s mood is persistently higher day to day and she feels less depressed and anxious. She is re-engaging with her usual daily activities and seeing her family regularly again. She is more confident and optimistic about her ability to cope with the future.
Dr Anita Goraya