lapses

I’m a very visual person, I love to see what I’m doing, and I use visual imagery a lot in my language and my processing. Many of our clients are also visual – or they’re kinaesthetic – and they need to see and manipulate rather than listen and talk.

At some point while working with a person it can be helpful to diagram a situation so that you and the client can see what is going on – and the influences that may be having an effect on the situation. In some CBT language this is called ‘psychoeducation’ but I prefer to call it ‘mapping’. To me, the client and I are mapping what happens so we can both discover new ground.

It often starts when I’ve been asking about automatic thoughts – those quick images or phrases that fly through when we encounter a situation. They happen all the time and reflect underlying processes and judgements that influence our emotions and actions. Often they pass through without us being aware of them, but their influence is very strong. Sometimes untangling the thought, the emotion and the action can be difficult, so I start with the event and remain open to working out, with the client, what happened next.

I’ve attached a worksheet that you can use with a person, although I have to admit to mainly drawing in freeform on a whiteboard or handy pieces of paper! Whiteboards are great because if you make an error or want to revise something you can easily wipe it out, which can really make an impact on the person when they reflect on the effect of changing their automatic thought.

cb-model-worksheet

You can start with almost any situation – but for occupational therapists or physiotherapists, I find it can be a great tool to use when someone hasn’t followed through with home learning (their ‘mission’). You can pick a time when they didn’t do their exercise, for example, and work out what went through their mind, and find out any underlying beliefs – or external influences – that made it difficult for them to choose to do what they had agreed. For example in this situation – I’ve added in colour some of the therapeutic processes being used.

Therapist: “How did you go with your walking plan over the week?”

Client: “Uh, only got out once – I just had one of those weeks”

T:”How about we go through exactly what happened one of those days you meant to do it but didn’t?”

C:”OK, I suppose so”

T:”So what day can you remember most easily?”
Elicits readily remembered event

C:”Thursday morning, the weather was foul and the kids were playing up and my back was sore and I just didn’t feel up to it”

T: “Let’s start from the first time you thought about your walk. What went through your mind?”
Eliciting automatic thought or image

C: “I thought, Oh no, my back is just too sore and I’m going to be too tired today”

T: “Let’s put that down on the map. Then can you remember how you were feeling at the time?”
Moves to identify the emotion. For some people, this is very difficult and the therapist needs to work through behaviours and thoughts several times, or provide prompts for the type of emotion being experienced.

C: “Guilt! I knew I should be going, but I just didn’t feel up to it.”

T: “So you felt guilt then – any other feeling? What about when you though you would be too tired today?”
Simple reflection, but working through the superficial emotion to a deeper emotion more relevant to the thought the client had.

C: “I suppose I felt quite down then”

T: “So you felt quite down. What does that feel like in your body?”
Simple reflection. Links this with physical/behavioural changes in the body, drawing together the link between thoughts, emotions and pain.

C: “Heaviness in my chest, and my back feels so stiff and sore”

T: “What did you do then?”

C: “I carried on with the housework, but I went quite slowly and was grumpy all day. It was a bad day.”

T: “So, what else was going on that day?”

C: “The kids were being awful and shut in, and all I wanted was a bit of peace and quiet”

T: “Sounds like a real challenge to keep it together when all these things stack up – how did you manage before your back was sore?”
Slightly more complex reflection, elicits previous positive coping strategy. Therapist would draw on the map that the kids were influencing the situation too, also the client’s thought that ‘all she wanted was a bit of peace and quiet’

C: “I would have packed them up and headed out to the park to give them a breather, and myself a break.”

T: “Am I reading you right that getting out is a good thing when you’re feeling a bit stressed?”
Further reflection, this time extending it to include the concept of responses to stress – this could be explored further in another session. What are her typical responses to stress, what situations stress her, how does stress manifest itself in her body, how does pain and exercise influence stress. At this stage the therapist could simply record ‘stress’ on the map, with an arrow pointing to the event ‘going for a walk’

C: “Yup. My back just gets in the way so much”

T: “So it seems that on a horrible day, when the kids are acting up and you’re feeling a bit sore and down, you’d usually get out and about and take a break, but you thought on that day that you would be too tired to do that. Have I got it right?”
A longer reflection, which could almost be called ‘a bouquet’ – gathering together all the relevant pieces of information, summarising and asking whether the therapist has heard it correctly.

C: “Yes, that’s about it”

T: “On the one hand you felt too sore and tired to do anything much, but on the other hand you had a whole day when the kids were acting up AND you were sore and now you feel guilty for not exercising! Where does that leave you?”
Therapist starts to develop ambivalence about the situation, and ensures responsibility for working a way through this rests with the client.

C: “Stuck!”

T: “What are some of your options on a day like that?”
By asking the client for options, the therapist demonstrates faith in the clients own abilities, builds on the client’s strengths and preferences, while helping the client remain focused on achieving both of her valued activities – being a good parent who can keep her cool, and getting a bit fitter despite her pain.

At this point, the therapist is opening up the opportunity for the client to start problem solving ways to achieve both exercise goals and being a good parent.

I hope you’ve enjoyed this wee piece of how I might have worked through a situation where someone hasn’t followed through with home learning – it’s a very common situation, but allows us a chance to work through the factors that will probably influence lapses or relapses once the client leaves us.
More tomorrow!