112 COGNITIVE THERAPY IN CLINICAL PRACTICE

C: I’d feel terrible.

T : [Inductive question.] Anything else?

C:Well it would be in the papers. People would know all about me and I hoped that wouldn’t happen since we moved. I’d lose my friends. I might even lose my job.

Explaining the role of cognitions

At this point, it was explained to the client how what had emerged from the session so far could go on to help him with his problems. In summary, the explanation was something like this, including checks with the client periodically that he understood and was in agreement.

T:Most people think that it’s what happens to them that makes them feel and do things. You’ve said that when things get dull you feel like exposing yourself, and when you see someone and are in suitable circumstances, you end up doing it. I want to suggest to you that there is something else that makes you more likely to feel like doing it, and end up doing it, and that is your thoughts, what goes through your head both at the time and about the whole problem. [Check with client.]

It seems to me that if you think you can’t control your problem, if you tell yourself you can’t control it, it’s less likely

that you will control it. Also if you don’t think of any bad effects of doing it, you are likely only to think of wanting to do it and that will make it more likely. [Check with client.]

We’ve just discovered together that you actually can control the problem better than you realised. You’ve started to think of whether you actually need to do it. Also you’ve told me all sorts of bad things that could happen if you start up again, which you normally avoid thinking about, but which might just help in your efforts at control. [Check with client.]

The client reported understanding the model, and that it made some sense to him, agreeing that his thinking was not quite consistent with his reality.

The self-help task

A prompt card was discussed and agreed upon, as a good way to enable the client to remind himself of his new thinking strategies. The client wrote out his alternative, more realistic thoughts on the card as follows:

SELF HELP CARD

1.I can control my problem.

2.I can control it without having treatment.

3.I don’t really need to do it, even when life is dull.

4.There are likely to be bad consequences if I start again and get caught:

prison

lose my friends lose my job feel terrible

It was suggested that during the two weeks before the next session the client should remind himself of his new thoughts and why they were more accurate than his old ones, as a matter of routine. In addition he should use the card to help him resist urges, or to combat any automatic thoughts he experienced about exposing himself, whether triggered by an outside event (e.g. seeing a woman walking past work when he was alone) or not.

Session five

The aim of this session was to evaluate how effective the cognitive changes made in the previous session, and the use of the prompt card to maintain these changes, have been in helping the client control or reduce urges to expose. A decision should then be reached by mutual agreement as to what and when the next therapy involvement should be. The following extract from the session illustrates what was said.

C:The card has been a help as a reminder. I realise I am in control and I don’t really need to do it. The pleasure side is a big problem though. I really like doing it.

T: Have you reminded yourself of the deterrents?