Session seven28/04/11

Think about a behaviour which you are ambivalent about changing and design a matrix with the following headings◦ Benefits of maintaining my current behaviour are ◦ Benefits of changing my behaviour are ◦ Negatives of maintaining my current behaviour ◦ Negatives of changing my behaviour are...

Strategies to encourage self motivating statements◦ Asking about the good things◦ Examining the less good things◦ Life satisfactions

Counsellor `Can you tell me some of the good things about your amphetamine use?'

Client 'It gives me loads of energy, I feel alive.' Counsellor 'So you enjoy feeling more energetic?' Client 'Yes I get more done, I work as a waitress and when

I finished work I never felt like going out. I was too tired. Now I just have a bit of speed and off I go. (Pause). I also like the fact I can have a few drinks and I don't get drunk.'

Counsellor 'So your use of speed has very real benefits. You have the energy to go out and when you drink alcohol you don't feel like you are getting drunk. Is there anything else you like about using speed?'

The highlighting and exploration of concerns is an important strategy.

It is concern about the negative aspects of the behaviour that can be used to motivate change.

Counsellors must not define the problem or confront the client about what they see as his/her problem.

Get the client to reflect on when they were younger and ask how he/she imagined life would be, and how that fits with life now.

Ask then how the client sees himself/herself in two years time if he/she carries on as things are now. Ask the client how he/she feels about that. Would the client like to make changes? What is stopping him/her?◦ The timescales need to be appropriate to the

concerns mentioned and the client's age. With a younger person you may focus more on the immediate future and talk in terms of months rather than years.

Validate lack of readiness Clarify: decision is theirs Encourage re-evaluation of current behavior Encourage self-exploration, not action Explain and personalize the risk

Validate lack of readiness Clarify: decision is theirs Encourage evaluation of pros and cons of

behavior change Identify and promote new, positive outcome

expectations

Identify and assist in problem solving re: obstacles

Help client to identify social support Verify that client has underlying skills for

behavior change Encourage small initial steps

Focus on restructuring cues and social support

Bolster self-efficacy for dealing with obstacles

Combat feelings of loss and reiterate long-term benefits

Plan for follow-up support Reinforce internal rewards Discuss coping with relapse

Evaluate trigger for relapse Reassess motivation and barriers

Plan stronger coping strategies

* The reality of living substance free may be an extremely frightening one for them as their lives may have revolved around the obtaining and using substances

◦ Substance use can assist people to deal with pain, whether physical or psychological (self-medication)

◦ The effects of withdrawal for the client outweighs the benefits of ceasing use

◦ The fear of not knowing what their lives would be like without the substance

◦ They may be mandated or forced by a significant other to attend and that alone may make them resistant to change

Can take various forms..◦ Anger◦ Superficial compliance◦ Testing boundaries◦ Silence◦ Changing the subject

In pairs brainstorm what some actions or comments may demonstrate client resistance and then share your ideas with the group

If a client feels hopeless◦ Provide hope◦ Share success stories◦ Evaluate prior attempts and explore alternative

strategies When a client has too much fun to stop

◦ Explore negative consequences◦ Focus on how behaviour affects others◦ Shift focus from problematic issue e.g. Explore

financial issues instead of drug use itself

If a client is rationalising◦ Continue to make clear connection between

behaviour and consequences◦ Do not dispute their reasons however use them to

your advantage◦ Build their confidence in their ability to change

If a client is rebellious◦ Ensure they feel in charge at all times◦ Offer choices for managing change◦ Link autonomy and freedom to change

CBT is a treatment approach that is based on the concept that the way we think effects how we respond. People can interpret the same life event very differently, leading to many & varied emotional & behavioural consequences. Some of these consequences can be helpful, & some not so helpful in our day to day lives.◦ http://www.health.qld.gov.au/rbwh/docs/cbt.pdf

◦ human behaviour is learned◦ the same learning processes can create

problem behaviours throughout a person’s life◦ behaviour is determined by environment◦ thought and feelings can be altered through the

application of learning principles◦ practising skills learnt in counselling in one’s

own environment is essential to the ongoing behaviour change

◦ individuality must be considered when delivering a program/intervention

◦ comprehensive assessment forms the basis of treatment outcomes

(Rogers, 1957)

therapy is here and now and relatively brief. Detailed exploration of the past is not deemed necessary to move forward

◦ although it is structured and words towards set goals, it is flexible and takes into account client’s presenting needs

◦ the client drives the therapy whilst the worker facilitates it through a collaborative process

Intervention is relatively brief Detailed exploration of the past not

necessary to move forward Flexible and responsive to client’s needs Client driven Continual evaluation and monitoring Assists client to link thoughts with

behaviour and emotion Client’s practice skills external to sessions

People behave in certain ways due to their experiences and personality

Maladaptive thought patterns drive maladaptive behaviour- addressing these can change behaviour

Individual’s interpretation of situations can lead to varied emotional and behavioural repsonses

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Three different people, George, Susan & Alex, stub their toe on an uneven piece of paving in the middle of the mall.

George thinks – “Oh no. I am such a fool. How could I do something so stupid? Everyone has seen & thinks I am a complete idiot!”

Response - Feels embarrassed, humiliated, self-conscious & distressed. Avoids contact with others. Quickly returns home.

Susan thinks – “I could have really injured myself. The Council should have fixed this/ prevented this. It is an outrage & a disgrace!”

Response - Feels anxious, flustered, very angry & stressed. Curt in dealings with people that day. Stressed all day.

Alex thinks – “Ouch! What was that? Oops, I just stubbed my toe! Well, I’m OK, so I’ll just keep walking!”

Response - Doesn’t give it a second thought. No effect on the day.

Tenants of CBT lie in classical conditioning and operant conditioning

That is that an individual’s behaviour is governed by contingencies (rewards or punishments)

Behaviour that is rewarded or reinforced will continue, regardless of whether the behaviour is adaptive or maladaptive

Consider an adolescent who responds with aggression in order to get their own way at home. They are ultimately rewarded for their use of aggression through getting what they want. This behaviour is likely to continue and aggressive behaviour used in all realms of their lives.

Avoidance behaviour can also be explained through conditioning

Summer, a 21 year old student, one night after leaving the library is attacked and raped in the school parking lot. From that night on she is terrified of parking lots at night, and avoids them at all costs. This is true (1) even though she knows the chance of her being attacked again is very unlikely and (2) even in the presence of a protective friend her terror is sustained. Furthermore, even thinking about parking lots at night (while in a safe place) makes her extremely nervous.

Summer, in this example, has associated parking lots at night (CS) with being rapped (CR). Therefore, though fear of being attacked (UR) is normal in the presence of an attacker (US) it is present even without the presentation of an attacker (CR).

http://www.thriveboston.com/counseling/how-classical-conditioning-integrates-into-cognitive-behavioral-therapy-treatment/

CBT would focus on disputing Summer’s irrational belief developed from the trauma of being raped.

Systematic desensitisation would also be used to introduce Summer to parking lots without the fear and in a same environment

Exposure of anxiety provoking stimulus (Anxiety increases and becomes unpleasant)→ no avoidance, no escape (anxiety gets worse)→ Anticipated terrible outcome does not manifest itself (anxiety lessens) → client understands the stimulus is not harmful → avoidance of stimulus lessens.

How would CBT be used to address depression?