Cognitive Behavioural Therapy (CBT)

CBT can be helpful if you find that the way that you think about things (including endo), your feelings, or actions, are getting in the way of living the life you want.

Often when people consider psychological self-management approaches, like CBT, they will ask questions like 'How much time will be involved?', 'Do I have to stop my other treatments (e.g. medication)?', and 'How will I know if these tools are working?' Adding psychological tools to your management toolkit does not mean that you have to make any specific changes to how you currently manage your endometriosis. 

The variety of endometriosis-related symptoms, and their associated consequences, vary considerably from person to person, so you might find that you prefer some CBT techniques over others, and that some techniques that work for someone else, may or may not work for you. This is perfectly normal and okay. You might also find that CBT techniques don’t change your endometriosis-related experiences straight away, but become more useful with practice. Using psychological tools and techniques does take effort and practice. However, once you have mastered them, you will be able to use them again and again in life, and not just in relation to your endometriosis.

Side stepping the comparison game

Your endometriosis experience is unique to you. Your symptoms may be relatively new or you may have experienced them for a very long time.  We often hear people compare their experience to others and make comments such as 'I shouldn’t complain…', 'it’s worse for others…', 'I should be able to cope….' It’s important not to compare your endometriosis-related experience to another person’s – this is referred to as the ‘Comparison Game’ and it can cause you to minimise your own lived experience. In fact, minimising the distress associated with symptoms of endometriosis is something that we learn to do early on, and can be reinforced by well-meaning doctors, family members, friends or colleagues. 

Using CBT techniques differs from medical approaches that you may have tried previously for your endometriosis symptoms. CBT techniques are not designed to remove the symptoms of endometriosis but rather to assist you to cope with and manage the distress and impact of these symptoms on your daily life. 

How do I get the most benefit in managing endometriosis from CBT?

A useful first step is understanding CBT techniques and how they may be applied to assist you to manage the consequences of endometriosis.

• What can I expect from a CBT approach to managing endometriosis? CBT is a form of psychological therapy that focuses on the way people think and act in certain situations. CBT focuses on how the actions we take (behaviours) are influenced by the way we think (cognitions) and feel (emotions, physical sensations). Understanding how our thoughts and feelings influence how we act is an important component in CBT and is linked to our values (what matters the most to us) and goals. CBT techniques can help you to identify whether your behaviours are helping you to live a life consistent with what matters to you most.
• CBT is a present-focused therapy: Although understanding how your early life experiences can shape and influence how you respond to situations in the present, CBT focuses primarily on what we do, or don’t do, to manage our current difficulties or concerns. CBT helps you to identify patterns in your thoughts and behaviours that may be maintaining the distress or difficulties you are currently experiencing.
• CBT requires practice: Simply reading about CBT techniques is not likely to lead to positive change. CBT techniques require practice but you will find that they become easier to apply as you become more familiar with them. CBT techniques are transferable – you can apply them to your endometriosis-related distress or to other areas in your life where you may be struggling.
• CBT is designed to assist you to become your own psychologist: CBT therapists and programs will ultimately have the aim to equip you with a variety of tools and techniques. You can think of the process of CBT programs like a staircase – the programs will show you the steps, but you will be the one taking each step forward, with a lot or a little guidance from the program or psychologist at different times.

CBT techniques for managing endometriosis-related emotional and physical symptoms

• Understanding your values and setting goals: Often the first step in CBT is to set some goals for treatment and to reconnect with what is important in your life. You can think of them as a compass and road map – the compass (values) guides the direction that you are heading, and the roadmap (goals) tells you how you arrive at your destination.
• Understanding the link between your thoughts and feelings: CBT focuses on the thoughts and feelings that show up for someone during certain situations. This might include a specific situation (e.g., having your surgery cancelled due to COVID restrictions) that occurred in the past, present, or future. Sometimes the situation may be sensations that you experience (e.g., endometriosis-related pain or fatigue). CBT helps you to understand how the way that you view a situation influences how you feel and what you do to cope. Negative thoughts about your endometriosis-related symptoms can increase these symptoms rather than decrease them. It’s important to remember that the answer is not as simple as ‘thinking positively’ or ‘ignoring your thoughts’. Neither of these coping responses will assist you to manage the impact of your endometriosis in the long-term. In fact, in psychology we have a saying “What you resist persists”. You need to learn new ways to focus your attention and identify when your thoughts are leading to actions that take you away from what is important to you.
• Strategies for managing pain and distress: Learning how to relax your body can assist to manage the physical and emotional consequences of endometriosis. During the relaxation response your body becomes quiet and restful. You may notice a change in the intensity of your endometriosis-related symptoms such as pain, muscle tension, or anxiousness. Much like other CBT skills, the relaxation response is a skill that can be learned, and the more you practice it, the better you get at it. The most effective form of relaxation for managing endometriosis-related distress and tension is to engage in exercises that directly focus on your respiration rate (breathing) or on muscle tension.
• Diaphragmatic breathing is one way to manage stress and induce the relaxation response and can be used on its own or in conjunction with other forms of relaxation. Place one hand on your belly and one hand on your chest and simply breathe deeply in and out while imagining the air travelling right down past your chest to your belly. Concentrate on where the air is travelling and notice which hand seems to be moving the most. If the hand on your chest is moving the most then the breath is not flowing right down to your diaphragm. If you notice your shoulders moving up and down as you breathe in and out you are probably ‘chest breathing’ rather than ‘belly breathing’. Try thinking of your belly as a soft balloon that you are inflating with air on the in-breath, and then letting all the air out of the balloon on the out-breath.
  
• If you experience persistent pelvic pain, learning how to notice the difference between tense and relaxed muscles is important. If you experience pelvic pain during or after sexual intercourse, learning how to relax the muscles in your abdomen and pelvic area may be of assistance. One way to learn the difference between tense and relaxed muscles is to practice Progressive Muscle Relaxation or PMR for short. This involves tensing and releasing different areas of your body in turn. The focus is on recognising when your body is starting to store tension. Much like diaphragmatic breathing, PMR takes practice.

Additional resources

Psychology for endo