Model

1

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.

2

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

3

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

4

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).

5

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,

6

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

7

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

8

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.

9

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.

10

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

11

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

Beck, A. T. (1976).Cognitive therapy and the emotional disorders.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1987). Cognitive therapy of

depression.The Guilford Press.

Bennett-Levy, J., Thwaites, R., Chaddock, A., & Davis, M. (2009). Reflective Practice in

CognitiveBehavioural Therapy: The Engine of Lifelong Learning.

Bennett-Levy, J., Butler, G., Fennell, M., Hackmann, A., Mueller, M., & Westbrook, D.

(2005). Oxford guide to behavioural experiments in cognitive therapy. Oxford University

Press.

Donker, T., Griffiths, K. M., Cuijpers, P., & Christensen, H. (2009). Psychoeducation for

depression, anxiety and psychological distress: a meta-analysis. BMC medicine, 7(1), 79.

Ellis, A. (1962), Reason and emotion in psychotherapy. Oxford, England: Lyle Stuart.

12

Greenberger, D., & Padesky, C. A. (1995). Mind over mood: Change how you feel by

changing the way you think. The Guilford Press.

Prochaska, J. O., & DiClemente, C. C. (1982).Transtheoretical therapy: Toward a more

integrative model of change. Psychotherapy: Theory, Research & Practice, 19(3), 276.

Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of

smoking: toward an integrative model of change. Journal of consulting and clinical

psychology, 51(3), 390.

Wells, A. (1992). Stress. In A. Freeman & F. Dattilio (eds.): Comprehensive casebook of

cognitive therapy. New York: Plenum Press

Westbrook, D., Kennerly, H. & Kirk, J. (2007).An Introduction to Cognitive Behaviour

Therapy: Skills and Applications. Sage: London.

13