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CBT Technique Helps Guide Decision Making

A payoff matrix can serve as a valuable tool in working with clients struggling with unrealistic beliefs or harmful behaviors. In this excerpt from the Hazelden Co-Occurring Disorders Program, the authors discuss applying cognitive behavior therapy.

By Mark McGovern and faculty from Dartmouth Medical School

In constructing a payoff matrix, the clinician assumes that for the person adhering to a belief that is unsupported by evidence, the belief serves an important function in that person's life. It is not illogical or irrational to hold on to these negative beliefs. Constructing a payoff matrix helps you identify the patient's perceived costs and benefits of holding on to an old and inaccurate belief versus changing that belief to a more accurate one. Once the costs and benefits have been identified, those perceptions can be the focus of further attention.

When constructing a payoff matrix, you create a table with four rows and two columns. The first box in the first column contains a heading that corresponds to the advantages of a patient keeping or holding on to the belief in question, and the first box in the second column contains a heading that corresponds to the advantages of changing the belief or thought.

In addition, the third box in the first column is a heading associated with disadvantages of keeping a thought, and the third box in the second column refers to the disadvantages of changing a thought. You then work with the patient to identify

1. the advantages of keeping or holding on to the thought (second box in column 1),
2. the disadvantages of keeping or holding on to that thought (last box in column 1),
3. the advantages of adopting the new thought (second box in column 2) and, finally,
4. the disadvantages of giving up the old thought and adopting the new one (last box in column 2).

Having identified these advantages and disadvantages, you and your patients can then mutually explore and challenge some of these perceptions. Specifically, you may help patients challenge the perceived benefits of holding on to or giving up a particular belief. Realizing the high cost some patients pay for holding on to certain beliefs can be beneficial.

Assume a collaborative stance with the patient. Help him or her understand the benefits of holding on to certain beliefs compared to the costs of giving up those beliefs. For example, one patient continued to believe that she was somehow responsible for the sexual abuse she experienced in childhood. One advantage of clinging to this belief was that it gave her an illusion of control. If she was partly or even wholly responsible for her own sexual abuse, then she might have greater control in preventing such events from happening in the future. The greatest disadvantage of holding on to that belief was that she felt bad about herself when she had intrusive memories of her childhood sexual abuse.

She identified that the primary advantage of accepting the belief that she was not responsible for her abusive experiences was better self-esteem. The primary disadvantage of giving up responsibility was that the world seemed scarier, less predictable, and less under her control. Examining these advantages and disadvantages helped her identify and challenge the more fundamental belief that "the world is an extremely unpredictable and dangerous place." After analyzing her thoughts in the payoff matrix, she could retain or change her thoughts, which allowed her to make informed choices based on the perceived advantages and disadvantages of each alternative. Such an analysis illustrates to patients the price they pay for adhering to unrealistic beliefs concerning responsibility for traumatic events.

When conducting a payoff matrix, you will find that for patients one of the most common disadvantages of giving up unrealistic thoughts or beliefs about control or responsibility over events lies within accepting a view of the world that recognizes a certain amount of unpredictable risk and danger. Some patients may experience relief when they are able to develop more realistic perceptions of risk and danger. However, some patients experience high levels of anxiety when they perceive there to be any risk, and this anxiety may serve as a barrier to developing more realistic perceptions.

In these circumstances, rather than attempting to modify a patient's perceptions of risk, it is preferable to help the patient accept that level of risk in the world. The patient may need to understand and accept that a certain amount of risk in living is inescapable. To get on with his or her life, the patient needs to work on accepting the risks he or she faces on a day-to-day basis and is likely to face in the future. Patients who accept this risk can then be helped to modify their beliefs concerning excessive control over or responsibility for past and future events.

For patients who absolutely cannot accept this degree of risk, the clinician can focus the discussion on exploring possible lifestyle changes that might reduce those perceptions of risk even further. However, these patients will need a great deal of help in learning that no one can escape all risks.

The preceding passage is excerpted from the Hazelden Co-occurring Disorders Program, Cognitive Behavioral Therapy curriculum. Learn more about the Hazelden Co-occurring Disorders Program

Evidence-based treatment models

The Hazelden Co-occurring Disorders Program helps treatment programs implement effective, integrated services for people with non-severe mental health disorders that co-occur with substance use disorders.

Integrated Combined TherapiesIntegrating Combined Therapies utilizes a combination of motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), and Twelve Step facilitation (TSF) therapy. Each of these models of therapy has been proven successful when used in community addiction treatment programs.

Cognitive-Behavioral TherapyCognitive-Behavioral Therapy, utilizes cognitive-behavioral therapy (CBT) principles to address the most common psychiatric problems in both mental health and addiction treatment settings.

Read more about the Hazelden Co-occurring Disorders Program

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