Chapter 4 Session 3: Behavioral Interventions

Goals

To identify your ICD triggers and strategize ways of managing ■

them in real life

To identify healthy behaviors to implement in place of your ■

impulsive behaviors

To identify a minimum of two leisure skill goals and steps to ■

accomplish those goals

ICD Triggers and Healthy Behaviors

All individuals who suffer from ICDs have certain triggers that lead them to engage in their impulsive behaviors. For example, being close to a casino will often trigger a pathological gambler to engage in gambling. A bad day at work may trigger a person with spending problems to engage in compulsive buying. A disagreement with a friend or family member may lead a person with PY to start a fi re to relieve the tension resulting from the confl ict. However, it would be misleading to believe that it is only external things or circumstances that provoke us to act impulsively. We must also take into consider- ation how we perceive these situations and their associated triggers. For example, not everyone that enters a casino, store, or circum- stance in which a fi re could be started has an urge to act impulsively. If individuals without an ICD have thoughts about acting impulsively, they may not act on them because they are fully aware of consequences, whereas clients with an ICD often focus only on the “rewarding” aspects of their impulsive behavior before and during engaging in that behavior. You will explore beliefs associated with your impulsive behavior in a later session, which will provide additional protection against acting impulsively. This session will focus on identifying and planning for triggers, while implementing healthy

behaviors to reduce the risk of engaging in impulsive behaviors. The good news is that you can directly act upon these triggers, as well as work on modifying your beliefs.

Exposure to Situational Triggers

You will discuss with your therapist ways you can avoid situations in which you feel you have no or little control over your impulsive behaviors, or reduce the intensity of a trigger if you fi nd yourself in a situation that may trigger the behavior. Individuals going through this program typically have little control over their impulse control problems during the early stages of treatment, and must stay away from unnecessary tests of their ability to abstain. Gamblers must absolutely stay away from casinos or gambling opportunities, and are encouraged to request that their favorite gambling institutions ban them. Clients with uncontrollable spending need to stay out of stores and away from the Internet. Clients with KM must also stay out of stores. In cases in which you have been caught stealing in specifi c stores, you are likely to be banned already and would be watched by security. If you are impulsively starting fi res, you may need to eliminate all exposure to fi res. For example, you should avoid monitoring news or police scanners for occurrence of fi res, and refrain from viewing material (e.g., movies, media, chat rooms) related to fi res. Self-exclusion is, without a doubt, the fi rst strategy to use in order to avoid exposure to ICD triggers.

Here are some additional strategies that will help you to deal with exposure to ICD triggers. You and your therapist will work to identify unnecessary and avoidable ICD triggers. The time of day can often be a trigger, in terms of when you are most likely to engage in the impulsive behavior.

Strategies for Managing ICD Triggers Pathological Gamblers (PG)

preventing themselves from stopping at their usual place of gambling. If you have a gambling problem, consider doing the following:

Change driving routes to avoid driving past the gambling ■

establishment, or signs advertising it, on your way home. Establish a carpool with coworkers, family, or friends. Doing ■

this will reduce the temptation and ability to gamble. Avoid going to places where you can gamble. If, despite ■

everything, you insist on going to bars, it is preferable that you only go to bars where there are no pull tabs or other gambling opportunities.

Cancel membership in any casino “rewards” programs, and ■

make sure they take you off of their mailing lists. Gamblers often report being triggered by “free” rooms or slot machine credits from casino mailings. It is important to eliminate this potential trigger.

As with compulsive buyers, pathological gamblers will be asked ■

to consider leaving all credit and debit cards with a trusted friend or family member, or in a secure place (e.g., lockbox or safe) when leaving home each day.

Compulsive Buyers (CB)

Compulsive buyers may shop online late at night when family ■

members are asleep, or early in the morning once everyone has left for the day. Your spouse or loved one could assist in adjusting security settings on the computer to prevent this habit. In addition:

You should also resist the temptation to “window shop,” ■

especially if this behavior leads you to making unnecessary purchases.

Consider only shopping for essentials by making and not ■

deviating from shopping lists.

Because most compulsive shoppers prefer to shop alone, ■

In addition to leaving credit and debit cards at home or with a ■

friend, it is advisable that you carry only a small amount of cash with you each day. This way, if you ﬁ nd yourself in a store, you will not have the ability to make a purchase. However, you can always apply for more credit cards, so you may wish to consider leaving your identiﬁ cation at home. Of course, we are not suggesting that you drive without a license, so this strategy may not work for those individuals who drive on a regular basis. If you primarily shop online, you may need to be banned ■

altogether from computers at home, as well as at work, if possible. All record of credit cards with online merchants will need to be deleted. Another drastic measure would be requiring a friend or family member to cosign or authorize payment. Obviously, there are ways of sidestepping these suggestions, but we strongly encourage you to do everything possible to make it less convenient for you to engage in impulsive behaviors. Impulsive Stealers (KM)

If you engage in stealing behaviors, it is advised that you steer clear of the stores from which you typically steal.

If you tend to steal at the same time of the day (e.g., Friday ■

night after work), your therapist will work with you to come up with other activities you can do instead (e.g., exercising after work or having dinner with colleagues).

Because going to stores with someone may reduce the chance ■

of your stealing, make sure you only go to stores if someone is with you. If you have problems with stealing, you can ask a friend or family member to accompany you whenever you enter a situation that has triggered your behaviors in the past. It can also be helpful to review the consequences of your ■

stealing habits (e.g., getting caught, going to jail, etc.) before entering a situation that may trigger your impulse to steal. Compulsive Fire Starters (PY)

If you suffer from PY, you have already worked with your therapist in the last session to begin identifying your triggers. In this session, you will continue your work on triggers by developing a plan for engaging in alternative leisure activities during down time to keep you from starting ﬁ res.

Ask yourself when and where you are most likely to set ﬁ res. You ■

started this exercise in the previous session but in this session, you and your therapist will explore your triggers in more detail. Try to avoid being left alone when conditions are ideal for ﬁ re ■

setting. If possible, restrict your access to anything related to fi re setting for at least several weeks. This may entail removing all fi re-starting instruments, including lighters, matches, gasoline, etc., from your home. Enlist the help of a trusted friend or family member to rid your immediate surroundings of items that may facilitate fi re setting.

Signiﬁ cant Others or Friends who May Serve as ICD Triggers

If you typically engage in impulsive behaviors with others (e.g., you have a gambling or shopping “buddy”), your therapist will work with you to develop a plan for resisting invitations from him or her to engage in impulsive behaviors. Your therapist may use role-play activities to help you strengthen your assertiveness skills. In these exercises, you will practice refusing offers to engage in problem behaviors. These role-play activities will help you assert yourself when real-life pressures from others present themselves.

Another strategy for combating pressure from others to engage in impulsive behaviors is to disclose your ICD to friends and family, if they are not already aware of it. It is important to tell those close to you that you are suffering from an ICD and seeking treatment to manage it. If you ﬁ nd that some people are not supportive, or help to trigger your behavior, you will have to rethink your relationship with them. It is not healthy to surround yourself with individuals who may wish to “sabotage” your efforts to make healthy changes. Relationship Difﬁ culties

People with ICDs often isolate themselves because of their impulsive behaviors and, little by little, they abandon friends and family.

Friends and family may also make efforts to distance themselves from the person with the ICD, due to diminished trust, inability of the person to follow through, constant and persistent problems with money, and/or legal problems. Impulsive behaviors can place great strain on relationships. For example, gamblers and compulsive shoppers that make frequent requests for money to cover debts, and neglect to pay back friends and loved ones, may ﬁ nd themselves alienated from the very people they need to be supportive.

If you ﬁ nd that your ICD is negatively affecting your relationship with friends and loved ones, your therapist may recommend an additional family session (see Chapter 8). It is important to have a solid support system as you participate in this program. Your therapist will help you determine whether you need guidance in re-establishing relationships.

Other Behaviors, Mood States, or Problems That Contribute to ICD Behaviors

ICDs are essentially behavioral addictions . This description is useful, as it suggests that people with these behaviors may also have other addictive behaviors, such as drinking or overeating. In the case of alcohol, drinking often contributes to poor decision making, with an inability to assess long-term consequences. In the case of ICD behaviors, drinking alcohol may increase the likelihood of engaging in the ICD behavior, while decreasing the ability to consider the consequences accurately. If drinking is a problem in its own right, it must be addressed either before or simultaneously with the ICD.

When you are stressed or depressed, you are less likely to attempt to inhibit your ICD behavior. “To heck with it all” becomes a common thought when work, family, or ﬁ nancial stress is extreme, or when we are feeling depressed. These feelings should be discussed with your therapist. It is possible that cognitive-behavioral strategies for mood or anxiety problems may need to be used in addition to the sessions for the ICD behavior.

If other problems are contributing to your ICD behaviors, then problem-solving strategies may be useful. The ﬁ rst step in problem- solving is to clearly deﬁ ne the problem, in an attempt to avoid

impulsive reactions. The act of clearly defi ning a problem often gives better answers in the end. Writing questions and answers to better clarify the problem (e.g., What exactly is bothering me? If I am concerned about fi nances, what exactly about my fi nances bothers me?) is often useful in slowing down your thoughts and behaviors and, instead, spending time on problem-solving. The act of writing problems down often allows us to see them as less intense or over- whelming than they may seem when they are just swirling around in our heads. Writing also allows you to list as many possible solutions to the problem as you can, to provide an ample number of options. Having options often makes us feel less trapped, thereby reducing the need to escape into impulsive behavior.

Controlling Your Impulsive Behaviors

In the next section, you will use the Controlling Impulsive Behaviors

Questionnaire to describe the situations you consider the most risky

for you, and then estimate the extent to which you believe you are able to resist the urge to engage in your impulsive behavior if you ﬁ nd yourself in one of those situations. This exercise will allow your therapist to determine which situations need to be addressed in order to create a behavioral intervention plan tailored to your needs. If you suffer from PY, you may already have completed this form with the help of your therapist during the last session. If this is the case, you may move on to completing the Controlling ICD Triggers form on page 44.

Controlling Impulsive Behaviors Questionnaire

Please describe your high-risk situations for engaging in impulsive behaviors. (For example: “when I am bored and have nothing to do” or “when I just had an argument with my boss”). Then, indicate on a scale of 0 to 5, your level of conﬁ dence to control your behaviors if you faced these situations at the present time.

Situation 1

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