Jon E. Grant, Christopher B. Donahue, Brian L. Odlaug. Overcoming Impulse Control Problems_ A Cognitive-Behavioral Therapy Program..pdf

Overcoming Impulse Control Problems

editor-in-chief David H. Barlow, PhD

scientific advisory board Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

Overcoming Impulse Control Problems: A CognitiveBehavioral Therapy Program Wo r k b o o k Jon E. Grant • Christopher B. Donahue • Brian L. Odlaug

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About Treatments ThatWork™

One of the most difficult problems confronting patients with various disorders and diseases is finding the best help available. Everyone is aware of friends or family who have sought treatment from a seemingly reputable practitioner, only to find out later from another doctor that the original diagnosis was wrong, or the treatments recommended were inappropriate or perhaps even harmful. Most patients, or family members, address this problem by reading everything they can about their symptoms, seeking out information on the Internet, or aggressively “asking around” to tap knowledge from friends and acquaintances. Governments and healthcare policymakers are also aware that people in need don’t always get the best treatments—something they refer to as “variability in healthcare practices.” Now, healthcare systems around the world are attempting to correct this variability by introducing evidence-based practice. This simply means that it is in everyone’s interest that patients get the most upto-date and effective care for a particular problem. Healthcare policymakers have also recognized that it is very useful to give consumers of healthcare as much information as possible, so that they can make intelligent decisions in a collaborative effort to improve health and mental health. This series, Treatments ThatWork™ is designed to accomplish just that. Only the latest and most effective interventions for particular problems are described, in user-friendly language. To be included in this series, each treatment program must pass the highest standards of evidence available, as determined by a scientific advisory board. Thus, when individuals suffering from these problems, or their family members, seek out an expert clinician who is familiar with these interventions and decides that they are appropriate, they will have confidence that they are receiving the best care available. Of course, only your healthcare professional can decide on the right mix of treatments for you.

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This workbook is designed for your use as you work with a qualified mental health professional to change your unwanted impulsive behaviors, whether you suffer from out of control gambling, compulsive buying, uncontrollable urges to steal things (kleptomania), or a destructive fascination with fire (pyromania). The program is composed of 6 sessions, with the option of an additional family session, and has been scientifically validated and proven effective for helping people overcome their impulse control disorders (ICDs). Over the course of treatment, your therapist will teach you about your ICD and how to recognize those situations or events that trigger your impulses. You will learn strategies for managing these triggers, as well as techniques for monitoring your thoughts and changing your erroneous beliefs about your behaviors. Home practice and daily self-monitoring are essential to success, and this workbook contains all the forms and worksheets you will need to complete all in-session and at-home assignments. Based on the principles of cognitive-behavioral therapy (CBT), this program has a strong educational component that can help you manage your problems independently, once you have completed formal therapy. David H. Barlow, Editor-in-Chief, Treatments ThatWork™ Boston, MA

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Acknowledgments

The authors wish to thank Robert Ladouceur, Nancy Petry, and Matt Kushner, all of whom provided invaluable guidance during the early development of this manualized treatment. Robert Ladouceur also generously allowed us to expand upon aspects of his earlier treatment manual for pathological gambling, and apply them to other impulse control disorders.

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Contents

Chapter 1

Introduction to the Program 1

Chapter 2

Session 1: Education and Motivational Enhancement 9

Chapter 3

Session 2: Financial Planning (PG, CB) Alternate Content for PY: ICD Trigger Planning Alternate Content for KM: Plan for Managing Stolen Goods 17

Chapter 4

Session 3: Behavioral Interventions 35

Chapter 5

Session 4: Imaginal Exposure 49

Chapter 6

Session 5: Cognitive Therapy for Impulsive Beliefs 55

Chapter 7

Session 6: Relapse Prevention 69

Chapter 8

Session 7: Family Session (Optional) 79 Appendix of Forms

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Chapter 1

Introduction to the Program

Goals ■ To learn about the impulsive behaviors treated in this

program: Gambling, spending, stealing, fire setting ■ To learn about this treatment program and what it will

involve

What Is an Impulse Control Disorder? Impulse control disorders (ICDs) include pathological gambling (PG), kleptomania/compulsive stealing (KM), pyromania (PY), and compulsive buying (CB). ICDs are characterized by difficulties in resisting urges to engage in behaviors that are excessive and/or ultimately harmful to self or others. ICDs are relatively common among adolescents and adults, are associated with co-occurring problems such as depression or anxiety, and can be effectively treated with behavioral and pharmacological therapies. Although the extent to which the ICDs share clinical, genetic, phenomenological, and biological features is incompletely understood, many of the ICDs share common core qualities: 1. Repetitive or compulsive engagement in a behavior despite negative consequences. 2. Limited control over the problematic behavior. 3. An urge or craving is experienced prior to engagement in the problematic behavior. 4. A hedonistic (e.g., pleasure-seeking) quality during the performance of the problematic behavior.

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These features have led to a description of ICDs as “behavioral addictions.” We will define each ICD problem addressed in this workbook. We believe all participants in the Cognitive Behavioral Therapy for Impulse Control Disorders (CBT-ICD) program need to be well informed about their specific ICD, to understand how common the problem is, and to be knowledgeable about the symptoms, behaviors, and thoughts associated with their ICD.

What Is Pathological Gambling? Pathological gambling (PG) is characterized by a loss of control over gambling, deception about the extent of involvement with gambling, family and job disruption, theft, and chasing losses. Despite its high prevalence, PG often remains untreated. According to a 1999 report of the National Gambling Impact Study Commission, 97% of problem gamblers in the United States fail to seek treatment. Although the history of gambling treatment extends over several decades, there is a surprising lack of reliable knowledge regarding what constitutes an effective treatment for problem gambling. Cognitive-behavioral interventions, however, such as the program described in this workbook, have been scientifically proven to be effective for treating PG.

What Is Kleptomania? Kleptomania (KM) is characterized by the repetitive, uncontrollable stealing of items not needed for personal use. Although KM typically appears in early adulthood or late adolescence, the disorder has been reported in children as young as 4 years old, and in adults as old as 77 years old. Intense guilt and shame are commonly reported by those suffering from KM. Items stolen are typically hoarded, given away, returned to the store, or thrown away. Many individuals with KM (64% to 87%) have been apprehended at some time due to their stealing behavior. Individuals may avoid stealing when immediate arrest is likely, but the chances of apprehension are usually not fully taken into account. Although a sense of pleasure, gratification, or relief is experienced at the time of the theft,

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individuals will describe a feeling of guilt, remorse, or depression soon afterwards.

What Is Pyromania? Pyromania (PY) is classified as an ICD because pyromaniacs cannot control their impulses to deliberately start fires. Pyromaniacs start fires to induce euphoria, and often fixate on institutions of fire control like fire stations and firefighters. They may even habitually listen to police scanners to find out when and where fires occur. After starting a fire, most pyromaniacs experience a relief in tension and feelings of gratification. Pyromania is included in the CBT-ICD program based on the fact that it shares many qualities with other ICDs.

What Is Compulsive Buying? Compulsive buying (CB; also referred to as compulsive shopping) is fairly common, with approximately 1.4%–5% of the population suffering from this behavior. The problem typically begins in late adolescence, and a greater proportion of compulsive buyers are women. Compulsive buyers commonly have co-occurring depression and anxiety disorders, substance use disorders, and eating disorders. Compulsive buyers can experience a significant urge to engage in the problem behavior, with little control over their actions. The act of buying may be accompanied by feelings of excitement or euphoria, often followed by depressed mood, shame, and/or letdown once the buying experience is complete. The goal of the purchase may often have nothing to do with the actual item, but rather to alter one’s mood. Compulsive buying is often preceded by negative affect, including feelings of anger, boredom, anxiety, with the purchase providing temporary relief. Buying may occur year-round or happen in binges, with purchases for self or overindulgent purchases for loved ones. The purchases can occur in a range of venues, with Internet shopping adding significant flexibility and convenience for quick purchases. Common items purchased by compulsive buyers include clothing, shoes, jewelry, and electronics.

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Description of Cognitive-Behavioral Therapy for Impulse Control Disorders (CBT-ICD) Cognitive-behavioral therapy (CBT) is based on the knowledge that our thoughts cause our feelings and behaviors, not external things like people, situations, and events. CBT is structured and goaloriented, with the therapeutic goal of helping you unlearn your unwanted reactions and learn a new way of reacting. A critical component of the program is to question the thoughts related to your impulsive behaviors. You need to look at your thoughts as being hypotheses or theories that can be questioned, tested, and corrected if they are inaccurate. For example, if you suffer from PG, you may have thoughts such as, “I am bound to win eventually. I just need to keep playing.” CBT helps you question these inaccurate thoughts by having you realize that although you may win on occasion, you seldom walk away with your winnings. If you suffer from CB, you may have thoughts such as, “I am only going to buy one thing today. I can control my spending.” However, the reality is that you end up buying multiple items, and spend much more time and money than you originally had intended. This program will help you realize the truth of your actions, and help you to change your impulsive behaviors. CBT has a strong educational emphasis, with the expectation that when people understand how and why they are doing well, they can continue to practice those behaviors to make themselves well. This is why therapy assignments between sessions are critical to realizing therapeutic change. As part of this program, you will be expected to complete assigned readings, self-monitoring of thoughts and behaviors, and practice between sessions the skills you have learned in session. Goal achievement (if obtained) could take a very long time if a person were only to think about the techniques and topics taught for one hour each week. Procrastination and/or avoidance must be addressed if these behaviors begin to interfere with therapy. After all, the goal of the CBT-ICD program is to achieve long-term abstinence from your impulsive behavior. Program Outline You will meet with your therapist for 6 sessions, with the option of an additional family session at some point during the program.

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You and your therapist will determine together whether a family session is necessary. Following is an outline of the program and a list of concepts that will be covered: ■ Pre-treatment assessment ■ Session 1: Evaluation of motivation to quit impulsive behaviors

and introduction of self-monitoring ■ Session 2: Financial planning (for PG and CB clients);

alternative content for PY and KM clients; introduction to identifying ICD triggers ■ Session 3: Behavioral intervention, preparation for ICD

Triggers ■ Session 4: Exposure therapy (via guided imagery) ■ Session 5: Impulsive beliefs: cognitive therapy ■ Session 6: Relapse prevention ■ Session 7: Family involvement (optional)

What to Expect As part of this treatment program, you will be asked to make significant lifestyle changes in an effort to get your impulsive behavior under control. Impulse control disorders are serious and require a great deal of effort and practice to overcome. You have shown some inclination to change your impulsive behaviors by just showing up for treatment, so you are obviously motivated to work on your problem. If you are uncertain whether your impulsive behavior is problematic at this point, the CBT-ICD program will, at the very least, help you to explore how it affects you and different parts of your life. You and your therapist will initially complete a thorough assessment of your impulsive behavior and related problems. The information obtained during the assessment will then be used in your therapy sessions, and will help you and the therapist in guiding treatment. As you have already read, CBT has a strong educational component that can help you manage your problems independently once

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you have completed formal therapy. The program is comprised of 6 sessions, with the option of an additional family session, and has been scientifically validated and proven effective for helping people overcome their ICD. It is important to understand that therapy does not stop once you are done seeing your therapist. Rather, you will be expected to practice the skills and strategies beyond therapy until new, healthy habits are formed and you are more confident in managing your impulsive behaviors. We understand that clients will bring different expectations to the CBT-ICD program, and you and your therapist will work together to ensure that the treatment is individualized to you. Expect to receive new “homework assignments” each week, which are designed to increase insight and to help you regain control of your impulsive behavior. Unlike homework you would receive in school, therapy assignments will not be graded. You will not “fail” treatment if you do not complete the homework. However, homework is a key component of therapy, so it is very important that you do your best to complete each assignment. Each therapy session will include the following parts: ■ Check-in, review of homework, and review of the previous

week (successes and challenges) ■ Education ■ Presentation of a new skill area ■ Practice new skill with therapist ■ Homework assignment

Initial Assessment During the first meeting, your therapist will want to complete several assessment measures to confirm your diagnosis and to understand the severity of your behaviors. Because therapy may differ depending upon whether you have a mild ICD or a severe ICD, your therapist will want to determine how frequently you engage in the ICD behavior, how intense the behavior is, and how the ICD

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behavior affects your life and ability to function in other aspects of your life. It will be important to tell your therapist about the consequences of your behavior, even if the consequences involve legal problems. It is also important to tell the therapist about how the ICD behavior affects others in your life (e.g., marital problems, joint financial difficulties). This provides information that is essential to the therapist in understanding how severe the ICD is, and how the ICD has affected your life. This initial assessment is crucial for tailoring a treatment plan that fits with your specific needs. Your therapist will begin your assessment by asking you a number of questions from the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) for your specific ICD. These questions will help both you and your therapist determine whether you meet formal criteria for an ICD. In addition to the SCID interview, your therapist will administer additional interviews in order to assess your ICD and other mental and physical health challenges (e.g., mood and anxiety disorders, addiction, health problems). Knowledge of these challenges will help you and the therapist to tailor your treatment to address concerns that might otherwise go unnoticed. These “co-occurring” problems can greatly affect treatment for your ICD and, consequently, it is very important that these issues are addressed along with your ICD.

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Chapter 2

Session 1: Education and Motivational Enhancement

Goals ■ To learn about your specific ICD ■ To work with your therapist to increase and maintain

motivation for treatment ■ To begin daily self-monitoring of your behaviors ■ To review your finances, if you have problems with gambling

or spending

Education In this session your therapist will explain your ICD behavior (e.g., what is known about the behavior, what are the possible causes of the behavior, how does the behavior relate to other problems you have, or other problems in your family). Understanding the ICD behavior should reduce some of the stigma and shame associated with it, whereas talking about the behavior should provide the therapist with additional information about how your ICD affects you as a unique individual. The educational aspect of the initial assessment may also provide you with some additional motivation to get control over the behavior.

Staying Motivated The behaviors often associated with ICDs are difficult because you want to stop them, yet on some level you receive some positive

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feelings from engaging in them (e.g., a sense of control, power, excitement, etc.). Most people do not want to admit that they enjoy or find some pleasure in their ICD behaviors. In fact, clients will frequently respond to questions about their specific ICD behaviors by stating, “I don’t like anything about it.” While this may be true at the time they are sitting in the therapist’s office, most people readily recognize that there are often very positive aspects to the behavior (e.g., the behavior may reduce stress, at least momentarily, or provide an escape from family or work issues, etc.). In fact, although many people say, “I want to stop the behavior,” what they really mean is that they want to stop the consequences of their behavior. Because of these feelings, you may be ambivalent at times about stopping the behavior. Many people feel that they are getting rid of a good, although problematic, “friend” when they stop their ICD behavior. Therefore, motivation to control the behavior may come and go over the course of treatment. Finding the motivation to control the behavior will be crucial to prevent relapse. You will spend time in this session reviewing the different ways your ICD has affected you, and assessing your motivation and readiness to quit your impulsive behavior. Work with your therapist to complete the Motivation to Quit Impulsive Behavior form provided in this workbook. This will help you to see the negative effects that your ICD has on your life. This worksheet will also help you to realize the benefits of stopping your impulsive behaviors.

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Motivation to Quit Impulsive Behavior

1) Positive aspects of impulsive behavior (what are the positive things the impulsive behavior gives me?)

2) Negative aspects of quitting (what do I lose if I stop the impulsive behavior?)

3) What are the negative consequences of the impulsive behavior (current and future?)

4) What are the advantages of quitting the impulsive behavior (what do I have to gain?)

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Why do you to continue acting impulsively (gambling, buying, stealing, or fire-setting) and why do you want to stop? The following exercise will help you think more closely about the reasons why you engage in impulsive behaviors in the first place, and why you want to change your behavior. What I Like About My Impulsive Behavior _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ What I Hate About My Impulsive Behavior _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Reasons Why I Want to Stop My Impulsive Behavior _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

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Imagine, on all levels, what my life will be like when I stop the impulsive behavior:

Career:_______________________________________________ _________________________________________________________

Friendships: __________________________________________ _________________________________________________________

Intimate Life: _________________________________________ ____________________________________________________ Family Relationships:____________________________________ _________________________________________________________

Economics:___________________________________________ ____________________________________________________ Hobbies/Recreational Activities:____________________________ ____________________________________________________ Monitoring Daily monitoring of thoughts, feelings, and behaviors is essential to gaining control over your ICD problem. Simply not thinking about your behavior will not help you stop it. You may not want to think about your ICD behavior because you’re ashamed of it, or ashamed of the consequences of your behavior. However, pretending the problem is less severe than it is will not help your therapist provide the necessary level of treatment. Therefore, keeping a daily diary will allow you to record—in real time—how intense your desires are to engage in the behavior, how much you’re actually doing the behavior, and what may have triggered you to engage in the behavior. The Daily ICD Behavior Diary (a modification of Ladouceur and Lachance’s Daily Self-Monitoring Diary for Pathological Gambling) allows you to record all aspects of your behavior. In addition, as you gain more control over the behavior, you will actually see, in your own words, how much progress you have made. It is important for you to complete the diary every day. 13

Daily ICD Behavior Diary

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening at that time and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. (For gambling and spending problems). How much money did I spend on gambling (excluding wins) or shopping? 6. (For shopping problems) How much money did I spend? What did I buy? What did I do with it? 7. (For stealing problems). What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today, and what was happening in my life today (e.g., depressed, bored, frustrated, happy, anxious, too busy at work, fight with spouse)? 9. (For stealing and fire setting problems). Was I caught engaging in an illegal act, and if so, what were the legal consequences?

/

/

/

/

/

/

/

/

/

/

/

/

/

/

Homework

✎ Review your completed Motivation to Quit Impulsive Behavior form daily, as a reminder of the consequences of your impulsive behavior. You will discuss the consequences of your behavior in more detail at the next session.

✎ Begin daily recording of your behaviors using the Daily ICD Behavior Diary. Additional copies are provided in the Appendix, or you may make photocopies.

✎ If you have problems with gambling or overspending, your therapist may ask you to complete the Financial Spending Form in the next chapter (see page 19).

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Chapter 3

Session 2: Financial Planning (PG, CB) Alternate Content for PY: ICD Trigger Planning Alternate Content for KM: Plan for Managing Stolen Goods

Goals ■ To identify and plan strategies for managing finances, if you

have debt-related problems due to gambling or compulsive buying ■ To create a plan for managing stolen goods, if you have

problems with stealing ■ To identify a support system and begin to identify triggers,

if you have problems with fire-setting

Introduction Some of the content in this chapter may not apply to you. If you do not suffer from pathological gambling or compulsive buying, you may skip the first section on financial concerns. If you’d like to read it, however, please feel free. Almost anyone can benefit from advice for managing finances. If you do not have problems with stealing, you do not need to create a plan for managing stolen goods. Likewise, if your impulsive behaviors do not include starting fires, you do not yet need to begin identifying ICD triggers (you will be doing this next session).

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Monitoring Spending In order to increase self-awareness of spending and money management in general, you will begin to keep a weekly and monthly budget of all expenses. A financial budget will help to increase awareness of spending behaviors and gambling debt, and facilitate planning for debt repayment. It will also help you to review your finances overall, in order to discourage future reckless spending and gambling. At this time, you and your therapist will begin to discuss how you manage your money. If your spouse or significant other manages money, it may be helpful for him or her to be involved in this session. At the very least, you will need to share the recommendations from this session with your significant other. There needs to be “transparency” in how your money is managed, especially if there has been a lot of secrecy about your spending or gambling debt. A certain percentage of gamblers and compulsive buyers may ignore or avoid thinking about their accumulated debt. Of course, avoidance may not be possible when you have taken out several mortgages on your home or filed for bankruptcy. Gamblers and compulsive buyers may also be quite adept at “moving money around” in order to cover spending and gambling expenditures. Constantly thinking about, or trying not to think about, money problems can lead to other mental health problems, such as anxiety and depression— problems that are common in those with an ICD. At the end of last session, your therapist may have asked you to complete the Financial Spending Form on page 19. If you completed the form, your therapist will review it with you in this session. It is important that all sources of expenditures be listed. Purposely ignoring certain debts will not make them go away. Only if you are honest on the financial spending form can your therapist accurately and effectively help with any financial stress you may be feeling. You will continue to use this form to monitor your spending for at least the next week or two. This will help you get a better overall picture of your expenses before you attempt to create a weekly or monthly budget. Managing your spending and being aware of your expenses will allow you to create a budget that will help you pay down your gambling or spending-related debt. Please feel free to photocopy the form from the book, or use the additional copies provided in the appendix. 18

Financial Spending Form

Expense (Including Debt)

Weekly

Monthly

Example 1: Groceries

150 (3/2–3/8)

600

Example 2: Visa

240 (minimum payment)

Monthly Income

+(

)

Total Monthly Expenses:

−(

)

Balance

=(

)

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Creating a Budget After you have monitored your expenses for a few weeks, you will work together with your therapist to create a workable budget. We encourage you to enlist the help of your friends and family in putting this budget together. Although talking about finances, even with close friends or family, can be embarrassing, it is important to have a support system in place. Friends and family members can help keep you on track by checking in with you periodically to see if you are adhering to the budget. You need to keep in mind that trying to “keep up appearances” by pretending that your finances are fine has not worked. Close friends or family can be important allies in keeping you honest about your debt, and can provide emotional support during this difficult time. Asking friends or family to help you with this process may also result in transforming their frustration with your behavior into a positive experience for them. We find that family or friends often express strong negative emotions toward a person when they feel they cannot help, or do not know how to help. Having them assist with your budget not only helps you, but also helps build a positive working relationship with them. In planning a budget, there are several factors to consider, including credit card payments, household bills, and necessities such as food, shelter, and clothing. If you have outstanding gambling or spendingrelated debt, we encourage you to use more of your discretionary money (after all other expenses are paid) to pay down high-interest credit card debt. You may need to consider cutting back spending in certain areas of your life in an effort to pay down debt. For example, instead of going out to eat, you may have to plan a menu each week and eat most meals at home, buying only those groceries that are necessary. You may have to reconsider family trips and vacations. Smaller cuts may be made in order to free up money, such as canceling magazine subscriptions or eliminating cable television. This may be difficult for you, but it is a necessary step toward taking control of your finances. In some cases, you may need an additional job to

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help with the budget. In the case of compulsive spending, you should start with selling items you have acquired due to that spending. The money garnered from the sale can go toward paying down debt. The most important goal of developing a budget is to increase your awareness of where your money is going. Use the Financial Budget Form provided to create your personal budget.

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Financial Budget Form

Monthly Expense

Budget (Goal)

Previous Amount Spent on this Item

Difference

Where can the difference be applied? (e.g., Visa card to pay more than minimum)

Example 1: Groceries

900

1000

100

Ways to Increase Monthly Income

Expected Income

Amount that can be used to decrease existing debt

Where the money can be used to reduce debt

Example 1: Part-time job

$800

$400 after taking out taxes, gas money, etc.

Pay down Visa bill

Monthly Income

+(

)

Total Actual Monthly Expenses:

−(

)

Balance

=(

)

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Strategies to Improve Your Financial Situation You and your therapist will review suggestions for changing how you handle your money. Not all suggestions will apply to your situation, but work together with your therapist to identify strategies that might work for you. Keep in mind that some of these suggestions will be challenging. For example, handing all of the responsibility for managing your money to a significant other, or giving a significant other access to your banking and/or credit card accounts, may feel like you are giving up too much control. It may also make you feel like you are being punished and treated like a child. However, when we think about being “in control,” we must take into consideration the impulsive behavior for which you are getting treatment. You have demonstrated, by entering and being eligible for this program, that you meet criteria for an ICD. Your gambling and/ or spending is out of control, and is causing significant negative consequences. Having someone take control of your money will actually help you to regain control over your problem. You should also keep in mind that turning your finances over to someone else is not a permanent change. Once you are in control of your ICD, you can once again have control over your credit cards, bank accounts, etc. In cases where you cannot identify anyone close to you to help manage your money, you and your therapist may discuss appointing a payee or an objective financial advisor to work with you in managing your money. These strategies are considered temporary, but would not change until you have demonstrated some control, including a reduction in your urge to engage in impulsive behaviors, developing new insights regarding your behavior, and implementing new, healthier habits. Following is a list of suggestions for managing your finances. ■ Restrict your access to money; have a loved one give you a

weekly amount of cash based on your spending and budget forms (eliminate credit and debit cards). ■ Have your paycheck directly deposited into a savings account,

not a checking account. ■ Have expenses paid directly out of the savings account via

automatic payment.

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■ Schedule weekly meetings with a significant other or loved one

to go over financial issues, bills, etc. ■ Get help from a credit counselor or an agency that can help

you with your budget. ■ Learn how to develop a budget that fits your income and

expenses. ■ Make firm plans to pay off your debts (starting with the most

urgent). ■ Designate a cosigner for your bank withdrawals. ■ Give a clear message to friends and family not to give you

personal loans. ■ Plan non-gambling/non-shopping activities around payday. ■ Inform a significant other about incoming money (e.g., income

tax return). ■ Ask someone else to get the mail, in order to limit your access

to checks and income. ■ Choose the strategies that you think will work for you, and list

them on the form on page 25.

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Strategies I Will Use to Manage My Finances

Strategy

Others Involved

Plan to Implement Strategy

1. 2. 3. 4. 5.

Commitment to Quitting my Impulsive Behavior: By signing this

document, I am making a commitment to myself and my loved ones to implement and use the strategies above for managing my finances. I must make every effort possible to follow the above suggestions in order to get my impulsive behavior under control and to manage my debt responsibly. If I do not follow through with this commitment, there will be no change in my impulsive behavior and I acknowledge that I will likely cause more problems for myself and those that care for me. Client Signature __________________________ Date _____________________

Significant Other/Family Member Signature __________________________ Date _____________________

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Managing Stolen Goods – Impulsive Stealing/Kleptomania (KM) If you struggle with kleptomania, you may not have significant financial problems but, rather, have a surplus of stolen merchandise at home valued at differing amounts. Clients that steal impulsively often keep, hoard, discard, or return stolen items, with the latter indicating that individuals may actually profit financially from the thefts committed. You and your therapist will work together to help prevent you from benefiting financially from the stolen merchandise. This session will include focusing on the development of a plan to deal with stolen merchandise, which can include the donation of stolen merchandise to charity (as long as no charitable contribution for tax purposes is used). Your therapist will encourage you to identify possible alternatives for getting rid of the stolen merchandise. You will be asked to enlist the support of a loved one, including friends and relatives, and/or a possible sponsor if you belong to a support group for your impulsive behavior. Having other people besides your therapist involved will help keep you accountable for your actions. These supportive people can also help you after you complete your formal therapy sessions. Plan for Dealing with Stolen Merchandise

The following list is not necessarily comprehensive, but provides some framework for beginning to discard your stolen merchandise. Consider the following suggestions: ■ Identify charities of interest, to include charities that accept

donated merchandise. Clothing is accepted by most organizations (e.g., The Salvation Army, Goodwill, Dress for Success). ■ Inform your family and loved ones of your plan to discard

stolen items. This provides some measure of accountability outside of the therapist–client relationship.

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■ Identify local schools that may use certain items (e.g.,

electronics, office supplies). Be aware, however, that you may run into obstacles when donating to certain programs. You may be required to present warranties or proof of purchase. Use the worksheet provided to identify the charities you will donate to, and when you will make the donation. Remember to ask a friend or family member to accompany you when making the donation. You will be required to present a receipt for the donated items at your next therapy session.

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Date

Charity/Organization

Support Person

Plan to Implement Strategy

Commitment to Quitting my Impulsive Behavior: By signing this

document, I am making a commitment to myself and my loved ones to implement and use the strategies above for getting rid of my stolen merchandise in such a manner that I do not profit in any way. I must make every effort possible to follow the above suggestions in order to get my impulsive behavior under control. If I do not follow through with this commitment, there will be no change in my impulsive behavior and I acknowledge that I will likely cause more problems for myself and those that care for me.

Client Signature __________________________ Date _____________________

Significant Other/Family Member Signature __________________________ Date _____________________ __________________________ Date _____________________

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Identifying Triggers for Impulsive Fire Setting (PY) If you suffer from pyromania (PY), you may not have any financial problems related to fire setting. One exception may be legal fees, if you have been arrested for your impulsive behavior. The following content will also be covered in your next therapy session, but today you will begin to identify those situations that put you at risk for fire setting. First, you will list the most common ICD triggers for fire setting on the My Triggers for Fire Setting form provided on page 30. Then you will rate your confidence in being able to resist the urge to set fires, should you have the opportunity, using the Controlling Impulsive Behaviors Questionnaire provided on page 31. Your therapist will then give you a homework assignment to begin identifying possible solutions to help you resist fire-setting tendencies. Your therapist will want to know about successful strategies that you have used in the past to resist the urge to set fires. When listing your ICD triggers, please consider all the influences on your impulsive behavior, such as your state of mind, mood, stressors, and/or conflict.

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My Triggers for Fire Setting When completing this form, please report as many details as possible. For example, time of day, how much time you have to plan for and actually set fires; if you’re feeling bored, upset, angry, anxious, depressed, happy; what you would need to have access to (fire-setting material) before you could set fires; if you’re alone or with others; if you have other plans during this high-risk time, if you are accountable to anyone (e.g., boss, peers, loved ones); where you are, or where you would typically set fires. ICD trigger #1: ICD trigger #2: ICD trigger #3: ICD trigger #4: ICD trigger #5:

After identifying your ICD triggers, the next step will be to transfer this information to the Controlling Impulsive Behaviors Questionnaire on page 31 and rate your confidence in resisting the urge when facing the identified ICD triggers. This exercise will allow your therapist to create a behavioral intervention plan to suit your needs. You will further develop this questionnaire at your next session.

30

Controlling Impulsive Behaviors Questionnaire Please describe your high-risk situations for engaging in impulsive fire-setting behaviors. (For example: “when I am bored and have nothing to do” or “when I just had an argument with my boss”). Then, indicate on a scale of 0 to 5, your level of confidence to control your fire-setting behaviors if you faced these situations at the present time. Situation 1 ____________________________________________________ ____________________________________________________ ____________________________________________________ If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior?

1

2

3

No Control

4

Moderate Control

5 Total Control

Situation 2 ____________________________________________________ ____________________________________________________ ____________________________________________________ If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior?

1 No Control

2

3 Moderate Control

4

5 Total Control

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Situation 3 ____________________________________________________ ____________________________________________________ ____________________________________________________ If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior? 1

2

3

No Control

4

Moderate Control

5 Total Control

Situation 4 ____________________________________________________ ____________________________________________________ ____________________________________________________ If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior? 1

2

3

No Control

4

Moderate Control

5 Total Control

Situation 5 ____________________________________________________ ____________________________________________________ ____________________________________________________ If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior?

1 No Control

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2

3 Moderate Control

4

5 Total Control

Homework

✎ Continue daily recording of your behaviors using the Daily ICD Behavior Diary. Additional copies are provided in the appendix, or you may make photocopies. If you suffer from PG or CB:

✎ Continue monitoring weekly spending using the Financial Spending Form. You and your therapist will use the information from this form to create a personalized budget.

✎ As directed by your therapist, begin filling out the Financial Budget Form.

✎ Review your completed Strategies I Will Use to Manage My Finances form and begin implementing strategies reviewed in the session. If you suffer from KM:

✎ Begin implementing the plan for dealing with stolen merchandise. If you suffer from PY:

✎ Identify members of your support system, and begin identifying triggers for fire-setting using the My Triggers for Fire Setting form and the Controlling Impulsive Behaviors Questionnaire.

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Chapter 4

Session 3: Behavioral Interventions

Goals ■ To identify your ICD triggers and strategize ways of managing

them in real life ■ To identify healthy behaviors to implement in place of your

impulsive behaviors ■ To identify a minimum of two leisure skill goals and steps to

accomplish those goals

ICD Triggers and Healthy Behaviors All individuals who suffer from ICDs have certain triggers that lead them to engage in their impulsive behaviors. For example, being close to a casino will often trigger a pathological gambler to engage in gambling. A bad day at work may trigger a person with spending problems to engage in compulsive buying. A disagreement with a friend or family member may lead a person with PY to start a fire to relieve the tension resulting from the conflict. However, it would be misleading to believe that it is only external things or circumstances that provoke us to act impulsively. We must also take into consideration how we perceive these situations and their associated triggers. For example, not everyone that enters a casino, store, or circumstance in which a fire could be started has an urge to act impulsively. If individuals without an ICD have thoughts about acting impulsively, they may not act on them because they are fully aware of consequences, whereas clients with an ICD often focus only on the “rewarding” aspects of their impulsive behavior before and during engaging in that behavior. You will explore beliefs associated with your impulsive behavior in a later session, which will provide additional protection against acting impulsively. This session will focus on identifying and planning for triggers, while implementing healthy

35

behaviors to reduce the risk of engaging in impulsive behaviors. The good news is that you can directly act upon these triggers, as well as work on modifying your beliefs.

Exposure to Situational Triggers You will discuss with your therapist ways you can avoid situations in which you feel you have no or little control over your impulsive behaviors, or reduce the intensity of a trigger if you find yourself in a situation that may trigger the behavior. Individuals going through this program typically have little control over their impulse control problems during the early stages of treatment, and must stay away from unnecessary tests of their ability to abstain. Gamblers must absolutely stay away from casinos or gambling opportunities, and are encouraged to request that their favorite gambling institutions ban them. Clients with uncontrollable spending need to stay out of stores and away from the Internet. Clients with KM must also stay out of stores. In cases in which you have been caught stealing in specific stores, you are likely to be banned already and would be watched by security. If you are impulsively starting fires, you may need to eliminate all exposure to fires. For example, you should avoid monitoring news or police scanners for occurrence of fires, and refrain from viewing material (e.g., movies, media, chat rooms) related to fires. Self-exclusion is, without a doubt, the first strategy to use in order to avoid exposure to ICD triggers. Here are some additional strategies that will help you to deal with exposure to ICD triggers. You and your therapist will work to identify unnecessary and avoidable ICD triggers. The time of day can often be a trigger, in terms of when you are most likely to engage in the impulsive behavior.

Strategies for Managing ICD Triggers Pathological Gamblers (PG)

Gamblers frequently report that they gamble after work. Because they generally take the same route home, they have difficulty

36

preventing themselves from stopping at their usual place of gambling. If you have a gambling problem, consider doing the following: ■ Change driving routes to avoid driving past the gambling

establishment, or signs advertising it, on your way home. ■ Establish a carpool with coworkers, family, or friends. Doing

this will reduce the temptation and ability to gamble. ■ Avoid going to places where you can gamble. If, despite

everything, you insist on going to bars, it is preferable that you only go to bars where there are no pull tabs or other gambling opportunities. ■ Cancel membership in any casino “rewards” programs, and

make sure they take you off of their mailing lists. Gamblers often report being triggered by “free” rooms or slot machine credits from casino mailings. It is important to eliminate this potential trigger. ■ As with compulsive buyers, pathological gamblers will be asked

to consider leaving all credit and debit cards with a trusted friend or family member, or in a secure place (e.g., lockbox or safe) when leaving home each day. Compulsive Buyers (CB) ■ Compulsive buyers may shop online late at night when family

members are asleep, or early in the morning once everyone has left for the day. Your spouse or loved one could assist in adjusting security settings on the computer to prevent this habit. In addition: ■ You should also resist the temptation to “window shop,”

especially if this behavior leads you to making unnecessary purchases. ■ Consider only shopping for essentials by making and not

deviating from shopping lists. ■ Because most compulsive shoppers prefer to shop alone,

consider only shopping if you have someone with you.

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■ In addition to leaving credit and debit cards at home or with a

friend, it is advisable that you carry only a small amount of cash with you each day. This way, if you find yourself in a store, you will not have the ability to make a purchase. However, you can always apply for more credit cards, so you may wish to consider leaving your identification at home. Of course, we are not suggesting that you drive without a license, so this strategy may not work for those individuals who drive on a regular basis. ■ If you primarily shop online, you may need to be banned

altogether from computers at home, as well as at work, if possible. All record of credit cards with online merchants will need to be deleted. Another drastic measure would be requiring a friend or family member to cosign or authorize payment. Obviously, there are ways of sidestepping these suggestions, but we strongly encourage you to do everything possible to make it less convenient for you to engage in impulsive behaviors. Impulsive Stealers (KM)

If you engage in stealing behaviors, it is advised that you steer clear of the stores from which you typically steal. ■ If you tend to steal at the same time of the day (e.g., Friday

night after work), your therapist will work with you to come up with other activities you can do instead (e.g., exercising after work or having dinner with colleagues). ■ Because going to stores with someone may reduce the chance

of your stealing, make sure you only go to stores if someone is with you. If you have problems with stealing, you can ask a friend or family member to accompany you whenever you enter a situation that has triggered your behaviors in the past. ■ It can also be helpful to review the consequences of your

stealing habits (e.g., getting caught, going to jail, etc.) before entering a situation that may trigger your impulse to steal. Compulsive Fire Starters (PY)

Along with clients with other ICDs, compulsive fire starters may engage in their impulsive behavior whenever they have down time.

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If you suffer from PY, you have already worked with your therapist in the last session to begin identifying your triggers. In this session, you will continue your work on triggers by developing a plan for engaging in alternative leisure activities during down time to keep you from starting fires. ■ Ask yourself when and where you are most likely to set fires. You

started this exercise in the previous session but in this session, you and your therapist will explore your triggers in more detail. ■ Try to avoid being left alone when conditions are ideal for fire

setting. If possible, restrict your access to anything related to fire setting for at least several weeks. This may entail removing all fire-starting instruments, including lighters, matches, gasoline, etc., from your home. Enlist the help of a trusted friend or family member to rid your immediate surroundings of items that may facilitate fire setting. Significant Others or Friends who May Serve as ICD Triggers

If you typically engage in impulsive behaviors with others (e.g., you have a gambling or shopping “buddy”), your therapist will work with you to develop a plan for resisting invitations from him or her to engage in impulsive behaviors. Your therapist may use role-play activities to help you strengthen your assertiveness skills. In these exercises, you will practice refusing offers to engage in problem behaviors. These role-play activities will help you assert yourself when real-life pressures from others present themselves. Another strategy for combating pressure from others to engage in impulsive behaviors is to disclose your ICD to friends and family, if they are not already aware of it. It is important to tell those close to you that you are suffering from an ICD and seeking treatment to manage it. If you find that some people are not supportive, or help to trigger your behavior, you will have to rethink your relationship with them. It is not healthy to surround yourself with individuals who may wish to “sabotage” your efforts to make healthy changes. Relationship Difficulties

People with ICDs often isolate themselves because of their impulsive behaviors and, little by little, they abandon friends and family.

39

Friends and family may also make efforts to distance themselves from the person with the ICD, due to diminished trust, inability of the person to follow through, constant and persistent problems with money, and/or legal problems. Impulsive behaviors can place great strain on relationships. For example, gamblers and compulsive shoppers that make frequent requests for money to cover debts, and neglect to pay back friends and loved ones, may find themselves alienated from the very people they need to be supportive. If you find that your ICD is negatively affecting your relationship with friends and loved ones, your therapist may recommend an additional family session (see Chapter 8). It is important to have a solid support system as you participate in this program. Your therapist will help you determine whether you need guidance in re-establishing relationships. Other Behaviors, Mood States, or Problems That Contribute to ICD Behaviors

ICDs are essentially behavioral addictions. This description is useful, as it suggests that people with these behaviors may also have other addictive behaviors, such as drinking or overeating. In the case of alcohol, drinking often contributes to poor decision making, with an inability to assess long-term consequences. In the case of ICD behaviors, drinking alcohol may increase the likelihood of engaging in the ICD behavior, while decreasing the ability to consider the consequences accurately. If drinking is a problem in its own right, it must be addressed either before or simultaneously with the ICD. When you are stressed or depressed, you are less likely to attempt to inhibit your ICD behavior. “To heck with it all” becomes a common thought when work, family, or financial stress is extreme, or when we are feeling depressed. These feelings should be discussed with your therapist. It is possible that cognitive-behavioral strategies for mood or anxiety problems may need to be used in addition to the sessions for the ICD behavior. If other problems are contributing to your ICD behaviors, then problem-solving strategies may be useful. The first step in problemsolving is to clearly define the problem, in an attempt to avoid

40

impulsive reactions. The act of clearly defining a problem often gives better answers in the end. Writing questions and answers to better clarify the problem (e.g., What exactly is bothering me? If I am concerned about finances, what exactly about my finances bothers me?) is often useful in slowing down your thoughts and behaviors and, instead, spending time on problem-solving. The act of writing problems down often allows us to see them as less intense or overwhelming than they may seem when they are just swirling around in our heads. Writing also allows you to list as many possible solutions to the problem as you can, to provide an ample number of options. Having options often makes us feel less trapped, thereby reducing the need to escape into impulsive behavior.

Controlling Your Impulsive Behaviors In the next section, you will use the Controlling Impulsive Behaviors Questionnaire to describe the situations you consider the most risky for you, and then estimate the extent to which you believe you are able to resist the urge to engage in your impulsive behavior if you find yourself in one of those situations. This exercise will allow your therapist to determine which situations need to be addressed in order to create a behavioral intervention plan tailored to your needs. If you suffer from PY, you may already have completed this form with the help of your therapist during the last session. If this is the case, you may move on to completing the Controlling ICD Triggers form on page 44.

41

Controlling Impulsive Behaviors Questionnaire Please describe your high-risk situations for engaging in impulsive behaviors. (For example: “when I am bored and have nothing to do” or “when I just had an argument with my boss”). Then, indicate on a scale of 0 to 5, your level of confidence to control your behaviors if you faced these situations at the present time. Situation 1 _________________________________________________________ _________________________________________________________ _________________________________________________________

If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior?

1

2

No Control

3

4

Moderate Control

5 Total Control

Situation 2 _________________________________________________________ _________________________________________________________ _________________________________________________________

If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior?

1 No Control

42

2

3 Moderate Control

4

5 Total Control

Situation 3 _________________________________________________________ _________________________________________________________ _________________________________________________________

If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior? 1

2

No Control

3

4

Moderate Control

5 Total Control

Situation 4 _________________________________________________________ _________________________________________________________ _________________________________________________________

If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior? 1

2

No Control

3

4

Moderate Control

5 Total Control

Situation 5 _________________________________________________________ _________________________________________________________ _________________________________________________________

If you had to face this situation at the present time, to what extent would you have confidence in controlling your impulsive behavior? 1 No Control

2

3 Moderate Control

4

5 Total Control

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Controlling ICD Triggers In the spaces below, describe the ICD triggers that affect you the most, and indicate how you might deal with them. ICD Triggers

Healthy Behaviors

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

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Developing Leisure Skills For many people, the impulsive behavior they are engaging in takes the place of activities that they used to enjoy doing. Once you stop engaging in your impulsive behaviors, however, you will find that suddenly you have a lot of free time on your hands. What will you do then? Start by thinking about the activities and interests you pursued before your ICD monopolized most of your time. What were your passions and hobbies? Did you enjoy playing golf or basketball? Did you enjoy knitting, going on walks, or doing volunteer work? As you ask yourself this question, you may become aware of numerous activities that you have neglected or completely abandoned as the impulsive behavior became increasingly important in your life. If you never developed interests in other leisure time activities, this will provide an opportunity for you to begin exploring all the possibilities. Use the Life Categories form on page 46 to list activities (new or otherwise) that you would like to engage in now that you are getting your ICD under control. Be sure to list activities you can do on your own, as well as those that require the presence of other people. List potential activities according to the categories listed on the form, and rank order them according to degree of difficulty. It is important to be specific in your goal setting so there is some accountability. Be specific in terms of a timeline for attaining the goal (e.g., goal attained in 1 month), as well as how much time will be spent on the activity (e.g., 1 hour per day, Mon–Fri). Also, make sure the activity is clearly defined (e.g., “call my brother once per week and discuss my progress in therapy”).

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Life Categories *Difficulty Rating of Activities 1(least difficult) to 10(most difficult)* Category

Activities

Rank*

1. Relationships (Family, Social, Intimate)

1.____________________________________

_____

2.____________________________________

_____

2. Employment/Career/ Education

1.____________________________________

_____

2.____________________________________

_____

1.____________________________________

_____

2.____________________________________

_____

1.____________________________________

_____

2.____________________________________

_____

1.____________________________________

_____

2.____________________________________

_____

1.____________________________________

_____

2.____________________________________

_____

1.____________________________________

_____

2.____________________________________

_____

1.____________________________________

_____

2.____________________________________

_____

3. Hobbies/Recreation

4. Volunteer

5. Physical Health

6. Spirituality

7. Psychological/Emotional

8. Domestic

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Homework

✎ Continue daily recording of your behaviors using the Daily ICD Behavior Diary in Chapter 2. Additional copies are provided in the Appendix, or you may make photocopies.

✎ Begin combating your ICD triggers by implementing the healthy behaviors you listed on the Controlling ICD Triggers form.

✎ Complete the Life Categories form (if not done in-session) and begin engaging in leisure activities. If you suffer from PG or CB:

✎ Continue monitoring weekly spending using the Financial Spending Form in Chapter 3 of the workbook.

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Chapter 5

Session 4: Imaginal Exposure

Goals ■ To learn about exposure therapy and how it is used to treat

impulsive behaviors ■ To work together with your therapist to develop an imaginal

exposure script that includes all the relevant internal and external triggers related to your impulsive behavior ■ To participate in your first imaginal exposure in session

Introduction to Exposure Therapy A unique element of the CBT-ICD program is the use of cue exposure therapy (CE). The goal of CE, which has proven to be effective (based on scientific studies) with fear or anxiety related problems, is to decrease fear through repeated exposure to the feared stimuli. For example, if someone is afraid of dogs, a CE exercise for that person may involve being exposed to a dog in a controlled environment (e.g., pet store, neighbor’s house) so the person can learn that it is possible to be safe in the presence of a dog (e.g., not all dogs bite). There is preliminary evidence that CE therapy can help those with ICDs learn to control urges to engage in impulsive behaviors. As opposed to traditional CE therapy, where the person is exposed to a real-life situation, CE for impulse control disorders uses what it called imaginal exposure. Imaginal exposure is a technique that involves using your imagination to place yourself in a typical trigger situation in order to activate the urge to engage in impulsive behavior, so you can practice resisting it. In this program, we use CE therapy along with negative mood induction (NMI). NMI involves focusing on the negative consequences of the problem behavior while the urge to engage in the impulsive behavior is active. For example, if you have problems with overspending, your 49

therapist may ask you to imagine yourself in your favorite store when there is a sale going on. Your therapist may begin by describing how you typically plan for a shopping outing, which will likely activate the urge before you imagine entering the store. Your therapist will then describe the store to you in detail, activating your urge to buy something. Next, your therapist will introduce the negative consequences of making a purchase (e.g., you will not be able to limit your spending, you will have to hide your purchases from your spouse or significant other, you will feel guilty for buying items you don’t need, etc.). What to Expect The purpose of imaginal exposure is for you to imagine yourself in a trigger situation and feel as if it were really happening to you. It is important that you try your hardest to imagine yourself in the situation. You must be aware of the thoughts, feelings, sights, sounds, and sensations you experience when you are in that situation. To do this, you have to be good at vivid imagination, and this takes practice. Your therapist will help ease you into the exercise with a few easy scenes to imagine and visualize. During this exercise, you may experience an urge to engage in your impulsive behavior. You are expected to have an urge, which is necessary in order to benefit from this exercise. Your therapist will help you create an exposure script specific to your ICD using the Imaginal Exposure Script form on page 51. Your therapist will read the script of your impulsive behavior experience aloud, while you listen with your eyes closed. While you are experiencing an urge, your therapist will introduce the negative consequences of your impulsive behavior, as reported by you, followed by a description of healthy coping strategies. You will be asked to rate the intensity of your urges during the exercise using the Imaginal Exposure Rating Form on page 54. During the in-session imaginal exposure, your therapist will make a recording for you to use in your homework assignments between sessions. For homework, you will listen to this recording and use the Imaginal Exposure Rating Form to rate your responses to the imagined scene. Your urge to engage in impulsive behavior will likely decrease after listening to the exposure multiple times, as you become more familiar with the content and less reactive. The goal is for your urge to decrease by at least 50%.

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Imaginal Exposure Script 1. Describe a situation where you typically would engage in your impulsive behavior. Describe exactly what you imagine happening, step by step, and your urge to act impulsively. Describe as many details about the experience as possible, including all your senses—what you imagined or actually did see, hear, smell, etc. If relevant, would you be using alcohol, drugs, smoking, etc.? What physical symptoms are you aware of (e.g., rapid heart rate, sweating, restlessness) and what negative consequences do you anticipate from your impulsive behavior? Finally, imagine coping with the urge and resisting it. ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

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2. Symptoms: Record all symptoms that accompany this feared situation. Difficulty breathing

Nausea/ abdominal distress

Muscle tension

Racing/pounding heart

Chest pain/ discomfort

Dry throat

Choking sensation

Hot/cold flashes

Restless/ pacing

Numbness/tingling

Sweating

Shakiness/ trembling

Faint/dizziness

Other

Potential Challenges During Exposures As previously mentioned, imaginal exposure is a difficult skill to master. It requires intense concentration and a vivid imagination. In order for the exposure to be effective, you must be able to put yourself in the situation. You must feel as though the events are actually happening to you at that very moment. What if I don’t react to the imaginal exposure?

Some individuals may have difficulty focusing on the imagery during the exposure, or may not have included all relevant information. If you are not reacting to the imagery, there may be other reasons. For example, you may not be following the instruction of focusing on the imagery as if it is happening “in the moment.” You may be distracted by thinking about something else during the exercise. You may have difficulty generating imagery. You may also be resistant to completely focusing on the imagery, or overly pessimistic about this treatment approach. It is okay to have a healthy skepticism about this approach. By taking on this viewpoint, you can wait and see what happens and go into the exercise with an open mind. In our research, however, we have observed that the majority of clients

52

report an increase in urges during exposure, very similar to what is experienced in actual impulsive behavior situations. What if the exposure triggers my urge and I end up slipping and engaging in impulsive behavior?

As mentioned previously, the goal of the exercise is to activate your urge and the accompanying thoughts, feelings, and physical symptoms associated with your impulsive behavior. The negative consequences portion of the exposure is designed to be a potent reminder of what actually happens when you engage in your impulsive behavior, and will likely have the effect of decreasing your urge not long after it is activated. We have also developed other strategies to make it less convenient and more challenging to engage in your impulsive behaviors, even if you experience an urge. Through the repeated practice of listening to your imaginal exposure tape, you will be expected to gain more insight and be less reactive to impulsive behavior triggers.

Homework

✎ Continue daily recording of your behaviors using the Daily ICD Behavior Diary in Chapter 2. Additional copies are provided in the Appendix, or you may make photocopies.

✎ Begin combating your ICD triggers by implementing the healthy behaviors you listed on the Controlling ICD Triggers form.

✎ Practice imaginal exposure for a total of 4 repetitions per day, twice in the morning and twice in the evening, and record urge ratings on the Imaginal Exposure Rating Form at the end of the chapter. Continue the imaginal exposure exercise daily until there is a 50% or greater reduction in peak urge rating or until the next therapy session, whichever happens first. If you suffer from PG or CB:

✎ Continue monitoring weekly spending using the Financial Spending Form in Chapter 3 of the workbook.

53

Imaginal Exposure Rating Form

0

10

None

20 Mild

Date (Exercise)

Morning Practice 1 (am) Morning Practice 2 (am) Evening Practice 1 (pm) Evening Practice 2 (pm)

54

30

40

50

60

70

Moderate

Pre-tape Urge

80 Severe

Peak Level of Urge

90

100 Extreme

Post-tape Urge

Chapter 6

Session 5: Cognitive Therapy for Impulsive Beliefs

Goals ■ To identify erroneous beliefs related to your ICD ■ To learn how to evaluate objective evidence that supports and

contradicts impulsive beliefs ■ To learn how to develop healthy, alternative beliefs related to

your impulsive behavior ■ To develop a financial budget, if you have debt-related

problems due to gambling or compulsive buying

Assessment of Beliefs In this session, you will be asked to identify your specific thought process before, during, and after an episode of impulsive behavior. It has been our experience that an individual’s thought process changes markedly in the life cycle of an episode of impulsive behavior. Typically, the person starts out feeling a positive emotion at the thought of engaging in the impulsive behavior (e.g., optimism, hope, or excitement). During the event, the person usually focuses on the positive effects. Once the event is over, however, the person typically feels regret, shame, embarrassment, or remorse. You were introduced to this cycle in the previous session through participation in imaginal exposure exercises. You have also learned behavioral interventions to limit your exposure to cues that can trigger impulsive behaviors. The next step in the process is helping you to understand that behind every action, there is a thought. In this session, you will learn how to evaluate your beliefs, and how those beliefs influence your actions.

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If gambling is your primary problem, you will work with your therapist in identifying your gambling routine. For example, your therapist may ask how long you typically play your preferred game or slot machine, what your strategy or thinking is if your machine is unavailable, and when and if you change machines, as well as why. Your therapist will also review laws of chance or randomness with you, in order to develop a more objective understanding of gambling odds. More information about the laws of chance can be found at the end of the chapter. As a person who suffers from an ICD, you may find that you “rationalize” your behavior and make efforts to quickly forget or ignore the negative consequences of your impulsive behavior. One way to increase your awareness of this tendency to forget or ignore is to identify and record impulsive behavior episodes using the ABC Log on page 64 (more details are provided in the next section). The very act of recording is expected to increase awareness and help you understand your thinking errors. The ultimate goal of using cognitive therapy for an ICD is to correct thinking errors in the moment the thoughts are operating and influencing your behavior —when the urge to engage in the impulsive behavior is high.

The ABCs of Impulsive Behavior Let’s begin by first defining the ABCs of impulsive behavior: A = Activating event (ICD trigger) B = impulsive Beliefs C = Consequence (urge and behavior) D = Dispute impulsive beliefs E = Effect change Activating Event

The A, or activating event, is what triggered your urge to engage in the impulsive behavior. Refer back to Chapter 4 (Session 3) where you first worked with your therapist to identify your triggers.

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List the activating event or trigger in the appropriate column of the ABC Log on page 64. Belief

The B of impulsive behavior is belief, or how you think your impulsive behavior will affect your mood. Will it make you happy or excited? The belief is also what you expect to come from the episode. Will you win money? Will you get away with stealing? It may be helpful for you to look at your beliefs in terms of predictions or expectations. Your therapist will ask you to rate the degree of certainty that an impulsive belief is valid on a scale of 0–100 (on the ABC Log), with 0 signifying no certainty at all, and 100 signifying absolute certainty that the impulsive belief or prediction will happen as predicted. Once you have identified and recorded the impulsive belief in observable and measurable terms, you can begin to use evidence to dispute it. Consequence

The C of impulsive behavior stands for consequences. Your therapist will ask you to rate the intensity of your urge to engage in the impulsive behavior (using a scale of 0–100), as well as what you did (“did I engage in the impulsive behavior?”), on the ABC Log. Dispute

Disputing is a strategy to help you think more objectively about your impulsive behavior. Use the Disputing Impulsive Beliefs form on page 63 to identify evidence for and against your impulsive beliefs. This exercise will ultimately bring to light the short-term vs. long-term effects of your ICD. When disputing your impulsive beliefs, it may be helpful to consider the following: ■ For gamblers – Evaluate possible misconceptions of the laws of

chance or randomness (see handout at end of chapter). ■ Review illusions of control – For example, how much time did

you plan to spend in the impulsive behavior? How much time did you actually spend engaged in the impulsive behavior?

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■ Mood changes – For how long do you experience a relief in

tension, if you are using your impulsive behaviors to change your mood? Review with your therapist your mood states before, during, and after engaging in an impulsive behavior. Be objective. ■ Consider past experiences – Refer back to times you

experienced an urge and resisted it. Remember that urges will come and go. You do not have to act on them. Once you have identified evidence for and against your impulsive beliefs on the Disputing Impulsive Beliefs form, transfer the evidence back to the appropriate column of the ABC Log, along with the alternative beliefs you came up with. Be sure to rate your certainty in the dispute that was developed using the 0-100 rating. Effect Change

The effect change column of the ABC Log is an opportunity to evaluate the effectiveness, or E of impulsive beliefs, of the disputing evidence, and alternative beliefs. After doing so, you will rerate your degree of certainty in your original impulsive belief, as well as your urge to engage in the related impulsive behavior (B and C columns of the ABC Log). Figures 6.1–6.4 show completed ABC Logs for clients with different ICDs.

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Date/ Time

Monday 8 am

A Activating Event (ICD Trigger)

B Belief (Rate certainty 0–100)

C Consequence (Rate intensity 0–100)

I received coupons in the mail for my favorite store and then started to plan when I could get to the store, maybe right after work, I could even get out early to shop a little longer and find a good deal.

I will be able to stop when I plan to, spend the amount I want, and walk away with purchasing what I planned to.

I will not spend uncontrollably.

Rating = 80 Revised rating = 35

D Dispute (Rate certainty 0–100)

When I examine the evidence, I know that I quickly forget about all the limits I have set for myself, I have Rating = 80 rarely if ever stopped shopping when I planned to, always spend more than I Revised rating = 30 plan to, and buy way more than I intended. The next time I think about shopping, I need to remind myself that I have limited control over my spending, and it would be irresponsible to even go window shopping. I always feel guilty after excessive shopping, especially when my significant other sees the bill, causing more arguments about our increasing debt. Rating = 90

Figure 6.1

Sample ABC Log for CB

E Effect Change (Rerate certainty in belief and intensity of urge 0–100 in Columns B and C)

After considering the dispute, I would rerate how certain I was in the initial belief, as well as the intensity of my urge to shop.

Date/ Time

A Activating Event (ICD Trigger)

Saturday Bored, thinking 9 pm about finding a store where I could grab something, nothing planned for tonight, everyone is busy, notice excitement when I think about the thrill of stealing something.

B Belief (Rate certainty 0–100)

C Consequence (Rate intensity 0–100)

I know stealing will be exciting, will bring me relief from boredom, and I will get away with it.

I will not get caught.

Rating = 80

Rating = 80

Revised rating = 20

Revised rating = 30

D Dispute (Rate certainty 0–100)

I do experience excitement and a rush of adrenaline before and during a stealing episode. I have had several close calls where store attendants have come close to catching me in the act. That increases the excitement in the moment, but as soon as I get home, I just add this item to the stack of other stolen merchandise. Every time I look at the stuff I have stolen, I feel a mix of guilt and shame. Each time I steal, I seem to need to take more risks to get the same level of excitement, which could result in me getting caught, jeopardizing my livelihood and relationships. The excitement quickly fades each time and then I am back to feeling bored, maybe even depressed. Each theft brings less and less satisfaction and I am getting closer to being caught. When I am not stealing something, I am constantly thinking about it, and this is interfering with other important parts of my life. Stealing is holding me back from commitment to work and relationships. The risk/excitement is not worth the cost. Rating = 100

Figure 6.2

Sample ABC Log for KM

E Effect Change (Rerate certainty in belief and intensity of urge 0–100 in Columns B and C)

After considering the dispute, I would rerate how certain I was in the initial belief, as well as the intensity of my urge to steal.

Date/ Time

A Activating Event (ICD Trigger)

Friday End of the week, 5:30 pm nothing planned, stressful at work, have $300 available and I could drive by the casino on my way home from work. Spouse has an afterwork gathering, so I will have time to go and get home before he is done.

B Belief (Rate certainty 0–100)

C Consequence (Rate intensity 0–100)

I am sure I will win

I will walk away with Now that I consider all the winnings evidence, I don’t find it so believable that I will be able to win, and walk away with Rating = 75 the winnings. I also recognize the laws of Revised rating = 30 chance are working against me and usually favor the house. I will get home late and my spouse will be upset with me again, he has threatened to leave me if I don’t quit gambling and giving all of our savings away to the casino.

Rating = 80 Revised rating = 40

D Dispute (Rate certainty 0–100)

Rating = 85 Figure 6.3

Sample ABC Log for PG

E Effect Change (Rerate certainty in belief and intensity of urge 0–100 in Columns B and C)

After considering the dispute, I would rerate how certain I was in the initial belief, as well as the intensity of my urge to gamble.

Date/ Time

A Activating Event (ICD Trigger)

Sunday I have some 11:30 pm downtime, late at night, no plans with anyone, start to think about how fire would look in the nighttime, start to notice excitement

B Belief (Rate certainty 0– 100)

C Consequence (Rate intensity 0– 100)

Fire-setting will lead to excitement and will be fun and I will not cause any damage/harm.

I will have fun and no one will get hurt and nothing will get damaged.

Rating = 90 Revised rating = 25

Rating = 90 Revised rating = 40

D Dispute (Rate certainty 0–100)

I do experience excitement and a rush of adrenaline when I think about setting a fire, when planning it, and when engaged in the act of fire-setting. I never consider the negative consequences of fire setting until after the fact. The elated mood quickly fades each time I do it. I can increase excitement again by imagining fires set in the past. I notice that I spend a lot of time thinking about fire, use up most of my free time thinking about fires, researching ways to set fires, and listening to police scanners. I have had several fires get out of control, burned garage down, set field of grass on fire, and I have been caught in the past. I have burned my hands, lost hair on my body and had to make excuses to medical personnel, friends, and coworkers. I used to have other hobbies that were healthy and that could be exciting, the benefits lasted longer (e.g., mountain biking, rock climbing), were not illegal, and I did not cause anyone harm. Although fire-setting is exciting, the thrill does not last and I risk more harm to self and others each time I do it. I think about it and spend so much time on this habit, maybe it is not as fun and exciting as I thought. Rating = 80

Figure 6.4

Sample ABC Log for PY

E Effect Change (Rerate certainty in belief and intensity of urge 0–100 in Columns B and C)

After considering the dispute, I would rerate how certain I was in the initial belief, as well as the intensity of my urge to start a fire.

Disputing Impulsive Beliefs What is my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence for my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence against my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the alternative viewpoint? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the rational response? _________________________________________________________ _________________________________________________________ _________________________________________________________

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ABC Log

Date/ Time

A Activating Event (ICD Trigger)

B Belief (Rate certainty 0–100)

C Consequence (Rate intensity 0–100)

D Dispute (Rate certainty 0–100)

E Effect Change (Rerate certainty in belief and intensity of urge 0–100 [Columns B and C])

Additional Suggestions for Cognitive Therapy The Disputing Impulsive Beliefs Form and the ABC Log must be used whenever you experience an urge to engage in your impulsive behavior. If you do not experience an urge, use the forms to evaluate past episodes of the behavior. In order for this strategy to be effective, you must complete the forms in real time, as close to the actual event as possible. Our moods and beliefs often change quickly as time passes, and it will be hard for you to accurately remember and capture how you were feeling, days or even several hours after the fact. Consequently, it is important that you photocopy the forms from the book and keep copies with you at all times. If you do not use these forms on a regular basis, you will likely not see much of a change in your thoughts and behaviors. Take the example of someone who is prescribed an antibiotic medication and instructed to take the pills twice a day for ten days. If the person does not take the medication as prescribed, the infection will not go away. The same holds true for cognitive therapy. If you forget to practice the techniques, or if you practice them only periodically, you won’t see a change in your symptoms. You are being asked to develop a new habit, and when we are learning something new, it usually takes consistent practice. Make an effort to practice the cognitive strategy on a regular basis, as assigned, observe if there is any change in how you cope with impulsive beliefs, and note the effect on your symptoms.

Creating a Financial Budget—Pathological Gambling and Compulsive Buying (PG and CB) You and your therapist will begin to develop a financial budget based on your self -monitoring of spending over the past several weeks. The budget will include all current income and expenses, and will specifically address short-term and long-term plans to begin paying down gambling or shopping related debt. Refer to Chapter 3 (page 22) for a copy of the Financial Budget Form and guidelines.

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Homework

✎ Continue daily recording of your behaviors using the Daily ICD Behavior Diary introduced in Chapter 2. Additional copies are provided in the Appendix, or you may make photocopies.

✎ Continue combating your ICD triggers by implementing the healthy behaviors you listed on the Controlling ICD Triggers form in Chapter 4.

✎ If your peak urge has not decreased by 50% or greater, continue practicing imaginal exposure twice in the morning and twice in the evening for a total of 4 times per day, and record urge ratings on the Imaginal Exposure Rating Form introduced in Chapter 5. If peak urge rating has decreased by 50% or greater, then use the imaginal exposure recording as needed.

✎ Complete the ABC Log and Disputing Impulsive Beliefs Form whenever you experience an urge to engage in impulsive behaviors. Please photocopy the forms from the book, and carry copies with you at all times. It is important to complete these forms in “real time,” at the very moment you experience the urge. If this is not possible, quickly note your urge intensity and complete the forms as soon after the fact as you can. If you suffer from PG or CB:

✎ Begin to use and monitor your financial budget that was developed with your therapist in this session.

For Pathological Gamblers—Basic Information on Games of Chance ■ The more familiar a person becomes with a game, the more he

or she has a tendency to increase the size of the bet in succeeding games. ■ The more a game requires active participation (e.g., Roulette,

Blackjack, Lotto), the more one tends to make large bets, and the more one develops all sorts of erroneous beliefs about one’s ability to play the game. By “erroneous beliefs” we mean misconceptions that run counter to the principles of games of chance.

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■ When gamblers are asked to verbalize what they think while

playing, 70% of what they say constitutes irrational beliefs that violate the principles of probability. While gamblers develop erroneous beliefs in a variety of ways, it is usually a lack of knowledge about the laws of probability that underlie such beliefs. Here are the basic principles that one should understand about games of chance. ■ What exactly is chance, or randomness? By definition, chance is

something that one cannot predict. Chance is that which is unforeseeable, and over which one has no control. One sometimes says that an event happened by chance and without my intention. ■ Slot machines, video poker, Roulette, craps, and Lotto all work

on the same principle. However one plays, one has no control over the outcome. The fact that you can choose or decide the amount of the bet, the numbers you bet on, or the time and place of playing, gives the impression that you can influence the outcome. All these variables create the illusion of control over the game. They give the impression that there are a number of ways of increasing one’s chances of winning. Only chance determines the outcome. With these machines you are powerless, and can in no way increase your chances of winning. ■ If you toss a coin, you have a 1 in 2 chance of getting tails.

Even if tails comes up three times in a row, there is a still a 50% chance of getting tails on the next toss. In fact, the probability that tails will come up is always 50%—no matter what has come up in the past. It is thus erroneous to believe that tails will come up because the last three tosses were heads. ■ Remember that each bet has two dimensions: (1) the proba-

bilities of winning and losing; and (2) the size of the pay-off. You will notice that bets with the highest risk have the largest pay-offs, while bets with less risk have smaller pay-offs. Therefore, if you have an advantage in one dimension, you will automatically have a disadvantage in the other.

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■ It is impossible for you to maximize your chances of winning.

The only thing you can do is minimize your losses (by betting less). Casinos are businesses. The games are always set up for the advantage of the house. Thus, in the long run, and distributed over a large number of games, the machines are guaranteed to return only a small percentage of whatever is fed into them.

CHANCE IS ALWAYS AGAINST YOU (Adapted from Ladouceur, R., & Lachance, S. (2007). Overcoming pathological gambling. Oxford: Oxford University Press.)

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Chapter 7

Session 6: Relapse Prevention

Goals ■ To review all the skills you have learned thus far, and prepare to

use them independently ■ To identify ongoing supports for maintaining the progress you

have made ■ To determine if there is a need for referrals for additional

treatment (e.g., marriage and family therapy, individual therapy for other mental health challenges) ■ To identify and discuss relapse prevention strategies

Planning for the Future You have made significant changes in the past several weeks, and are likely still in the process of adjusting to these changes. You have, we hope, practiced and noticed benefits from the skills and strategies learned in the CBT-ICD program. You must keep in mind, as you are ending formal sessions with your therapist, that therapy does not really end. You must keep practicing the skills learned in this program until you have developed new, healthy habits. If you have been successful in managing your impulsive behavior over the course of your therapy, you have demonstrated that you have the ability to retain control. Keep in mind that although you met with your therapist once per week, you benefited the most from practicing the CBT-ICD program strategies on your own, with the support of family and friends, between sessions. You have already demonstrated some independence in managing your impulsive behavior, and you can continue to do so. Some individuals may need more support than others, and you must be able to recognize your need for help and allow others to assist you. You have not only made

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changes in your impulsive behavior, but we hope that you look at this therapy program as an opportunity for a change in your “lifestyle.” You learned in this program how the impulsive behavior has been interfering in many areas of your life, possibly preventing you from pursuing important life goals. Use the momentum you have gained from learning to manage your impulsive behavior, and continue to work on and develop new goals for yourself. You can continue to use the Life Categories form in Chapter 4 as a format for goal identification and achievement.

Reevaluation Your therapist will review your progress to date by re-administering some of the diagnostic interviews and questionnaires that you completed at the beginning of treatment. This assessment will help you and your therapist determine if you still meet the diagnostic criteria for the ICD. You may ask, why do I need to know this or why would I want to know? A reevaluation of your symptoms can help you to see further evidence of your progress. The assessment findings will be combined with your report, and family reports of changes noticed during therapy. The reevaluation will also be a reminder of what symptoms, beliefs, and behaviors are a signal to you and your loved ones that you are slipping into old habits. We will talk about “slips” and how to cope with them later in this session.

Future Triggers You must be prepared for future triggers or stressors that may elicit an urge and subsequently put you at risk for engaging in impulsive behaviors. It can be helpful to list future ICD triggers, and possible healthy behaviors you can practice to prevent impulsive behaviors.

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Planning for Future Triggers List major life events that may occur in the near future. _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

List strategies for coping with these or similar situations. _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

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Critical Skills and Strategies to Practice We cannot stress enough the importance of ongoing practice of the skills learned in therapy. We encourage you to continue the following exercises. ■ Daily self-monitoring of urges and any impulsive behaviors.

Ongoing self-monitoring of urges and behaviors will serve to maintain self-awareness of activating events (triggers) and your reactions. ■ ICD trigger management. Maintain plans for dealing with

ICD triggers. Avoid all unnecessary exposures to situational triggers, and attempt to engage in healthy coping activities when experiencing distress, boredom, or struggling with conflict. ■ Financial management. If you suffer from PG or CB, continue

to use a financial budget and adhere to a long-term plan for paying down debt. You may need to continue having significant others or designated support persons manage your finances until you feel confident of doing it on your own. The long-term plan is to phase out the monitoring done by the support person once you have increased control over your impulsive behaviors. You may also consider consulting with a credit counselor or financial advisor for long-term financial planning. ■ Use the Disputing Impulsive Beliefs form and the ABC Log

whenever you experience an urge to engage in impulsive behavior. Continue to use these forms until there is a change in your thinking, such that the objective evidence against acting impulsively becomes more automatic and accessible when an urge is experienced. ■ Leisure skill development. Continue to plan for and

implement regular leisure activities. Be sure to try a variety of activities, such as regular exercise, volunteering, social activities, hobbies (established and new), etc. If you enjoy high-risk activities, explore healthy alternatives such as downhill skiing or rock climbing. You can also build upon

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goals set earlier in treatment. For example, you may be ready to increase the intensity of exercise, from 2 days per week, 30 minutes each time, to 4 days per week for 1 hour per day. The point is to continually challenge yourself and look for opportunities for growth. ■ Imaginal exposure. Practice imaginal exposure as needed, using

the recording provided to you by your therapist. ■ Problem solving. Use the problem-solving method whenever

you experience interpersonal distress, or encounter any problem that may have served as a trigger for your impulsive behavior in the past.

Relapse Prevention If you suddenly find yourself wanting to engage in your impulsive behavior, or if you have already done so, stop for a moment. Look at and listen to what is going on inside you. This desire to act impulsively is telling you that you are in danger. Compare your episode of impulsive behavior to having a flat tire. What should a driver do when he has a flat tire? The first thing he should do is stop quickly, but safely, and pull over to the side of the road. Then, the driver should consult his manual and follow the emergency procedures to solve his “flat tire” problem. If you have the desire to engage in impulsive behavior, or if you have already done so, stop and find a quiet place where you will be less distracted by the temptation. Once you have stopped, consult the emergency measures provided at the end of the chapter. Feel free to photocopy them so you can carry them with you at all times. On these pages you will find the precise instructions you need to follow to avoid a relapse.

Ending Therapy As treatment formally comes to an end, please feel free to ask your therapist questions and voice any concerns you may have about ending therapy. Your therapist will provide referrals for additional treatment as needed, and may recommend ICD support groups.

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You and your therapist will schedule a follow-up visit in approximately one month to ensure progress is maintained. Additional follow-up visits will be scheduled at the discretion of you and your therapist. Your therapist may suggest an additional therapy session for you and your family (see Chapter 8). We highly recommend the family session in order to give family members and significant others the opportunity to ask questions and receive guidance on how to best support you.

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Emergency Procedures 1. Remain calm.

Your first reaction to temptation, whether you have actually engaged in impulsive behavior or not, may be to feel guilty and blame yourself for what has happened. This is a normal reaction and one you should expect. The only danger is that you give in to temptation and lose control. If you are tempted to engage in impulsive behavior, try the following suggestions: ■ Give yourself enough time to allow the temptation to appear

and subside. If you do not give in to the temptation when it first appears, there is a good chance that it will go away after a short time. ■ Don’t condemn yourself; rather, play the role of an observer

and wait for the reaction to pass. It does not help to be self-critical in these situations. ■ Whatever you do, try not to give in to the temptation, as this

might reawaken your old habits. Consider the example of a person sober from alcohol for six months. If the person had alcohol in a dessert, would it justify the person saying, “I messed up! I ate some food with alcohol in it and now everything is ruined. I might as well return to drinking!” If you give in to temptation, it will only become more difficult to control yourself. However, keep in mind that a slip is not the same as a total relapse. Rather than viewing it as a sign of complete failure, see it as an opportunity to learn from your mistake. 2. Remember your resolution.

After a slip, the main problem is maintaining your motivation to regain control. Perhaps you believe that you have failed completely and want to give up. Once again, this is a normal reaction. The following may help you: ■ Think about why you decided to stop the impulsive behavior

in the first place. Think about the long-term benefits of this

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decision. Is it worth throwing all this away just because you have run into a problem? ■ Talk to yourself and try to reconcile the part of yourself that

wants to stop the impulsive behavior with the part that wants to give up everything you have worked so hard to achieve. Remember that you are trying to change your habits for your own good. ■ Look back at all the effort you have invested and the progress

you have made. Try to be a little optimistic instead of focusing on your current difficulties. Do you really think that a single slip wipes out all the progress you have made? Remember your resolution and your long-range goals. Don’t forget, you alone control your actions and you are the master of your fate! 3. Carefully analyze the situation that has led to your slip or the urge to act impulsively.

Resist the impulse of blaming yourself for what has happened, because self-blame only makes it more difficult to take corrective action. Learn from the slip. ■ Ask yourself the following questions: When you felt the urge,

what was the context, what time of day was it, who was present and who was absent, what was your mood and what you were doing? Above all, try to remember what thoughts might have triggered this urge. What thoughts brought about your slip? Were there any warning signs before you slipped? What was the high-risk situation? The answer to each of these questions can give you important clues that may sharpen your vigilance against future urges to engage in impulsive behavior. ■ If such slips occur more frequently, it means that something is

happening and you need to take care of it. Have you tried to do something to prevent a slip from happening? If so, what strategy have you used to counteract your urge? Why was this strategy ineffective? What can you do next time that will be more effective? If, on the other hand, you have done nothing to prevent a slip, why not? Has your motivation weakened? Why?

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■ Go over the event in your mind. Mentally review all the ways

you know that might help avoid giving in to temptation. Try to replace irrational beliefs that feed your desire to engage in impulsive behavior, with more realistic thoughts. Don’t forget that it is you who controls your thoughts and actions.

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Chapter 8

Session 7: Family Session (Optional)

Goals ■ To discuss with your family the specifics of your ICD, the

treatment program you have just completed, and how they can assist in your recovery

Purpose of Family Session There are three distinct goals of the family session: 1. Explaining the therapy to the family members/significant others so they are aware of progress and changes made, and what ongoing support you will need. 2. Allowing you the opportunity to inform family members/ significant others about your impulsive behavior in a safe, neutral setting. 3. Assessing what your family members/significant others may need to help them better cope with this problem.

Education about ICD and the CBT-ICD Program Your therapist will take the opportunity to inform family members and significant others about the disease model of impulsive behaviors, and the goals of CBT in changing the brain. Your therapist may draw parallels to diabetes or alcoholism to illustrate the biological underpinnings of ICDs. Family members may report differing concerns based on the type of ICD. Family members of individuals who suffer from PG and CB may often have great anger toward the person due to the financial problems, lying, and manipulation that is often symptomatic of an

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ICD. Family members may misperceive the discussion about the biology of the ICD as an “excuse” for you. It is important to stress that although there are strong biological factors underlying the ICD, you are in control of whether you seek treatment and keep working on the therapy. This allows both you and your family and significant others to understand that although the illness may be beyond your control, the choice to do the therapy, and do it thoroughly, is within your control. Family members may also want to know about the genetics or heritability of ICD. They may be worried about their children or other family members. Your therapist will inform family and significant others of important facts about the ICD problem. He or she will also stress that although there are genetic links within families, genetics plays only a part of the development of an ICD. Environmental issues, developmental processes, and unknown factors also account for the disorders. Your family will be made aware that other family members may develop this problem, but that it is not your “fault” if children or other biological family members struggle with impulsive behaviors. Family members will be disabused of the notion that your illness is any sort of “infection” within the family. Family members will also be informed that they did not cause your impulsive behavior, and do not have to atone for their guilt by taking care of all the problems resulting from your actions (e.g., paying off your gambling or spending debt, returning stolen items to the store, or dealing with the legal problems that may have resulted from your impulsive behaviors).

Debt Related Concerns for PG and CB If you suffer from PG or CB, your family members may feel that they need to “rescue” you financially, either because they feel guilty or because they worry about you. Your family will be informed that you are working on, or will be working on, payment plans, and that “bailing you out” is not generally a good idea. You need to be honest with your family about your debt, and about any repercussions relating to that debt. Although we do not want your family and friends to “bail you out,” we do want them to support you in managing

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your finances and adhering to the budget you created in Session 2 (see Chapter 3). Your therapist will inform your family about your payment plan, if one was developed. It is important that family members realize that they are a priority. In other words, household debt will be addressed before anything else. This stresses the idea that the welfare of the family comes first.

Suggestions for Family Member Support The family session provides a safe setting for you to discuss your impulse control problems with those close to you. Family members can be important allies in managing the symptoms of the ICD. The family session allows you the opportunity to discuss the extent of your impulsive behavior problems, the reality of the resulting problems, and the plans or other solutions that have been put in place to deal with the problems. Specific ways in which family members may help with the therapy include: 1. Family members may be told how they can help remove or reduce your triggers for impulsive behaviors. For example, if feeling lonely on Friday night is a trigger, your family can plan social activities on Friday night and invite you to join them. 2. Family members may want to continue to work with you on debt. If feeling overwhelmed by debt is a trigger to shop or gamble, then regular meetings with your family to discuss bills may alleviate the catastrophic thinking and avoidance surrounding debt. 3. Family members may be enlisted to help with new healthier behaviors. Ask your family and friends to join you in leisure activities as discussed in Chapter 4. 4. Inform family members about the warning signs of relapse. If they know what to look for, they can help you handle any slips and get you back on track.

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Helping Family Members Cope Family members often find that attending support groups can be helpful. Visiting with other people with similar problems, as well as with other family members, can help you and your family to realize that you are not alone in dealing with impulsive behavior problems. Share with your family the following suggestions for obtaining support: ■ If you have problems with gambling, suggest that family

members attend Gamblers Anonymous and/or Gam-Anon meetings. If your family members have gambling problems of their own, help them find a qualified mental health professional and reputable treatment program. Your therapist can help you with referrals. ■ Encourage family members to research support groups online. ■ You may even suggest family and/or couples therapy,

particularly if your ICD has negatively affected your relationship with your spouse or partner.

Wrap-Up Family members and significant others can be important allies in managing impulsive behaviors. The family session allows you to discuss the extent of your impulsive behavior, and the reality of the negative consequences. It is important that you are honest with your family about all the negative consequences of your impulsive behavior, especially if they are not fully aware of what is going on. You can take the opportunity during this family session to make requests of your family members that will aid you in your recovery. For example, your family and significant others may need to control or monitor your expenses for an extended period of time. Family and significant others may also need some time to learn to trust you again with regard to your impulsive behavior. This session will provide an opportunity for family and significant others to provide

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feedback and ask questions about how to best support you. If interpersonal conflict has served as a trigger for your impulsive behavior, it may be advisable to work on open, assertive communication. Improved communication will take practice, and you may benefit from couples or marriage counseling with your significant other to reverse unhealthy (e.g., blaming, accusing) communication patterns.

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You may wish to use the form provided below to set personal and family goals to assist in your recovery from your ICD. An example goal is provided to help you develop your own.

Goal

Actions

Timeline

Improved communication with spouse

Set aside 30 minutes each day, in the evening, after dinner, to discuss what went well today, challenges, and share feelings.

Next 3 months

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Appendix of Forms

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Daily ICD Behavior Diary

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

/

/

/

/

/

/

/

/

/

/

/

/

/

/

DAILY ICD BEHAVIOR DIARY

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

/

/

/

/

/

/

/

/

/

/

/

/

/

/

DAILY ICD BEHAVIOR DIARY

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

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DAILY ICD BEHAVIOR DIARY

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

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DAILY ICD BEHAVIOR DIARY

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

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DAILY ICD BEHAVIOR DIARY

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

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DAILY ICD BEHAVIOR DIARY

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

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DAILY ICD BEHAVIOR DIARY

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

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DAILY ICD BEHAVIOR DIARY

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

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DAILY ICD BEHAVIOR DIARY

Date:

1. To what extent do I feel my impulsive behavior is under control? 0—10—20—30—40—50—60—70—80—90—100 not at all a little moderately very much completely 2. How strong is my desire to act on the impulsive behavior today? 0—10—20—30—40—50—60—70—80—90—100 nonexistent weak average high very high 3. Did I engage in the impulsive behavior today? If so, what was happening today and/or how was I feeling? 4. How much time (hours & minutes) did I spend on impulsive behavior? 5. For gambling and spending problems – How much money did I spend on gambling (excluding wins) or shopping? 6. For shopping problems – How much money did I spend? What did I buy? What did I do with it? 7. For stealing problems – What was the value of the item(s) stolen and what did I do with the stolen item(s)? 8. How did I feel today and what was happening in my life today (e.g., depressed, bored, frustrated, happy, and anxious, too busy at work, fight with spouse) 9. For stealing and fire-setting problems – Was I caught engaging in an illegal act and if so, what were the legal consequences?

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Financial Spending Form Expense (Including Debt)

Weekly

Monthly

Example 1: Groceries

150 (3/2–3/8)

600

Example 2: Visa

240 (minimum payment)

Monthly Income

+(

)

Total Monthly Expenses:

−(

)

Balance

=(

)

96

Financial Spending Form

Expense (Including Debt)

Weekly

Monthly

Monthly Income

+(

)

Total Monthly Expenses:

−(

)

Balance

=(

)

97

Financial Spending Form

Expense (Including Debt)

Weekly

Monthly

Monthly Income

+(

)

Total Monthly Expenses:

−(

)

Balance

=(

)

98

Disputing Impulsive Beliefs What is my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence for my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence against my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the alternative viewpoint? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the rational response? _________________________________________________________ _________________________________________________________ _________________________________________________________

99

Disputing Impulsive Beliefs What is my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence for my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence against my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the alternative viewpoint? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the rational response? _________________________________________________________ _________________________________________________________ _________________________________________________________

100

Disputing Impulsive Beliefs What is my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence for my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence against my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the alternative viewpoint? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the rational response? _________________________________________________________ _________________________________________________________ _________________________________________________________

101

Disputing Impulsive Beliefs What is my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________ What is the evidence for my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence against my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the alternative viewpoint? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the rational response? _________________________________________________________ _________________________________________________________ _________________________________________________________

102

Disputing Impulsive Beliefs What is my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence for my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence against my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the alternative viewpoint? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the rational response? _________________________________________________________ _________________________________________________________ _________________________________________________________

103

Disputing Impulsive Beliefs What is my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence for my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence against my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the alternative viewpoint? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the rational response? _________________________________________________________ _________________________________________________________ _________________________________________________________

104

Disputing Impulsive Beliefs What is my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence for my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence against my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the alternative viewpoint? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the rational response? _________________________________________________________ _________________________________________________________ _________________________________________________________

105

Disputing Impulsive Beliefs What is my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence for my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the evidence against my impulsive belief? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the alternative viewpoint? _________________________________________________________ _________________________________________________________ _________________________________________________________

What is the rational response? _________________________________________________________ _________________________________________________________ _________________________________________________________

106

ABC Log

Date/ Time

A Activating Event (ICD Trigger)

B (Belief) (Rate certainty 0-100)

C (Consequence) (Rate intensity 0-100)

D (Dispute) (Rate certainty 0-100)

E (Effect Change) (Rerate certainty in belief and intensity of urge 0–100 [columns B and C])

ABC Log

Date/ Time

A Activating Event (ICD Trigger)

B (Belief) (Rate certainty 0-100)

C (Consequence) (Rate intensity 0-100)

D (Dispute) (Rate certainty 0-100)

E (Effect Change) (Rerate certainty in belief and intensity of urge 0–100 [columns B and C])

ABC Log

Date/ Time

A Activating Event (ICD Trigger)

B (Belief) (Rate certainty 0-100)

C (Consequence) (Rate intensity 0-100)

D (Dispute) (Rate certainty 0-100)

E (Effect Change) (Rerate certainty in belief and intensity of urge 0–100 [columns B and C])

ABC Log

Date/ Time

A Activating Event (ICD Trigger)

B (Belief) (Rate certainty 0-100)

C (Consequence) (Rate intensity 0-100)

D (Dispute) (Rate certainty 0-100)

E (Effect Change) (Rerate certainty in belief and intensity of urge 0–100 [columns B and C])

ABC Log

Date/ Time

A Activating Event (ICD Trigger)

B (Belief) (Rate certainty 0-100)

C (Consequence) (Rate intensity 0-100)

D (Dispute) (Rate certainty 0-100)

E (Effect Change) (Rerate certainty in belief and intensity of urge 0–100 [columns B and C])

ABC Log

Date/ Time

A Activating Event (ICD Trigger)

B (Belief) (Rate certainty 0-100)

C (Consequence) (Rate intensity 0-100)

D (Dispute) (Rate certainty 0-100)

E (Effect Change) (Rerate certainty in belief and intensity of urge 0–100 [columns B and C])

ABC Log

Date/ Time

A Activating Event (ICD Trigger)

B (Belief) (Rate certainty 0-100)

C (Consequence) (Rate intensity 0-100)

D (Dispute) (Rate certainty 0-100)

E (Effect Change) (Rerate certainty in belief and intensity of urge 0–100 [columns B and C])

ABC Log

Date/ Time

A Activating Event (ICD Trigger)

B (Belief) (Rate certainty 0-100)

C (Consequence) (Rate intensity 0-100)

D (Dispute) (Rate certainty 0-100)

E (Effect Change) (Rerate certainty in belief and intensity of urge 0–100 [columns B and C])