Model

Introduction Throughout this assignment I aimed to change my exercise behaviour over a five week period. I attempted to do so by increasing frequency of exercise using a behavioural experiment. I drew upon cognitive behavioural therapy (CBT frameworks and was able to appreciatethe process of change. The focus of this assignment will be reflections about the process experienced! part of the "evaluation principle# in CBT ($estbrook! %ennerley & %irk! '(() . *eflections relate to frameworks used! what I have learnt from the process and how it may translate to clinical experience. +ersonal experiential work enhances a therapist#s "personal development#! aiding better practice (Bennett,-evy et al! '((. and reflecting on one,self during such processes is at the "heart# of CBT (Bennett,-evy! Thwaites! Chaddock & /avis! '((0 . Behavioural experiments are widely used in CBT to alleviate distress. B1sare influenced by the "behavioural principle#2 taken from behavioural therapy (BT ! stating behaviour influences thought and emotion ($estbrook! %ennerley & %irk! '(() . 3istorically BT presented itself as a reaction to 4reud#s work on psychoanalysis! reported through narratives. Behavioural therapists were not impressed by lack of empirical evidence,something which was of great importance to their epistemology. BT used empiricism to gain knowledge of people and believed observable behaviour indicates how people feel. BT could only progress so far without recognising inner workings of our minds such as thoughts! beliefs and interpretations2 such processes are inescapable for individuals ($estbrook! %ennerley & %irk! '(() . Cognitive therapy (CT emerged as a result during the 50)(s in the "cognitive revolution#! focusing on these processes with 6aron Beck and 6lbert 1llis as influential figures (Beck! 507'2 1llis! 507'2 Beck! *ush! 8haw & 1mery! 509) . B1s within CBT take the same empirical stance of BT! but embraces the unobservable processes identified in CT.

Both approaches combine to formCBT. 1verything conducted within CBT is evidence based! stated in the "empirical principle# ($estbrook! %ennerley & %irk! '(() . +rocesses of change $hen change occurs! individuals have been found to progress through five stages! highlighted in the "cycle of change# (+rochaska &/iClemente! 509' . The first stage is "pre, contemplation# in which the individual sees little reason to change! accompanied by feeling unable to change. /uring this stage! clinicians provide information detailing positive aspects of change. The second stage is "contemplation# in which the patient can see the need to change. They are inquisitive about change! identifying pros and cons! but are unable to see how it can be achieved. Clinicians will be reinforcing how change is possible. The third stage is "action# in which the individual accepts need for change and sets goals. 1ngagement with change commences while the individual monitors progress. Clinicians provide encouragement! praise and support! particularly when new barriers arise. The fourth stage is "maintenance# in which the individual is striving to consolidate change. There is a battle with relapse so support from the therapist is crucial. The fifth potential stage is "relapse#2 the patient feels a sense of failure and may regress to old behaviour. :oals are neglected coupled with self,efficacy (+rochaska &/iClemente! 509' . These stages have been shown when making a change within therapy or independently2 demonstrated with smoking cessation (+rochaska & /iClemente! 509; . 4urthermore! individuals typically progress through the stages in order2 however some may regress throughout the stages then progress again (+rochaska & /iclemente! 509' . By acknowledging stages! therapists can be aware of what input they should give and when. $hen this assignment was presented! I identified myself in the "contemplation# stage. I was aware I should increase exercise frequency but focused more on negative aspects such as not

having enough time! loss of fitness and physical exhaustion without focusing on the positivesdespite being aware of them. <y regular exercise is sporadic and I have been living outside my value of "I only live once! I need to look after myself#. I see this as a conflict. $hen I then began engaging! I noticed myself in the "action# stage. 6side from needing to participate in change for this assignment! I acknowledged benefits. I made an effort to focus on the positive aspects of exercising more. 4or me! these included improved mental and physical state and social time with friends. 6t the start of CBTand therefore at the beginning of my =ourney to change! an assessment is carried out! where information about the problem is sought. 8ometimes this is achieved by using a timeline. I created a timeline to reflect upon frequency of exercise behaviour from '((> to present day2 shown in figure 5. It highlights as time goes on! exercise frequency decreased.

1xercising > times a week (athletics and =udo

/ecrease to twice a week (only =udo

<inor car crash! hardly any exercise (sometimes none! sometimes once a week, very sporadic

'((>

'((.

'((7

'(()

'((9

'((0

'(5(

'(55

'(5'

+resent day

/ecrease to at least once a week (=udo at ?niversity

Figure 1.Timeline showing exercise frequency from 2004- present day.

The therapist then collaboratively creates a formulation! attempting to make sense of the issue. The formulation can be conducted using the "interacting systems principle#! explained by the "hot cross bun# model (+adesky & :reenberger! 500. incorporating physiological symptoms! emotions! behaviour and thoughts to create a "maintenance cycle#. In order to gain
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an understanding of myissue! I created a formulation of my current situation! shown in figure '.

Thoughts

nt nme o r i Env
Physical Reactions Blushing! increased heart rate! shaky! butterflies

"I should exercise# "I#m being laBy# "<y back will hurt# "I#m not as good anymore#. "I#m not fit enough anymore# Emotions 8adness! frustration! anxietyAfear! shameAdisappointment

Behaviour 6void exercising! plan then fail to exercise.

Figure 2. My hot cross !un" formulation illustrating processes prior to change. Ta#en from the hot cross !un" model $%ades#y & 'reen!erger( 1))*+

This formulation shows thoughts triggered negative emotions andrelated symptoms. <y behaviour wasavoidant or actions were unsuccessful. 1ach point on the cycle maintained each other and in order for behaviour change to occur this cycle neededaltering. 6fter formulating my maintenance cycle! I set a goal to provide structure for the five weeks. In CBT goals should be 8<6*T($estbrook! %ennerley & %irk! '(() @Specific! Measureable! Attainable! RealisticARelevant and have a Time frame. This is shown in table 5.(. I also used an 6BC chartto monitor beliefs and emotions from a specific situation by identifying an activating event (6 ! and acknowledging subsequent thoughts and beliefs (B and emotions! behaviour or physiological responses (C (1llis! 507' .
Specific By the end of the five weeks! I want to increase exercise behaviour to at least 5

Measureable Attainable RealisticArelevant Time

once a week and feel good about it. I will measure this by keeping a diary of activity in the form of 6BC charts This goal will be a challenge due to perceptions of self being not as good as I used to be. This goal is realistic and I am willing to achieve it. In addition! it is relevant to my values of looking after myself. 57th Cctober ,'(th Dovember (my . week time frame

Ta!le 1.0 My ,M-.T goal for the fi/e wee#s.

4acilitating change $eek one $ith my 8<6*T goal set! intervention started. $eek one of my plan to facilitate change wasn#t successful. I planned toexercise twice! but didn#t. 8ubsequently! two similar entries were in my 6BC diary. Cn both occasions triggering events were having the opportunity to relax. Ithought I wouldrather be doing something else and had specific thoughts of "I#m tired# and "I want to relax#! consequently I failed to exercise2I experiencedemotions of guilt and sadness. In CBT! psychoeducation has shown to be effective at reducing symptomsof depression! anxiety and distress (/onker! :riffiths! Cui=pers & Christensen! '((0 2 I reminded myself of the benefits of exercise by researching them.

$eek two I felt more positive in week two! given the research I had done! but felt I should conduct a B1. B1s are designed to test the validity of a person#s "existing beliefs about themselves! others and the world# (Bennett, -evy et al! '((> as cited in $estbrook! %ennerley & %irk! '(() . The thought tested may be derived from formulations or an 6BC chart.
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In order to set up the experiment! I identified a belief to be tested2 "0f 0 exercise 0 will get upset !ecause 0"m not as good as 0 used to !e". I used a graded hierarchy approach to prevent feeling overwhelmed. I broke activities down into stages2 details of each stage can be seen in figure ;. 8tage 5 is the easiest with stage > being the hardest.

Perceived difficulty

4. Exercising on my own more than once a week 3. Exercising on my own once a week 2. Exercising with others more than once a week 1. Exercising with others once a week

Figure 1. ,tages in my !eha/ioural experiment using graded hierarchy approach

In week two I planned to attend Eumba with my sisters once. In addition to planning! I laid my clothes out before going out to encourage me to engage2 this was my activating event and was successful. Thoughts experienced were "0 had fun with my sisters" and "0 en2oyed myself and feel happy". 3appiness is a positive emotion! so I experienced subsequent action behaviours like smiling and laughing. This motivated me because I spontaneously went for a run with a friend later that week. 6gain thoughts were positive and encompassed emotions of happiness and pride. $eek three This week I attempted to move up the hierarchy to stage two! where I attempted to exercise with others more than once this week. /espite technically completing this last week! I was reluctant to rush to stage three.

6gain! I planned to go to Eumba with my sisters! but I also planned to go for a run with one of them. 8imilar thoughts to last week! including "0 had fun" were experienced! along with positive emotions. The encouragement of my sisters also helped! especially when running. <y sister told me how she needed external motivation! so we helped each other! which again elicited happiness and good feelings about me. This is the opposite to my belief in question so change was happening. $eek four In week four I moved to stage three on the hierarchy! which was to exercise on my own once. I accepted I wouldn#t include Eumba (as my sisters were there but would still attend as I en=oy it. I planned to go for a short run later in the week. 3owever! due to traffic on my way home from university! I was late home and couldn#t attend Eumba. This eventimpactedmy mood! because in my thought diary! I wrote"traffic meant 0 couldn"t go to 3um!a". I added "the stupid people in the traffic 2am made me late#! externalising the problem! even though it may have been something uncontrollable. I think this! in turn impacted on my emotions for the rest of the week! meaning when I was planning to go for a run! I didn#t. I felt I had failed and experienced emotions of sadness and disappointment.

$eek five Because of the difficulty I experienced in week four! I decided to move back to stage two@ trying to exercise more than once a week with others. I accepted I wouldn#t be able to attend Eumba because of getting home late from university. Instead I planned to go swimming with a friend. I en=oy swimming! but I tend to get ear infections! so in advance I purchased ear plugs to prevent this being an avoidance tactic. I explained to my friend about this assignment

and told her it#s important to me to attend. 8he text me a motivational message beforehand whichreminded me of all the positives of exercising and subsequently I attended swimming. I thought "0 felt good !ecause my friend said she was proud of me". I planned with the same friend to go for a run later in the week! which I succeeded with. I was aware that the following week I should have attempted to move back up to stage three and begin exercising on my own. I drew upon my positive emotions and instead of driving to town one day! I walked. I called this a '.. stage to the hierarchy. The walk was about half an hour but I managed to do it on my own effortlessly. I am confident with walking this distance compared to running. 6fter! I felt emotions of pride. *eflection Cverall! I have found the process of facilitating behaviour change difficult. 6lthough I didn#t reach stage four in the hierarchy! I felt positive after exercise which disproved the belief I was testing. I found the "hot cross bun# formulation to be extremely useful throughout the process. I was able to refer to it when filling out my 6BC chart to track how thoughts changed and if emotions became more positive. In CBT it is important to secure a formulation to refer to throughout. Conversely! I found setting a 8<6*T goal somewhat useful in providing overall structure to the five weeks2 however I didn#t find myself referring to it throughout the process. I found the B1 challenging but the graded hierarchy made it more manageable and made change more likely. /espite this! Irelapsed in week three but I believe this could have been prevented by including more stages to the hierarchy should I go through this process again. I think I over estimated how easy it would be for me to move up through the stages. This

highlights how in CBT attention should be put on including stages which are achievable and realistic! otherwise! like me the individual may experience a sense of discouragement and failure! resulting in lack of progress. I expected the process of moving through thesestages to be quicker than it was2 I found maintaining the exercise stated at each stage difficult! making progression challenging. In week three I relapsed and didn#t exercise at all. I can now empathise with individuals who go through CBT and relapse too and having experienced the disheartening feeling! can understand the need for the support of the therapist to guide them and provide encouragement. $hen I succeeded! I could feel a sense of increased self, efficacy. The thoughts in my 6BC chart were more positive and I went on to achieve more. The problem was maintaining this week by week. /uring the process I have found it demandingreflecting to the extent that is needed within CBT! specifically when monitoring thoughts derived from particular situations and then reflecting on emotions experienced. I felt uncomfortable and self,conscious. I found I was asking myself questions to delve deeper in to reflection. 4or me! this demonstrated how important techniques such as guided discovery and socratic dialogue can be within a therapy session because you are prompted to think deeper! whereas when you are alone it can be hard to achieve ($ells! 500' .$hen relating to clinical experience! an individual partaking in CBT may have similar difficulties when reflecting and completing charts and diaries like the 6BC chart. 1specially if it is the first time the individual has had to do this. 8o for someone going through this process! they must be aware of how best to deal with emotions that may arise. Throughout the process! I encountered difficulty maintaining motivation. 1xternal motivation such as family and friends aided success in engaging in exercise. I often spoke with family members and my boyfriend about positives of exercise! which helped. $hen I discussed this assignment with peers! my worries about the behaviour change were relieved somewhat

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because they validated my emotions! however because my family were unaware of the detail of CBT frameworks! they were less validating! saying things such as "=ust do itF# $hen relating this to clinical experience! I believe it#s important to identify a support network outside of therapy sessions! explain the workto them and draw upon this support should one feel lacking in motivation as they can give you the boost you need and validate difficulties. Cther factors impeding on change included emotional factors2 I found it hard having to face up to how little I exercise now compared to the amount I used to partake in. This elicited emotions of sadness and upset. 3owever! events such as a minor car crash and medical issues have been obstacles which have made engaging in more exercise difficult. In a clinical setting! the individual may have intense emotional factors! which impede on change to a greater extent. $hen we are emotional! our thoughts become irrational eliciting negative automatic thoughts and in turn we may make negative appraisals about ourselves! resulting in negative emotions and behaviour. 1nvironmental factors alsohad an impact on whether or not I engaged in exercise. It had been particularly windy and rainy the previous few weeks! which played a part in me missing planned exercise simply because I thought "0"d rather !e inside". Cther factors such as university work load! seeing my boyfriend and spending time with my family got in the way of me exercising. 6rguably these could be seen as avoidant tactics! which may be the focus of sessions within CBT. 8ummary By using the frameworks common in CBT! I was able to facilitate change of my exercise behaviour by increasing frequency over the five weeks. I was somewhat successful with this and provided evidence against my belief tested in the B1! which overall has given me a sense of achievement. I encountered difficulties applying theory to practice! but when I succeeded!
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I felt positive emotions. $hen I wasn#t!I experienced a sense of failure so am able to empathise with people who have CBT and appreciate how difficult the process of change can be! even with a seemingly trivial issue.

*eferences Beck! 6. T. (50)7 .Cognitive therapy and the emotional disorders. Beck! 6. T.! *ush! 6. G.! 8haw! B. 4.! & 1mery! :. (509) . 4ogniti/e therapy of depression.The :uilford +ress. Bennett,-evy! G.! Thwaites! *.! Chaddock! 6.! & /avis! <. ('((0 . *eflective +ractice in CognitiveBehavioural Therapy@ The 1ngine of -ifelong -earning. Bennett,-evy! G.! Butler! :.! 4ennell! <.! 3ackmann! 6.! <ueller! <.! & $estbrook! /. ('((. . 5xford guide to !eha/ioural experiments in cogniti/e therapy. Cxford ?niversity +ress. /onker! T.! :riffiths! %. <.! Cui=pers! +.! & Christensen! 3. ('((0 . +sychoeducation for depression! anxiety and psychological distress@ a meta,analysis. 6M4 medicine! 7(5 ! )0. 1llis! 6. (507' ! .eason and emotion in psychotherapy. Cxford! 1ngland@ -yle 8tuart.

:reenberger! /.! & +adesky! C. 6. (500. . Mind o/er mood8 4hange how you feel !y changing the way you thin#. The :uilford +ress. +rochaska! G. C.! & /iClemente! C. C. (509' .Transtheoretical therapy@ Toward a more integrative model of change. %sychotherapy8 Theory( .esearch & %ractice! 1)(; ! ')7.

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+rochaska! G. C.! & /iClemente! C. C. (509; . 8tages and processes of self,change of smoking@ toward an integrative model of change. 9ournal of consulting and clinical psychology! *1(; ! ;0(. $ells! 6. (500' . ,tress. In 6. 4reeman & 4. /attilio (eds. @ 4omprehensi/e case!oo# of cogniti/e therapy. Dew Hork@ +lenum +ress $estbrook! /.! %ennerly! 3. & %irk! G. ('(() .-n 0ntroduction to 4ogniti/e 6eha/iour Therapy8 ,#ills and -pplications. 8age@ -ondon.

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