Litigios y contingencias

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 signifi cant 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 benefi ts 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 pro-

gram 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 benefi ted the most from practicing the CBT-ICD program strategies on your own, with the support of family and friends, between sessions. You have already demon- strated 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

changes in your impulsive behavior, but we hope that you look at this therapy program as an opportunity for a change in your “life- style.” 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 con- tinue to use the Life Categories form in Chapter 4 as a format for goal identifi cation and achievement.

Reevaluation

Your therapist will review your progress to date by re-administering some of the diagnostic interviews and questionnaires that you com- pleted 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 fi ndings 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.

Planning for Future Triggers

List major life events that may occur in the near future.

_________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

List strategies for coping with these or similar situations.

_________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

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 confl ict.

■ Financial management . If you suffer from PG or CB, continue to use a fi nancial budget and adhere to a long-term plan for paying down debt. You may need to continue having

signifi cant others or designated support persons manage your fi nances until you feel confi dent 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 fi nancial advisor for long-term fi nancial 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

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 fi nd 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 impul- sively is telling you that you are in danger. Compare your episode of impulsive behavior to having a fl at tire. What should a driver do when he has a fl at tire? The fi rst 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 “fl at tire” problem. If you have the desire to engage in impulsive behavior, or if you have already done so, stop and fi nd 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 fi nd 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.

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 ses- sion in order to give family members and signifi cant others the opportunity to ask questions and receive guidance on how to best support you.

Emergency Procedures 1. Remain calm.

Your fi rst reaction to temptation, whether you have actually engaged in impulsive behavior or not, may be to feel guilty and blame your- self 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 fi rst 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 diffi cult 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 ■

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 diffi culties.

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 diffi cult 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?

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.