A Case Using Behaviour Therapy

Author: Jane Barry

Rose has come to counselling to help relieve her fears about driving. About 15 years ago, she had an accident while driving and has not driven a car since. She has recently applied for a job, and she will need to use a car to get there. She feels motivated to learn to drive again, however every time she even thinks about driving she experiences mild anxiety attacks. The Counsellor has decided to use Behaviour Techniques with Rose to help her overcome her fears.

A précis of the sessions is as follows. For ease of writing the Professional Counsellor is abbreviated to “C”.

Background Information

Rose has never been a confident driver; however what little confidence she had was lost after she was involved in an accident. The accident was fairly serious and both Rose and the other driver sustained injuries. Rose was not at fault in the accident, however she blames herself for not being quick enough to avoid the accident. She has been very fearful about driving since that time, which has resulted in her refusal to drive for 15 years.

Rose says that she experiences anxiety whenever she is a passenger in a car. She states that she breaks out in a cold sweat, feels light headed her vision blurs and her hands and legs shake. The only exception to this is when her husband, George drives. When asked about the reasons for this exception, Rose said that George talks to her and keeps her calm while they are driving. Over time Rose has become increasingly relaxed with his driving.

Rose has accepted a position as a receptionist for a suburban accountant. She is excited about getting back into full-time work, especially since her children have grown up and are leaving home. The office, at which she works is located about 20 minutes from her home, however there is no public transport connection between her home and workplace. Rose will initially rely on the help of her husband and eldest daughter to get to and from work, however this arrangement is only temporary due to her family’s changing schedules. Rose realises that she needs to consider driving herself to work if she intends to keep her job in the long-term.

Rose’s expectations about therapy are uncertain. She hopes to be able to overcome her fears of driving enough to get herself to her job. She is concerned that she has not driven for over 15 years and wonders if it is too late to start now. On the positive side, she knows that she has the support of her husband and the motivation to get to work to assist her in reaching her goal.

On completing a Personality Need Type Profile, Rose was found to have moderate type “C” needs.

Session Content

In the initial session, “C” inquired into Rose’s problem with driving and spent some time building a rapport with her. Rose seemed quite motivated to change her behaviour, especially as she was concerned about keeping her new job in the long term. Rose’s relationship with her husband was another important motivator, as he helped her to remain calm while driving. “C” suggested that Rose invite George along to the next session, so that George could become part of the strategies they devised.

“C” defined some of Rose’s goals, as he understood them. These included relearning to drive, building up her confidence, reducing her anxiety levels, driving both to and from work each day, and driving to friend’s places, or the shops, on the weekend. Rose did not want to drive during the night. Rose confirmed these goals and rated them according to her preferences. Initially she wanted to reduce her anxiety while driving and relearn to drive and then she wanted to be able to drive to and from work on a regular basis.

Since the accident, Rose explained that she felt very uncertain about her driving abilities and believed that she was an unsafe driver. She thought that her lack of confidence in her driving abilities attributed to her having the accident in the first place. “C” and Rose discussed her negative beliefs and looked at the consequences of those beliefs. “C” was able to convince Rose to consider that accidents are indeed part of the risks taken when driving and that not all traffic situations are predictable. “C” explained that people learn to become safe drivers through experience and by learning from their mistakes.

“C” explained to Rose that she needed to learn to become a safe, confident driver. Since the accident she had not given herself the opportunity to learn to be a safe, confident driver again. She had decided that she was not a safe driver based on the accident and so assumed that she could never learn to become one.

“C” assigned Rose some homework to learn about safe drivers. “C” had previously compiled some videotapes on defensive driving from the Department of Transport. He gave Rose one of these to watch. The video demonstrated people who were safe drivers and those who were not. “C” asked Rose to make a personal list of what qualities she thought were important for safe drivers and to say which driver she identified with most of all. “C” intended to use the video to display appropriate driving models to Rose, from which she could learn.

George accompanied Rose to the next counselling session. Rose and “C” discussed the homework activity firstly. Rose had defined several important characteristics of safe drivers which included: good observation skills, remaining calm in emergencies, a good understanding of road rules, keeping to speed limits and respecting other drivers. “C” suggested that these were areas that both Rose and George could work on together.

Together with “C”, Rose devised a long-term plan to achieve her goals. “C” explained that the plan would be broken up into small, manageable steps, which would allow Rose to achieve her goal more easily. This process (systematic desensitisation) would help to slowly build up Rose’s confidence in driving, rather than trying to encourage Rose to drive to work the next day, which would be too confronting and anxiety producing for her.

The first step of the plan was for Rose and George to play relaxing music in the car whenever they drove. The music was to be used during those times when Rose was feeling calm about being in the car. “C” hoped that Rose would learn to associate the relaxing music with relaxed driving. “C” was careful to ensure that the music was calming, but not so relaxing as to make them drowsy. Rose and George were to carry this out for about 2 weeks. During this time “C” asked Rose to sit in the drivers seat of the car when the car was parked, in order to desensitise herself to her fear.

Rose sat in the car each day for 5 minutes and then slowly increased the time to 20 minutes. After one week, Rose turned the ignition on and sat in the car for similar times. She practiced changing gears, pressing the brake, using the indicators and adjusting her mirrors, while the car was parked and running. Rose also played the calming music while she sat in the car, which helped her to relax.

The second step for Rose was to drive the car on quiet streets or in a large car park, with George present at all times. George would play an important role by providing a safe driving model for Rose to follow. He would also be able to tutor Rose in ways that supported her type “C” needs for security

Rose and George committed themselves to start the program on weekends at 8.00am. George would drive to a remote suburb or car park, and Rose would spend 20 minutes driving the car with George’s support. When Rose reached her target time, she would increase that time by 5 minutes the following day.

“C” gave Rose a logbook to fill out. This logbook contained a record of her drives and the length of time she drove. She was also instructed to rate the anxiety that she felt while driving the car. Where 0 equalled no anxiety, 5 equalled moderate anxiety (sweaty hands, fast heart rate, dry mouth) and 10 equalled high levels of anxiety (faint headed, nauseous, impairment of judgement). “C” asked Rose to identify the highest level of anxiety she felt she could handle while driving. Rose thought that at level 7 she would feel too nervous to drive. “C” then explained to Rose that whenever she felt anxiety to a level of 7, she was to stop the car carefully and play the relaxation tape until she felt calm enough to drive once more. Rose also needed to record the time she spent calming down, in her logbook.

George’s role was to help Rose remain calm and to encourage her while she drove. “C” reinforced to George that it was important that he remained calm at all times and never contributed to Rose’s anxiety levels. George was to ensure that Rose reached her goal time for each drive and he was only to praise her when she had succeeded. “C” reinforced to George that he was to model calm and safe driving behaviours for Rose to be guided by.

The next week, both Rose and George appeared a bit despondent. Rose had experienced high levels of anxiety the first day and had only managed to drive for about 5 minutes. They had waited for over an hour for Rose to calm down and eventually George had driven home. Rose had not wanted to attempt a driving lesson again. When asked about the incident, Rose said that she gave in to her desire not to drive. She just wanted to have George drive her and not have to force herself. She said that she felt disappointed in herself because she had given up so easily.

Together “C” and Rose explored some ways to increase Rose’s motivation to drive. “C” suggested going back to an easier task, like sitting in the car driver’s seat of the car and starting the engine. Rose felt that she had already achieved this task and preferred to tackle the driving. Her concern was that she didn’t have the will power to start driving again and needed some extra encouragement.

“C” suggested they think of something to negatively reinforce Rose’s behaviour. “C” explained that negative reinforcement increases the likelihood of a behaviour occurring, through the avoidance of an unpleasant consequence. Rose thought that driving avoided the unpleasant consequence of having to walk or take public transport. “C” then suggested that the unpleasant consequence of Rose not fulfilling her goal could be George driving home from the car park alone, while Rose caught the bus or walked.

It seemed that the car park was on the direct route of their local bus and was only a 40-minute walk home. Though Rose was a little hesitant, she agreed that she was more likely to drive if she thought that she would have to walk home. George agreed that he would be able to carry out his side of the program if it became necessary for him to leave, so long as Rose did not become angry.

“C” suggested that they draw up a contract in the session to agree to this proposal. “C” explained that both parties needed to demonstrate their commitment to the contract so that it would ease any tension caused by George leaving Rose behind in the car park. Both George and Rose signed the contract.

The negative reinforcement and contract strategy worked and next week, Rose drove around the car park for 20 minutes the first day and 25 minutes the second day. After a month, Rose had progressed to driving for an hour around country lanes and driving home after these journeys. Rose would use the relaxation music in the car to calm her down when she felt anxiety over the level of 7 (this was according to her internal stress rating scale). Her logbook recorded the increased time she spent in the car and a reduction in the time she spent calming herself. This logbook helped to reinforce her growing confidence in her driving ability.

Three months into her program, Rose had started to drive to work. She and George began early in the morning (on a weekend) when there was little traffic around. Rose attempted firstly the drive to work only, then the drive from work only, then both together. Rose then worked her way to driving to and from work, in peak hour traffic, assisted by George. Eventually, Rose did achieve her goal to drive to and from work on her own.

To finalise the program, “C” and Rose developed some longer term goals which included completing a defensive driving course and visiting friends on the weekends. To continue to reinforce her driving behaviour Rose decided to save some of her salary towards buying a newer car for herself.

By implementing the Behaviour Modification Program, Rose found that she had the capabilities and will power to become a safer driver. She was very proud of her new found confidence, both on the road and in herself.

End of Session

Some points to consider with Behaviour Therapy:

Behaviour therapy concerns itself with action-oriented approaches to solving behavioural problems. This means that it relies on the active participation of the client, and the collaboration of the therapist.

Behaviour Therapy was developed from behavioural theories such as classical and operant conditioning. It is based on principles of scientific method – whereby the procedures of the therapy are clearly stated (goals), tested (applied and measured) and revised based on the assessments made.

The procedures of Behaviour therapy are educational and are designed to fit the unique needs of the individual and the environment in which the behaviours are occurring.

The goals of therapy are for the therapist to explain the nature and course of the treatment and to identify the goals that are relevant to the client. Then the client and counsellor collaborate, to initiate conduct and evaluate the strategies and progress.

The techniques of Behaviour Therapy include the following:

• Relaxation training – where clients are given exercises to practice relaxing their thoughts and muscles.
• Systematic desensitisation – where clients are gradually desensitised to fear inducing stimuli, or stimuli that cause compulsive and obsessive behaviours.
• Modeling – where clients learn to perform new behaviours by observing the behaviour of other people.
• Assertion training – where client’s challenge their own negative self-statements and develop more appropriate self-statements that will lead to assertive behaviours. Assertion training also includes practicing newly acquired, assertive behaviours.