Overcoming Impulse Control Problems. A Cognitive Behavioral Therapy Program Workbook Oxford University Press 2011

Overcoming Impulse Control Problems
editor-in-chief
David H. Barlow, PhD
scientific
advisory board
Anne Marie Albano, PhD
Gillian Butler, PhD
David M. Clark, PhD
Edna B. Foa, PhD
Paul J. Frick, PhD
Jack M. Gorman, MD
Kirk Heilbrun, PhD
Robert J. McMahon, PhD
Peter E. Nathan, PhD
Christine Maguth Nezu, PhD
Matthew K. Nock, PhD
Paul Salkovskis, PhD
Bonnie Spring, PhD
Gail Steketee, PhD
John R. Weisz, PhD
G. Terence Wilson, PhD

Overcoming Impulse
Control Problems:
A Cognitive-
Behavioral Therapy
Program
Wo r k b o o k
Jon E. Grant • Christopher B. Donahue • Brian L. Odlaug
1
1
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on acid-free paper
About Treatments ThatWork™
One of the most difficult problems confronting patients with vari-

ous disorders and diseases is finding the best help available. Everyone
is aware of friends or family who have sought treatment from a seem-
ingly reputable practitioner, only to find out later from another
doctor that the original diagnosis was wrong, or the treatments rec-
ommended were inappropriate or perhaps even harmful. Most
patients, or family members, address this problem by reading every-
thing they can about their symptoms, seeking out information on
the Internet, or aggressively “asking around” to tap knowledge from
friends and acquaintances. Governments and healthcare policy-
makers are also aware that people in need don’t always get the best
treatments—something they refer to as “variability in healthcare
practices.”
Now, healthcare systems around the world are attempting to correct

this variability by introducing evidence-based practice. This simply
means that it is in everyone’s interest that patients get the most up-
to-date and effective care for a particular problem. Healthcare poli-
cymakers have also recognized that it is very useful to give consumers
of healthcare as much information as possible, so that they can make
intelligent decisions in a collaborative effort to improve health and
mental health. This series, Treatments ThatWork™ is designed to
accomplish just that. Only the latest and most effective interventions
for particular problems are described, in user-friendly language.
To be included in this series, each treatment program must pass the
highest standards of evidence available, as determined by a scientific
advisory board. Thus, when individuals suffering from these prob-
lems, or their family members, seek out an expert clinician who is
familiar with these interventions and decides that they are appropri-
ate, they will have confidence that they are receiving the best care
available. Of course, only your healthcare professional can decide on
the right mix of treatments for you.
v
This workbook is designed for your use as you work with a quali-
fied mental health professional to change your unwanted impulsive
behaviors, whether you suffer from out of control gambling, com-
pulsive buying, uncontrollable urges to steal things (kleptomania),
or a destructive fascination with fire (pyromania). The program is
composed of 6 sessions, with the option of an additional family ses-
sion, and has been scientifically validated and proven effective for
helping people overcome their impulse control disorders (ICDs).
Over the course of treatment, your therapist will teach you about
your ICD and how to recognize those situations or events that
trigger your impulses. You will learn strategies for managing these
triggers, as well as techniques for monitoring your thoughts and
changing your erroneous beliefs about your behaviors. Home prac-
tice and daily self-monitoring are essential to success, and this work-
book contains all the forms and worksheets you will need to complete
all in-session and at-home assignments.
Based on the principles of cognitive-behavioral therapy (CBT), this

program has a strong educational component that can help you
manage your problems independently, once you have completed
formal therapy.
David H. Barlow, Editor-in-Chief,

Treatments ThatWork™
Boston, MA
vi
Acknowledgments
The authors wish to thank Robert Ladouceur, Nancy Petry, and

Matt Kushner, all of whom provided invaluable guidance during the
early development of this manualized treatment. Robert Ladouceur
also generously allowed us to expand upon aspects of his earlier treat-
ment manual for pathological gambling, and apply them to other
impulse control disorders.
vii
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Contents
Chapter 1 Introduction to the Program 1

Chapter 2 Session 1: Education and Motivational
Enhancement 9
Chapter 3 Session 2: Financial Planning (PG, CB)
Alternate Content for PY: ICD Trigger Planning
Alternate Content for KM: Plan for Managing
Stolen Goods 17
Chapter 4 Session 3: Behavioral Interventions 35
Chapter 5 Session 4: Imaginal Exposure 49
Chapter 6 Session 5: Cognitive Therapy for
Impulsive Beliefs 55
Chapter 7 Session 6: Relapse Prevention 69
Chapter 8 Session 7: Family Session (Optional) 79
Appendix of Forms 85
ix
Chapter 1 Introduction to the Program
Goals
■ To learn about the impulsive behaviors treated in this

program: Gambling, spending, stealing, fire setting
■ To learn about this treatment program and what it will

involve
What Is an Impulse Control Disorder?
Impulse control disorders (ICDs) include pathological gambling

(PG), kleptomania/compulsive stealing (KM), pyromania (PY), and
compulsive buying (CB). ICDs are characterized by difficulties in
resisting urges to engage in behaviors that are excessive and/or ulti-
mately harmful to self or others. ICDs are relatively common among
adolescents and adults, are associated with co-occurring problems
such as depression or anxiety, and can be effectively treated with
behavioral and pharmacological therapies. Although the extent to
which the ICDs share clinical, genetic, phenomenological, and bio-
logical features is incompletely understood, many of the ICDs share
common core qualities:
1. Repetitive or compulsive engagement in a behavior despite

negative consequences.
2. Limited control over the problematic behavior.
3. An urge or craving is experienced prior to engagement in the
problematic behavior.
4. A hedonistic (e.g., pleasure-seeking) quality during the
performance of the problematic behavior.
1
These features have led to a description of ICDs as “behavioral
addictions.” We will define each ICD problem addressed in this
workbook. We believe all participants in the Cognitive Behavioral
Therapy for Impulse Control Disorders (CBT-ICD) program
need to be well informed about their specific ICD, to understand
how common the problem is, and to be knowledgeable about the
symptoms, behaviors, and thoughts associated with their ICD.
What Is Pathological Gambling?
Pathological gambling (PG) is characterized by a loss of control over

gambling, deception about the extent of involvement with gam-
bling, family and job disruption, theft, and chasing losses. Despite
its high prevalence, PG often remains untreated. According to a
1999 report of the National Gambling Impact Study Commission,
97% of problem gamblers in the United States fail to seek treatment.
Although the history of gambling treatment extends over several
decades, there is a surprising lack of reliable knowledge regarding
what constitutes an effective treatment for problem gambling.
Cognitive-behavioral interventions, however, such as the program
described in this workbook, have been scientifically proven to be
effective for treating PG.
What Is Kleptomania?
Kleptomania (KM) is characterized by the repetitive, uncontrollable

stealing of items not needed for personal use. Although KM typi-
cally appears in early adulthood or late adolescence, the disorder has
been reported in children as young as 4 years old, and in adults as
old as 77 years old. Intense guilt and shame are commonly reported
by those suffering from KM. Items stolen are typically hoarded,
given away, returned to the store, or thrown away. Many individuals
with KM (64% to 87%) have been apprehended at some time
due to their stealing behavior. Individuals may avoid stealing
when immediate arrest is likely, but the chances of apprehension are
usually not fully taken into account. Although a sense of pleasure,
gratification, or relief is experienced at the time of the theft,
2
individuals will describe a feeling of guilt, remorse, or depression
soon afterwards.
What Is Pyromania?
Pyromania (PY) is classified as an ICD because pyromaniacs cannot

control their impulses to deliberately start fires. Pyromaniacs start
fires to induce euphoria, and often fixate on institutions of fire con-
trol like fire stations and firefighters. They may even habitually listen
to police scanners to find out when and where fires occur. After
starting a fire, most pyromaniacs experience a relief in tension and
feelings of gratification. Pyromania is included in the CBT-ICD
program based on the fact that it shares many qualities with other
ICDs.
What Is Compulsive Buying?
Compulsive buying (CB; also referred to as compulsive shopping) is

fairly common, with approximately 1.4%–5% of the population
suffering from this behavior. The problem typically begins in late
adolescence, and a greater proportion of compulsive buyers are
women. Compulsive buyers commonly have co-occurring depres-
sion and anxiety disorders, substance use disorders, and eating disor-
ders. Compulsive buyers can experience a significant urge to engage
in the problem behavior, with little control over their actions. The
act of buying may be accompanied by feelings of excitement or
euphoria, often followed by depressed mood, shame, and/or letdown
once the buying experience is complete. The goal of the purchase
may often have nothing to do with the actual item, but rather to
alter one’s mood. Compulsive buying is often preceded by negative
affect, including feelings of anger, boredom, anxiety, with the pur-
chase providing temporary relief. Buying may occur year-round or
happen in binges, with purchases for self or overindulgent purchases
for loved ones. The purchases can occur in a range of venues, with
Internet shopping adding significant flexibility and convenience for
quick purchases. Common items purchased by compulsive buyers
include clothing, shoes, jewelry, and electronics.
3
Description of Cognitive-Behavioral Therapy for Impulse Control Disorders (CBT-ICD)
Cognitive-behavioral therapy (CBT) is based on the knowledge that

our thoughts cause our feelings and behaviors, not external things
like people, situations, and events. CBT is structured and goal-
oriented, with the therapeutic goal of helping you unlearn your
unwanted reactions and learn a new way of reacting. A critical com-
ponent of the program is to question the thoughts related to your
impulsive behaviors. You need to look at your thoughts as being
hypotheses or theories that can be questioned, tested, and corrected if
they are inaccurate. For example, if you suffer from PG, you may have
thoughts such as, “I am bound to win eventually. I just need to keep
playing.” CBT helps you question these inaccurate thoughts by having
you realize that although you may win on occasion, you seldom walk
away with your winnings. If you suffer from CB, you may have
thoughts such as, “I am only going to buy one thing today. I can con-
trol my spending.” However, the reality is that you end up buying
multiple items, and spend much more time and money than you orig-
inally had intended. This program will help you realize the truth of
your actions, and help you to change your impulsive behaviors.
CBT has a strong educational emphasis, with the expectation that

when people understand how and why they are doing well, they can
continue to practice those behaviors to make themselves well. This
is why therapy assignments between sessions are critical to realizing
therapeutic change. As part of this program, you will be expected to
complete assigned readings, self-monitoring of thoughts and behav-
iors, and practice between sessions the skills you have learned in
session. Goal achievement (if obtained) could take a very long time
if a person were only to think about the techniques and topics taught
for one hour each week. Procrastination and/or avoidance must be
addressed if these behaviors begin to interfere with therapy. After all,
the goal of the CBT-ICD program is to achieve long-term absti-
nence from your impulsive behavior.
Program Outline
You will meet with your therapist for 6 sessions, with the option of
an additional family session at some point during the program.
4
You and your therapist will determine together whether a family
session is necessary.
Following is an outline of the program and a list of concepts that

will be covered:
■ Pre-treatment assessment
■ Session 1: Evaluation of motivation to quit impulsive behaviors

and introduction of self-monitoring
■ Session 2: Financial planning (for PG and CB clients);
alternative content for PY and KM clients; introduction to
identifying ICD triggers
■ Session 3: Behavioral intervention, preparation for ICD

Triggers
■ Session 4: Exposure therapy (via guided imagery)
■ Session 5: Impulsive beliefs: cognitive therapy
■ Session 6: Relapse prevention
■ Session 7: Family involvement (optional)
What to Expect
As part of this treatment program, you will be asked to make sig-

nificant lifestyle changes in an effort to get your impulsive behavior
under control. Impulse control disorders are serious and require a
great deal of effort and practice to overcome. You have shown some
inclination to change your impulsive behaviors by just showing up
for treatment, so you are obviously motivated to work on your prob-
lem. If you are uncertain whether your impulsive behavior is prob-
lematic at this point, the CBT-ICD program will, at the very least,
help you to explore how it affects you and different parts of your life.
You and your therapist will initially complete a thorough assessment
of your impulsive behavior and related problems. The information
obtained during the assessment will then be used in your therapy
sessions, and will help you and the therapist in guiding treatment.
As you have already read, CBT has a strong educational component
that can help you manage your problems independently once
5
you have completed formal therapy. The program is comprised of
6 sessions, with the option of an additional family session, and has
been scientifically validated and proven effective for helping people
overcome their ICD. It is important to understand that therapy does
not stop once you are done seeing your therapist. Rather, you will
be expected to practice the skills and strategies beyond therapy
until new, healthy habits are formed and you are more confident in
managing your impulsive behaviors.
We understand that clients will bring different expectations to the

CBT-ICD program, and you and your therapist will work together
to ensure that the treatment is individualized to you. Expect to
receive new “homework assignments” each week, which are designed
to increase insight and to help you regain control of your impulsive
behavior. Unlike homework you would receive in school, therapy
assignments will not be graded. You will not “fail” treatment if you
do not complete the homework. However, homework is a key com-
ponent of therapy, so it is very important that you do your best to
complete each assignment.
Each therapy session will include the following parts:

■ Check-in, review of homework, and review of the previous
week (successes and challenges)
■ Education
■ Presentation of a new skill area
■ Practice new skill with therapist
■ Homework assignment
Initial Assessment
During the first meeting, your therapist will want to complete sev-
eral assessment measures to confirm your diagnosis and to under-
stand the severity of your behaviors. Because therapy may differ
depending upon whether you have a mild ICD or a severe ICD,
your therapist will want to determine how frequently you engage in
the ICD behavior, how intense the behavior is, and how the ICD
6
behavior affects your life and ability to function in other aspects of
your life. It will be important to tell your therapist about the conse-
quences of your behavior, even if the consequences involve legal
problems. It is also important to tell the therapist about how the
ICD behavior affects others in your life (e.g., marital problems, joint
financial difficulties). This provides information that is essential to
the therapist in understanding how severe the ICD is, and how the
ICD has affected your life. This initial assessment is crucial for
tailoring a treatment plan that fits with your specific needs.
Your therapist will begin your assessment by asking you a number of
questions from the Structured Clinical Interview for Diagnostic and
Statistical Manual of Mental Disorders (SCID) for your specific
ICD. These questions will help both you and your therapist deter-
mine whether you meet formal criteria for an ICD. In addition to
the SCID interview, your therapist will administer additional inter-
views in order to assess your ICD and other mental and physical
health challenges (e.g., mood and anxiety disorders, addiction,
health problems). Knowledge of these challenges will help you and
the therapist to tailor your treatment to address concerns that
might otherwise go unnoticed. These “co-occurring” problems can
greatly affect treatment for your ICD and, consequently, it is very
important that these issues are addressed along with your ICD.
7
Chapter 2 Session 1: Education and Motivational
Enhancement
Goals
■ To learn about your specific ICD
■ To work with your therapist to increase and maintain

motivation for treatment
■ To begin daily self-monitoring of your behaviors
■ To review your finances, if you have problems with gambling

or spending
Education
In this session your therapist will explain your ICD behavior (e.g.,
what is known about the behavior, what are the possible causes of
the behavior, how does the behavior relate to other problems you
have, or other problems in your family). Understanding the ICD
behavior should reduce some of the stigma and shame associated
with it, whereas talking about the behavior should provide the ther-
apist with additional information about how your ICD affects you
as a unique individual. The educational aspect of the initial assess-
ment may also provide you with some additional motivation to get
control over the behavior.
Staying Motivated
The behaviors often associated with ICDs are difficult because

you want to stop them, yet on some level you receive some positive
9
feelings from engaging in them (e.g., a sense of control, power,
excitement, etc.). Most people do not want to admit that they enjoy
or find some pleasure in their ICD behaviors. In fact, clients will
frequently respond to questions about their specific ICD behaviors
by stating, “I don’t like anything about it.” While this may be true at
the time they are sitting in the therapist’s office, most people readily
recognize that there are often very positive aspects to the behavior
(e.g., the behavior may reduce stress, at least momentarily, or pro-
vide an escape from family or work issues, etc.). In fact, although
many people say, “I want to stop the behavior,” what they really
mean is that they want to stop the consequences of their behavior.
Because of these feelings, you may be ambivalent at times about
stopping the behavior. Many people feel that they are getting rid of
a good, although problematic, “friend” when they stop their ICD
behavior. Therefore, motivation to control the behavior may come
and go over the course of treatment. Finding the motivation to con-
trol the behavior will be crucial to prevent relapse.
You will spend time in this session reviewing the different ways your
ICD has affected you, and assessing your motivation and readiness
to quit your impulsive behavior. Work with your therapist to com-
plete the Motivation to Quit Impulsive Behavior form provided in
this workbook. This will help you to see the negative effects that
your ICD has on your life. This worksheet will also help you to real-
ize the benefits of stopping your impulsive behaviors.
10
Motivation to Quit Impulsive Behavior
1) Positive aspects of impulsive behavior (what are the 2) Negative aspects of quitting (what do I lose if I
positive things the impulsive behavior gives me?) stop the impulsive behavior?)
3) What are the negative consequences of the impulsive 4) What are the advantages of quitting the impulsive
behavior (current and future?) behavior (what do I have to gain?)
11
Why do you to continue acting impulsively (gambling, buying,
stealing, or fire-setting) and why do you want to stop?
The following exercise will help you think more closely about the
reasons why you engage in impulsive behaviors in the first place, and
why you want to change your behavior.
What I Like About My Impulsive Behavior
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
What I Hate About My Impulsive Behavior
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Reasons Why I Want to Stop My Impulsive Behavior
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
12
Imagine, on all levels, what my life will be like when I stop the
impulsive behavior:
Career:_______________________________________________
_________________________________________________________
Friendships: __________________________________________
_________________________________________________________
Intimate Life: _________________________________________
____________________________________________________
Family Relationships:____________________________________
_________________________________________________________
Economics:___________________________________________
____________________________________________________
Hobbies/Recreational Activities:____________________________
____________________________________________________
Monitoring
Daily monitoring of thoughts, feelings, and behaviors is essential to

gaining control over your ICD problem. Simply not thinking about
your behavior will not help you stop it. You may not want to think
about your ICD behavior because you’re ashamed of it, or ashamed
of the consequences of your behavior. However, pretending the
problem is less severe than it is will not help your therapist provide
the necessary level of treatment. Therefore, keeping a daily diary will
allow you to record—in real time—how intense your desires are to
engage in the behavior, how much you’re actually doing the behav-
ior, and what may have triggered you to engage in the behavior. The
Daily ICD Behavior Diary (a modification of Ladouceur and
Lachance’s Daily Self-Monitoring Diary for Pathological Gambling)
allows you to record all aspects of your behavior. In addition, as you
gain more control over the behavior, you will actually see, in your
own words, how much progress you have made. It is important for
you to complete the diary every day.
13
Daily ICD Behavior Diary
Date: / / / / / / / / / / / / / /
1. To what extent do I feel my impulsive behavior is under control?

0—10—20—30—40—50—60—70—80—90—100
not at all a little moderately very much completely
2. How strong is my desire to act on the impulsive behavior today?

0—10—20—30—40—50—60—70—80—90—100
nonexistent weak average high very high
3. Did I engage in the impulsive behavior today? If so, what was happening at
that time and/or how was I feeling?
4. How much time (hours & minutes) did I spend on impulsive behavior?
5. (For gambling and spending problems). How much money did I spend on
gambling (excluding wins) or shopping?
6. (For shopping problems) How much money did I spend? What did I buy?
What did I do with it?
7. (For stealing problems). What was the value of the item(s) stolen and
what did I do with the stolen item(s)?
8. How did I feel today, and what was happening in my life today (e.g.,
depressed, bored, frustrated, happy, anxious, too busy at work, fight with
spouse)?
9. (For stealing and fire setting problems). Was I caught engaging in an illegal
act, and if so, what were the legal consequences?
Homework
✎ Review your completed Motivation to Quit Impulsive Behavior

form daily, as a reminder of the consequences of your impulsive
behavior. You will discuss the consequences of your behavior in
more detail at the next session.
✎ Begin daily recording of your behaviors using the Daily ICD

Behavior Diary. Additional copies are provided in the
Appendix, or you may make photocopies.
✎ If you have problems with gambling or overspending, your
therapist may ask you to complete the Financial Spending Form
in the next chapter (see page 19).
15
Chapter 3 Session 2: Financial Planning (PG, CB)
Alternate Content for PY: ICD Trigger
Planning Alternate Content for KM:
Plan for Managing Stolen Goods
Goals
■ To identify and plan strategies for managing finances, if you

have debt-related problems due to gambling or compulsive
buying
■ To create a plan for managing stolen goods, if you have

problems with stealing
■ To identify a support system and begin to identify triggers,
if you have problems with fire-setting
Introduction
Some of the content in this chapter may not apply to you. If you do
not suffer from pathological gambling or compulsive buying, you
may skip the first section on financial concerns. If you’d like to read
it, however, please feel free. Almost anyone can benefit from advice
for managing finances.
If you do not have problems with stealing, you do not need to create
a plan for managing stolen goods. Likewise, if your impulsive behav-
iors do not include starting fires, you do not yet need to begin
identifying ICD triggers (you will be doing this next session).
17
Monitoring Spending
In order to increase self-awareness of spending and money manage-

ment in general, you will begin to keep a weekly and monthly budget
of all expenses. A financial budget will help to increase awareness of
spending behaviors and gambling debt, and facilitate planning
for debt repayment. It will also help you to review your finances
overall, in order to discourage future reckless spending and gam-
bling. At this time, you and your therapist will begin to discuss how
you manage your money. If your spouse or significant other man-
ages money, it may be helpful for him or her to be involved in this
session. At the very least, you will need to share the recommenda-
tions from this session with your significant other. There needs to be
“transparency” in how your money is managed, especially if there
has been a lot of secrecy about your spending or gambling debt.
A certain percentage of gamblers and compulsive buyers may ignore
or avoid thinking about their accumulated debt. Of course, avoid-
ance may not be possible when you have taken out several mortgages
on your home or filed for bankruptcy. Gamblers and compulsive
buyers may also be quite adept at “moving money around” in order
to cover spending and gambling expenditures. Constantly thinking
about, or trying not to think about, money problems can lead to
other mental health problems, such as anxiety and depression—
problems that are common in those with an ICD.
At the end of last session, your therapist may have asked you to com-
plete the Financial Spending Form on page 19. If you completed the
form, your therapist will review it with you in this session. It is
important that all sources of expenditures be listed. Purposely ignor-
ing certain debts will not make them go away. Only if you are honest
on the financial spending form can your therapist accurately and
effectively help with any financial stress you may be feeling. You will
continue to use this form to monitor your spending for at least the
next week or two. This will help you get a better overall picture of
your expenses before you attempt to create a weekly or monthly
budget. Managing your spending and being aware of your expenses
will allow you to create a budget that will help you pay down your
gambling or spending-related debt.
Please feel free to photocopy the form from the book, or use the
additional copies provided in the appendix.
18
Financial Spending Form
Expense (Including Debt) Weekly Monthly
Example 1: Groceries 150 (3/2–3/8) 600
Example 2: Visa 240 (minimum payment)
Monthly Income +( )
Total Monthly Expenses: −( )
Balance =( )
19
Creating a Budget
After you have monitored your expenses for a few weeks, you
will work together with your therapist to create a workable budget.
We encourage you to enlist the help of your friends and family
in putting this budget together. Although talking about finances,
even with close friends or family, can be embarrassing, it is impor-
tant to have a support system in place. Friends and family members
can help keep you on track by checking in with you periodically
to see if you are adhering to the budget. You need to keep in mind
that trying to “keep up appearances” by pretending that your finances
are fine has not worked. Close friends or family can be important
allies in keeping you honest about your debt, and can provide
emotional support during this difficult time. Asking friends or family
to help you with this process may also result in transforming their
frustration with your behavior into a positive experience for
them. We find that family or friends often express strong negative
emotions toward a person when they feel they cannot help, or do
not know how to help. Having them assist with your budget not
only helps you, but also helps build a positive working relationship
with them.
In planning a budget, there are several factors to consider, including

credit card payments, household bills, and necessities such as food,
shelter, and clothing. If you have outstanding gambling or spending-
related debt, we encourage you to use more of your discretionary
money (after all other expenses are paid) to pay down high-interest
credit card debt. You may need to consider cutting back spending in
certain areas of your life in an effort to pay down debt. For example,
instead of going out to eat, you may have to plan a menu each week
and eat most meals at home, buying only those groceries that are
necessary. You may have to reconsider family trips and vacations.
Smaller cuts may be made in order to free up money, such as cancel-
ing magazine subscriptions or eliminating cable television. This may
be difficult for you, but it is a necessary step toward taking control
of your finances. In some cases, you may need an additional job to
20
help with the budget. In the case of compulsive spending, you should
start with selling items you have acquired due to that spending. The
money garnered from the sale can go toward paying down debt. The
most important goal of developing a budget is to increase your
awareness of where your money is going.
Use the Financial Budget Form provided to create your personal

budget.
21
Financial Budget Form
Monthly Expense Budget Previous Amount Difference Where can the difference
(Goal) Spent on this Item be applied? (e.g., Visa card
to pay more than minimum)
Example 1: 900 1000 100

Groceries
Ways to Expected Amount that can be Where the money can be

Increase Income used to decrease used to reduce debt
Monthly Income existing debt
Example 1: $800 $400 after taking out Pay down Visa bill
Part-time job taxes, gas money, etc.
Monthly Income +( )
Total Actual Monthly Expenses: −( )
Balance =( )
22
Strategies to Improve Your Financial Situation
You and your therapist will review suggestions for changing how you
handle your money. Not all suggestions will apply to your situation,
but work together with your therapist to identify strategies that
might work for you. Keep in mind that some of these suggestions
will be challenging. For example, handing all of the responsibility
for managing your money to a significant other, or giving a signifi-
cant other access to your banking and/or credit card accounts, may
feel like you are giving up too much control. It may also make you
feel like you are being punished and treated like a child. However,
when we think about being “in control,” we must take into consid-
eration the impulsive behavior for which you are getting treatment.
You have demonstrated, by entering and being eligible for this
program, that you meet criteria for an ICD. Your gambling and/
or spending is out of control, and is causing significant negative
consequences. Having someone take control of your money will
actually help you to regain control over your problem. You should
also keep in mind that turning your finances over to someone else is
not a permanent change. Once you are in control of your ICD, you
can once again have control over your credit cards, bank accounts,
etc. In cases where you cannot identify anyone close to you to help
manage your money, you and your therapist may discuss appointing
a payee or an objective financial advisor to work with you in manag-
ing your money. These strategies are considered temporary, but
would not change until you have demonstrated some control,
including a reduction in your urge to engage in impulsive behaviors,
developing new insights regarding your behavior, and implementing
new, healthier habits. Following is a list of suggestions for managing
your finances.
■ Restrict your access to money; have a loved one give you a
weekly amount of cash based on your spending and budget
forms (eliminate credit and debit cards).
■ Have your paycheck directly deposited into a savings account,

not a checking account.
■ Have expenses paid directly out of the savings account via
automatic payment.
23
■ Schedule weekly meetings with a significant other or loved one
to go over financial issues, bills, etc.
■ Get help from a credit counselor or an agency that can help
you with your budget.
■ Learn how to develop a budget that fits your income and

expenses.
■ Make firm plans to pay off your debts (starting with the most
urgent).
■ Designate a cosigner for your bank withdrawals.
■ Give a clear message to friends and family not to give you

personal loans.
■ Plan non-gambling/non-shopping activities around payday.
■ Inform a significant other about incoming money (e.g., income

tax return).
■ Ask someone else to get the mail, in order to limit your access
to checks and income.
■ Choose the strategies that you think will work for you, and list
them on the form on page 25.
24
Strategies I Will Use to Manage My Finances
Strategy Others Involved Plan to Implement Strategy
1.
2.
3.
4.
5.
Commitment to Quitting my Impulsive Behavior: By signing this

document, I am making a commitment to myself and my loved ones
to implement and use the strategies above for managing my finances.
I must make every effort possible to follow the above suggestions in
order to get my impulsive behavior under control and to manage my
debt responsibly. If I do not follow through with this commitment,
there will be no change in my impulsive behavior and I acknowledge
that I will likely cause more problems for myself and those that care
for me.
Client Signature
__________________________ Date _____________________
Significant Other/Family Member Signature
__________________________ Date _____________________
25
Managing Stolen Goods – Impulsive Stealing/Kleptomania (KM)
If you struggle with kleptomania, you may not have significant

financial problems but, rather, have a surplus of stolen merchandise
at home valued at differing amounts. Clients that steal impulsively
often keep, hoard, discard, or return stolen items, with the latter
indicating that individuals may actually profit financially from the
thefts committed. You and your therapist will work together to help
prevent you from benefiting financially from the stolen merchan-
dise. This session will include focusing on the development of a plan
to deal with stolen merchandise, which can include the donation of
stolen merchandise to charity (as long as no charitable contribution
for tax purposes is used). Your therapist will encourage you to iden-
tify possible alternatives for getting rid of the stolen merchandise.
You will be asked to enlist the support of a loved one, including
friends and relatives, and/or a possible sponsor if you belong to a
support group for your impulsive behavior. Having other people
besides your therapist involved will help keep you accountable for
your actions. These supportive people can also help you after you
complete your formal therapy sessions.
Plan for Dealing with Stolen Merchandise
The following list is not necessarily comprehensive, but provides

some framework for beginning to discard your stolen merchandise.
Consider the following suggestions:
■ Identify charities of interest, to include charities that accept

donated merchandise. Clothing is accepted by most
organizations (e.g., The Salvation Army, Goodwill, Dress for
Success).
■ Inform your family and loved ones of your plan to discard
stolen items. This provides some measure of accountability
outside of the therapist–client relationship.
26
■ Identify local schools that may use certain items (e.g.,
electronics, office supplies). Be aware, however, that you may
run into obstacles when donating to certain programs. You may
be required to present warranties or proof of purchase.
Use the worksheet provided to identify the charities you will donate
to, and when you will make the donation. Remember to ask a friend
or family member to accompany you when making the donation.
You will be required to present a receipt for the donated items at
your next therapy session.
27
Date Charity/Organization Support Person Plan to Implement Strategy
Commitment to Quitting my Impulsive Behavior: By signing this

document, I am making a commitment to myself and my loved ones
to implement and use the strategies above for getting rid of my stolen
merchandise in such a manner that I do not profit in any way. I must
make every effort possible to follow the above suggestions in order
to get my impulsive behavior under control. If I do not follow
through with this commitment, there will be no change in my
impulsive behavior and I acknowledge that I will likely cause more
problems for myself and those that care for me.
Client Signature
__________________________ Date _____________________
Significant Other/Family Member Signature
__________________________ Date _____________________
__________________________ Date _____________________
28
Identifying Triggers for Impulsive Fire Setting (PY)
If you suffer from pyromania (PY), you may not have any financial
problems related to fire setting. One exception may be legal fees, if
you have been arrested for your impulsive behavior. The following
content will also be covered in your next therapy session, but today
you will begin to identify those situations that put you at risk for fire
setting. First, you will list the most common ICD triggers for fire
setting on the My Triggers for Fire Setting form provided on
page 30. Then you will rate your confidence in being able to resist
the urge to set fires, should you have the opportunity, using the
Controlling Impulsive Behaviors Questionnaire provided on
page 31. Your therapist will then give you a homework assignment
to begin identifying possible solutions to help you resist fire-setting
tendencies. Your therapist will want to know about successful strate-
gies that you have used in the past to resist the urge to set fires.
When listing your ICD triggers, please consider all the influences on
your impulsive behavior, such as your state of mind, mood, stressors,
and/or conflict.
29
My Triggers for Fire Setting
When completing this form, please report as many details as possi-

ble. For example, time of day, how much time you have to plan for
and actually set fires; if you’re feeling bored, upset, angry, anxious,
depressed, happy; what you would need to have access to (fire-setting
material) before you could set fires; if you’re alone or with others; if
you have other plans during this high-risk time, if you are account-
able to anyone (e.g., boss, peers, loved ones); where you are, or where
you would typically set fires.
ICD trigger #1:
ICD trigger #2:
ICD trigger #3:
ICD trigger #4:
ICD trigger #5:
After identifying your ICD triggers, the next step will be to

transfer this information to the Controlling Impulsive Behaviors
Questionnaire on page 31 and rate your confidence in resisting the
urge when facing the identified ICD triggers. This exercise will
allow your therapist to create a behavioral intervention plan to suit
your needs. You will further develop this questionnaire at your next
session.
30
Controlling Impulsive Behaviors Questionnaire
Please describe your high-risk situations for engaging in impulsive

fire-setting 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 confidence to con-
trol your fire-setting behaviors if you faced these situations at the
present time.
Situation 1
____________________________________________________
____________________________________________________
____________________________________________________
If you had to face this situation at the present time, to what extent
would you have confidence in controlling your impulsive behavior?
1 2 3 4 5
No Control Moderate Control Total Control
Situation 2
____________________________________________________
____________________________________________________
____________________________________________________
1 2 3 4 5
31
Situation 3
____________________________________________________
____________________________________________________
____________________________________________________
1 2 3 4 5
Situation 4
____________________________________________________
____________________________________________________
____________________________________________________
1 2 3 4 5
Situation 5
____________________________________________________
____________________________________________________
____________________________________________________
1 2 3 4 5
32
Homework
✎ Continue daily recording of your behaviors using the Daily

ICD Behavior Diary. Additional copies are provided in the
appendix, or you may make photocopies.
If you suffer from PG or CB:

✎ Continue monitoring weekly spending using the Financial
Spending Form. You and your therapist will use the
information from this form to create a personalized budget.
✎ As directed by your therapist, begin filling out the Financial

Budget Form.
✎ Review your completed Strategies I Will Use to Manage My
Finances form and begin implementing strategies reviewed in
the session.
If you suffer from KM:

✎ Begin implementing the plan for dealing with stolen
merchandise.
If you suffer from PY:

✎ Identify members of your support system, and begin
identifying triggers for fire-setting using the My Triggers for
Fire Setting form and the Controlling Impulsive Behaviors
Questionnaire.
33
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 fire to
relieve the tension resulting from the conflict. 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 fire could be started has an urge to act impulsively.
If individuals without an ICD have thoughts about acting impul-
sively, 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 addi-
tional protection against acting impulsively. This session will focus
on identifying and planning for triggers, while implementing healthy
35
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 find 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
specific stores, you are likely to be banned already and would be
watched by security. If you are impulsively starting fires, you may
need to eliminate all exposure to fires. For example, you should avoid
monitoring news or police scanners for occurrence of fires, and
refrain from viewing material (e.g., movies, media, chat rooms)
related to fires. Self-exclusion is, without a doubt, the first 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 iden-
tify 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)
Gamblers frequently report that they gamble after work. Because

they generally take the same route home, they have difficulty
36
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,
consider only shopping if you have someone with you.
37
■ 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 find 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 identification 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)
Along with clients with other ICDs, compulsive fire starters may
engage in their impulsive behavior whenever they have down time.
38
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 fires.
■ Ask yourself when and where you are most likely to set fires. 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 fire
setting. If possible, restrict your access to anything related to
fire setting for at least several weeks. This may entail removing
all fire-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 fire setting.
Significant 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 find 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 Difficulties
People with ICDs often isolate themselves because of their impulsive

behaviors and, little by little, they abandon friends and family.
39
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 shop-
pers that make frequent requests for money to cover debts, and
neglect to pay back friends and loved ones, may find themselves
alienated from the very people they need to be supportive.
If you find 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 con-
sider 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 financial 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 first step in problem-
solving is to clearly define the problem, in an attempt to avoid
40
impulsive reactions. The act of clearly defining 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 finances, what exactly about my finances 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
find 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.
41
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 confidence to control your behaviors
if you faced these situations at the present time.
Situation 1
_________________________________________________________
_________________________________________________________
_________________________________________________________
1 2 3 4 5
Situation 2
_________________________________________________________
_________________________________________________________
_________________________________________________________
1 2 3 4 5
42
Situation 3
_________________________________________________________
_________________________________________________________
_________________________________________________________
1 2 3 4 5
Situation 4
_________________________________________________________
_________________________________________________________
_________________________________________________________
1 2 3 4 5
Situation 5
_________________________________________________________
_________________________________________________________
_________________________________________________________
1 2 3 4 5
43
Controlling ICD Triggers
In the spaces below, describe the ICD triggers that affect you the
most, and indicate how you might deal with them.
ICD Triggers Healthy Behaviors
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
44
Developing Leisure Skills
For many people, the impulsive behavior they are engaging in takes
the place of activities that they used to enjoy doing. Once you stop
engaging in your impulsive behaviors, however, you will find that
suddenly you have a lot of free time on your hands. What will you
do then?
Start by thinking about the activities and interests you pursued
before your ICD monopolized most of your time. What were your
passions and hobbies? Did you enjoy playing golf or basketball?
Did you enjoy knitting, going on walks, or doing volunteer work?
As you ask yourself this question, you may become aware of numer-
ous activities that you have neglected or completely abandoned
as the impulsive behavior became increasingly important in your
life. If you never developed interests in other leisure time activities,
this will provide an opportunity for you to begin exploring all the
possibilities.
Use the Life Categories form on page 46 to list activities (new or
otherwise) that you would like to engage in now that you are getting
your ICD under control. Be sure to list activities you can do on your
own, as well as those that require the presence of other people. List
potential activities according to the categories listed on the form,
and rank order them according to degree of difficulty. It is important
to be specific in your goal setting so there is some accountability. Be
specific in terms of a timeline for attaining the goal (e.g., goal attained
in 1 month), as well as how much time will be spent on the activity
(e.g., 1 hour per day, Mon–Fri). Also, make sure the activity is clearly
defined (e.g., “call my brother once per week and discuss my prog-
ress in therapy”).
45
Life Categories
*Difficulty Rating of Activities 1(least difficult) to 10(most difficult)*
Category Activities Rank*
1. Relationships 1.____________________________________ _____

(Family, Social,
Intimate)
2.____________________________________ _____
2. Employment/Career/ 1.____________________________________ _____

Education
2.____________________________________ _____
3. Hobbies/Recreation 1.____________________________________ _____
2.____________________________________ _____
4. Volunteer 1.____________________________________ _____
2.____________________________________ _____
5. Physical Health 1.____________________________________ _____
2.____________________________________ _____
6. Spirituality 1.____________________________________ _____
2.____________________________________ _____
7. Psychological/Emotional 1.____________________________________ _____
2.____________________________________ _____
8. Domestic 1.____________________________________ _____
2.____________________________________ _____
46
Homework

ICD Behavior Diary in Chapter 2. Additional copies are
provided in the Appendix, or you may make photocopies.
✎ Begin combating your ICD triggers by implementing the

healthy behaviors you listed on the Controlling ICD Triggers
form.
✎ Complete the Life Categories form (if not done in-session) and
begin engaging in leisure activities.

Spending Form in Chapter 3 of the workbook.
47
Chapter 5 Session 4: Imaginal Exposure
Goals
■ To learn about exposure therapy and how it is used to treat

impulsive behaviors
■ To work together with your therapist to develop an imaginal

exposure script that includes all the relevant internal and
external triggers related to your impulsive behavior
■ To participate in your first imaginal exposure in session
Introduction to Exposure Therapy
A unique element of the CBT-ICD program is the use of cue expo-

sure therapy (CE). The goal of CE, which has proven to be effective
(based on scientific studies) with fear or anxiety related problems, is
to decrease fear through repeated exposure to the feared stimuli. For
example, if someone is afraid of dogs, a CE exercise for that person
may involve being exposed to a dog in a controlled environment
(e.g., pet store, neighbor’s house) so the person can learn that it is
possible to be safe in the presence of a dog (e.g., not all dogs bite).
There is preliminary evidence that CE therapy can help those with

ICDs learn to control urges to engage in impulsive behaviors. As
opposed to traditional CE therapy, where the person is exposed to a
real-life situation, CE for impulse control disorders uses what it called
imaginal exposure. Imaginal exposure is a technique that involves using
your imagination to place yourself in a typical trigger situation in
order to activate the urge to engage in impulsive behavior, so you can
practice resisting it.
In this program, we use CE therapy along with negative mood induction
(NMI). NMI involves focusing on the negative consequences of the
problem behavior while the urge to engage in the impulsive behavior
is active. For example, if you have problems with overspending, your
49
therapist may ask you to imagine yourself in your favorite store when
there is a sale going on. Your therapist may begin by describing how
you typically plan for a shopping outing, which will likely activate the
urge before you imagine entering the store. Your therapist will then
describe the store to you in detail, activating your urge to buy some-
thing. Next, your therapist will introduce the negative consequences
of making a purchase (e.g., you will not be able to limit your spend-
ing, you will have to hide your purchases from your spouse or signifi-
cant other, you will feel guilty for buying items you don’t need, etc.).
What to Expect
The purpose of imaginal exposure is for you to imagine yourself in a

trigger situation and feel as if it were really happening to you. It is
important that you try your hardest to imagine yourself in the situa-
tion. You must be aware of the thoughts, feelings, sights, sounds, and
sensations you experience when you are in that situation. To do this,
you have to be good at vivid imagination, and this takes practice.
Your therapist will help ease you into the exercise with a few easy
scenes to imagine and visualize. During this exercise, you may expe-
rience an urge to engage in your impulsive behavior. You are expected
to have an urge, which is necessary in order to benefit from this exer-
cise. Your therapist will help you create an exposure script specific to
your ICD using the Imaginal Exposure Script form on page 51. Your
therapist will read the script of your impulsive behavior experience
aloud, while you listen with your eyes closed. While you are experi-
encing an urge, your therapist will introduce the negative conse-
quences of your impulsive behavior, as reported by you, followed by
a description of healthy coping strategies. You will be asked to rate
the intensity of your urges during the exercise using the Imaginal
Exposure Rating Form on page 54. During the in-session imaginal
exposure, your therapist will make a recording for you to use in your
homework assignments between sessions. For homework, you will
listen to this recording and use the Imaginal Exposure Rating Form to
rate your responses to the imagined scene. Your urge to engage in
impulsive behavior will likely decrease after listening to the exposure
multiple times, as you become more familiar with the content and
less reactive. The goal is for your urge to decrease by at least 50%.
50
Imaginal Exposure Script
1. Describe a situation where you typically would engage in your

impulsive behavior. Describe exactly what you imagine
happening, step by step, and your urge to act impulsively.
Describe as many details about the experience as possible,
including all your senses—what you imagined or actually did
see, hear, smell, etc. If relevant, would you be using alcohol,
drugs, smoking, etc.? What physical symptoms are you aware of
(e.g., rapid heart rate, sweating, restlessness) and what negative
consequences do you anticipate from your impulsive behavior?
Finally, imagine coping with the urge and resisting it.
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
51
2. Symptoms: Record all symptoms that accompany this feared
situation.
Difficulty Nausea/ Muscle Other

breathing abdominal tension
distress
Racing/pounding heart Chest pain/ Dry throat

discomfort
Choking sensation Hot/cold flashes Restless/

pacing
Numbness/tingling Sweating
Shakiness/ Faint/dizziness
trembling
Potential Challenges During Exposures
As previously mentioned, imaginal exposure is a difficult skill to

master. It requires intense concentration and a vivid imagination. In
order for the exposure to be effective, you must be able to put your-
self in the situation. You must feel as though the events are actually
happening to you at that very moment.
What if I don’t react to the imaginal exposure?
Some individuals may have difficulty focusing on the imagery during

the exposure, or may not have included all relevant information. If
you are not reacting to the imagery, there may be other reasons. For
example, you may not be following the instruction of focusing on
the imagery as if it is happening “in the moment.” You may be dis-
tracted by thinking about something else during the exercise. You
may have difficulty generating imagery. You may also be resistant to
completely focusing on the imagery, or overly pessimistic about this
treatment approach. It is okay to have a healthy skepticism about
this approach. By taking on this viewpoint, you can wait and see
what happens and go into the exercise with an open mind. In our
research, however, we have observed that the majority of clients
52
report an increase in urges during exposure, very similar to what is
experienced in actual impulsive behavior situations.
What if the exposure triggers my urge and I end up slipping and engaging in
impulsive behavior?
As mentioned previously, the goal of the exercise is to activate your

urge and the accompanying thoughts, feelings, and physical symp-
toms associated with your impulsive behavior. The negative conse-
quences portion of the exposure is designed to be a potent reminder
of what actually happens when you engage in your impulsive behav-
ior, and will likely have the effect of decreasing your urge not long
after it is activated. We have also developed other strategies to make
it less convenient and more challenging to engage in your impulsive
behaviors, even if you experience an urge. Through the repeated
practice of listening to your imaginal exposure tape, you will be
expected to gain more insight and be less reactive to impulsive
behavior triggers.
Homework

ICD Behavior Diary in Chapter 2. Additional copies are
✎ Begin combating your ICD triggers by implementing the

form.
✎ Practice imaginal exposure for a total of 4 repetitions per day,

twice in the morning and twice in the evening, and record urge
ratings on the Imaginal Exposure Rating Form at the end of
the chapter. Continue the imaginal exposure exercise daily until
there is a 50% or greater reduction in peak urge rating or until
the next therapy session, whichever happens first.

Spending Form in Chapter 3 of the workbook.
53
Imaginal Exposure Rating Form
0 10 20 30 40 50 60 70 80 90 100
None Mild Moderate Severe Extreme
Date (Exercise) Pre-tape Urge Peak Level of Urge Post-tape Urge
Morning Practice 1 (am)
Morning Practice 2 (am)
Evening Practice 1 (pm)
Evening Practice 2 (pm)
54
Chapter 6 Session 5: Cognitive Therapy for
Impulsive Beliefs
Goals
■ To identify erroneous beliefs related to your ICD
■ To learn how to evaluate objective evidence that supports and

contradicts impulsive beliefs
■ To learn how to develop healthy, alternative beliefs related to

your impulsive behavior
■ To develop a financial budget, if you have debt-related

problems due to gambling or compulsive buying
Assessment of Beliefs
In this session, you will be asked to identify your specific thought

process before, during, and after an episode of impulsive behavior. It
has been our experience that an individual’s thought process changes
markedly in the life cycle of an episode of impulsive behavior.
Typically, the person starts out feeling a positive emotion at the
thought of engaging in the impulsive behavior (e.g., optimism, hope,
or excitement). During the event, the person usually focuses on the
positive effects. Once the event is over, however, the person typically
feels regret, shame, embarrassment, or remorse. You were introduced
to this cycle in the previous session through participation in imaginal
exposure exercises. You have also learned behavioral interventions to
limit your exposure to cues that can trigger impulsive behaviors. The
next step in the process is helping you to understand that behind
every action, there is a thought. In this session, you will learn how to
evaluate your beliefs, and how those beliefs influence your actions.
55
If gambling is your primary problem, you will work with your
therapist in identifying your gambling routine. For example, your
therapist may ask how long you typically play your preferred game
or slot machine, what your strategy or thinking is if your machine is
unavailable, and when and if you change machines, as well as why.
Your therapist will also review laws of chance or randomness with
you, in order to develop a more objective understanding of gam-
bling odds. More information about the laws of chance can be found
at the end of the chapter.
As a person who suffers from an ICD, you may find that you “ratio-
nalize” your behavior and make efforts to quickly forget or ignore
the negative consequences of your impulsive behavior. One way to
increase your awareness of this tendency to forget or ignore is to
identify and record impulsive behavior episodes using the ABC Log
on page 64 (more details are provided in the next section). The very
act of recording is expected to increase awareness and help you
understand your thinking errors. The ultimate goal of using cogni-
tive therapy for an ICD is to correct thinking errors in the moment
the thoughts are operating and influencing your behavior —when
the urge to engage in the impulsive behavior is high.
The ABCs of Impulsive Behavior
Let’s begin by first defining the ABCs of impulsive behavior:
A = Activating event (ICD trigger)

B = impulsive Beliefs
C = Consequence (urge and behavior)
D = Dispute impulsive beliefs
E = Effect change
Activating Event
The A, or activating event, is what triggered your urge to engage in

the impulsive behavior. Refer back to Chapter 4 (Session 3) where
you first worked with your therapist to identify your triggers.
56
List the activating event or trigger in the appropriate column of the
ABC Log on page 64.
Belief
The B of impulsive behavior is belief, or how you think your impul-

sive behavior will affect your mood. Will it make you happy or
excited? The belief is also what you expect to come from the episode.
Will you win money? Will you get away with stealing? It may be
helpful for you to look at your beliefs in terms of predictions or
expectations. Your therapist will ask you to rate the degree of cer-
tainty that an impulsive belief is valid on a scale of 0–100 (on the
ABC Log), with 0 signifying no certainty at all, and 100 signifying
absolute certainty that the impulsive belief or prediction will happen
as predicted.
Once you have identified and recorded the impulsive belief in
observable and measurable terms, you can begin to use evidence to
dispute it.
Consequence
The C of impulsive behavior stands for consequences. Your therapist

will ask you to rate the intensity of your urge to engage in the impul-
sive behavior (using a scale of 0–100), as well as what you did
(“did I engage in the impulsive behavior?”), on the ABC Log.
Dispute
Disputing is a strategy to help you think more objectively about

your impulsive behavior. Use the Disputing Impulsive Beliefs form
on page 63 to identify evidence for and against your impulsive
beliefs. This exercise will ultimately bring to light the short-term vs.
long-term effects of your ICD. When disputing your impulsive
beliefs, it may be helpful to consider the following:
■ For gamblers – Evaluate possible misconceptions of the laws of
chance or randomness (see handout at end of chapter).
■ Review illusions of control – For example, how much time did

you plan to spend in the impulsive behavior? How much time
did you actually spend engaged in the impulsive behavior?
57
■ Mood changes – For how long do you experience a relief in
tension, if you are using your impulsive behaviors to change
your mood? Review with your therapist your mood states
before, during, and after engaging in an impulsive behavior.
Be objective.
■ Consider past experiences – Refer back to times you
experienced an urge and resisted it. Remember that urges will
come and go. You do not have to act on them.
Once you have identified evidence for and against your impulsive
beliefs on the Disputing Impulsive Beliefs form, transfer the evi-
dence back to the appropriate column of the ABC Log, along with
the alternative beliefs you came up with. Be sure to rate your certainty
in the dispute that was developed using the 0-100 rating.
Effect Change
The effect change column of the ABC Log is an opportunity to

evaluate the effectiveness, or E of impulsive beliefs, of the disputing
evidence, and alternative beliefs. After doing so, you will rerate your
degree of certainty in your original impulsive belief, as well as your
urge to engage in the related impulsive behavior (B and C columns
of the ABC Log).
Figures 6.1–6.4 show completed ABC Logs for clients with different
ICDs.
58
E
Effect Change
(Rerate
A B C D certainty in
Date/ belief and
Activating Event Belief Consequence Dispute
Time intensity of
(ICD Trigger) (Rate certainty 0–100) (Rate intensity 0–100) (Rate certainty 0–100)
urge 0–100
in Columns
B and C)
Monday I received coupons in I will be able to stop I will not spend When I examine the evidence, I know After
8 am the mail for my when I plan to, spend uncontrollably. that I quickly forget about all the considering the
favorite store and the amount I want, limits I have set for myself, I have dispute, I would
then started to plan and walk away with Rating = 80 rarely if ever stopped shopping when I rerate how
when I could get to purchasing what I planned to, always spend more than I certain I was
the store, maybe planned to. Revised rating = 30 plan to, and buy way more than in the initial
right after work, I I intended. belief, as well
could even get out Rating = 80 as the intensity
early to shop a little The next time I think about shopping, of my urge to
longer and find a Revised rating = 35 I need to remind myself that I have shop.
good deal. limited control over my spending, and
it would be irresponsible to even go
window shopping. I always feel guilty
after excessive shopping, especially
when my significant other sees the
bill, causing more arguments about our
increasing debt.
Rating = 90
Figure 6.1
Sample ABC Log for CB
E
Effect Change
B C
A (Rerate certainty
Belief Consequence D
Date/ Activating in belief and
(Rate (Rate Dispute
Time Event intensity of urge
certainty intensity (Rate certainty 0–100)
(ICD Trigger) 0–100 in
0–100) 0–100)
Columns B and
C)
Saturday Bored, thinking I know I will not get I do experience excitement and a rush of adrenaline After
9 pm about finding a stealing will caught. before and during a stealing episode. I have had several considering the
store where I be exciting, close calls where store attendants have come close to dispute, I would
could grab will bring me catching me in the act. That increases the excitement rerate how
something, nothing relief from in the moment, but as soon as I get home, I just add this certain I was in
planned for tonight, boredom, and item to the stack of other stolen merchandise. the initial belief,
everyone is busy, I will get Every time I look at the stuff I have stolen, I feel a as well as the
notice excitement away with it. mix of guilt and shame. Each time I steal, I seem to intensity of my
when I think about need to take more risks to get the same level of urge to steal.
the thrill of Rating = 80 Rating = 80 excitement, which could result in me getting caught,
stealing something. jeopardizing my livelihood and relationships. The
Revised Revised excitement quickly fades each time and then I am back
rating = 20 rating = 30 to feeling bored, maybe even depressed.
Each theft brings less and less satisfaction and I am

getting closer to being caught. When I am not stealing
something, I am constantly thinking about it, and this
is interfering with other important parts of my life.
Stealing is holding me back from commitment to work
and relationships. The risk/excitement is not worth
the cost.
Rating = 100
Figure 6.2
Sample ABC Log for KM
E
Date/ A B C D
Effect Change
Time Activating Event Belief Consequence Dispute
(Rerate certainty in
(ICD Trigger) (Rate certainty 0–100) (Rate intensity 0–100) (Rate certainty 0–100)
belief and intensity of
urge 0–100 in Columns
B and C)
Friday End of the week, I am sure I will win I will walk away with Now that I consider all the After considering the
5:30 pm nothing planned, winnings evidence, I don’t find it so dispute, I would rerate
stressful at work, believable that I will be able how certain I was in the
have $300 available to win, and walk away with initial belief, as well as
and I could drive by Rating = 80 Rating = 75 the winnings. I also the intensity of my urge
the casino on my way recognize the laws of to gamble.
home from work. Revised rating = 40 Revised rating = 30 chance are working against
Spouse has an after- me and usually favor the
work gathering, so I house. I will get home late
will have time to go and my spouse will be upset
and get home before with me again, he has
he is done. threatened to leave me if I
don’t quit gambling and giving
all of our savings away to
the casino.
Rating = 85
Figure 6.3
Sample ABC Log for PG
E
B C
A Effect Change
Belief Consequence D
Date/ Activating (Rerate certainty in
(Rate (Rate Dispute
Time Event belief and intensity
certainty 0– intensity 0– (Rate certainty 0–100)
(ICD Trigger) of urge 0–100 in
100) 100)
Columns B and C)
Sunday I have some Fire-setting I will have I do experience excitement and a rush of adrenaline After considering
11:30 pm downtime, will lead to fun and no one when I think about setting a fire, when planning it, the dispute, I would
late at night, excitement will get hurt and when engaged in the act of fire-setting. I never rerate how certain I
no plans with and will be and nothing consider the negative consequences of fire setting was in the initial
anyone, start fun and I will will get until after the fact. The elated mood quickly fades belief, as well as the
to think about not cause any damaged. each time I do it. I can increase excitement again by intensity of my urge
how fire damage/harm. imagining fires set in the past. I notice that I spend to start a fire.
would look in Rating = 90 a lot of time thinking about fire, use up most of my
the Rating = 90 free time thinking about fires, researching ways to
nighttime, Revised set fires, and listening to police scanners. I have had
start to Revised rating = 40 several fires get out of control, burned garage down,
notice rating = 25 set field of grass on fire, and I have been caught in
excitement the past. I have burned my hands, lost hair on my body
and had to make excuses to medical personnel, friends,
and coworkers. I used to have other hobbies that
were healthy and that could be exciting, the benefits
lasted longer (e.g., mountain biking, rock climbing),
were not illegal, and I did not cause anyone harm.
Although fire-setting is exciting, the thrill does not

last and I risk more harm to self and others each
time I do it. I think about it and spend so much time
on this habit, maybe it is not as fun and exciting as
I thought.
Rating = 80
Figure 6.4
Sample ABC Log for PY
Disputing Impulsive Beliefs
What is my impulsive belief?

_________________________________________________________
_________________________________________________________
_________________________________________________________
What is the evidence for my impulsive belief?

_________________________________________________________
_________________________________________________________
_________________________________________________________
What is the evidence against my impulsive belief?
_________________________________________________________
_________________________________________________________
_________________________________________________________
What is the alternative viewpoint?
_________________________________________________________
_________________________________________________________
_________________________________________________________
What is the rational response?
_________________________________________________________
_________________________________________________________
_________________________________________________________
63
ABC Log
Date/ A B C D E
Time Activating Event Belief Consequence Dispute Effect Change
(ICD Trigger) (Rate certainty 0–100) (Rate intensity 0–100) (Rate certainty 0–100) (Rerate certainty in belief and intensity
of urge 0–100 [Columns B and C])
Additional Suggestions for Cognitive Therapy
The Disputing Impulsive Beliefs Form and the ABC Log must be
used whenever you experience an urge to engage in your impulsive
behavior. If you do not experience an urge, use the forms to evaluate
past episodes of the behavior.
In order for this strategy to be effective, you must complete the

forms in real time, as close to the actual event as possible. Our moods
and beliefs often change quickly as time passes, and it will be hard
for you to accurately remember and capture how you were feeling,
days or even several hours after the fact. Consequently, it is impor-
tant that you photocopy the forms from the book and keep copies
with you at all times.
If you do not use these forms on a regular basis, you will likely not
see much of a change in your thoughts and behaviors. Take the
example of someone who is prescribed an antibiotic medication and
instructed to take the pills twice a day for ten days. If the person
does not take the medication as prescribed, the infection will not go
away. The same holds true for cognitive therapy. If you forget to
practice the techniques, or if you practice them only periodically,
you won’t see a change in your symptoms.
You are being asked to develop a new habit, and when we are learn-
ing something new, it usually takes consistent practice. Make an
effort to practice the cognitive strategy on a regular basis, as assigned,
observe if there is any change in how you cope with impulsive beliefs,
and note the effect on your symptoms.
Creating a Financial Budget—Pathological Gambling and Compulsive Buying (PG and CB)
You and your therapist will begin to develop a financial budget based
on your self -monitoring of spending over the past several weeks.
The budget will include all current income and expenses, and
will specifically address short-term and long-term plans to begin
paying down gambling or shopping related debt. Refer to Chapter 3
(page 22) for a copy of the Financial Budget Form and guidelines.
65
Homework
✎ Continue daily recording of your behaviors using the Daily ICD

Behavior Diary introduced in Chapter 2. Additional copies are
✎ Continue combating your ICD triggers by implementing the

form in Chapter 4.
✎ If your peak urge has not decreased by 50% or greater, continue
practicing imaginal exposure twice in the morning and twice in
the evening for a total of 4 times per day, and record urge
ratings on the Imaginal Exposure Rating Form introduced in
Chapter 5. If peak urge rating has decreased by 50% or greater,
then use the imaginal exposure recording as needed.
✎ Complete the ABC Log and Disputing Impulsive Beliefs Form

whenever you experience an urge to engage in impulsive
behaviors. Please photocopy the forms from the book, and
carry copies with you at all times. It is important to complete
these forms in “real time,” at the very moment you experience
the urge. If this is not possible, quickly note your urge intensity
and complete the forms as soon after the fact as you can.

✎ Begin to use and monitor your financial budget that was
developed with your therapist in this session.
For Pathological Gamblers—Basic Information on Games of Chance
■ The more familiar a person becomes with a game, the more he

or she has a tendency to increase the size of the bet in
succeeding games.
■ The more a game requires active participation (e.g., Roulette,

Blackjack, Lotto), the more one tends to make large bets, and the
more one develops all sorts of erroneous beliefs about one’s ability
to play the game. By “erroneous beliefs” we mean misconceptions
that run counter to the principles of games of chance.
66
■ When gamblers are asked to verbalize what they think while
playing, 70% of what they say constitutes irrational beliefs that
violate the principles of probability.
While gamblers develop erroneous beliefs in a variety of ways, it is

usually a lack of knowledge about the laws of probability that under-
lie such beliefs. Here are the basic principles that one should under-
stand about games of chance.
■ What exactly is chance, or randomness? By definition, chance is
something that one cannot predict. Chance is that which is
unforeseeable, and over which one has no control. One
sometimes says that an event happened by chance and without
my intention.
■ Slot machines, video poker, Roulette, craps, and Lotto all work
on the same principle. However one plays, one has no control
over the outcome. The fact that you can choose or decide the
amount of the bet, the numbers you bet on, or the time and
place of playing, gives the impression that you can influence
the outcome. All these variables create the illusion of control
over the game. They give the impression that there are a
number of ways of increasing one’s chances of winning.
Only chance determines the outcome. With these machines
you are powerless, and can in no way increase your chances of
winning.
■ If you toss a coin, you have a 1 in 2 chance of getting tails.
Even if tails comes up three times in a row, there is a still a 50%
chance of getting tails on the next toss. In fact, the probability
that tails will come up is always 50%—no matter what has
come up in the past. It is thus erroneous to believe that tails
will come up because the last three tosses were heads.
■ Remember that each bet has two dimensions: (1) the proba-
bilities of winning and losing; and (2) the size of the pay-off.
You will notice that bets with the highest risk have the largest
pay-offs, while bets with less risk have smaller pay-offs. There-
fore, if you have an advantage in one dimension, you will
automatically have a disadvantage in the other.
67
■ It is impossible for you to maximize your chances of winning.
The only thing you can do is minimize your losses (by betting
less). Casinos are businesses. The games are always set up for
the advantage of the house. Thus, in the long run, and
distributed over a large number of games, the machines are
guaranteed to return only a small percentage of whatever is fed
into them.
CHANCE IS ALWAYS AGAINST YOU
(Adapted from Ladouceur, R., & Lachance, S. (2007). Overcoming

pathological gambling. Oxford: Oxford University Press.)
68
Chapter 7 Session 6: Relapse Prevention
Goals
■ To review all the skills you have learned thus far, and prepare to
use them independently
■ To identify ongoing supports for maintaining the progress you

have made
■ To determine if there is a need for referrals for additional
treatment (e.g., marriage and family therapy, individual therapy
for other mental health challenges)
■ To identify and discuss relapse prevention strategies
Planning for the Future
You have made significant changes in the past several weeks, and are
likely still in the process of adjusting to these changes. You have, we
hope, practiced and noticed benefits from the skills and strategies
learned in the CBT-ICD program. You must keep in mind, as you
are ending formal sessions with your therapist, that therapy does not
really end. You must keep practicing the skills learned in this pro-
gram until you have developed new, healthy habits. If you have been
successful in managing your impulsive behavior over the course of
your therapy, you have demonstrated that you have the ability to
retain control. Keep in mind that although you met with your
therapist once per week, you benefited the most from practicing
the CBT-ICD program strategies on your own, with the support
of family and friends, between sessions. You have already demon-
strated some independence in managing your impulsive behavior,
and you can continue to do so. Some individuals may need more
support than others, and you must be able to recognize your need
for help and allow others to assist you. You have not only made
69
changes in your impulsive behavior, but we hope that you look at
this therapy program as an opportunity for a change in your “life-
style.” You learned in this program how the impulsive behavior
has been interfering in many areas of your life, possibly preventing
you from pursuing important life goals. Use the momentum you
have gained from learning to manage your impulsive behavior, and
continue to work on and develop new goals for yourself. You can con-
tinue to use the Life Categories form in Chapter 4 as a format for goal
identification and achievement.
Reevaluation
Your therapist will review your progress to date by re-administering

some of the diagnostic interviews and questionnaires that you com-
pleted at the beginning of treatment. This assessment will help you
and your therapist determine if you still meet the diagnostic criteria
for the ICD. You may ask, why do I need to know this or why would
I want to know? A reevaluation of your symptoms can help you to
see further evidence of your progress. The assessment findings will
be combined with your report, and family reports of changes noticed
during therapy. The reevaluation will also be a reminder of what
symptoms, beliefs, and behaviors are a signal to you and your loved
ones that you are slipping into old habits. We will talk about “slips”
and how to cope with them later in this session.
Future Triggers
You must be prepared for future triggers or stressors that may elicit
an urge and subsequently put you at risk for engaging in impulsive
behaviors. It can be helpful to list future ICD triggers, and possible
healthy behaviors you can practice to prevent impulsive behaviors.
70
Planning for Future Triggers
List major life events that may occur in the near future.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
List strategies for coping with these or similar situations.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
71
Critical Skills and Strategies to Practice
We cannot stress enough the importance of ongoing practice of the

skills learned in therapy. We encourage you to continue the following
exercises.
■ Daily self-monitoring of urges and any impulsive behaviors.

Ongoing self-monitoring of urges and behaviors will serve to
maintain self-awareness of activating events (triggers) and your
reactions.
■ ICD trigger management. Maintain plans for dealing with
ICD triggers. Avoid all unnecessary exposures to situational
triggers, and attempt to engage in healthy coping activities
when experiencing distress, boredom, or struggling with
conflict.
■ Financial management. If you suffer from PG or CB, continue

to use a financial budget and adhere to a long-term plan for
paying down debt. You may need to continue having
significant others or designated support persons manage your
finances until you feel confident of doing it on your own. The
long-term plan is to phase out the monitoring done by the
support person once you have increased control over your
impulsive behaviors. You may also consider consulting with a
credit counselor or financial advisor for long-term financial
planning.
■ Use the Disputing Impulsive Beliefs form and the ABC Log
whenever you experience an urge to engage in impulsive
behavior. Continue to use these forms until there is a change in
your thinking, such that the objective evidence against acting
impulsively becomes more automatic and accessible when an
urge is experienced.
■ Leisure skill development. Continue to plan for and
implement regular leisure activities. Be sure to try a variety
of activities, such as regular exercise, volunteering, social
activities, hobbies (established and new), etc. If you enjoy
high-risk activities, explore healthy alternatives such as
downhill skiing or rock climbing. You can also build upon
72
goals set earlier in treatment. For example, you may be ready to
increase the intensity of exercise, from 2 days per week,
30 minutes each time, to 4 days per week for 1 hour per day.
The point is to continually challenge yourself and look for
opportunities for growth.
■ Imaginal exposure. Practice imaginal exposure as needed, using
the recording provided to you by your therapist.
■ Problem solving. Use the problem-solving method whenever

you experience interpersonal distress, or encounter any
problem that may have served as a trigger for your impulsive
behavior in the past.
Relapse Prevention
If you suddenly find yourself wanting to engage in your impulsive

behavior, or if you have already done so, stop for a moment. Look at
and listen to what is going on inside you. This desire to act impul-
sively is telling you that you are in danger. Compare your episode of
impulsive behavior to having a flat tire. What should a driver do
when he has a flat tire? The first thing he should do is stop quickly,
but safely, and pull over to the side of the road. Then, the driver
should consult his manual and follow the emergency procedures to
solve his “flat tire” problem. If you have the desire to engage in
impulsive behavior, or if you have already done so, stop and find a
quiet place where you will be less distracted by the temptation. Once
you have stopped, consult the emergency measures provided at the
end of the chapter. Feel free to photocopy them so you can carry
them with you at all times. On these pages you will find the precise
instructions you need to follow to avoid a relapse.
Ending Therapy
As treatment formally comes to an end, please feel free to ask your

therapist questions and voice any concerns you may have about
ending therapy. Your therapist will provide referrals for additional
treatment as needed, and may recommend ICD support groups.
73
You and your therapist will schedule a follow-up visit in approximately
one month to ensure progress is maintained. Additional follow-up
visits will be scheduled at the discretion of you and your therapist.
Your therapist may suggest an additional therapy session for you and
your family (see Chapter 8). We highly recommend the family ses-
sion in order to give family members and significant others the
opportunity to ask questions and receive guidance on how to best
support you.
74
Emergency Procedures
1. Remain calm.
Your first reaction to temptation, whether you have actually engaged

in impulsive behavior or not, may be to feel guilty and blame your-
self for what has happened. This is a normal reaction and one you
should expect. The only danger is that you give in to temptation and
lose control. If you are tempted to engage in impulsive behavior, try
the following suggestions:
■ Give yourself enough time to allow the temptation to appear

and subside. If you do not give in to the temptation when it
first appears, there is a good chance that it will go away after a
short time.
■ Don’t condemn yourself; rather, play the role of an observer

and wait for the reaction to pass. It does not help to be
self-critical in these situations.
■ Whatever you do, try not to give in to the temptation, as this
might reawaken your old habits. Consider the example of a
person sober from alcohol for six months. If the person had
alcohol in a dessert, would it justify the person saying,
“I messed up! I ate some food with alcohol in it and now
everything is ruined. I might as well return to drinking!”
If you give in to temptation, it will only become more difficult to

control yourself. However, keep in mind that a slip is not the same
as a total relapse. Rather than viewing it as a sign of complete failure,
see it as an opportunity to learn from your mistake.
2. Remember your resolution.
After a slip, the main problem is maintaining your motivation to

regain control. Perhaps you believe that you have failed completely
and want to give up. Once again, this is a normal reaction. The
following may help you:
■ Think about why you decided to stop the impulsive behavior

in the first place. Think about the long-term benefits of this
75
decision. Is it worth throwing all this away just because you
have run into a problem?
■ Talk to yourself and try to reconcile the part of yourself that
wants to stop the impulsive behavior with the part that wants
to give up everything you have worked so hard to achieve.
Remember that you are trying to change your habits for your
own good.
■ Look back at all the effort you have invested and the progress
you have made. Try to be a little optimistic instead of focusing
on your current difficulties.
Do you really think that a single slip wipes out all the progress you
have made? Remember your resolution and your long-range goals.
Don’t forget, you alone control your actions and you are the master
of your fate!
3. Carefully analyze the situation that has led to your slip or the urge to act impulsively.
Resist the impulse of blaming yourself for what has happened,

because self-blame only makes it more difficult to take corrective
action. Learn from the slip.
■ Ask yourself the following questions: When you felt the urge,
what was the context, what time of day was it, who was present
and who was absent, what was your mood and what you were
doing? Above all, try to remember what thoughts might have
triggered this urge. What thoughts brought about your slip?
Were there any warning signs before you slipped? What was the
high-risk situation? The answer to each of these questions can
give you important clues that may sharpen your vigilance
against future urges to engage in impulsive behavior.
■ If such slips occur more frequently, it means that something is

happening and you need to take care of it. Have you tried to
do something to prevent a slip from happening? If so, what
strategy have you used to counteract your urge? Why was this
strategy ineffective? What can you do next time that will be
more effective? If, on the other hand, you have done nothing to
prevent a slip, why not? Has your motivation weakened? Why?
76
■ Go over the event in your mind. Mentally review all the ways
you know that might help avoid giving in to temptation. Try to
replace irrational beliefs that feed your desire to engage in
impulsive behavior, with more realistic thoughts. Don’t forget
that it is you who controls your thoughts and actions.
77
Chapter 8 Session 7: Family Session (Optional)
Goals
■ To discuss with your family the specifics of your ICD, the

treatment program you have just completed, and how they
can assist in your recovery
Purpose of Family Session
There are three distinct goals of the family session:
1. Explaining the therapy to the family members/significant

others so they are aware of progress and changes made, and
what ongoing support you will need.
2. Allowing you the opportunity to inform family members/
significant others about your impulsive behavior in a safe,
neutral setting.
3. Assessing what your family members/significant others may
need to help them better cope with this problem.
Education about ICD and the CBT-ICD Program
Your therapist will take the opportunity to inform family members

and significant others about the disease model of impulsive behav-
iors, and the goals of CBT in changing the brain. Your therapist may
draw parallels to diabetes or alcoholism to illustrate the biological
underpinnings of ICDs.
Family members may report differing concerns based on the type of

ICD. Family members of individuals who suffer from PG and CB
may often have great anger toward the person due to the financial
problems, lying, and manipulation that is often symptomatic of an
79
ICD. Family members may misperceive the discussion about the
biology of the ICD as an “excuse” for you. It is important to stress
that although there are strong biological factors underlying the ICD,
you are in control of whether you seek treatment and keep working
on the therapy. This allows both you and your family and significant
others to understand that although the illness may be beyond your
control, the choice to do the therapy, and do it thoroughly, is within
your control.
Family members may also want to know about the genetics or heri-
tability of ICD. They may be worried about their children or other
family members. Your therapist will inform family and significant
others of important facts about the ICD problem. He or she will
also stress that although there are genetic links within families, genet-
ics plays only a part of the development of an ICD. Environmental
issues, developmental processes, and unknown factors also account
for the disorders. Your family will be made aware that other family
members may develop this problem, but that it is not your “fault” if
children or other biological family members struggle with impulsive
behaviors. Family members will be disabused of the notion that your
illness is any sort of “infection” within the family. Family members
will also be informed that they did not cause your impulsive behav-
ior, and do not have to atone for their guilt by taking care of all the
problems resulting from your actions (e.g., paying off your gambling
or spending debt, returning stolen items to the store, or dealing with
the legal problems that may have resulted from your impulsive
behaviors).
Debt Related Concerns for PG and CB
If you suffer from PG or CB, your family members may feel that
they need to “rescue” you financially, either because they feel guilty
or because they worry about you. Your family will be informed that
you are working on, or will be working on, payment plans, and that
“bailing you out” is not generally a good idea. You need to be honest
with your family about your debt, and about any repercussions relat-
ing to that debt. Although we do not want your family and friends
to “bail you out,” we do want them to support you in managing
80
your finances and adhering to the budget you created in Session 2
(see Chapter 3). Your therapist will inform your family about your
payment plan, if one was developed. It is important that family
members realize that they are a priority. In other words, household
debt will be addressed before anything else. This stresses the idea
that the welfare of the family comes first.
Suggestions for Family Member Support
The family session provides a safe setting for you to discuss your
impulse control problems with those close to you. Family members
can be important allies in managing the symptoms of the ICD. The
family session allows you the opportunity to discuss the extent of
your impulsive behavior problems, the reality of the resulting prob-
lems, and the plans or other solutions that have been put in place to
deal with the problems.
Specific ways in which family members may help with the therapy
include:
1. Family members may be told how they can help remove or

reduce your triggers for impulsive behaviors. For example, if
feeling lonely on Friday night is a trigger, your family can plan
social activities on Friday night and invite you to join them.
2. Family members may want to continue to work with you on
debt. If feeling overwhelmed by debt is a trigger to shop or
gamble, then regular meetings with your family to discuss
bills may alleviate the catastrophic thinking and avoidance
surrounding debt.
3. Family members may be enlisted to help with new healthier
behaviors. Ask your family and friends to join you in leisure
activities as discussed in Chapter 4.
4. Inform family members about the warning signs of relapse.
If they know what to look for, they can help you handle any
slips and get you back on track.
81
Helping Family Members Cope
Family members often find that attending support groups can be

helpful. Visiting with other people with similar problems, as well as
with other family members, can help you and your family to realize
that you are not alone in dealing with impulsive behavior problems.
Share with your family the following suggestions for obtaining
support:
■ If you have problems with gambling, suggest that family

members attend Gamblers Anonymous and/or Gam-Anon
meetings. If your family members have gambling problems of
their own, help them find a qualified mental health
professional and reputable treatment program. Your therapist
can help you with referrals.
■ Encourage family members to research support groups online.
■ You may even suggest family and/or couples therapy,

particularly if your ICD has negatively affected your
relationship with your spouse or partner.
Wrap-Up
Family members and significant others can be important allies in

managing impulsive behaviors. The family session allows you to dis-
cuss the extent of your impulsive behavior, and the reality of the
negative consequences. It is important that you are honest with your
family about all the negative consequences of your impulsive behav-
ior, especially if they are not fully aware of what is going on. You can
take the opportunity during this family session to make requests of
your family members that will aid you in your recovery. For exam-
ple, your family and significant others may need to control or mon-
itor your expenses for an extended period of time. Family and
significant others may also need some time to learn to trust you
again with regard to your impulsive behavior. This session will pro-
vide an opportunity for family and significant others to provide
82
feedback and ask questions about how to best support you. If inter-
personal conflict has served as a trigger for your impulsive behavior,
it may be advisable to work on open, assertive communication.
Improved communication will take practice, and you may benefit
from couples or marriage counseling with your significant other to
reverse unhealthy (e.g., blaming, accusing) communication patterns.
83
You may wish to use the form provided below to set personal and
family goals to assist in your recovery from your ICD. An example
goal is provided to help you develop your own.
Goal Actions Timeline
Improved Set aside 30 minutes each day, in the evening, after dinner, Next 3
communication to discuss what went well today, challenges, and share feelings. months
with spouse
84
Appendix of Forms
85
Daily ICD Behavior Diary
Date: / / / / / / / / / / / / / /

0—10—20—30—40—50—60—70—80—90—100

0—10—20—30—40—50—60—70—80—90—100
3. Did I engage in the impulsive behavior today? If so, what was

happening today and/or how was I feeling?
4. How much time (hours & minutes) did I spend on impulsive

behavior?
5. For gambling and spending problems – How much money

did I spend on gambling (excluding wins) or shopping?
6. For shopping problems – How much money did I spend?

What did I buy? What did I do with it?
7. For stealing problems – What was the value of the item(s)

stolen and what did I do with the stolen item(s)?
8. How did I feel today and what was happening in my life today
(e.g., depressed, bored, frustrated, happy, and anxious, too busy
at work, fight with spouse)
9. For stealing and fire-setting problems – Was I caught engaging

in an illegal act and if so, what were the legal consequences?
DAILY ICD BEHAVIOR DIARY
Date: / / / / / / / / / / / / / /

0—10—20—30—40—50—60—70—80—90—100

0—10—20—30—40—50—60—70—80—90—100


behavior?




Date: / / / / / / / / / / / / / /
1. To what extent do I feel my impulsive behavior is under

control?
0—10—20—30—40—50—60—70—80—90—100
2. How strong is my desire to act on the impulsive

behavior today?
0—10—20—30—40—50—60—70—80—90—100


behavior?




Date: / / / / / / / / / / / / / /

0—10—20—30—40—50—60—70—80—90—100

0—10—20—30—40—50—60—70—80—90—100

4. How much time (hours & minutes) did I spend on

impulsive behavior?
5. For gambling and spending problems – How much money did

I spend on gambling (excluding wins) or shopping?

7. For stealing problems – What was the value of the item(s) stolen
and what did I do with the stolen item(s)?
(e.g., depressed, bored, frustrated, happy, and anxious, too busy at
work, fight with spouse)
9. For stealing and fire-setting problems – Was I caught engaging in

an illegal act and if so, what were the legal consequences?
Date: / / / / / / / / / / / / / /

0—10—20—30—40—50—60—70—80—90—100

0—10—20—30—40—50—60—70—80—90—100


impulsive behavior?




Date: / / / / / / / / / / / / / /

0—10—20—30—40—50—60—70—80—90—100

0—10—20—30—40—50—60—70—80—90—100


behavior?




Date: / / / / / / / / / / / / / /

0—10—20—30—40—50—60—70—80—90—100

0—10—20—30—40—50—60—70—80—90—100


impulsive behavior?



Date: / / / / / / / / / / / / / /

0—10—20—30—40—50—60—70—80—90—100

0—10—20—30—40—50—60—70—80—90—100


impulsive behavior?




Date: / / / / / / / / / / / / / /

0—10—20—30—40—50—60—70—80—90—100

0—10—20—30—40—50—60—70—80—90—100


impulsive behavior?



Date: / / / / / / / / / / / / / /

0—10—20—30—40—50—60—70—80—90—100

0—10—20—30—40—50—60—70—80—90—100


impulsive behavior?




Example 1: Groceries 150 (3/2–3/8) 600
Example 2: Visa 240 (minimum payment)
Monthly Income +( )
Balance =( )
96
Monthly Income +( )
Balance =( )
97
Monthly Income +( )
Balance =( )
98

_________________________________________________________
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99

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100

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101

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102

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103

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104

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105

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106
ABC Log
Date/ A B C D E
Time Activating Event (Belief) (Consequence) (Dispute) (Effect Change)
(ICD Trigger) (Rate certainty 0-100) (Rate intensity 0-100) (Rate certainty 0-100) (Rerate certainty in belief
and intensity of urge 0–100 [columns B and C])
ABC Log
Date/ A B C D E
ABC Log
Date/ A B C D E
ABC Log
Date/ A B C D E
ABC Log
Date/ A B C D E
ABC Log
Date/ A B C D E
ABC Log
Date/ A B C D E
ABC Log
Date/ A B C D E

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Overcoming Impulse Control Problems

David H. Barlow, PhD

Anne Marie Albano, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Peter E. Nathan, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

Jon E. Grant • Christopher B. Donahue • Brian L. Odlaug

Oxford New York

Copyright © 2011 by Oxford University Press, Inc.

ISBN-13 978-0-19-973880-9 Paper

Printed in the United States of America

One of the most difﬁcult problems confronting patients with vari-

Now, healthcare systems around the world are attempting to correct

Based on the principles of cognitive-behavioral therapy (CBT), this

David H. Barlow, Editor-in-Chief,

The authors wish to thank Robert Ladouceur, Nancy Petry, and

Chapter 1 Introduction to the Program 1

■ To learn about the impulsive behaviors treated in this

■ To learn about this treatment program and what it will

What Is an Impulse Control Disorder?

Impulse control disorders (ICDs) include pathological gambling

1. Repetitive or compulsive engagement in a behavior despite

What Is Pathological Gambling?

Pathological gambling (PG) is characterized by a loss of control over

Kleptomania (KM) is characterized by the repetitive, uncontrollable

Pyromania (PY) is classiﬁed as an ICD because pyromaniacs cannot

What Is Compulsive Buying?

Compulsive buying (CB; also referred to as compulsive shopping) is

Cognitive-behavioral therapy (CBT) is based on the knowledge that

CBT has a strong educational emphasis, with the expectation that

Following is an outline of the program and a list of concepts that

■ Session 1: Evaluation of motivation to quit impulsive behaviors

■ Session 3: Behavioral intervention, preparation for ICD

■ Session 5: Impulsive beliefs: cognitive therapy

■ Session 6: Relapse prevention

■ Session 7: Family involvement (optional)

As part of this treatment program, you will be asked to make sig-

We understand that clients will bring different expectations to the

Each therapy session will include the following parts:

■ Presentation of a new skill area

■ Practice new skill with therapist

■ To learn about your speciﬁc ICD

■ To work with your therapist to increase and maintain

■ To begin daily self-monitoring of your behaviors

■ To review your ﬁnances, if you have problems with gambling

The behaviors often associated with ICDs are difﬁcult because

What I Like About My Impulsive Behavior

What I Hate About My Impulsive Behavior

Reasons Why I Want to Stop My Impulsive Behavior

Intimate Life: _________________________________________

Daily monitoring of thoughts, feelings, and behaviors is essential to

1. To what extent do I feel my impulsive behavior is under control?

______ Date _

______ Date _

______ Date _

______ Date _

______ Date _