Skills in Cognitive Behaviour Counselling & Psychotherapy FRANK WILLS (2008) London: SAGE CHAPTER 5 SKILLS FOR WORKING ON CHANGING BEHAVIOUR

1. Behavioural focus in CBT The influence of behaviour on emotion. The influence of emotion on behaviour. Behavioural change promotes cognitive change. Cognitive change promotes behavioural change.

2. History of Behaviourism, cognitivism and CBT Behaviourism: Pavlov, Watson, Skinner. Reputation of behaviourism as something cold and scientific done with rats. Behaviourism began to break out of its original confines by recognising thinking as an internal behaviour. Proactivity and self-efficacy: the work of Albert Bandura. The benefits of humble change over insightful staying the same.

3. Behavioural analysis as a part of CBT assessment How triggers may be avoided or modified How responses can be avoided or modified. Behavioural analysis gives us a a working window on clients life. Link with goals for therapy.

4. Self-monitoring Questions for ABCs (Table 5.2): questions focused on finding out about antecedents, behaviours and consequences of behaviour. Meta-messages of self-monitoring: the client gets an image and verbal representation of what change might be like. Activation – key strategy for tackling prime symptoms of depression – inactivity, social isolation and rumination – (a lot of time to think) – see Emery (1999).

5. Behavioural activation Physiology of inactivity connected to depression, and activity to recovery (CAVEAT – dont overdo things). Promoting behavioural quantity – scheduling. Scheduling helps to lessen negative self-focus.

6. Mastery and pleasure Promoting behavioural quality – mastery and pleasure, and pleasure predicting. Achievement and enjoyment – absorbing life goals (Dryden, Ellis). Also helps to overcome negative self-focus of I dont do anything interesting any more.

7. Behavioural experiment Cognitive focus: devised to test negative belief. Belief testing – e.g., a good starting point with depressed clients is I wouldnt enjoy that now Im depressed – link to pleasure predicting (Emery, 1999). Steps in devising and running the experiment.

8. Promoting coping behaviours Graduated task assignment – Beck at al. (1979). Step by step/phasing: starting with simplest and/or most easily accomplished behaviours. Shaping responses: working towards a desired behaviour. Building a floor – can be helpful to get client to think, If the worst happens, would I cope? Use self and other rewards – money works sometimes!

9. Assertiveness Help client to distinguish between aggression, assertiveness and passivity: assertiveness is about asking for what you want but not necessarily getting it. Many books books on assertiveness contain lists of assertive rights: at least one of which is highly relevant to the client. Technique 1: The broken record – see Burns (1999a). Technique 2: It can sometimes be helpful to think about how you can be both assertive and empathic: I know this might seem a pain to you but what I want is … Sometimes clients feel they have to be goody-goody and can benefit by the liberation of being assertively their grumpy or naff selves.

10. Relaxation Many clients can benefit from some kind of relaxation intervention: it is worth taking some trouble over discussing the rationale for this to make sure it fits the clients life and also does not get used as safety behaviour. There are many different procedures that may include elements of tensing and relaxing muscles – progressive muscle relaxation. Breathing and paying attention to breath Relaxation is often a useful prelude to visualisation. Mindfulness usually has some relaxation element. Exercise – devise your own relaxation procedure.

11. Facing up to fears Systematic desensitisation – essential to go towards the feared object – even if only slowly. Can be powerful to work in vivo (in the clients environment) and sometimes for therapist to be there. Caveats – stuff happens – e.g., intense client reactions that take some time to settle when therapist may need to be elsewhere. Solution: have a contingency plan. Exercise: See Suggestion on p. 105.

Combining behavioural work with other therapy activities Example: CBT work with PTSD often involves combining work focused on intrusive symptoms with narrative work on reliving and reprocessing the trauma story, and behavioural work focused on avoidance symptoms. CB therapists can use agenda-setting to introduce both narrative and behavioural work either in the same session or as separate sessions. For example, working with a person traumatised after a road traffic accident by a) processing the meaning of the accident, and b) devising a series of graduated steps to help the person get back in a car, travel, drive, etc.

The therapy relationship in behavioural work Behavioural work often processed best by keeping things simple and not being a smart Alec and by keeping things goal-focused. (Despite the propaganda of other therapy models, clients often appreciate this kind of approach!) Behavioural work needs interpersonal skill just as much as any other type of therapy, and behavioural and CB therapists seem to be just as interpersonally skilled as other therapists (evidence: Sloane et al., 1975; Keijsers et al., 2000). Paradoxically because behavioural techniques can run themselves, the behavioural therapist may have more attention available to focus on the interpersonal relationship.