Cognitive Behavioural Therapy in the menopause
CBT is much in vogue these days, along with counseling and mindfulness. But what is CBT precisely? How does it work? And how does it differ from other types of treatment?
We asked Dr Anita Goraya to explain.
Anita was a practicing GP in the NHS for 18 years. She has extensive experience of long term conditions and their impact on and by mental ill-health. She gained her first qualification as a CBT therapist in 2018 and is continuing her studies at the University of Oxford.
Anita has also worked in a commercial environment as a Director in the Healthcare practice of a large Management Consultancy company (EY).
Anita has also been a Leadership Associate at the pre-eminent health policy charity, the King’s Fund. She was awarded Fellowship of the Royal College of GPs in 2014 as a mark of achievement, in recognition of her significant contribution to General Practice.
We are grateful for her contribution towards explaining how CBT may help women searching for relief of menopause symptoms.
What is CBT?
CBT is a talking therapy, pioneered in the 1960s by a psychiatrist called Aaron Beck. It 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.
How does CBT work?
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.
Imagine that the arrows linking the boxes are made of elastic bands. If we were to pick up the box labeled ‘Behaviours’ and pull it to the left, it would naturally increase tension on the other boxes too. All the arrows would stretch a bit and at first, the other boxes would resist and try to pull the ‘Behaviours’ box back to its original position. This means that in the early stages of CBT, a person can sometimes experience an initial upsurge in her troubling thoughts and feelings. But if she is persistent with holding Behaviour in its new position, fairly soon, the whole system will shift in the desired direction.
And that’s the essence of CBT – identifying those thoughts and behaviours that maintain your current emotional or physical distress and then restructuring or reinterpreting them more realistically and helpfully. By changing behaviours and thoughts (the B and the T in CBT), distress and suffering is reduced.
This means that CBT entails learning many new skills. At the outset, these skills include identifying and monitoring those automatic, negative, distressing feelings and thoughts. You then move onto generating more realistic and helpful thoughts and translating them into new behaviours. You then test out and refine these new ways of thinking and behaving by putting them into practice between sessions as ‘homework’ tasks.
How is CBT different from other types of treatment?
CBT is a practical and time-limited therapy in which you learn new skills to take away and apply in real life. The therapeutic work in counselling, by contrast, is within the very act of talking and being listened to in an empathic and non-judgmental way – there is little skills training in counselling. CBT also differs from other talking therapies in focusing mainly on what is maintaining your problems in the present day, rather than exploring in depth what caused them in the past.
Another psychological approach is that of mindfulness. Mindfulness is the psychological process used to bring one’s attention to experiences occurring in the present moment (and away from ruminating on the past or worrying about the future). Mindfulness is less interested in the actual content of the distressing thoughts than on altering your relationship with those thoughts. The focus therefore is not on restructuring distressing thoughts, but learning to recognise that whatever their content, they are simply thoughts and you can ‘detach’ yourself from them. The so-called ‘third wave’ of CBT, developed in the early 2000’s, includes Mindfulness-based CBT Therapy. Traditional CBT also frequently includes mindfulness exercises.
It’s worth noting that CBT is definitely more than just ‘positive thinking’. It’s about developing ‘realistic’ thinking, so that how we perceive and interpret our world becomes less distorted and more accurately approximates to the facts.
What’s the evidence base for CBT for menopausal symptoms?
The gold standard for evidence-based treatments in the NHS is defined by the National Institute for Health and Care Excellence (NICE). NICE produced its first guideline for the diagnosis and management of menopause in 2015. It recommends CBT as a treatment option for the anxiety and/or depressed mood experienced by women during the menopause transition and post menopause.
In addition, a 2018 review of 12 studies showed that 74% of women who received CBT or Mindfulness-based Therapy/Behavioural Therapy experienced less bother from hot flushes than women who received no psychological therapy. Interestingly, these women did not have fewer hot flushes than the non-treatment group, but were less bothered by them because they had increased their coping skills.
This demonstrable success for psychological therapy is especially welcome for women who are not medically suitable for hormonal treatment, such as those with a history of breast cancer. It’s also great news for those who do not want HRT or cannot tolerate its side effects.
Dr Anita Goraya
How do I access CBT?
You can ask your GP to refer you for CBT via the IAPT service (Improving Access to Psychological Therapies). In some areas, you may be able to self refer to IAPT.
Alternatively you can see a CBT therapist privately, without a GP referral. Always look for someone who is accredited professionally by the British Association for Behavioural and Cognitive Psychotherapists:
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