Behavioural Interventions and Coping Techniques

Behavioural interventions target behaviours. Key behavioural interventions are:

• behavioural exposure (helping the client to face up to situations they have been avoiding)
• exposure with response prevention (ERP – reducing checking behaviours and reassurance-seeking)
• activity monitoring and scheduling (helping clients to monitor their activities and plan in a schedule of activities)

There are also behavioural experiments/tests, which – despite their name – in fact span both thoughts and behaviours; they involve the client setting themselves a goal but seeing this as an experiment rather than as something they must achieve.

This means that whatever the outcome, the client generates new information that may enhance self-awareness and/or build new healthier cognitions and patterns.

Other techniques in CBT that focus on behaviours are teaching the client coping strategies (e.g. breathing, relaxation, grounding and distraction techniques, often based on mindfulness), problem-solving methods and relapse prevention.

Use of Behavioural Techniques

The combination of interventions and techniques used depends on the detailed presentation of the client, though CBT is also a manualised therapy – meaning that there are treatment manuals that provide evidence-based guidelines on the most effective interventions for different mental-health conditions.

While cognitive techniques tend to be used with anxious clients, behavioural techniques are particularly useful in working with depressed clients, using activity monitoring and scheduling to increase motivation.

It can be useful therefore to:

• ascertain whether the client comes with any mental-health diagnosis, for example from their GP
• look carefully at the results of assessment measures completed during your first session with the client – for example, checking whether the client scores more highly on depression or on anxiety measures (there are also additional measures available to measure other mental-health conditions, for example body dysmorphic disorder, obsessive compulsive disorder etc.)
• examine the client’s formulation, which you will have drawn up after the initial session, identifying whether it is thoughts or behaviours that are the prevalent issue for the client, and so the logical starting point for therapy.

Behavioural Exposure

This technique is used to help clients with anxiety face situations that they may have been avoiding, by gradually building their tolerance of the situation.

First, it is necessary to provide psycho-education on the idea that avoidance in fact breeds greater anxiety, and helps maintain negative thoughts and so unhelpful maintenance cycles.

Second, the therapist and client will together draw up a graded hierarchy – sometimes known as a fear ladder – showing a series of goals, each building on the one before. In this way, they break down the gap between where the client is now and where they need to be into small steps that feel manageable.

So if, for example, a client was fearful of travelling by bus, especially during busy times, the steps might look something like this:

1. Watch a video on YouTube of someone travelling by bus.
2. Watch buses going by from your window.
3. Walk to the bus stop and watch the buses going by from there.
4. If possible, get onto a stationary bus that is going nowhere (e.g. in a transport museum).
5. Get onto a quiet bus and travel one stop, before getting off and walking back home.
6. Next time, travel for two stops on a quiet bus.
7. Then travel for five stops on a quiet bus.
8. Stay on a quiet bus for the whole journey.
9. Repeat steps 5 to 8 but at a busy time.

ERP

This technique, which is used specifically with clients who have obsessive compulsive disorder (OCD) also aims to eliminate avoidance, but at the same time to reduce the checking and reassurance-seeking behaviours that are common in this group (in other words, to remove the compulsions).

Again, psycho-education is an important first step, teaching the client that in fact all humans have unwelcome thoughts, so normalising this experience.

For example, in the bus-travel example above, a person with OCD might feel they can only do this if they also practise a ritual or safety behaviour, such as sitting on a certain seat on the bus, checking their position on a map as they travel, or having a lucky mascot with them.

ERP seeks to help them let go of this ritual while following the graded hierarchy – so increasing psychological flexibility and giving the person the opportunity to learn that they do not in fact need the ritual that they had been hanging onto.

Activity Monitoring and Scheduling

This technique is commonly used for clients with depression, as a way to help them become more active and involved with life again. The idea is again to move in baby steps, gradually building the level of activity to increase engagement with life at a manageable pace.

First, the therapist may ask the client to complete an activity monitoring sheet, showing how they are currently spending their time. This can provide useful evidence in counselling clients who may believe, for example, that they haven’t time to do any exercise or other healthy activity.

The therapist and client can then together set targets for activity each day/week, gradually building this to the desired level.

Behavioural Experiments

These can be seen as both cognitive and behavioural in approach. They involve attempting a task or activity as described above, but viewing this as an experiment rather than a goal, with the aim of learning from this.

The attempt produces new evidence that can help overturn negative thinking, providing new or different information that can help the client move forward.

For example, a client who would like to feel free to dine at a restaurant without having to have a companion but who thinks that other people would be bound to stare at them if they ate alone might do this and observe others’ reactions.

The likelihood would be that they would see that in fact people were just focusing on eating their own meals, which would in turn increase the client’s sense of confidence and freedom to do this again in future.

Coping and Other Techniques

Various techniques are used to support the other interventions described above, and to help maintain progress for clients. There are many different kinds of relaxation strategies, for example:

• breathing techniques – e.g. square breathing and 4-7-8 breathing
• progressive muscular relaxation
• grounding techniques
• distraction approaches (e.g. counting backwards from 100, or visualising yourself in a peaceful place) – this needs to be used in moderation only, to minimise avoidance.

The first three techniques have links to mindfulness, which has been proven to help reduce both anxiety and depression.

For clients who have external problems that cannot be completely controlled by adjusting their own thoughts and behaviours, the therapist may teach problem-solving methods, using worksheets to look at problems, resources available, goals and options.

As the end of therapy approaches – and CBT often offers only a short course of sessions – it is important to work on relapse prevention, supporting the client to become their own therapist and to be fully aware of their own strengths and resources.

Common techniques here include flashcards and rainy day letters with reminders of their learning in therapy, and positive messages based on rational thoughts and helpful behaviours.

Reference

Simmons J & Griffiths R (2014) CBT for Beginners, Sage