Cbt
Transcript of Cbt
Model
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Introduction
Throughout this assignment I aimed to change my exercise behaviour over a five week
period. I attempted to do so by increasing frequency of exercise using a behavioural
experiment. I drew upon cognitive behavioural therapy (CBT) frameworks and was able to
appreciatethe process of change. The focus of this assignment will be reflections about the
process experienced, part of the ‘evaluation principle’ in CBT (Westbrook, Kennerley &
Kirk, 2007). Reflections relate to frameworks used, what I have learnt from the process and
how it may translate to clinical experience. Personal experiential work enhances a therapist’s
‘personal development’, aiding better practice (Bennett-Levy et al, 2005) and reflecting on
one-self during such processes is at the ‘heart’ of CBT (Bennett-Levy, Thwaites, Chaddock
& Davis, 2009).
Behavioural experiments are widely used in CBT to alleviate distress. BEsare influenced by
the ‘behavioural principle’; taken from behavioural therapy (BT), stating behaviour
influences thought and emotion (Westbrook, Kennerley & Kirk, 2007). Historically BT
presented itself as a reaction to Freud’s work on psychoanalysis, reported through narratives.
Behavioural therapists were not impressed by lack of empirical evidence-something which
was of great importance to their epistemology. BT used empiricism to gain knowledge of
people and believed observable behaviour indicates how people feel. BT could only progress
so far without recognising inner workings of our minds such as thoughts, beliefs and
interpretations; such processes are inescapable for individuals (Westbrook, Kennerley &
Kirk, 2007). Cognitive therapy (CT) emerged as a result during the 1970s in the ‘cognitive
revolution’, focusing on these processes with Aaron Beck and Albert Ellis as influential
figures (Beck, 1962; Ellis, 1962; Beck, Rush, Shaw & Emery, 1987). BEs within CBT take
the same empirical stance of BT, but embraces the unobservable processes identified in CT.
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Both approaches combine to formCBT. Everything conducted within CBT is evidence based,
stated in the ‘empirical principle’ (Westbrook, Kennerley & Kirk, 2007).
Processes of change
When change occurs, individuals have been found to progress through five stages,
highlighted in the ‘cycle of change’ (Prochaska &DiClemente, 1982). The first stage is ‘pre-
contemplation’ in which the individual sees little reason to change, accompanied by feeling
unable to change. During this stage, clinicians provide information detailing positive aspects
of change. The second stage is ‘contemplation’ in which the patient can see the need to
change. They are inquisitive about change, identifying pros and cons, but are unable to see
how it can be achieved. Clinicians will be reinforcing how change is possible. The third stage
is ‘action’ in which the individual accepts need for change and sets goals. Engagement with
change commences while the individual monitors progress. Clinicians provide
encouragement, praise and support, particularly when new barriers arise. The fourth stage is
‘maintenance’ in which the individual is striving to consolidate change. There is a battle with
relapse so support from the therapist is crucial. The fifth potential stage is ‘relapse’; the
patient feels a sense of failure and may regress to old behaviour. Goals are neglected coupled
with self-efficacy (Prochaska &DiClemente, 1982). These stages have been shown when
making a change within therapy or independently; demonstrated with smoking cessation
(Prochaska & DiClemente, 1983). Furthermore, individuals typically progress through the
stages in order; however some may regress throughout the stages then progress again
(Prochaska & Diclemente, 1982). By acknowledging stages, therapists can be aware of what
input they should give and when.
When this assignment was presented, I identified myself in the ‘contemplation’ stage. I was
aware I should increase exercise frequency but focused more on negative aspects such as not
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having enough time, loss of fitness and physical exhaustion without focusing on the
positivesdespite being aware of them. My regular exercise is sporadic and I have been living
outside my value of ‘I only live once, I need to look after myself’. I see this as a conflict.
When I then began engaging, I noticed myself in the ‘action’ stage. Aside from needing to
participate in change for this assignment, I acknowledged benefits. I made an effort to focus
on the positive aspects of exercising more. For me, these included improved mental and
physical state and social time with friends.
At the start of CBTand therefore at the beginning of my journey to change, an assessment is
carried out, where information about the problem is sought. Sometimes this is achieved by
using a timeline. I created a timeline to reflect upon frequency of exercise behaviour from
2004 to present day; shown in figure 1. It highlights as time goes on, exercise frequency
decreased.
Figure 1.Timeline showing exercise frequency from 2004- present day.
The therapist then collaboratively creates a formulation, attempting to make sense of the
issue. The formulation can be conducted using the ‘interacting systems principle’, explained
by the ‘hot cross bun’ model (Padesky & Greenberger, 1995) incorporating physiological
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Present day
Exercising 4 times a week (athletics and judo)
Decrease to twice a week (only judo)
Decrease to at least once a week (judo at University)
Minor car crash, hardly any exercise (sometimes none, sometimes once a week- very sporadic)
2004 2005 2006 2007 2008 2009 2010 2011 2012
symptoms, emotions, behaviour and thoughts to create a ‘maintenance cycle’. In order to gain
an understanding of myissue, I created a formulation of my current situation, shown in figure
2.
Figure 2. My ‘hot cross bun’ formulation illustrating processes prior to change. Taken from the ‘hot cross bun’
model (Padesky & Greenberger, 1995)
This formulation shows thoughts triggered negative emotions andrelated symptoms. My
behaviour wasavoidant or actions were unsuccessful. Each point on the cycle maintained
each other and in order for behaviour change to occur this cycle neededaltering.
After formulating my maintenance cycle, I set a goal to provide structure for the five weeks.
In CBT goals should be SMART(Westbrook, Kennerley & Kirk, 2007):Specific,
Measureable, Attainable, Realistic/Relevant and have a Time frame. This is shown in table
1.0. I also used an ABC chartto monitor beliefs and emotions from a specific situation by
identifying an activating event (A), and acknowledging subsequent thoughts and beliefs (B)
and emotions, behaviour or physiological responses (C) (Ellis, 1962).
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Physical Reactions
Blushing, increased heart rate, shaky, butterflies
Behaviour
Avoid exercising, plan then fail to exercise.
Thoughts
‘I should exercise’
‘I’m being lazy’ ‘My back will hurt’
‘I’m not as good anymore’.
‘I’m not fit enough anymore’
Emotions
Sadness, frustration, anxiety/fear,
shame/disappointment
Environment
Specific By the end of the five weeks, I want to increase exercise behaviour to at least once a week and feel good about it.
Measureable I will measure this by keeping a diary of activity in the form of ABC charts Attainable This goal will be a challenge due to perceptions of self being not as good as I
used to be.Realistic/relevant This goal is realistic and I am willing to achieve it. In addition, it is relevant to
my values of looking after myself. Time 16th October -20th November (my 5 week time frame)
Table 1.0 My SMART goal for the five weeks.
Facilitating change
Week one
With my SMART goal set, intervention started. Week one of my plan to facilitate change
wasn’t successful. I planned toexercise twice, but didn’t. Subsequently, two similar entries
were in my ABC diary. On both occasions triggering events were having the opportunity to
relax. Ithought I wouldrather be doing something else and had specific thoughts of ‘I’m tired’
and ‘I want to relax’, consequently I failed to exercise;I experiencedemotions of guilt and
sadness.
In CBT, psychoeducation has shown to be effective at reducing symptomsof depression,
anxiety and distress (Donker, Griffiths, Cuijpers & Christensen, 2009); I reminded myself of
the benefits of exercise by researching them.
Week two
I felt more positive in week two, given the research I had done, but felt I should conduct a
BE. BEs are designed to test the validity of a person’s ‘existing beliefs about themselves,
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4. Exercising on my own more than once a week
3. Exercising on my own once a week
2. Exercising with others more than once a week
1. Exercising with others once a week
others and the world’ (Bennett- Levy et al, 2004 as cited in Westbrook, Kennerley & Kirk,
2007). The thought tested may be derived from formulations or an ABC chart.
In order to set up the experiment, I identified a belief to be tested; ‘If I exercise I will get
upset because I’m not as good as I used to be’. I used a graded hierarchy approach to prevent
feeling overwhelmed. I broke activities down into stages; details of each stage can be seen in
figure 3. Stage 1 is the easiest with stage 4 being the hardest.
Figure 3. Stages in my behavioural experiment using graded hierarchy approach
In week two I planned to attend Zumba with my sisters once. In addition to planning, I laid
my clothes out before going out to encourage me to engage; this was my activating event and
was successful. Thoughts experienced were ‘I had fun with my sisters’ and ‘I enjoyed myself
and feel happy’. Happiness is a positive emotion, so I experienced subsequent action
behaviours like smiling and laughing. This motivated me because I spontaneously went for a
run with a friend later that week. Again thoughts were positive and encompassed emotions of
happiness and pride.
Week three
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Perc
eive
d di
fficu
lty
This week I attempted to move up the hierarchy to stage two, where I attempted to exercise
with others more than once this week. Despite technically completing this last week, I was
reluctant to rush to stage three.
Again, I planned to go to Zumba with my sisters, but I also planned to go for a run with one
of them. Similar thoughts to last week, including ‘I had fun’ were experienced, along with
positive emotions. The encouragement of my sisters also helped, especially when running.
My sister told me how she needed external motivation, so we helped each other, which again
elicited happiness and good feelings about me. This is the opposite to my belief in question
so change was happening.
Week four
In week four I moved to stage three on the hierarchy, which was to exercise on my own once.
I accepted I wouldn’t include Zumba (as my sisters were there) but would still attend as I
enjoy it. I planned to go for a short run later in the week. However, due to traffic on my way
home from university, I was late home and couldn’t attend Zumba. This eventimpactedmy
mood, because in my thought diary, I wrote‘traffic meant I couldn’t go to Zumba’. I added
‘the stupid people in the traffic jam made me late’, externalising the problem, even though it
may have been something uncontrollable. I think this, in turn impacted on my emotions for
the rest of the week, meaning when I was planning to go for a run, I didn’t. I felt I had failed
and experienced emotions of sadness and disappointment.
Week five
Because of the difficulty I experienced in week four, I decided to move back to stage two:
trying to exercise more than once a week with others. I accepted I wouldn’t be able to attend
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Zumba because of getting home late from university. Instead I planned to go swimming with
a friend. I enjoy swimming, but I tend to get ear infections, so in advance I purchased ear
plugs to prevent this being an avoidance tactic. I explained to my friend about this assignment
and told her it’s important to me to attend. She text me a motivational message beforehand
whichreminded me of all the positives of exercising and subsequently I attended swimming. I
thought ‘I felt good because my friend said she was proud of me’. I planned with the same
friend to go for a run later in the week, which I succeeded with.
I was aware that the following week I should have attempted to move back up to stage three
and begin exercising on my own. I drew upon my positive emotions and instead of driving to
town one day, I walked. I called this a 2.5 stage to the hierarchy. The walk was about half an
hour but I managed to do it on my own effortlessly. I am confident with walking this distance
compared to running. After, I felt emotions of pride.
Reflection
Overall, I have found the process of facilitating behaviour change difficult. Although I didn’t
reach stage four in the hierarchy, I felt positive after exercise which disproved the belief I
was testing.
I found the ‘hot cross bun’ formulation to be extremely useful throughout the process. I was
able to refer to it when filling out my ABC chart to track how thoughts changed and if
emotions became more positive. In CBT it is important to secure a formulation to refer to
throughout. Conversely, I found setting a SMART goal somewhat useful in providing overall
structure to the five weeks; however I didn’t find myself referring to it throughout the
process.
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I found the BE challenging but the graded hierarchy made it more manageable and made
change more likely. Despite this, Irelapsed in week three but I believe this could have been
prevented by including more stages to the hierarchy should I go through this process again. I
think I over estimated how easy it would be for me to move up through the stages. This
highlights how in CBT attention should be put on including stages which are achievable and
realistic, otherwise, like me the individual may experience a sense of discouragement and
failure, resulting in lack of progress. I expected the process of moving through thesestages to
be quicker than it was; I found maintaining the exercise stated at each stage difficult, making
progression challenging. In week three I relapsed and didn’t exercise at all. I can now
empathise with individuals who go through CBT and relapse too and having experienced the
disheartening feeling, can understand the need for the support of the therapist to guide them
and provide encouragement. When I succeeded, I could feel a sense of increased self-
efficacy. The thoughts in my ABC chart were more positive and I went on to achieve more.
The problem was maintaining this week by week.
During the process I have found it demandingreflecting to the extent that is needed within
CBT, specifically when monitoring thoughts derived from particular situations and then
reflecting on emotions experienced. I felt uncomfortable and self-conscious. I found I was
asking myself questions to delve deeper in to reflection. For me, this demonstrated how
important techniques such as guided discovery and socratic dialogue can be within a therapy
session because you are prompted to think deeper, whereas when you are alone it can be hard
to achieve (Wells, 1992).When relating to clinical experience, an individual partaking in CBT
may have similar difficulties when reflecting and completing charts and diaries like the ABC
chart. Especially if it is the first time the individual has had to do this. So for someone going
through this process, they must be aware of how best to deal with emotions that may arise.
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Throughout the process, I encountered difficulty maintaining motivation. External motivation
such as family and friends aided success in engaging in exercise. I often spoke with family
members and my boyfriend about positives of exercise, which helped. When I discussed this
assignment with peers, my worries about the behaviour change were relieved somewhat
because they validated my emotions, however because my family were unaware of the detail
of CBT frameworks, they were less validating, saying things such as ‘just do it!’ When
relating this to clinical experience, I believe it’s important to identify a support network
outside of therapy sessions, explain the workto them and draw upon this support should one
feel lacking in motivation as they can give you the boost you need and validate difficulties.
Other factors impeding on change included emotional factors; I found it hard having to face
up to how little I exercise now compared to the amount I used to partake in. This elicited
emotions of sadness and upset. However, events such as a minor car crash and medical issues
have been obstacles which have made engaging in more exercise difficult. In a clinical
setting, the individual may have intense emotional factors, which impede on change to a
greater extent. When we are emotional, our thoughts become irrational eliciting negative
automatic thoughts and in turn we may make negative appraisals about ourselves, resulting in
negative emotions and behaviour.
Environmental factors alsohad an impact on whether or not I engaged in exercise. It had been
particularly windy and rainy the previous few weeks, which played a part in me missing
planned exercise simply because I thought ‘I’d rather be inside’. Other factors such as
university work load, seeing my boyfriend and spending time with my family got in the way
of me exercising. Arguably these could be seen as avoidant tactics, which may be the focus of
sessions within CBT.
Summary
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By using the frameworks common in CBT, I was able to facilitate change of my exercise
behaviour by increasing frequency over the five weeks. I was somewhat successful with this
and provided evidence against my belief tested in the BE, which overall has given me a sense
of achievement. I encountered difficulties applying theory to practice, but when I succeeded,
I felt positive emotions. When I wasn’t,I experienced a sense of failure so am able to
empathise with people who have CBT and appreciate how difficult the process of change can
be, even with a seemingly trivial issue.
References
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