Action Plans (Homework) Flashcards
What are action plans?
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Why do we use action plans?
CBT + action plans = more effective than CBT alone
Similarly, degree of adherence to action plans is related to degree of improvement
These features/research findings are important to make the clients aware of, so they know why things will work and why they wont
What kinds of activities are done between sessions?
Read therapy notes everyday
Implement solutions to problems that were discussed in session
Monitor experiences to notice automatic thoughts
Respond proactively to negative cognitions:
- Reading their coping cards or therapy notes
- Using worksheets (if trained to use in session)
Practice new behavioural skills: e.g. (depends on client)
- Activity scheduling - social, self-care, exercise, those that bring a sense of pleasure or achievement
- Exposure techniques (especially for anxious clients)
- Bibliotherapy
- Interpersonal skills, social skills, communication skills, assertiveness skills
- Emotional regulation techniques, mindfulness or relaxation techniques
- Problem solving
- Sleep hygiene, eating regulation, decreasing the intake of harmful substances
It’s also important to make the distinction between a thinking problem or a skill deficit, as if you treat one as the other, you won’t get anywhere
What is an example of an activity scheduling exercise?
Pleasure scale:
- Use a 1-10 scale, on it, write an activity next to 0 that gives you no pleasure at all and next to 10 that gives you the most pleasure
- Now fill in points 2, 3, 5, 7/8 to give you a range (or everything)
Mastery scale:
- Use a second 1-10 scale, again think of a ‘0’ for you on this scale e.g. a time where you might have failed at something, didn’t get a promotion, lost a fight etc; and when you felt the greatest sense of mastery or accomplishment
- Fill in a few remaining points on the scales
Activity monitor:
- A chart that outlines every hour of the day for every day of the week
- Next to each hour is a brief description of what you did in that hour e.g. had breakfast, went for a run, got ready for work etc.
- Using the pleasure and mastery scales, you can now rate these daily activities in terms of the pleasure/mastery (P/M) you felt whilst completing them
e. g. walking the dog might be a P6M4 - Complete this activity monitor religiously for a week, inputting each activity as close to hourly as you can as retrospective recall is poor
What can you learn?
- Did you balance your time well?
- Did the same activities consistently cause you pleasure/displeasure?
- Are there any activities low in both mastery and pleasure Is there anything you can do about that? What was your mood like during these activities? What were you thinking?
What are exposure techniques?
Great for anxious clients
Consists of facing your fears in small/measured, but potentially increasing (with confidence) ways in order to let the bodies response to the anxiety-provoking situation adapt to a calmer state
Also provides a space to monitor and evaluate automatic thoughts, feelings and behaviours - chance to practice being mindful and employ other techniques; can record how anxious they were during the experience
Examples might include going out into a public place for someone that has a slight social phobia. This might increase over time to starting a small conversation with a stranger etc.
What is mindfulness meditation?
An attentive focus on breathing or other sensation, returning to this sensation when the mind gets lost in thought
Record a mindfulness meditation in session with the patient that they can go and listen to in their own time
Daily practice (of increasing lengths) is important
Useful for patients with anxiety and racing thoughts or depressive rumination
How do you practice assertiveness?
You can give your client a formula that can be applied, first in session with the therapist, then in real life situations when appropriate
e.g. “I disagree with what you are saying”… “Can I just interrupt you one second?”
How should you help a client write their therapy notes?
Its a good idea to ask the client in the first session whether they want to write their summaries down or have you do it for them
Have clients verbalise what they are going to write down before they write it down so you have a chance to clarify and emphasise
Ensure anything written down is comprehensive and clear - so it can be referenced during the week or later on in life
When discussing a point you think is particularly important for them to remember, you might ask them - “what do you think about including X in your notes?”
If they have missed something you feel the client has missed from their summary, you might also ask - “would you also like to remember…?”
How do you encourage clients to use their therapy notes?
Encourage them to read them every morning
And during the day, whenever they feel they need them
Some clients will do this readily, others need more reminding/encouragement/exploration of automatic thought about why they have not used them
Sometimes clients say they don’t have time to read their therapy notes, at this point, time the client reading the notes in session - it generally takes <30s - provides evidence that they can (and that there is just some other resistance to doing so that can be explored)
What are some general principals of behavioural modifications?
Make sure the assignments sound reasonable and have a significant chance of success
Work with what the client suggests if they suggest something, but adapt it if it seems unreasonable/feasible e.g. set this task as an end one for a few weeks time, and take smaller steps in the mean time
Predict potential difficulties in advance - whether that be practical/organisational or cognitive - and work through some problem solving with the client
Covert rehearsal:
- Run through the behaviour modification in session (either ‘imagine you are about to do X’ or using role play with the therapist) as way of uncovering potential barriers to success
- These can be explored with traditional CBT methods (what was going through your mind? etc)
Evaluate % likelihood of completion:
- Ask for a percentage likelihood that the task would be done at X time
- If not close to 100%, explore factors that might be having an impact at that time and whether they are modifiable or not
- If not, inquire about other feasible times
Consider developing a plan B
- In the event that plan A goes wrong
What is a credit list?
Getting the client to keep a list of all the small successes they accomplish during the day, in spite of their negative core beliefs or other desires to not complete tasks
Good to tackle ideas of worthlessness
If clients don’t want to keep a list, then a verbal affirmation to themselves e.g. “Its really good that I got myself to do this” - might be good enough
- Get clients to decide on own affirmations and write them down
Why do clients struggle to complete their action plans? How do you overcome these difficulties?
Therapists don’t give enough, clear instruction about what is expected of the clients outside of the session
- Ensure you go through exercises in session with your client
- Explain rationale for the exercises, or ask client why they think it might be important
- Check in with understanding regularly, especially in the early stages, get feedback
Failure to collaborate on plans i.e. therapist imposes
- “so given what we’ve covered, what do you think would be helpful to do..?”
Misunderstanding of existing client skill-base or difficulty of task: (even if client comes up with task themselves)
- “Do you think that is reasonable/attainable at the moment? With your current skills?”
- “Is there anything else that might be more appropriate? How could we start smaller and work up to that? Is there anything you would need to do first before you could achieve that?”
What are some other ways to facilitate action plans?
Most important question:
- “How likely are you to do the assignments on this action plan this week?”
- 90-100% is a level that is acceptable
- 75% - some things wont be done
- 50% - most probably wont be done
- e.g. “Why are you a 70 not a 40%?” - gives you an idea of what the persons strengths are, can be written down to reinforce
- e.g. “what is keeping you at a 70 not 100%?” - gives you an idea of barriers, can be problem solved
Make action plan easier/smaller/make some bits optional
Explore barriers to completion - practical or cognitive
When explored problems, re-ask:
- “now how likely are you to do the assignments on this action plan this week?”
If you can’t do your action plan, think about what automatic thoughts got in the way and bring them to session
You can get your clients to drop you a text or call to check in before/after a task
What kind of reminders can help people remember to do their behavioural tasks?
Phone alarms or gongs
Post-it notes (even blank ones if they dont want to be obvious about what they need reminding of)
Placing things by the door
Flashcards
`What are the general principles when reviewing action plans with clients?
Done a the beginning of the session - to reinforce the importance
“can we take a look at your action plan? What did you get done?”
