Believing in Behavior Change: A Final Step in Therapy

A patient had been working in therapy with me for nearly a year. She had started out as a woman who often felt powerless, angry, and depressed about situations at work and at home but would not speak up. Instead, she would have dialogues in her head, whole conversations in which she expressed how she felt. She did not realize that by not saying anything, she was left feeling impotent … a situation of her own making. 

As we explored her childhood and the take-away messages from her family of origin, she came to realize that her father had been demanding and authoritarian and that from him she learned, essentially, to shut up. She came to realize that her feisty temperament kept her from totally internalizing the disconfirming messages but left her unable to speak up when needed. 

From engaging in the mental dialogues, she already had the tools (in her head) to assert herself, and, as she worked in therapy, she began doing so. Over time, she would describe situations in which she had advocated for herself and, surprisingly to her, others had responded well to her. 

Recently, I asked her if she were aware that in recent months she was describing situations in which she was speaking up more and no longer simply having internal arguments that left her feeling powerless. She replied with a tentative, “Maybe.” 

I was reminded of a concept I had taught to other nurses about stress and coping— cognitive appraisal theory, the original version of which was put forward by Richard Lazarus (1). According to this theory, cognitive appraisal occurs when a person in a stressful situation considers factors that contribute to his response to stress. There are two parts to this appraisal: primary appraisal and secondary appraisal. 

In the stage of primary appraisal, an individual asks questions like, “What does this stressor and/ or situation mean for me?” The three typical answers to these questions are:

"This is not important to me."

"This is OK."

"This is stressful or harmful." 

Secondary appraisals involve feelings related to how one is able to deal with the stressor or the stress it produces. Examples of self-statements related to positive secondary appraisal are:

“I can handle this situation.”

“I will try whether my chances of success are high or not.”

“If this way fails, I can always try another method.” 

Obviously, examples of negative secondary appraisal are the polar opposite of these:

“I can’t handle this.”

“I won’t try.”

“There is no other way.” 

Despite seeming sequential, primary and secondary appraisal work in a reciprocal way, looping back during the stressful event. Unlike other theories where the stages usually come one after another, the secondary appraisal actually happens simultaneously with the primary appraisal. 

In the case of my patient, her appraisal that interactions consistently led to stress and to feeling powerless to change her coping were what brought her into therapy. But, while she was actually changing her coping skills, she had not really internalized that she was no longer powerless and was appraising situations in a way that looped back positively.  She had not developed self-efficacy, the strength of her belief in her own ability to reach goals (2).   

By commenting on her changing behaviors and then asking her to notice them as they happened between sessions, I hoped to help her change her secondary appraisal self-statements from “I can’t do this” to “I can handle this situation”, thus increasing self-efficacy. 

How do you help patients believe in their behavior changes? 

References 

1. Lazarus, R.S., Folkman, S. (1984). Stress, Appraisal and Coping. Springer Publishing Company, New York. 

2. Bandura, A., Adams, N.E., Beyer, J., Cognitive Processes Mediating Behavioral Change. Journal of Personality and Social Psychology, 1977, Vol. 35, No. 3, 125-139.

Leslie Durr, PhD, RN, PMHCNS-BC is an advanced practice psychiatric-mental health nurse with a private psychotherapy practice in Charlottesville, Virginia.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.