Behavior Change IRL: When the Needed Change is Existential

This is the sixth installment in my series on Behavior Change in Real Life.

Here are the other links:

Part 1: Behavior Change IRL: Introduction

Part 2: Behavior Change IRL: Start Before You Start

Part 3: Behavior Change IRL: Focus on Both the Journey and the Destination

Part 4: Behavior Change IRL: Align the External Environment So It's Right For You

Part 5: Behavior Change IRL: Reduce Any Drag From Your Inner Environment

This series is exploring all the approaches to behavior change I have encountered and leveraged in fifty years of studying the topic at both the individual and organizational levels.

Here is the taxonomy I am using to organize the various approaches:

?I. Start Before You Start

?II. Focus on Both the Destination and the Journey

III. Align the External Environment So It’s Right…for You

IV. Reduce Any Drag from Your Inner Environment?

?V. Access the Deeper Pools of Motivation

VI. Change the Game

In this installment, I am going to hit pause on chipping through to the six sections to shine a light on one particular approach.

When the Need for Change is Existential

Sometimes we set goals to accomplish something because we want to prove we can do it.? We might set an objective to run a race we have never run before or to finish something we started but left unfinished, like a degree.

Sometimes we set behavioral change objectives because we know that mastering something new or creating a new habit will benefit us in some important way.? For example, how we respond under stress or improved public speaking.

And sometimes something we are currently doing is so debilitating that if we don’t address it, a chance at a normal life, and sometimes even our very existence, seems like it is on the line.? Examples here include insomnia, eating disorders, anxiety, PTSD, etc.

Where do people turn when they really, no I mean really, have to change?? They turn to Cognitive Behavioral Therapy (CBT).?

CBT is the 500-lb Silverback gorilla of behavior change: it takes on all of the toughest behavior change challenges and it has a remarkable track record of success.

With the success record it has, the question I asked myself is what, if anything, can we learn from the CBT approach that can help individuals that have more quotidian behavior change challenges.?

In this section:

• The Mental Models Underlying CBT
• The Existential Behavioral Change Challenges CBT is Addressing
• Empirical Support for CBT
• A Hypothetical Course of Treatment
• Immunity-to-Change:?CBT-Lite
• Conclusion: What CBT’s Success Can Teach Us

CBT is the 500-lb Silverback gorilla of behavior change: it takes on all of the toughest behavior change challenges and it has a remarkable track record of success.

The Mental Models Underlying CBT

The earliest roots of CBT can be traced back to Stoicism (see Installment 3 of this series, Focus on the Journey and the Destination: Be more Stoic).? Stoic philosophers believed logic could be used to parse false beliefs that lead to destructive emotions and discard them.

CBT has built a simple causal chain upon that Stoic idea: environmental events result in thoughts or judgements.? Those thoughts result in feelings.? And those feelings lead to choices and behaviors:

Environmental triggers --> Thoughts --> Feelings --> Behavioral choices.?

This cycle repeats itself so many times that it becomes not only inveterate, but self-reinforcing, which can lead to worsening over time.

With that as the core mental model of the problem, CBT’s approach is built on the integration of the following principles:

• Cognitive Restructuring: identify and challenge negative thought patterns, replacing them with more rational and balanced thoughts. (See also Installment 5 of this series: Reduce Any Drag from Your Inner Environment)
• Behavioral Therapy: to help structure your environment to make better choices (see also Installment 4 of this series: Align the External Environment So It's Right...for You)
• Learning Theory: drawing on both classical and operant conditioning insights about how we learn, CBT emphasizes the role of learned behaviors and associations in the development and maintenance of behavioral patterns and provides structured exercises, exposure therapy, behavioral experiments, and skills training to unlearn maladaptive behaviors.
• Goal-oriented and Time-Bound: CBT believes in setting time-bound goals (see also “Kill Criteria" in the Start Before You Start installment) and measuring progress vs being open-ended (some forms of therapy) and never-ending (some uses of medication).
• Empiricism: CBT believes in deploying structured techniques and interventions backed by solid scientific evidence.
• Holistic: while the focus is primarily on thoughts and behaviors, the approach recognizes the influence of physiological factors, social context, and environmental stressors.? It leverages a collaborative approach with the therapist, group support, and adaptive, tailored responses to individual differences in environment and physiology.
• “Not Na?ve”: CBT recognizes and plans for people to slip, regress, and fall off the wagon by providing prophylactics and pre-programed actions for getting back on track.? (See also, the second installment of this series Start Before You Start…Don't Be Naive...all behavior change efforts should plan for failure)

The Existential Behavioral Change Challenges CBT is Addressing

Here is a partial list of the behavior change challenges CBT has been used on:?

• Borderline Personality Disorder
• Panic disorder
• Anger/Aggression problems
• Depression
• Insomnia
• Childhood Anxiety
• Chronic Fatigue
• General Anxiety Disorder
• Bulimia
• Obsessive-Compulsive Disorder

That list represents only the behavior change challenges for which there is good data about CBT’s effectiveness.?

But CBT has also taken on challenges with schizophrenia, bipolar disorder, PTSD, addiction and more.? It is just that the results in those areas, so far, are more muted or mixed.

But with the list presented here, CBT is kicking ass.

Empirical Support for CBT

I said at the beginning of this series, that few coaching interventions have much research backing behind them. That is decidedly not the case with CBT. It has been researched like no other behavior change approach.

Numerous randomized controlled trials (RCTs) and meta-analyses have demonstrated CBT’s effectiveness, even on the monstrously tough-nut problems it is being asked to crack.

An RCT study is one where there is some kind of control group, usually another treatment of some kind. CBT routinely shows not only statistical but also practical effect size differences.

Moreover, the effects have been observed in diverse populations including children, adolescents, adults, older adults, people of different cultural backgrounds, and individuals with comorbid conditions.?

Even further, the changes observed have been shown to sustain over time.??

Why is it so effective? Additional research has shown that it’s the change in?cognition that results from, for example, challenging and modifying maladaptive thoughts, that seems to be the key lever in producing positive outcomes.

A Hypothetical Course of Treatment

Here is how a series of sessions with a CBT therapist might progress.? In parentheses after each step, I highlight the related section in this Behavior Change IRL series so you can see how much fire-power CBT is bringing to the challenge of change.?

• The therapeutic model is described, which highlights the connection between thoughts (including common cognitive distortions such as black-and-white thinking), emotions, and behaviors. (Start Before You Start: Shine a light on change beliefs)
• The practitioner and client collaborate to set specific, measurable, achievable, relevant, and time-bound (SMART) goals. (Focus on Both the Destination and the Journey: Visualize; Focus on Both the Destination and the Journey: Define the incremental steps to the outcome)
• Automatic thoughts in response to triggers are identified and cognitive restructuring techniques, such as examining evidence for and against a belief, generating alternative interpretations, or re-attributing causes are used to modify unhelpful thoughts and replace them with more realistic and balanced ones.? (Reduce Any Drag from your Inner Environment: Understand your story)
• Behaviors are identified that are pleasurable and aligned with the behavioral change objective, as are behaviors that are counterproductive.? Ways to make the former easier and the latter harder are discussed (Align the External Environment So It’s Right…for You: Manage Friction…make targeted behaviors easier and make counterproductive behaviors harder).
• Skill-building is a key component of the CBT approach and often entails teaching clients specific coping skills to manage emotional distress more effectively. These skills may include meditation techniques, problem-solving strategies, assertiveness training, social skills development, pre-programmed countermeasures, or simple stress management techniques. (Focus on Both the Destination and the Journey: Skill-build the steps as needed & Reduce Any Drag from your Inner Environment: Don’t swing at bad pitches)
• Regular meetings with the therapist are used to celebrate progress and adjust approaches (Align the external environment so it’s right…for you: 1) Make your performance & progress visible...course correction feedback, 2) Leverage rewards (non-social)
• In addition to regular meetings with the therapist, support groups are also used to turbocharge the environment in support of change (Align the external environment so it’s right…for you: 1) Leverage rewards (social) & 2) Groups…environmental alignment on steroids)?
• CBT typically includes between-session assignments to consolidate learning and practice new skills. These assignments may involve keeping thought records, engaging in behavioral experiments, or practicing coping techniques. (Align the external environment so it’s right…for you: 1) get your reps in, 2) make your performance and progress visible)
• Towards the end of the engagement, the focus shifts to consolidating gains and preventing relapse. The client and therapist work together to identify potential challenges or triggers and develop relapse prevention plans and other strategies to maintain progress and cope with setbacks. (Start Before You Start: Don’t be na?ve)

In parentheses after each step, I highlight the related section in this Behavior Change IRL series so you can see how much fire-power CBT is bringing to the challenge of change.?

Immunity-to-Change:? CBT-Lite

Many would disagree, but I think of Immunity to Change (ITC) as CBT-Lite.?

ITC has the same behavioral and cognitive components CBT has. And like CBT, as the name implies, it is often introduced when the change challenge is a daunting one or the leader has been unable to make progress or change.

Because it is so popular with executive coaches and works well in corporate environments, I also refer to ITC as "CBT's corporate cousin."

Here is a high level overview of the approach.

A first step on the behavioral side is to ask clients to look at how they are avoiding what they say they want to do. Just making a list and asking clients to become aware of the choices they are making and to take accountability for them is powerful.

Then the cognitive side is brought in and clients are asked to imagine doing the opposite of their current avoidant behavior. That thought experiment often brings up a thunderhead of uncomfortable thoughts and feelings.

The client is asked to note the fear stories that come up, to connect the avoidant, counterproductive behavior with the fear stories, to precipitate out the “competing commitments” (what they are really committed to vs the change they say they are committed to) and finally to get to “the big assumption” (another fear story) which is locking the whole system in place.

Once the dynamic equilibrium of the system is seen, the way out of the woods is to come back to the behavioral side and design tests and collect data to chip away at the big assumption fear story.

Because it is so popular with executive coaches and works well in corporate environments, I also refer to ITC as "CBT's corporate cousin."

I find ITC’s approach to analyzing cognition and getting at the fear story and the underlying assumptions to be incredibly systematic and effective.?

Any individual trying to make change or any coach whose client is not making steady progress would be well served to understand the reinforcement/rewards the client is getting from the avoidant behaviors. ITC provides a step-by-step approach to this analysis.

However, I think the behavioral aspects of ITC are weak.? Maybe this is because the changes people apply ITC to are not the existential changes people who reach for CBT are wanting. But there is not the same effort to leverage the power of the environment (Align the External Environment so Its Right…for You) to support behavior change as there is with CBT.?

Conclusion: What CBT’s Success Can Teach Us

Above all, in the most silent hour of your night, ask yourself this: Must I write? Dig deep into yourself for a true answer. And if it should ring its assent, if you can confidently meet this serious question with a simple, "I must," then build your life upon it. ~Rilke, Letters to a Young Poet

It is easy to see why CBT has such a successful track record, despite the tough behavior change challenges it is taking on.?

Like mastermind groups and Twelve-step programs , CBT throws the kitchen sink at the challenge of behavior change, incorporating many of the behavior change support levers discussed in this series to support the change process.??

The core theme of this series is that IRL behavior change is messy, hard, and often not successful.? If you are taking on a sizeable change challenge or if you have been told by your company that there is no chance you get promoted unless you address a behavior or skill shortfall, a New Year’s resolution approach is not going to cut it.?

In Rilke’s, Letters to a Young Poet , he advised Leopardi to stop looking outside himself and look within:

Above all, in the most silent hour of your night, ask yourself this: Must I write? Dig deep into yourself for a true answer. And if it should ring its assent, if you can confidently meet this serious question with a simple, "I must," then build your life upon it.

Until you have that gut-check conversation with yourself about how important the change in question is to you, the odds are, honestly, not good.?

Once you do and you decide, challenging or not, this is a goal or a change you must make, then you too are going to need to throw the kitchen sink at the change effort and would be advised to aggregate as many of the levers we have been discussing in this series as possible if you want to succeed.

In the next installment, I will return to the taxonomy and cover how you can Access the Deeper Pools of Motivation to sustain you on the road to change.

Dennis Adsit, Ph.D. is the President of Adsum Insights and designer of The First 100 Days and Beyond , a consulting service for leaders in transition who need to get off to the best possible start in their new job.