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ISSUE: 1 YEAR: 2013VOLUME: 13

WORDS OF EASTERM.YAMAKURO ............. 1

SAVED BY A WHISPER: VOICES INMY HEAD SAVED MY LIFES.MARTINEZ-ROMERO .. .8

SELF-DEFEATING BEHAVIOURS:ASSESSMENT AND INTERVENTION INCOGNITIVE AND BEHAVIOURAL THERAPYM. MONTENEGRO ......... .4

InpactingtherapiesQU AR T ER L Y N EW S L ET T ER — MA R C H 2 01 3

I N T E G R A T I V E A F F I L I A T I O N F O R P S Y C H O L O G I C A L A N D C O M P L E M E N T A R Y T H E R A P I E S

I’ve always wondered on what maybe the representation of Easter for peo-ple who are not Christians or for thosewho may not be active Christians? Thefirst step is to look at the etymology ofEaster.

Easter is an old Christian traditionthat has been celebrated for nearly2000 years and it celebrates the resur-rection of Jesus Christ on the third‘day’ after his crucifixion at Calvary asdescribed in the New Testament(Aveni, 2004). It is likely that the firstChristians did not celebrate Easter aswe do today, nor did Jesus or his disci-ples started this tradition.

Direct evidence for the Easter festi-val begins to appear in the mid-secondcentury, but earlier roots of Easter mayhave been interlinked with the Jewishfestival of Passover, or the commemo-ration of the Exodus from Egypt fromthe time of Moses.

Modern Easter festival has nowtaken a different shape from what wasenvisaged all those hundreds of yearsago, when the Roman Catholic Churchimplemented the day to celebrate thedeath and resurrection of Jesus Christ.Easter now has mostly a commercial-ized connotation but there are stillgroups of people around the world that

see Easter time as an opportunity forrebirth of theirs goals, or re-startingtheir life, as if spring itself gave themsolar energy to feed the seeds in theirminds to make the New Year resolu-tion plans into reality.

It is not surprising to say that inmany cultures, such as China, or Iranthe New Year falls near to the springtime. Also if we look closely at the cur-rent calendar in use around the world,what we call the Gregorian calendar,the month count places March as thestart of the calendar year. Just look atthe months September, October, No-vember and December! (cont...)

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Editorial Spring WishesWelcome to our quarterly newsletter. As we pass through Spring holi-days and celebrations, like Easter, Passover, Spring Solstice, May Day,Pentecost, Nowrūz, Ēostre, and many others, we aim to wish everyone,in particular our readers, a message of new beginnings, confidence, in-creased self-esteem and prosperity in their hearts during these festivetimes. This edition is about Regeneration.

Mikao Yamakuro, Co-Director of InPACT.

Words of EasterBy M. Yamakuro

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They literally mean ‘7th’, ‘8th’, ‘9th’and ‘10th’ month. This is because theGregorian calendar was based on anearlier Roam Calendar where‘March’ was the start of the calendar,called ‘Kalendas Martius’.

However, what does this all haveto do with Easter and this newsletter?Well, in order to understand a festivaland its meaning we need to look atwhere it comes from and what it rep-resented to the people that created it.Even if now Easter is all about bun-nies, eggs, chocolate, cakes, flowers,and prize hunts, the meaning behindit is all about ‘restart of life’,‘rebirth’, ‘new opportunities’, and‘new energy’.

These concepts are all representedin the symbols we now use to repre-sent Easter, and it not coincidencethat Eggs are a great representation ofnew life, and spring is often the op-portunity for Earth to show human-kind the regeneration of all things.Easter is about hope. Hope for a bet-ter future, for a new opportunity, andfor a new life. This is what the mes-sage behind Jesus’ resurrectionstands for—Hope! In Buddhist tradi-tion Hope takes a similar position,which basically translates to bringingpeople a foundation to look into whatthey now have with a positive eyeinto the future and not dwelling intothe past errors and mistakes.

In Psychology, Hope is an impor-tant feature for recovery. AlfredAdler said: “We cannot think, feel,will, or act without the perception ofa goal” (Snyder, 1994, p.3). This per-ception of a goal is called ‘Hope’.Hope is the state which promotes thebelief in an outcome related to eventsand circumstances in one's life. De-spair is often regarded as the oppositeof hope. Hope is the "feeling thatwhat is wanted can be had or thatevents will turn out for the best" orthe act of "look[ing] forward tosomething with desire and reason-able confidence" or "feel[ing] thatsomething desired may happen" .

Hope is more important than tal-ent, skill, ability, resilience, con-sciousness, self-efficacy, optimism,passion, or inspiration. These are all

important features for well-being butwithout Hope, people struggle toachieve goals and finding meaning intheir life. It is not a coincidence thatHopelessness, and not depression, isthe best predictor for suicide and self-harm. People may be depressed butstill hopeful about their well-being,so it is vital that we address hopeless-ness before dealing with anythingelse.

Snyder proposed a “hope theory”by observing people and interactingwith them. Through his observations,Snyder was able to determine hisown definition of "hope"; “Hope isthe sum of the mental willpower andwaypower that you have for yourgoals”(Snyder, 1994, p. 7). Snyderfurther developed three hope-relatedconcepts:Goals: “Goals are objects, ex-

periences, or outcomes that weimagine and desire in ourminds”. Snyder determines that“the goals involving hope fallsomewhere between an impossi-bility and a sure thing” (p.8).Willpower: “Willpower is the

driving force in hopeful think-ing” (p.9). Willpower draws onthe perception of our desired goalas well as one’s mental energy. Italso depends on how well weunderstand our goal. Within psy-chotherapy, techniques are usedto home in on one’s desires andwishes, on how to focus on ourgoals, on how to obtain or attainthem, “…based on tacit knowl-edge” (p.10).Waypower: “Waypower reflects

the mental plans or road mapsthat guide hopefulthought” (p.10). There are impor-tant versus less important goalsthat play a part in one’s ability toplan through a goal, to map out aplan. Snyder says that hope is the“mental willpower and waypowerfor goals” (p. 13). Research hasfound that “persons with will-power thinking may not havewaypower thoughts to theirgoals” (p.13).

Ways to increase hopeHope is associated with a wide rangeof psychosocial and physical benefits(Snyder et al., 2011), and appears tobe an important component of thera-peutic change (Snyder & Lopez,2009) and coping with adversity(Linley & Joseph, 2004).

Many authors suggest the use ofhope enhancement strategies in clini-cal settings and in the community.For instance, Snyder et al. (2011)describe "hope therapy" or a series ofinterventions designed to elicit hope-ful cognitions and reduce distressamong adults referred to individual,marital, and group counselling.

Similarly, Magyar-Moe (2010)views hope as "a malleable strengththat can serve as an important thera-peutic change agent" (p. 141). Shedescribes several hope enhancementstrategies and suggests that mentalhealth practitioners use these tech-niques in their practice. Cheavensand colleagues (2006) offer specificways therapists might increase hope-ful thoughts in their clients within thecontext of cognitive therapy and de-scribe how clinicians might use vari-ous hope enhancement strategies totreat patients with Major DepressiveDisorder (Cheavens & Gum, 2010).

However, the evidence on thesestrategies seem weak and variable. Arecent meta-analysis (Weis & Speri-dakos, 2011) attempted to determinewhether any hope enhancementstrategies were associated with in-creased hopefulness, improved lifesatisfaction, and decreased psycho-logical distress among participants.Results revealed modest evidence forthe ability of hope enhancementstrategies to increase hopefulness orlife satisfaction and no consistentevidence that hope enhancementstrategies can alleviate psychologicaldistress.

Authors suggest that traditionalpsychotherapeutic interventions orother effective positive psychologicalconstructs (e.g., gratitude, optimism,mindfulness) might best be targetedin applied settings to increase well-being. Despite this we explore thehope enhancement (cont…)

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approaches as they seem to statistically(p<0.05) provide people with meaning,quality of life and self-esteem as wellas reductions in symptoms of depres-sion and anxiety (Cheavens et al.,2006). It is likely that at times you mayfeel hopeless, we all do and that is nor-mal. The trick is not to let hopelessnessget the best of us, and just tackle itstraight away.

The first step is to reflect on thethings you have got in life. If you can,write in a piece of paper or diary: peoplewho are around you and in your life. Foreach person write three good qualities,and why they are in your life. Also, foreach person write three ways in whichyou would help them if they needed.

Second, think about a moment inyour past that was really difficult for youbut that you managed it well. Write downwhat the problems was, how you felt atthe time when facing that problem, whatwere your fears, what were your goals,what gave you strength to carry on, howyou overcame the problem, and how you

felt after managing the problem. Doingthis helps you see that you can achievethings.

Third, write down three things youare planning to achieve soon, maybe to-morrow or this week. These can be dailygoals, like shopping or reading a book.What it is? How important is it for you?How are you going to prioritise it amidstyour other daily tasks? What if things gowrong, how will you manage it?

Fourth, just be kind to yourself. Weall fail at times. And just like the old say-ing “it doesn’t matter how many timesyou fall, what matters is that each timeyou get up on your feet and carry on”.

Take regular breaks from your dailytasks. You deserve time to yourself,and you need time to refuel your emo-tional energies. Just notice life aroundyou. Notice people walking and talk-ing, maybe smiling or in a rush. No-tice the sky, the rain, the sun, thewind, the birds and anything else thatsurrounds you. Take this opportunityto do something positive to others,

like a smile, a tip, a compliment, helpingsomeone or doing charity.

Finally, every day write down onegood thing about yourself, and why youthink that is good. This doesn't need to bea taxing activity. Just a positive word andwhy you think that word applies to you.If you struggle with that tasks, ask some-one that knows you well to help you withit. This may be embarrassing at first butit really helps boost your confidence andhope over time. If you still can’t ask peo-ple, then go back to step two and thinkabout one past situation that you man-aged well. This will give you somethingpositive to think about yourself.

References Aveni, A. (2004). "The Easter/Passover Season: Connecting Time's Broken Circle", The Book of the Year: A Brief History of Our Sea-

sonal Holidays. Oxford University Press. pp. 64–78 Cheavens, JS, & Gum, AM In Burns GW (Ed.) (2010). From here to where you want to be: Building the bridges with hope therapy in a

case of major depression. Happiness, healing, enhancement: Your casebook collection for applying positive psychology in therapy (pp.51–63). Hoboken, NJ: Wiley.

Cheavens, JS, Feldman, DB, Gum, A, Michael, ST, Snyder, CR (2006). Hope therapy in a community sample: A pilot investigation.Social Indicators Research, 77, 61–78.

Linley, PA, & Joseph, S (2004). Positive psychology in practice. New York: Wiley. Magyar-Moe, J (2010). Therapist's guide to positive psychological interventions. New York: Elsevier. Snyder, C. D. (1994). The Psychology of Hope: You Can Get Here from There. New York: The Free Press. Snyder, CR, & Lopez, SJ (2009). Oxford handbook of positive psychology. New York: Oxford University Press. Snyder, CR, Lopez, SJ, Pedrotti, JT (2011). Positive psychology: The scientific and practical exploration of human strengths. Thousand

Oaks, CA: Sage. Weis, R., & Speridakos, E. C. (2011). A Meta-Analysis of hope enhancement strategies in clinical and community settings. Psychology

of Well-Being: Theory, Research and Practice, 1:5 doi:10.1186/2211-1522-1-5

Remember that ‘hope’ starts withyou and the way you see life. No-tice what you have got now, re-member one of you past suc-cesses, think about the things youwant in life, be kind to yourself,notice life around you, and dosomething positive to others

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Case report written as part of my professional diplomain clinical psychotherapy and counseling exploring sev-eral approaches to deal with self-defeating behavioursin clinical practice.

People come to therapy for manyreasons, but more often than notwhen they have reached a pointwhere they feel they cannot copeanymore, and want professional helpto be able to move on with their life.Often people have the skills and resil-ience to improve, but emotional dis-tress will prevent them from step-ping-back from their problems, seetheir own strengths, and alternativesto the way they respond to their prob-lems. Different therapies will theoriseclients’ problems from differentcauses. If on one hand, cognitivetheories assume that a person’s prob-lems are caused by one’s thoughtsand beliefs about the self and theworld; on the other hand, behaviouraltheories assume learning, condition-ing and reinforcement as the basis forthe maintenance of psychologicaldistress. There are many other theo-ries and therapies around, but in thispaper we shall: explore the above twotherapies and attempt to formulate aclient’s self-defeating behavioursaround them.

Self-defeating behaviours are pat-terns of feelings, behaviours andthoughts that people often engage in,unknowingly, that will cause them tofail or even can bring them moreproblems to their life. Ford (2005)states that these behaviours oftenleave people exhausted and with lim-ited access to the vital life energy thatmotivates us to achieve our goals.Although, these behaviours are oftencharacterised by unconscious proc-esses that underline a person’s atti-tudes, Baumeister and Scher (1988)have defined self-defeating behav-

iours as “any deliberate or inten-tional behavior that has clear, defi-nitely or probably negative effects onthe self or on the self’s pro-jects” (p.3). They propose a three-process model of self-defeating be-haviours (see Figure 1).

Figure1. Model of Self-defeating behaviours

The intentionality of self-defeating behaviours is questionableas many people can engage in thesebehaviours without being aware ofthem, as they can lay deep down insubconscious processes. For exam-ple, one proposed theory that arguesin favour of the unconscious proc-esses on self-defeating behaviours is

the Freudian argument, which statesthat people have innate death drivesthat compel them to pursue their owndestruction (Freud, 1964). However,the unconscious processes of thesebehaviours also appear to be condi-tional to learning processes and howone sees in comparison to other peo-ple (Baumeister & Bushman, 2010).So, if a person with a dysfunctionaldegree of avoidance and social anxi-ety only has around them people whoare more avoidant and anxious thanthey are, it appears that their percep-tion of their difficulties will be less-ened by the severity of other people’sproblems. On the other hand, if thesame person lives in a setting wherepeople are outgoing and extravert,then the person’s self-defeating be-haviours of avoidance are likely tosurface as the person see him/herselfas less adapted than other people.Twenge, Catanese and Baumeister(2002) stated that people who areoften socially excluded from socialevents due to their perceived diffi-culties can become are more aggres-sive even towards innocent targets,are less willing to help or cooperate,engage in self-defeating behaviorslike risk-taking and procrastination ,and perform poorly on analyticalreasoning tasks.

This hypothesis makes it possibleto change patterns of self-defeatingbehaviours to more effective ones, ifwe change how people perceive theworld around them but also bychanging small things around the per-son with self-defeating behaviours.

(cont.)

“Your Beliefs become your Thoughts,Your Thoughts become your Words,Your Words become your Actions, YourActions become your Habits, Your Hab-its become your Values, Your Valuesbecome your Destiny.”

Mahatma GhandiIndian political and spiritual leader

(1869 - 1948)

Self-defeating behaviours:assessment and intervention incognitive and behavioural therapyBy M. Montenegro

Counter-productivestrategies

Trade-off

Primary self-destruction

People in this group, usuallyintentionally choose anaction that they know willbring harm to themselves.

A person chooses a certainoption that has some benefit butalso has the potential to causeharm to the person as well.

The person neither desires norforesees the harm to self. Aperson is pursuing a desirableoutcome but chooses a strategyor approach that backfires andproduces the opposite of thedesired result.

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People are more likely to behave in aself-defeating or destructive manner wheneither there are threats to their ego or whenthey have low self-esteem. When a personhas a low self-esteem, they are more likelyto be susceptible to having depression,anxiety and other psychological distress,which are problems that are usually di-rectly related to a less favourable self-appraisal (Baumeister & Bushman, 2010).Also, self-regulation failure is another pro-posed factor of self-defeating behaviours.One’s self regulation is related mostly toone’s self-control. Self-regulation allows aperson to prepare themselves to a certainsituation and adapt to that situation. Withself-regulation a person can either makesure they succeed or fail in a certain situa-tion. Ultimately, self-defeating behaviourmay often result from the failure of a per-son to regulate their behaviours in a posi-tive way (Baumeister, 1997).

In order to explore self-defeating be-haviours in clinical populations, it is essen-tial to provide a case example that can ma-terialise how self-defeating behaviours canbe detrimental to someone’s biopsychoso-cial wellbeing. As there are many types ofself-defeating behaviours, for instance:

1. Prioritizing your to-do list and thenstarting at the bottom;

2. Stopping for fast food when you’recommitted to healthy eating;

3. Focusing on what other people needto do rather than on what you need todo;

4. Getting on the phone with an oldfriend right before you’re supposedto be at the gym;

5. Saying no, no, no to your kids and 15minutes later giving in;

6. Saying that you want to lay off alco-hol and then meeting a friend for abeer;

7. Staying on the computer instead ofdoing the important assignment duenext week;

8. Longing to enhance your sex life andthen staying up late every nightwatching TV;

9. Dreaming about putting away moneyfor your future and then spendingmore than you make every month;

10.Saying you want to have a closerrelationship with your teenage kidsand then criticizing their choices;

11.Procrastinating taking actions thatwill give you what you desire;

12.Worrying about what other peoplethink of you;

13.You long to get out of debt, then youfind yourself catalog shopping onlinein the middle of the night;

14.Wanting to go out with friends but

saying no to them when they call;15.Wanting our partner near us but re-

jecting their approach or shouting atthem when they come home laterthan usual;

16.working extremely hard withoutmaking allowance for rest, relaxationand recreation or paying loving atten-tion to loved ones;

Mary (pseudonym), was a 64 year oldwidow that presented to therapy after re-ferral from her General practitioner (GP)due to increased social isolation and emo-tional agitation. She had been diagnosedwith social anxiety by her mental healthteam psychiatrist but she was more con-vinced that her problems were beingcaused by a breakdown in her relationshipwith her daughter. During assessmentMary revealed that her anxiety startedabout 5 years ago, after her daughter mar-ried a man who had been previouslyknown to Mary. She said that during herdaughter’s wedding Mary was helpingwith catering but as things were stressful,her daughter “snapped” at Mary and theyfell-out. Mary was asked to leave the wed-ding there and then.

It was apparent that there were othermore seated problems to this falling-out.So, after exploring this problem further,Mary revealed that 20 years ago, after shebecame a widow she met a younger man(20 years younger than her) when on anight out “with her friends” and they hadseveral sexual encounters. This experiencemade Mary feel younger, wanted and onceagain alive. By sheer coincidence or fate,20 years later this same man she had metthose years ago met her daughter and theygot married, thus he became Mary’s son-in-law and Mary was worried that herdaughter would find out about that“unspoken past” and this would destroyher daughter’s marriage.

Mary felt terribly guilty for this, eventhough she understood that no one couldhave predicted these events, and no onewas to blame. Mary avoided talking abouther feelings with anyone, including herother children, and would isolate herselffurther, often rejecting family gatheringsand invitations to home visits. When shefelt she could not avoid such visits, herbehaviour would be distancing from other,withdrawal, tearful for “no apparent rea-son” and being rude to her children. On theother hand, she wanted her childrennearby, very much close to her, as she feltlonely, ageing, and dreading what the fu-ture would bring her. However, Mary’serratic emotions and behaviours caused herfamily to distance more and not to call or

visit as often as before. We identified thatMary’s self-defeating behaviours wereisolation, avoidance, and being rude toothers, as they were producing the oppositeeffect to what Mary wanted.

Looking back at Mary’s past, we foundthat her mother was a hard workingwoman most of her life, caring for the chil-dren while the husband was out “at sea”,working as a fisherman for weeks straight.Mary would often long for her father’sarms to hug her when he was home, but assoon as he would be home the sooner hewould leave again. Later it was found thather father had depression and was havingextra-marital affairs, and he eventually leftthe family unit. With this experience,Mary’s mother became very reclusive,stopped working and did not leave thehome ever after that. Her mother was thendiagnosed with agoraphobia, but no treat-ment was ever effective. Mary cared forher mother, with great sorrow and respect,but also felt ambivalent towards her father,the man she still loved and held close toher heart, but the same man who hurt hermother and the entire family. Mary be-lieved that infidelity breaks marriages andmakes women weak and fragile. This be-lief was further emphasised throughMary’s second marriage, whereby her hus-band abandoned her for her best friend,and Mary felt deeply betrayed, vulnerableand broken-hearted.

Mary’s early beliefs and experienceswere playing on her own perceptions ofher more recent experiences. When shefound that her daughter had married a manwho Mary had had sex with many yearsago, her core beliefs started to bring theimage of her mother’s suffering, of a bro-ken family, and of psychological distress.Mary was unconsciously worried that thesame fate would happened to her daughter,but this time it would be her fault. Perhaps,as a young child Mary internalised that itwas also her fault that her father left, sincechildren often blame themselves for badthings that happened around them. PerhapsMary’s mother was never able to discussthis with Mary when she was a child, orthat it was her father’s choice to leave andnot due to anything Mary had done. Dur-ing therapy it was identified that recentlyMary’s son arranged a family holiday,whereas in the past Mary used to get muchinvolved in these family events, this timeher son did not invite her or even told heruntil a few days before they went on holi-day. Mary felt very hurt by this, and inparticular since her son’s wife told Marythat the family could not cope with her“constant crying, whining and moaning”,making the entire family depressed (cont.)

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with her behaviour. This event was a trig-ger for Mary to approach her GP onceagain and to receive psychotherapy, as thisled to a maintenance cycle of furtheravoidance of people and other self-defeating behaviours. A comprehensiveformulation/diagram is presented in Figure2 to summarise Mary’s self-defeating be-haviours.

Mary’s case example is complex, sinceit involves many triggers at different pointsin time that have the potential to be enforc-ing her current beliefs of unworthiness,solitude and loss. There are several treat-ments that could be used to support Maryon her way to recovery. We shall only ex-plore two of these due to space limitations,but more are available in Appendix A or inany good psychotherapy or psychologybook.

Cognitive restructuring in cognitive therapyOne potential approach, known as cog-

nitive therapy, could explore Mary’s cog-nitive processes, or how her thoughts areresponsible for perpetuating her psycho-logical problems (Carr & McNulty, 2006).This approach assumes that Mary’sthoughts and beliefs about her situation aremaking her feeling anxious and avoidingseeing her family – even though she wantsto be close to them and be loved by them.For example, Mary is invited by her son tocome to his house for a meal. Mary knowsthat the entire family will be there, andeven though she wants to go, she fears theconsequences of going, like crying, nag-ging, clinging, and being rude to them. Onthe other hand, she also fears rejection, toomany questions, and being ignored. Herdecision to decline the invitation is allbased on her assumptions on what willhappen, and not based on facts or reality.

Alternatively, Mary could have hadother thoughts, like: ”I would love to seemy family, it’s a great opportunity to betogether again and talk about a holiday orChristmas” or “ I rather not go, but it canbe a good time to see everyone togetherand chat a bit”. The same event can lead todifferent reactions in different people or onthe same person, and in the case of Marydepending on how she is feeling on thatday. These different reactions will dependon a person’s expectations, beliefs andattitudes; so, identifying and changingfaulty and negative thoughts and beliefscan change how people feel. So, with Marythe therapist would identify her negativethoughts, challenge them, and explorepositive thoughts and replace the negativethoughts with others based on more realsituations. This process also helps chang-

ing certain beliefs that Mary has aboutherself and about her family (Figure 3).

A positive aspect of this therapy is thatit can be done in the comfort of the therapyroom, it can be done in hypotheticalgrounds and in the person’s imagination.Another advantage, consists of findingmore creating ways of thinking about anissues, rather than reacting with the firstthing that comes to one’s mind. A disad-vantage is that it does not challenge theperson to pout in practice the learnt skills,and all is done “as if” the patient would do.Also, the person’s problems may be deeplyenrooted into a person’s childhood, whichis often ignored in this therapy and wouldneed a more psychodynamic approach(Beck, Rush, Shaw & Emery, 1979; Black-burn & Twaddle, 1996).

Systematic desensitization in behaviour therapyAnother technique widely used called

systematic desensitization, part of behav-iour therapy, explores the reasons why aperson avoids certain situations and plans agradual exposure to these events thatmakes the person feel anxious and afraid(Carr & McNulty, 2006). This approach isan important part of therapy, since it canadd to the one explored above in the sensethat if people change their thoughts or be-liefs about a situation but are never ex-posed to the situation that makesthem anxious and afraid, it is lesslikely that they will overcomethat barrier (Brewin, 1996).Avoiding will further reinforcetheir negative thoughts and be-liefs about the situation thatcauses anxiety. So, if Mary hadworked hard in changing theirthoughts and beliefs about herfamily, but never actually went to

see them, she could never put in practicewhat she had learnt and see that she couldactually cope better than she thought andher experience could actually be morepleasant than she was predicting.

In practice, Mary could learn relaxationtechniques, such as progressive musclerelaxation or deep breathing, in preparationfor those moments of high physical anxi-ety. This can be practiced at home, with orwithout music or recorded tapes. Next,Mary would be encouraged to create a listof the scariest situations that progress toher final goal. If her final goal is to re-establish a relationship with her daughter,she may start with the easier steps that canlead her to this goal, like talking to her onthe phone for 5 minutes, going shoppingwith her son and daughter, and so on. Eachstep should be SMART (specific, measur-able, achievable, realistic and time-constraint). Finally, Mary would be askedto work through each step, and staying inthat step until the person is comfortablewith the task and not afraid of it. This way,Mary will learn that her feelings will notharm her and are temporary. Mary caneasily switch to relaxation techniques eas-ily if she feels anxious in the situation.Mary will feel more confident in herself asshe achieves each one of her goals withsuccess.

This approach is a potential way to putinto practice some of the cognitive skillsexplored above, and would be ideal as anintegrative therapy. However, as a morepurist approach this model often ignorespsychic experiences, cognitive processesand any emotional responses that may beinvolved in a person’s problems. It ismostly based in learning theory that pre-sumes a mechanistic and reductionist viewthat people’s behaviours are mostlylearned through environment and notcaused by thoughts/beliefs. Positively, it isalso an approach that has been applied tomany problems, and even in people withsevere condition, such as learning disabil-ity and brain injury, so making changes toone’s environment or changing a one’sresistance to that environment can alterself-defeating behaviours. (cont.)

Figure 2: Mary’s formulation

Past life experiencesFather absent for many days; Father left the familyfor another woman; mother became reclusive anddependant on Mary; Mary became a widow; Marymet a younger man and they had sex; Mary’ssecond husband abandoned her for her best friend.

Core Beliefs “I‘m alone and unsupported”; “people don’t love me and will abandonme”; “when people are abandoned they become dependent, weak,broken-hearted”

Recent life experiencesRetirement from job; Daughtermarried with a man Mary met manyyears ago; falling out with daughterat her wedding.

EmotionAfraid of being

alone, anxious whenaround family.

BehaviourCrying, clinging to

people, rude to others,avoiding going out.

Negative thought“I’m invisible”, “they

don’t care”

PhysiologicalIncreased heart beat,tingling going up her

legs, heat-up.

Self-defeating

Presenting problemsSleep problems; suicidal ideation; “going low”, fear to go out; panicattacks; guilt; anxious; sad and hopeless; rude to people; avoidant offamily.

Activating EventFamily went on holidayand did not invite her

Challenging Negative Thoughts with Mary

Negative thought Cognitive distortion More realistic thought

What if I attack myfamily?

Predicting the worst I’ve never attacked my familybefore, so it’s unlikely that I will doit now.

If I’m rude to myfamily, it will beterrible!

Blowing things out ofproportion

If I’m rude, I’ll calm down again ina few minutes. That’s not soterrible.

My family will thinkI’m mad.

Jumping to conclusions My family are more likely to beconcerned with my well-being.

Figure 3: Mary’s negative thoughts

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Self-defeating behaviours can takemany forms and shapes, and be triggeredby many reasons, either from one’s long-distant past or during more recent lifeevents. Independently on where they comefrom or their function, they often preventpeople from moving on, as they are morelikely to counter-act a person’s intentionsand present as barriers. Theexample of Mary, exploredin this paper, demonstrateshow simple self-defeatingbehaviours that would pre-vent harm to come to her inother dangerous situations(from her past of present)are now preventing her fromleading a happy life andsocializing with her family.Moreover, Mary’s self de-feating behaviours are caus-ing her family to becomedistant and also avoidingher, perhaps because theyget upset by her, they fearupsetting her, or they alsohave their own self-defeating behaviours tocope with.

There are many therapiesthat could potentially helpMary overcome some ormost of her self-defeatingbehaviours. In particular, we

have explored a technique from cognitivetherapy and another from behaviour ther-apy, although there are many others thatcan be implemented in isolation or inte-grated with other therapies. Each therapy isvaluable as it addresses specific issues that

the client may present, and at times theseare enough to help the client move on.However, depending on the client's diffi-culties, such in the case of Mary, it is oftennecessary to introduce a range of therapiesthat address different problems at the sametime.

It is feasible, for example, to introduceMary to cognitive restruc-turing and systematic de-sensitization at the sametime, whilst trying to ad-dress dynamic issues thatshe may present from herchildhood. Independentlywhat therapy is introducedto the client it is importantto involve the client in theearly stages of choosing atherapy, as they are morelikely to engage in some-thing they want, ratherthan being imposed a ther-apy that is complex tofollow. Also, workingwith client’s in a positiveand sensitive way, andachieving small goals canempower the client to feelconfident and motivatedto continue to try newtechniques (Dudley &Kuyken, 2006).

References Baumeister, R. F., & Bushman, B. J. (2010). Social psychology and human nature (2nd ed.). Belmont, CA: Wadsworth. Baumeister, R.F. & Scher, S. (1988). Self-Defeating Behavior Patterns among Normal Individuals: Review and Analysis of Common

Self-Destructive Tendencies. American Psychological Association, 1-22 Baumeister, R.F. (1997). Esteem threat, self-regulatory breakdown, and emotional distress as factors in self-defeating behavior. Review

of General Psychology, 1, 145-174 Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy of Depression. New York: The Guilford Press. Blackburn, I. M. & Twaddle, V. (1996). Cognitive therapy in action: A practitioner’s casebook. London: Souvenir Press. Blackburn, I. M., James, I. A., & Flitcroft, A. (2006). Case formulation in depression. In N. Tarrier (Ed.), Case formulation in cognitive

behaviour therapy: The treatment of challenging and complex cases (pp. 113-141). Hove: Routledge. Brewin, C. (1996). Theoretical foundations of cognitive-behaviour therapy for anxiety and depression. Annual Review of Psychology, 47:

33-57. Carr, A., & McNulty, M. (2006). The handbook of adult clinical psychology. London: Routledge. Clark, D. A. & Steer, R. A. (1996). Empirical status of the cognitive model in anxiety and depression. In P. M. Salkovskis (Ed.), Fron-

tiers of cognitive therapy (pp. 75-96). New York: Guildford. Dudley, R. & Kuyken, W. (2006). Formulation in cognitive-behavioural therapy. In L. Johnstone & R. Dallos (Eds.), Formulation in

psychology and psychotherapy: Making sense of people’s problems (pp. 17-46). Hove: Routledge. Ford, D. (2005). The Best Year of Your Life: Dream it, Plan it, Live it. HarperCollins Freud, S. (1964). An outline of psychoanalysis, the standard edition of the complete psychological works of Sigmund Freud (Vol. XXIII).

London: The Hogarth Press and the Institute of Psychoanalysis. Nezu, A. M., & Nezu, C. M. (1993). Identifying and selecting target problems for clinical interventions: a problem-solving model. Psy-

chological Assessment, 5: 254-263. Singer, K. (2007). Breaking the cycle of self-defeating behaviours. Male Survivor. Online from: http://www.malesurvivor.org/

ArchivedPages/singer2.html [accessed 02.11.11] Twenge, J. M., Catanese, K. R., & Baumeister, R. F. (2002). Social exclusion causes self-defeating behavior. Journal of Personality and

Social Psychology, 83, 606-615.

Cognitive strategies

Identify a specific situation

Explore NATs* or assumptions

Explore emotions in response to NATs

Question evidence for belief or test validity ofbelief (Cost-benefit of NAT)

Explore alternative belief to replace NAT orassumption based on the evidence found

Rating the new belief (scale 0-10)

What emotions client has in this new beliefand how intense these are (scale 0-10)

Belief surveys

Challenging distortions within one of theirNATs, assumptions or beliefs

Thinking in shades of grey, rather than black &white

Re-attribution of failure from internalcharacteristics to external and transientfactors

Replace NATs and assumptions that focusexclusively on problematic aspects of asituation with alternatives that focus onpositive of the situation

Showing self-compassion by rephrasing NATsthat contain “should”, “must” with“sometimes”, “maybe”.

Behavioural strategies

Distraction and thought stopping –concentrate attention on another task,focusing on external object

Postponing rumination to a later time

Time-out and using relaxation, physicalexercise to reduce emotional distress –ideal for anger management and anxietystates

Imagery to modify negative moodstates, such as using anxiety provokingimages.

Physical activity at regular scheduledperiods to lift mood or calm down

Behavioural experiments to test validityof NATs, assumptions or beliefs

Safety behaviour experiments, especiallyfor certain anxiety disorders, to reducefear in the situation where safetybehaviours are not being used anymore

Pleasant event scheduling at regulartimes, to activate mood or calm down

Worry practice at regular times

Self-reward, self-praise for using copingstrategies.

Appendix A: Cognitive/Behavioural strategies

* NAT: Negative Automatic Thought

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I started hearing voices when Iwas very young. I can’t really re-member much, but to me the experi-ences were normal, and I neverthought otherwise until I started sec-ondary school and I learned that otherkids did not have the same experi-ences as I had with ‘voices’. Untilthen, I was oblivious to any potentialproblems - just like the old saying‘ignorance is bliss’, so was I in peacewith my voices and experiences.Voices were with me all the time,comforting me and guiding me on mydaily tasks. They were my friendswhen other kids did not want to playwith me, they were my helpers dur-ing homework and even they helpedme understand the world around me.

My experiences were commonknowledge in my family, especiallysince my grandmother was some sortof shaman or witch-doctor, as theycall it in my culture. I was told by mygrandmother that I had a gift, whichhad been passed down from genera-tions, that was meant to be used tohelp people. My voices were never aproblem until I started growing up,and learning new names for my ex-periences. Life was being put intoperspective.

When I migrated to the UK, topursue a career in healthcare I camein contact with the Diagnostic Man-ual for Mental Disorders. This was athe first time of my life when fearovercame me, and I felt weird, afreak and a criminal. The words psy-chosis, schizophrenia, mad, psy-chotic, crazy, and others startedhaunting me. Reading psychiatrictext books and journals was torture.

Learning that my experiences wereseen as bad and mental illness, washateful. I started feeling in conflictwith my voices, started doubting mypast and what my grandmother hadtold me about the origins of myvoices.

Text books and lecturers oftenemphasised that voice-hearing andauditory hallucinations are underly-ing symptoms of psychosis, perhapseven grounded in early life abuse andneglect. Despite this ‘evidence’ Icould not recall a single moment inlife when neglect and abuse was partof my life. Could these scientists andacademics be wrong? Or could mywhole life history be based on a mythand dogma to justify my ‘problem’?For the first time in my life historymy voices changed tone and contents,calling me a liar, a freak, a devil. Ifelt angry with myself, I felt disap-pointed that my gift was a curse,which would haunt me forever.

I started being ill, really ill, andstarted failing lectures and exams. Itold my doctor that I was hearingvoices. I was given medication toovercome this. I saw a psychiatristwho drugged me and labelled me as‘schizophrenic’. This label was hurt-ful, but gave me meaning and hopethat things would be fine soon. Call-ing home was a daunting experience,where I had to lie my family that Iwas ill but not telling them why.Eventually my mum ‘felt’ somethingas wrong with me. She flew to theUK to visit me, and I was reallyscared that I would be exposed to myfamily as a a and community as afreak of nature. People who saw me

with a gift could not see me ascursed. People from my culture oftenapproached me to consult me aboutmy gift, to get answers about theirpast and future. If only they knewwhat was going on.

My life was on hold, my career asa doctor was in jeopardy, and myfuture was bleak. I was so afraid andashamed of my schizophrenia that Iconsidered ending my life manytimes. When my mum arrived sheimmediately understood what wasgoing wrong with me. She did notuse many words, but was always sup-portive of my decisions. Her presencewas enough to help me through mydays. She cared for my physical andemotional well-being and gave mespace to sort out my psychologicalhealth.One day, feeling miserable, I read anarticle by Rufus May called ‘Changingthe power relationship with yourvoices’. (cont …)

I had achieved a life resolution andfreedom from the chains that stoppedme from achieving my emotional well-being. I was giving myself permissionto hear my voices without guilt andshame, and without being considered afreak. I eventually finished my medicaldegree and am now on a specialistpathway to become a psychiatrist. Myvoices have always been with me, andI considered myself a professional anda service-user and feel no shame forthat. My voices saved me!

Saved by a whisper!Voices in my head saved my life

By S. Martinez-Romero

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This was an inspirational workthat changed how I started seeingmyself in UK healthcare context.For those who don’t know RufusMay is a clinical psychologist whopractices in the UK. He also hearsvoices and has learned to live withthem in a positive way. He re-minded me of my grandmother,who always saw the ‘gift’ in theperson. Reading the article I com-mented with my mum. As alwaysshe said to me ‘follow you voices’.

I didn’t sleep well that night. Myvoices were in conflict. I had twomale and two female voices tellingme I was bad and I should be onmedication. I had three male voicesand one female voices telling me tonot give up on me and work on stop-ping the medication. I started writingdown in my journal everything thevoices told me, as if I was in trance.It must have been very late at night,as the event is fuzzy but the next daywhen I looked at my diary I sawthese scribbles over 10 pages. When Ilooked at them closely, and I noticeda list of pros and cons for stoppingmedication, and a list of pros andcons for continuing medication.

I was impressed. I showed it to mymother and explained it how it hap-pened. She said to me: your gift hasguided you once again. Follow what

is right for you”. Well, I knew whatwas right for me all along, but I wasunsure and felt insecure because Ithought that scientists, doctors adacademics knew best. I let them de-cide my life and label me as schizo-phrenic, when such label is the mostunscientific thing under the sun.There is no such thing as‘schizophrenia’ – it’s a name doctorsgive to symptoms they can’t explain.

What I now realised was that myvoices only became a problem to mewhen I allowed the standards of oth-ers to meddle with my cultural beliefsand standards. My voices wherenever distressing to me until otherpeople started making me believethat what I had was wrong, was adisease and was abnormal. The next

stage was a struggle, to convince mypsychiatrist that I did not wish tocontinue my medication. My psy-chiatrist nearly had a fit, stating thatif I decided to stop I could eventuallybe admitted to a mental health institu-tion and be put on worse medica-tions. I explained my view point andrequested a plan to safely terminatemy medication. My psychiatristgrudgingly agreed but requested areview every two months. I did at-tend every appointment, and my psy-chiatrist was surprised with the out-come, up to the point of even doubt-ing my wellness. At that point Ithanked him for his support and saidI did not need to see him and his ser-vices again.

I had achieved a life resolutionand freedom from the chains thatstopped me from achieving my emo-tional well-being. I was giving my-self permission to hear my voiceswithout guilt and shame, and withoutbeing considered a freak. I eventuallyfinished my medical degree and amnow on a specialist pathway to be-come a psychiatrist. My voices havealways been with me, and I consid-ered myself a professional and a ser-vice-user and feel no shame for that.My voices saved me!

If you are experiencing psycho-logical and emotional distressbecause of voice hearing orseeing things that other peoplesay are not there, speak to yourdoctor first to make sure thatyou are safe. Then go to RufusMay website ‘rufusmay.com’for more information on how toget positive help for yourvoices. There are many re-sources for people who hearvoices to help people copepositively with the experiences.

Distraction Techniques Relaxation Strategies Compassion techniques Making Sense of theExperience Challenging the Voices

• Watch comedy orinspirational films• Listen to music• Tidy the house• Shopping• Phone a friend• Gardening• Exercise• Wear ear-plugs• Reading aloud.• Puzzles, crosswords,soduko• Arts and crafts• Cooking.• Humming or singing.• Playing boardgames/cards/computer.

• Give yourself permission torelax• Recognise andacknowledge fears, thenconsciously let go of them• Meditation/Reiki• Massage/acupuncture/yoga• Focus on yourbreathing/breathe deeply• Listen to guided relaxationCDs• Listen to soothing music• Relax each muscleindividually• Take a warm, scented bath• Wear comfortable clothes• Eat a healthy diet• Get a pet, or help care forsomeone else’s.• Hold a safe, comfortingobject.• Sleeping.

• Keep a list of achievementsand strengths or a list ofpositive things other peoplehave said about you• Positive self-talk and self-forgiveness• Look at comforting itemse.g. e-mails, love letters,birthday cards, photos• Get help with practicalproblems e.g. housing,finances• Record positive statementsonto a CD• Do something nice for ‘me’each day• Keep in frequent contactwith support network, even iffeeling okay• Create a personalised crisisplan when you are feelingwell.

• Keep a record of what thevoices are saying.• Talk about the voices tosomeone you trust.• Join a self-help group, or setone up.• Identify the voices -number, gender, age etc.• Identifying triggers e.g.situations, emotions, otherpeople…• ‘Voice dialoguing’ - letsomeone you trust speakdirectly to the voices.• Talk to the voices, find outhow they feel.• Write poetry/proseregarding feelings.• Paint/draw emotions.• Accepting that the voicesthemselves are not theproblem, they are the result ofa deeper, underlying problem.

• Refuse to obey commands, ordelay obeying them.• Ask the voices to justify theircomments.• ‘Time sharing’ - schedule atime for them, and refuse tolisten until that time.• Mentally visualize a barrierbetween yourself and thevoices.• Set boundaries - refuse tospeak with negative voicesunless they are respectful.• Making deals e.g. “be quietnow and I’ll listen later”.• Using positive voices as allies.• Talk back to them (use amobile phone if in public).• Examine the validity of whatthey say e.g. Have they said thesame things before? Do theirpredictions always come true?

Table 1. Helpful and unhelpful strategies for coping with distressing voices (adapted from RufusMay.com)

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