jeudi 5 février 2009

Step 2: "behavioural"

Yes. Cognitive-behavioural therapy. So now that we've been over the cognitive part over and over, we come to the behavioural part.

You may have noticed in the post on cognitive techniques that some of them almost lead to the conclusion that action is necessary... but they don't really go there. In fact, I don't have any handouts about behavioural techniques, because all my handouts are uselessly focused on treating depression, which is mostly cognitive. So now I'll just have to write my own stuff entirely.

Consider the following: just because a cognition is uncomfortable, doesn't mean it's distorted. This is one thing my fired therapist would never agree with, but it's true.

Example 1: you're having the cognition "I'm fat." If your BMI is 22, it's a distorted cognition. If your BMI is 32, it's realistic. 32 is fat. Dangerously fat, in fact. If your BMI is 32 and you manage to CT yourself into thinking you're "svelte", you need your reality-testing checked. Some times, if you think you're fat, it's because you are fat. (I'm not picking on fat people, by the way, I'm picking on people who have distorted cognitions about being fat, because it's such an easy example to understand.)

Example 2: you're having the cognition "if I make a mistake at work, something horrible will happen." If you're a cashier in a supermarket, it's a distorted cognition. If you're the guy who filed work permits on Piper Alpha, it's realistic. If you misplace a work permit on Piper Alpha, the whole place might go up in flames and kill 160+ people. If you're filing work permits on Piper Alpha and you're telling yourself it's ok to make mistakes as long as your ego doesn't suffer, you need to get fired. Some times, if you think an error can have catastrophic consequences, it's because it really can.

Just because a cognition is uncomfortable, doesn't mean it's distorted. So, what do you do when you have a realistic uncomfortable cognition?

I have a very good book titled Being Happy by Andrew Matthews. One of the first things it says is "pain is your body's way of telling you something's wrong." If you get a burning sensation when you pee, that's your body's way of telling you something's wrong with your penis. If you get chest pains when you climb stairs, that's your body's way of telling you something's wrong with your heart. And so on. So likewise when your mind hurts, that's your mind's way of telling you there's something wrong. So, when something hurts, you need to change things. That's where the "behavioural" part comes in.

Beyond this, I can't really get specific, because how you change your behaviour depends on what's wrong. Maybe you're fat. Maybe you're incompetent. Maybe you're abusive. What you need to change will depend on what it is you're doing wrong, obviously. But in general, we can go back to the "cognitions" wallet card and ask ourselves 1) does this behaviour help me achieve my goals? and 2) does this behaviour make me feel the way I want to feel? The important difference though, is that with cognitions, you can do the questions after you have the cognition. With behaviours, in the beginning you will review past behaviours and see if they were maladaptive, but ideally you want to question your behaviour before you engage in it. There isn't really much point questioning your choices after you've eaten a gallon of pudding or you've killed somebody while drunk-driving. So to begin your practice, you'll want to spend some time sitting down identifying the behaviours that do not help you reach your goals and feel the way you want to feel, but once you know, the rest will depend on impulse control. Recognizing ahead of time that the behaviour you're about to engage in is on the "don't" list, and choosing not to engage in it. Again, supposing you're trying to lose weight and you see a cheesecake, and you tell yourself "self, eating a whole cheesecake does not help us achieve our goals", and then you eat the cheesecake anyway, well, there isn't much point in giving yourself a pep talk at all.

The good news is, impulse control, like controlling your cognitions, is something that comes with practice. Not so much if you have FASD, but even so, learning is possible. Like I used to say to an abusive guy I knew once, if you can control your bladder, you can control your mouth. And... the rest of you. Most of us know quite well when and where it's appropriate to pee, and we hold our bladder until it's appropriate to pee. Likewise, most of us do know quite well what is appropriate to say to another person, so we can choose to keep our mouths shut until we have something appropriate to say. Why do some people choose to say inappropriate things like name-calling or accusations or triangulation or etc? Who knows. But they're choosing to do it. Not all people are taught appropriate people skills as children, mind you, and if you're one who wasn't taught, then your behavioural therapy would include finding out what's appropriate, and practicing doing it. For example, I had to teach myself to say kind and supportive things to others, because that was not part of how I was raised. Any of you who were reading this blog when Chris was killed, you probably didn't notice, but I did: not one of my relatives offered any condolences. The most basic thing to say to a fellow human being: "I'm sorry for your loss." I had to teach myself that. And, I did. Likewise if your upbringing didn't teach you to listen to others instead of talking all the time, or "if you can't say something nice, don't say anything at all," or to chew with your mouth closed, or to be faithful to your spouse, or to be honest, these are all things you can teach yourself. None of us are slaves to our upbringing and that's one thing that always aggravates me (wait - that I choose to be aggravated by - no wait - by which I choose to be aggravated), is people who say "that's the way I was raised" and won't hear anything else about it.

None of us are constrained by how we were raised, or by our life experiences, or by our job training, or by our religion. We can be conditioned a certain way, but we still have free will. One time I loaded dyed diesel into a tanker and tagged it with regular gasoline tags. Then I got to the customer and looked at my tags and was paralysed. I knew exactly what I had loaded, and the bill of lading confirmed it, but by training, I'm conditioned not to offload if the tags don't match. And I pride myself on my adherence to my safety training. But, knowing rationally that there had been a mistake in tagging, I made a deal with myself that I would pail drain some product from a line, and if it turned out to be diesel, I'd offload it. And of course it was diesel, so I offloaded it. Now this may seem like a small thing, but it's not, because following tag procedures is extremely important and I'm much more conditioned to that than to, say, hold doors open for others. But we can all choose to break out of our conditioning as appropriate. And if our conditioning is maladaptive, then we need to break out of it. That's what the behavioural part of CBT does.

So... I think that's about what I have to say about it just now. I hope some of this made sense and is of some use to y'all. If you can think of any specific questions, I'd be happy to try and answer them.

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