Training session at EABCT2014.org The Hague, The Nehterlands 11th September 2014

1. The Willpower Workshop:
Enhancing cognitive control to improve outcomes
The Hague
The Netherlands
September 11th 2014
Frank Ryan Consultant Clinical Psychologist
Camden & Islington NHS Foundation Trust

2. Willpower is unique to humans …..
• Willpower enables us to
achieve long-term
goals and fulfil
aspirations.
• Willpower is essential
in order to overcome
compulsive habits such
as smoking or
excessive drinking.
• Willpower gives us the
strength to overcome
fear or avoidance.

3. Overview of workshop
Welcome and introductions
Goals of workshop
Exploring willpower
Scientific perspectives on willpower
Cognitive components of willpower
Willpower in CBT
Educating service users about willpower
Applications & competencies
The Willpower for Wellbeing Programme:
Seven steps to improved willpower

4. Willpower in psychotherapeutic contexts
• Overcoming emotionally
driven behaviours and
thought patterns entails
short term “pain” or
discomfort in order to
achieve long term or
deferred gain.
• At any given moment it
is easier to avoid than to
approach.
• This requires willpower.

5. Aims and expectations
• Learn that CBT is about essentially about changing
cognitive control:
-what boosts cognitive control is good;
-what reduces it is bad;
-what leaves it untouched is a waste of time and effort.
• Introduction to ways to boost and sustain willpower
• Posture exercise
• Skills take time to acquire; be patient!

6. Healthcare costs (in billions Euro ) of emotional and addictive disorders in 30
European countries (27 EU Plus N, CH and Iceland) Gustavsson et al 2011
80
70
60
50
40
30
20
10
0
Depression Addiction Anxiety disorders

7. Willpower and you…..
Identify an occasion:
1. When willpower
seemed to vanish and
you didn’t achieve your
goal.
2. When you used
willpower effectively to
promote and sustain
change.
Note contextual factors such as
tiredness, stress levels, personal
concerns.

8. PART ONE:
WILLPOWER IN CONTEXT

9. Cognitive control is pivotal in onset and recovery from
emotional or motivational/appetitive disorders
• Impaired cognitive control underlies psychological
disorders.
• Improved cognitive control is the key to successful
change.
• Goal definition and maintenance can influence
motivated attention. This places working memory
(WM) at the hub of cognitive and behavioural
change.
• Promoting WM efficiency is the way for CBT to go.
• Accordingly, recovery should also focus on neural
health (brain fitness)
f.ryan@imperial.ac.uk

10. What is cognitive control?
• Shifting attention
(engagement and
disengagement)
• Monitoring and updating
(short term memory
merging into working
memory)
• Inhibition of
prepotent/impulsive
responses
(Miyake et al 2000)

11. What is willpower (cognitive control in real life!)
• Maintaining effort
• Goal pursuit
• Supressing
impulses/ desires
• Overcoming
distraction
All of these cognitive
tasks tax the brain and
can deplete limited
supply of willpower:
self-regulation can
become a victim of its
own success!

12. Historical perspectives
Psychodynamic
tradition saw “ego”
as referee in battle
between insatiable
impulses “id”
and stringent,
perfectionistic
“super-ego”.
Ego equivalent to
willpower.

13. Cognitive therapy
• No systematic account
of willpower in the main
body of literature.
• Mental effort is implicit in
most if not all
therapeutic tasks e.g.
self-monitoring of faults;
reappraisal of long-held
beliefs; overriding safety
seeking behaviour.

14. Cognitive behaviour therapy
• “Relapse Prevention Skills
Training” model (Marlatt &
Gordon,1985; Marlatt &
Witkiewitz, 2005 ) used
functional behavioural
analysis (antecedents,
behaviour, consequences)
and induction of alternative
coping skills to facilitate and
maintain change.
• No explicit role accorded to
willpower.

15. Poetry, cognition and motivation
“Two principles of human
f.ryan@imperial.ac.uk
nature reign;
Self-love, to urge, and reason
to restrain;
Nor this a good, nor this a
bad we call,
Each works its end, to move
or govern all.”
Alexander Pope
An Essay on Man 1732

16. Attentional Control Theory see Eysenck, M. W., & Derakshan, N. (2011).
• Anxiety impairs efficiency
rather than effectiveness.
The task is accomplished
but with more effort.
• When anxiety levels are
high, goal directed
attention is impaired and
stimulus driven attention
potentiated.
• Implication is more mental
effort (willpower) is
needed. But this runs out.

17. Implications of recent cognitive neuroscience
findings
• Emotional disorders are maintained by enduring
changes in priorities and deficits in information
processing.
• Therapies that infiltrate and modify this, i.e. increase
cognitive control, are more likely to be effective.
• Targeting implicit (automatic) cognitive and
behavioural responses preserves willpower
• Automatic responses are always switched on,
draining willpower which is needed to override them.

18. Placing cognitive control/willpower centre stage:
Time for CHANGE
Change
Habits
And
Negative
Generation of
Emotion
(Ryan, 2006; 2013)

19. Cognitive Flexibility:
The blacksmith and the brain (derived from Daniel
Dennett)
• Blacksmiths
(uniquely!)make
their own tools;
• The brain “makes”
its own thinking
tools.
• (Will)power tools
are the most
flexible!

20. Thinking tools (1)
Thinking tool Example Specific way to
improve it
General way to
improve
it
Attentional
control /focus
Think of long
term, not short
term benefits e.g.
I’ll skip the party
but I’ll more likely
get a good grade;
I’ll become
healthier; I’ll look
good in a bikini
(not me!)
Meditation;
Reading novels;
Brain training
exercises;
Take predictable
and regular breaks
from
concentrating;
switch off your
phone for an
evening.
Keeping fit with
aerobic exercise
Managing stress,
relaxation
Social engagement
Mental stimulation
Omega 3s in diet.

21. Thinking tools (2)
Thinking tool Example Specific way to
improve it
General way to
improve
it
Updating progress
or monitoring
challenges
Keep a diary;
subscribe to email
or smart phone
alerts;
Rehearse your
goal frequently
anticipate
challenges and
how to cope with
them: If I am
tempted, then I
will….
Keeping fit with
aerobic exercise
Managing stress,
relaxation
Social engagement
Mental stimulation
Omega 3s

22. Thinking tools (3)
Thinking tool Example Specific way to
improve it
General way to
improve
it
Inhibition Saying no to a
cigarette when
you want one;
ignoring the
“50% off” sale
sign at the shoe
store.
Practice small
acts of self-denial;
avoid
sugary foods
such as muffins
and choose
foods that
release glucose
slowly – pulse,
most fruits ,or
whole meal
bread.
Keeping fit with
aerobic exercise
Managing stress,
relaxation
Social
engagement
Mental
stimulation
Omega 3s

23. Willpower depletion by anhedonia
Nicola 41
• History of CSA and subsequent abusive or exploitative relationships.
Bereavement .
• Avoidance of positive experiences due to reward deprivation as a child
• Personality: conscientious, but emotionally over controlled
• Coping strategies included binge drinking, avoidance and isolation
• Early experience: Joy suppressed= happiness is dangerous
• Activating event: flirting at work; went on date
Willpower depletion cycle:
• Avoidance of rewards/ negation of happiness> chronic low mood>
overreliance on willpower> willpower ultimately compromised by low
mood and consequential lack of rewards.

24. Managing emotions therapeutically requires willpower
• Keeping appointments with therapist
• Completing homework
a) behavioural tasks
b) cognitive reappraisals
c) relaxation/ mindfulness
d) Resisting/ overcoming emotionally driven
behaviours such as avoidance, safety
seeking or substance use.
• Parenting or caring duties
• Other personal or domestic commitments
• Work or study commitments

25. Willpower and CBT
• CBT defines dysfunction as the
product of patterns or occurrences
of automatic cognitive processes
and behavioural
approach/avoidance tendencies.
• These established patterns have the
momentum, even if they are
disliked, repugnant or self-defeating.
• Overcoming these well practiced
patterns is harder than “going with
the flow”.
• Reserves of willpower decrease with
time and effort.
• Reserves of willpower decrease in
the face of competition from emotion
e g when anxiety or craving is high,
precisely when self-control is most
needed

26. Overcoming motivated habits requires willpower:
but willpower is a limited resource
• Attentional control and working memory are
the key processes for directly managing or
augmenting willpower.
• Context, environment and lifestyle are the
key indirect processes .
• Focusing on a combination of these direct
and indirect processes and influences
promises to help boost and sustain willpower.
• This accords willpower or cognitive control
central role in CBT interventions.

27. PART TWO:
COGNITIVE PSYCHOLOGY AND
WILLPOWER

28. Seven steps to managing willpower effectively
·
• Willpower is a shared and hence limited resource that requires careful
stewardship,·
• Overcoming habits places particular demands on willpower·
• Selecting one goal at a time, or prioritising a series of specific sub-goals,
optimises willpower.·
• Willpower can be enhanced by practicing self-restraint in diverse
domains and the promotion of cognitive fitness.·
• Compassion and optimism foster willpower; emotional negativity
depletes it.·
• Willpower is usually challenged in ways that can be anticipated,
allowing for coping strategies to be rehearsed.·
• Reinforcing effort in advance of outcome is crucial, as the rewards
delivered by willed effort are often delayed.

29. Dual processing; fast and slow.
Level of
processing
Cognitive
appraisal
Cue detected
Controlled processing
(slow)
Activation of disorder
related beliefs: “I must get
out of here; I will have
more fun if I use cocaine"
Automatic processing
(fast)
Conditioned cue reactivity:
somatovisceral arousal
and approach/avoidance
mobilised.

30. In summary, its about the plumbing, not the poetry
• Cognitive therapy should make the focus on
cognitive control more explicit.
• This focus should be on coaching, boosting or
sustaining cognitive control (willpower)
• Historically cognitive therapy has inadvertently, or
perhaps indirectly, altered “plumbing” or cognitive
processes by introducing clients to a diverse array of
cognitive control skills e.g. overriding first thoughts;
maintaining a goal, as with behavioural experiments.
• This could be a covert contributor to therapeutic gain
across the spectrum of CBT applications.

31. Not a level playing field!
• Automatic
processes require
little, if any,
willpower to initiate
and proceed.
• Automatic
processes require
considerable
willpower to divert
or inhibit.

32. Personality factor Risk to willpower
when high
Risk to willpower
when low
Openness Distractability, becoming
bored by diet or health
routines
Creativity, good problem
solving skills
Conscientiousness Perfectionism, self-criticism
following
setbacks
Self-discipline;
purposeful; goal
orientated
Extraversion Impulsivity, high
sensitivity to instant
rewards (hedonistic)
High-level of social
support; capacity to
discover new rewarding
pursuits
Agreeableness Lack of assertion; being a
“people pleaser” can tax
willpower strength when
pursuing personal goals
High level of social
support; self-compassion
when willpower fails
Neuroticism
(emotional sensitivity)
Negative emotions sap
willpower and motivation
Emotional awareness;
overcoming negative
emotions offers big
incentive to change

33. Attention, Motivated !
“people become consciously aware of
an act only after they unconsciously
decide to engage in it. In addition, at
least some volitional behaviour does
not require any conscious
awareness at all: Goals and
motivation can be unconsciously
primed.”
Motivated attention initiates approach
and avoidance behaviours; resisting
this depletes willpower
The key variable is motivated
attention
Attention triggers action even
in the absence of
awareness.

34. Cycle of pre-occupation
Attribution of incentive
salience
Attentional bias
Contents of
Working memory
Attentional bias
Appetitive
behaviour
f.ryan@imperial.ac.uk

35. SEVEN STEPS TO IMPROVED
WILLPOWER

36. Step 1 Making the most of willpower
• Managing willpower effectively
• Recognising strengths and limitations
• Brain fitness
• Diet & mental fitness
• Physical fitness
• Less stress and more social support
• Broaden and build social networks and

37. It’s about the brain, stupid!
Neural Fitness Applying CBT with the aim of promoting
and sustaining willpower places brain
fitness centre stage. Four principles of
neural health:
• Novel or more effortful cognitive
challenge (e.g. brain training)
• Regular cardio vascular exercise
• Diet rich in Omega 3s, high
glycaemic index foods low sugar
low-fat
• Social engagement and networking
• Decreased or better managed
stress.

38. Build your willpower muscle, but don’t overdo it!
• Small acts of self control
(e.g. maintaining good
posture) can enhance
willpower (i.e. cognitive
control).
• Over exertion, tiredness
and high cognitive load
can diminish it.
• Therapist guides client
accordingly
f.ryan@imperial.ac.uk

39. Brain fitness
Cardio-respiratory exercise daily
Diverse Cardio-respiratory exercise
daily 20-30mins
Diverse cognitive challenge
Diet high in slow glycgaemic
release foods, Omega 3 & low in
added sugar, salt & certain fats
Prioritise goal, optimise working
memory load ( avoid overload,
but too much spare capacity
spills attention to “disorder
default” settings).
f.ryan@imperial.ac.uk

40. Working memory training
• limit the use of domain specific
strategies;
• minimise automatisation
• include tasks or stimuli that span
different modalities such as verbal
or visual memory
• require maintenance despite
interference
• oblige the trainee to conduct rapid
encoding and retrieval operations
• Adapts to trainees varying degrees
of proficiency Morrison &
Chien,2011
• “Just a minute” (BBC R4)
f.ryan@imperial.ac.uk

41. Step 2
Overcoming compulsive habits: the biggest challenge
to willpower
Emphasis on reversal of implicit cognitive
biases.
Focus on enhancing cognitive control (STM
and attention ) mechanisms via goal
maintenance
Prioritises impulse control strategies

42. Manage impulses (urges) and craving
• Stimulus Control
• Implementation intentions
• Be aware of and attempt to
correct cognitive biases
• Identify alternative rewards
• Self-monitoring
• Distance /de- centre /
mindfulness meditation
• Challenge expectancies and
implicit cognitions via
behavioural experiments
• Support self-efficacy
• Goal specificity

43. Contingency management
• Identify target behaviour
e.g. increased level of
attendance; homework
compliance; social
interaction; reduced
supplementary drug
use;
• Reinforce frequently
• Maintain for up to twelve
weeks.

44. Managing craving
Recognise thinking about drugs e.g “life is boring without cocaine”
or “I deserve a drink”. Include categories of testing personal
control and permission giving beliefs.
Distinguish between craving and hunger .
Avoid situations rich in appetitive cues e.g. parties where drugs
are ubiquitous- setting alternative goals is often a good strategy.
(Crack houses or cake shops!)
Identify and rehearse coping strategies e.g. drink refusal skills;
distraction; challenging your thoughts ; review negative
consequences ; focus on benefits of restraint; talk to supportive
friends or associates on programme; Think of longer term
benefits e.g. health, wellbeing weight loss.

45. Step 3
BEING SINGLE MINDED IS THE KEY TO
SUCCESS

46. Step 3 Key points
• Prioritise client’s goals
• Wherever possible, alligning goals with
values
• Install goal(s) in working memory
• Use cues, implementation plans and
“nudges” to ensure success

47. Making memory work
Working memory influences
attentional deployment;
This can be relatively
automatised if encoded as
a cue based
implementation plan.
Therapeutic Strategies:
Implementation intentions
e.g. If I feel anxious I will
practice slow, deep
breathing;
If I am offered a dessert I will
say “I’d love a fruit salad;
If I am offered cocaine I will
say “No thanks, I’ve quit”
f.ryan@imperial.ac.uk

48. “Road to recovery……is paved with good rehearsals.”
• Successful execution of any
task requires both controlled
and automatic processing.
Linking a forthcoming event
with a planned response
triggered by cue recruits
automatic processes.
• Robust practice has been
shown to increase automatic
inhibition of competing goals
(Palfai, p 416, Wiers & Stacey 2006)

49. Implementing intentions to change
If situation X occurs I will
perform behaviour Y e.g.
“If I have money I will do my
shopping before I do anything
else (e.g. gambling, buying
drugs)”
“If I am offered alcohol to drink
at the party I will say “no
thanks, but I would love a
mineral water”.
“ if I am introduced to somebody
new, then I will establish eye
contact” and repeat their
name.”
Prestwich et al (2006)

50. Neural substrates of “now” and “later”
• Executive control circuitry
is activated when
restrained smokers think
“later” rather than “now”
(e.g. DLPFC and cortico-striatal
pathways)
• Reduced activity in
amygdala, ventral striatum
and anterior cingulate
• Craving is reduced by
about a third
f.ryan@imperial.ac.uk

51. Manipulating expectancies:
Now vs later strategy
Immediate
consequences:
“Now”
Long-term
consequences:
“Later”
Short term and long term consequences of resuming smoking
Positive
expectancies
Feeling part of
the crowd; sheer
pleasure; less
boredom
None really! I
guess it means I
won't have to
worry about
saying no to
cigarette!
Negative
expectancies
Disappointment
(I've put a lot of
effort into quitting
smoking);My
breath will smell
when I get home
Risk of illness. I
may get cancer
and die!
Complete waste
of money.
Smoking is
pointless!
f.ryan@imperial.ac.uk

52. Working memory influences attention and behaviour
Goal in working memory is
stay in bed 30 minutes
more
Goal in working memory is
get up and meditate for 30
minutes
Thoughts that tend to flow
from the goal
It’s warm and cosy; Sleep is
as good for me as meditation;
that was a wonderful dream…
Meditation prepares me for
whatever happens during the
day; meditation is good for my
brain.
Attentional focus Comfort of warm bed, soft
pillow, insulated from reality.
Stillness of early morning;
Calmness of mind that follows
meditation
Behaviour that is more
likely
Stay in bed Get up and meditate

53. STEP FOUR:
CHANGE IS A JOURNEY THAT TAKES TIME

54. Demands on willpower can fluctuate
Stage of Change Level of willpower required Willpower enabling thought,
belief or action
Precontemplation Zero, perhaps occasional
awareness that something
needs to change
Assuming some awareness of
a need to change,
Contemplation Low to moderate,
commitment to imminent
action not made.
“There are some good things
but also some less good
things about my lifestyle”
(focusing on specific
example)
Involve loved ones or close
friends in your decision-making
Preparation Moderate, occasionally high.
Commitment to action within
days or weeks
“I've made a decision, now I
need to plan and implement
it” actions include practising
small acts of self-control;
physical exercise, keeping a
diary record of the behaviour
that you want to change

55. Stage of Change Level of willpower required Willpower enabling thought, belief or
action
Action High. You are now taking
steps to change and are
experiencing conflict choosing
new, less familiar behaviours
and suppressing familiar
behaviour patterns
Reward yourself for effort,
either by saying “well done!”;
or with a treat.
Defer difficult decisions or
projects if possible.
Maintenance Moderate. Union behaviour
patterns are becoming more
practiced and require less
effort.
Remind yourself of your
motives for embarking on
change. If your change
programme means avoiding
people or places (e.g. friends
who continue to smoke or use
cocaine) don't isolate
yourself. Broaden and build
social networks.
Relapse High. This is the critical stage
in the process of change.
Responding to a lapse or
relapse determines the
outcome of the planned
change
Put the setback in
perspective. If you bought and
smoked one pack of
cigarettes, count the days,
weeks, or months you
remained smoke-free. Instead
of thinking “I failed” , consider
“since January I was 95%
successful”. Identifying
triggers-the people, places, or
things that preceded the lapse

56. STEP FIVE: FOREWARNED IS FOREARMED

57. Recognising cues that trigger behaviour is essential
Internal cues:
• Emotional states
• Hunger/thirst
• Tiredness
• Higher cognitive
load/demand combined
with low working memory
capacity.
External or situational cues:
• People
• Places
• Things

58. STEP SIX: BE KIND TO YOURSELF WHEN
YOU FAIL

59. Acceptance and Commitment Therapy (ACT)
• ACT uses acceptance and mindfulness processes, and commitment
and behavior change processes, to produce greater psychological
flexibility.
– Psychological flexibility is contacting the present moment fully as a
conscious, historical human being, and based on what the situation
affords changing or persisting in behavior in the service of chosen
values.

60. Acceptance and Commitment Therapy
ACT
• Whatever the client is experiencing is not the
enemy – it’s the struggle against it that’s
harmful.
• You can’t rescue clients from the difficulty
and challenge of growth.
• Radical respect for clients’ values – the
issue is the workability of their lives, not your
opinions.

61. Higher Experiential Avoidance
is associated with…
• Higher anxiety
• More depression
• More overall pathology
• Poorer work
performance
• Inability to learn
• Substance abuse
• Lower quality of life
• History of sexual abuse
• High risk sexual
behavior
• BPD symptomatology
and depression
• Thought suppression
• Alexithymia
• Anxiety sensitivity
• Long term disability

62. Cognitive Defusion
Simple techniques:
• Just notice what your mind is telling you right now
Is this a helpful thought? Is this a good use of my time?
• Notice the form of the thought by describing it
Is it words, sounds or pictures? What does it sound like?
• “That is an interesting thought”
• Buying a thought vs having a thought
• Label your thoughts (“I am having the thought that . .
. “)
• Say it slowly, sing it, say it in a different voice
• Thank your mind
• Mind vs Experience (“workability” not “truth”)

63. Meditation
“a family of complex
emotional and
attentional regulatory
strategies developed for
various ends, including
the cultivation of well-being
and emotional
balance”
Lutz et al 2008,p163
Meditation enhances
neuronal competences
in self regulation.
Therapeutic strategies
include mindfulness
meditation.
“if your mind wanders, as it
surely will, gently bring
your attention back to your
breathing again and
again…”
f.ryan@imperial.ac.uk

64. Manipulating expectancies:
Now vs later strategy
Immediate consequences:
“Now”
Long-term
consequences:
“Later”
Short term and long term consequences of resuming smoking
Positive
expectancie
s
Feeling part of the
crowd; sheer pleasure;
less boredom
None really! I
guess it means I
won't have to
worry about
saying no to
cigarette!
Negative
expectancie
s
Disappointment (I've
put a lot of effort in to
quitting smoking);My
breath will smell when I
get home
Risk of illness. I
may get cancer
and die!
Complete waste
of money.
Smoking is
f.ryan@imperial.ac.uk

65. Neural substrates of “now” and “later”
Executive control circuitry is activated when restrained
smokers think “later” rather than “now” (e.g. DLPFC and
cortico-striatal pathways)
Reduced activity in amygdala, ventral striatum and anterior
cingulate
Craving is reduced by about a third
f.ryan@imperial.ac.uk

66. STEP 7 REWARD YOUR SELF FOR EFFORT

67. Key Points
• Rewards from willed effort are typically
delayed
• Unreinforced behaviour fades
• Willpower driven striving needs to be
reinforced at regular intervals along the
journey

68. The goal ladder
Goal Prepare a meal Reward
Step one Select a tasty recipe. Say “well done”; to your
friends on Facebook
Step two Make a shopping list. Sit down with a cup of
coffee to your favourite
magazine for 15 minutes
Step three Go to shop and buy food. Smile and chat to the
friendly shop assistant.
Step four Come back home Say “well done”, sit down
and have a banana!
Step five Check the recipe and
begin preparing the meal
Tell yourself that the plan
is going very well.
Consider inviting a friend
to join you.
Step six Sit down and enjoy the
meal!
Savour the food and
congratulate yourself.

69. The goal ladder
Goal Prepare a meal Reward
Step one Select a tasty recipe. Say “well done”; to your
friends on Facebook
Step two Make a shopping list. Sit down with a cup of
coffee to your favourite
magazine for 15 minutes
Step three Go to shop and buy food. Smile and chat to the
friendly shop assistant.
Step four Come back home Say “well done”, sit down
and have a banana!
Step five Check the recipe and begin
preparing the meal
Tell yourself that the plan
is going very well.
Consider inviting a friend
to join you.
Step six Sit down and enjoy the
meal!
Savour the food and
congratulate yourself.

70. Conclusion
CBT should aim to promote cognitive control both
within session (e.g. by CBM or WM training) and
between session (e.g. by meditation or cardio-exercise)
CBT needs to promote neural health and efficiency
through diverse means: cognitive control is hard
work for the brain!
Working memory is pivotal
Willpower is a useful term to translate cognitive
psychology /neuroscience findings into more general
settings
f.ryan@imperial.ac.uk

71. Two books, now for the workshop!