12) Behavioural Experiments

Question 1

How do the aims of behavioural experiments (1) differ to the aims of cognitive therapy (2)

Answer 1

Aims of CT
* Assist client to identify and reality-test unhelpful cognitions which underlie repeated negative patterns of emotion and behaviour, and
* To develop and test new, more adaptive cognitions that can give rise to a more positive experience of the self, others, and the world

Aims of BEs
* Similar to those of CT: They are used to help identify, test unhelpful cognitions

Question 2

List some methods for reappraising/changing assumptions and core beliefs (5)

Answer 2

• Socratic dialogue in therapy situation
• Role-play and post- reflection/discussion
  o Self and significant other
  o Different aspects of oneself (child-adult; emotion-reason)
• Imagery, analysis and discussion
• Behavioural experiments
• Learning/discovery tasks (HW) directed at cognitive restructuring

Question 3

List and outline what happens withins the 4 stages of cognitive restructuring. (4;3;3;3)

Answer 3

1) Prep
* Understanding client’s belief structures
* Overcoming resistance: validation responses
* Highlighting need for change (a la motivational interviewing)
* Identifying NATs, thinking biases, beliefs

2) Prep
* Select beliefs amenable to change (manuals may help)
* Building a case for change (e.g., gathering evidence that supports a reappraisal)
* Select one or more CT techniques worth trialling

3) Effect Change
* Socratic questions directed at the specific assumption/belief targeted for change
* Allow time for emotional processing
* Review effects, If necessary, change approach/technique/method

4) Consolidate change
* If effective, use techniques to consolidate change
* Use multiple approaches and methods that converge on same belief
* Tailor technique to what is most effective for client

Question 4

What are the 2 stages of cognitive restructuring for a BE?

Answer 4

• What is the precise prediction that I am testing and wanting to change?
• How can it be disproved?

Question 5

What is the most powerful method for bringing about change in cognitive therapy? Why?

Answer 5

BEs - disorders don’t arise from events per se, but to the meanings individuals give to these events

Question 6

Describe the cognitive vs. behavioural perspective regarding behavioural experiments.

Answer 6

• “for the behaviour therapist, the modification of behaviour is an end in itself; for the cognitive therapist it is a means to an end- namely cognitive change” (Beck et al., 1979, p. 119).
• Cognitive therapy assumes BEs work because they provide hard evidence related to clients’ beliefs

Question 7

What is the empirical evidence for BEs? (2)

Answer 7

Fairly recent, so still awaiting large RCTs
* One recent review of 14 studies concludes, “some evidence that BEs were more effective than exposure therapy alone” (McMillan & Lee, 2010)

One study compared automatic thought records with BEs to raise levels of awareness of internal processes.
* Produced same levels of awareness
* BEs produced greater cognitive and behavioural change
* Auto thought records believed “with the head” but not always “with the heart”
* BEs more likely to be believed and accepted (bc experienced)

Question 8

Identify the cognitive, affective, and behavioural components of BEs. (6)

Answer 8

• BEs address problem of
  o I can see the alternative, but I still don’t feel any different
• Experiential learning
• Emotional arousal
• Encode into memory
• Practice new plans & behaviours
• Learn through reflection

Question 9

Identify steps in the process of devising effective BEs. (4;1;3;3;1)

Answer 9

• Planning : designing the BE
  o identify beliefs for change
  o specify predictions
  o specify evidence for/against
• Experience: conduct the BE itself
• Observation of the outcome
  o examining what happened
  o did the evidence support the predictions?
• Reflection and learning:
  o making sense of BE
  o drawing key conclusions
• Planning: following up BE

Question 10

Identify 3 purpose that BEs can be used for

Answer 10

• Elaborating formulation
• Testing negative cognitions
• Conducting and testing new perspectives

Question 11

For the purpose of: 1) elaborating formulation or 2) testing negative cognitions, what
* BE design would you choose? (3)
* Type of BE (3)
* Level of cognitions targeted (3).. but mainly which one?
* what settings? (4)

Answer 11

BE design
* Hypothesis- testing experiments
* Test Ha
* Test Ha v Hb
* Test Hb

Type of BE
* Hypothesis- testing experiments
* Test Ha
* Test Ha v Hb
* Test Hb

Level of cognition
* Automatic thoughts
* **Conditional assumptions **
* Core beliefs

Settings
* Time & place
* In tx time
* Consulting room
* In vivo
Homework

Question 12

For the purpose of: conducting * testing new perspectives, what
* BE design would you choose? (1)
* Type of BE (3)
* Level of cognitions targeted (2)
* what settings? (7; 3)

Answer 12

BE design
* Discovery experiments: H vague or absent

Types of BE
* Observational experiments
* Direct observation (modelling)
* Surveys
* Information gathering other sources

Level of cognitions
* Preparation for reappraisal
* New assumptions and beliefs

Settings: People
* Client
* Therapist
* Stooges
* Family
* Friend
* Work
* General public

Settings: Resources
* Tape recorder
* video
* record sheets etc

Question 13

Identify and define the 3 types of hypothesis-testing BEs.

Answer 13

Test hypothesis A
* Tests validity of current unhelpful cognition
 Tight chest means, impending disaster, “I’m going to have a heart attack”
* In session hyperventilation test

Hypothesis A vs hypothesis B
* Compares unhelpful cognition with new potentially more helpful perspective
 Tight chest means…”this could just be anxiety”
 BEs test whether “heart attack” vs “anxiety” hypotheses better account for symptoms

Testing Hypothesis B
* Directs client’s attention towards situations and behaviours that are likely to provide evidence to support a new perspective
 Strange physical sensations are quite normal and nothing to be afraid of

Question 14

Define discovery BEs.
Give an example in relation to a SAD person who self-monitors excessively

Answer 14

• Clients have no clear hypothesis about the process maintaining a problem or what would happen if they behaved in a different way
• E.g. socially anxious person who self monitors excessively
   Asked to have conversation in session “as usual”
   Then with attention away from self
   May discover she enjoys conversations more

Question 15

Identify and describe the 2 types of BEs

Answer 15

Active
* Clients take the lead role
* Unhelpful cognition or behaviour identified and client deliberately thinks or acts in a different way in the problem situation
* Real or simulated situations (e.g. role plays)

Observational
* Direct observation (modelling)
 E.g., therapist handling spider in phobia
* Surveys or other sources (e.g., internet)
 Gather factual information or opinions about problematic situations
 Friend, family, colleagues, “experts”, or therapist
* Information gathering other sources

Question 16

How do you go about step 1 of planning a BE?

Answer 16

Identify beliefs for change
* Case formulation
* Behavioural assessment
* Discussions during therapy
* Intermediate beliefs or dysfunctional assumptions are good targets

Have a clear rationale
* is the purpose clear?

Clearly specify belief for change
* 0-100 rating of degree of belief helps assess change

Develop alternative perspectives
* What might be another way of looking at that?
* What would you say to another person who came to you with this problem?
* How might a person who cared about you understand this?
* Sometimes only tentative alternatives are offered by clients

Take emotions and physical symptoms into account
* Experiments want to change the way they feel, not think
* Thus, enquiring about emotions essential
* Changes in emotion often reflect cognitive change
* 0-100 ratings of emotions also helpful

Selecting the type of experiment
* Hypothesis-testing (Ha, Ha vs Hb, Hb)
* Observational (direct [modelling], surveys, info gathering from other sources)

What does the client need to test or discover?
* Is aim to undermine old pattern of thinking? (Hypothesis A)
* Direct comparison of old and new (A vs B)?
* To test a new one (Hypothesis B)
* Discovery oriented?
* Collaborative process… e.g., “how could you check out that idea?” “How could we find out”

Specify predictions
* Establish in fine detail what the Ct thinks will happen and how they will know this

Selecting time and place for BE
* In session, therapist guided
* With therapist outside consulting room
* External settings “real life”

Identify People and resources
* Equipment, record sheets, stooges (secretarial staff, colleagues, etc)
* Partners, families, friends etc
* Select “benign” people (at least first)

Think about what and how to observe and record outcomes
* Recording the experiment e.g., worksheets
* Date
* Identify thoughts to be tested. Rate belief (0- 100%)
* Have you identified alternative? Rate alt belief (0- 100%) - hypothesis B
* Devise experiment to test thought. Write down exactly what exactly will you do? Where, when?
* Identify likely problems. How will you deal with them?
 Outcome. What happened? What did you observe?
 What have you learned? (Rate old and alt beliefs)
 What next? What further expts can you do?

Preparing for problems
* What problems might arise when carrying this out?
* What might stop you from doing the task?
* Have a plan B

Question 17

How do you go about step 2 of doing a BE? (1; 3; 2; 2; 3; 1; 1; 1)

Answer 17

• Build morale and reinforce courage, praise
• Encourage full engagement
  o Risk of subtle avoidance during task, “going through the motions”
  o Use mindful awareness through guided discovery
   What did you just notice? What’s running through your mind right now? What’s happening to your anxiety? What do you observe around you?
• Provide reminders
  o In session, help clients recall rationale for BE, maintain focus on target cognitions
  o Out of session, flash cards can be used by pts
• Be sensitive to emotional state
  o Excessive anxiety or upset? Temporary withdrawal may be warranted
  o Overly comfortable-relaxed? Consider whether client avoiding experience.
• Remain flexible
  o BEs don’t always work out as expected
  o New cognitions can come to light
  o Be willing to back off, allow Ct to save face
• Monitor progress
  o What would you need to do to take this further?
• Confidentiality in public places
• Boundaries
  o e.g., when tx and Ct travelling to public places together? Or if seen in public together?

Question 18

How do you go about step 3 of doing a BE - e.g., what should you be observing? (7; 4; 2)

Answer 18

• Close review of what happened in the course of an experiment

What to observe?
* Thoughts feelings during and after
* Body state or sensations
* Behaviour (esp. safety or self protective measures)
* Notice other people in environment
* Aspects of environment (how crowded, space etc)
* Outcome of BE esp. impact on pts thinking or behaviour

Record impact of BE
* Written record sheets
* Rate degree of beliefs & intensity of emotions
* What went well not so well?
* What learned?

Active listening
* Empathy
* Distinguish between what client felt happened (I made a fool of myself) and what actually happened (How do you know? What reactions did you notice?)

Question 19

What is involved in step 4 of BE? (1; 4; 4)

Answer 19

Reflection: making sense of the experiment
* Aims to understand what the experiment means
* Guided discovery.
o “What do you make of this event?”
o “What does it tell you about yourself?”
o “How might you approach the same situation in the future?”
o “What does it tell you about other people?”
* Relate outcomes to previous knowledge and ideas
o How does what happened fit with your original predictions?
o How does it relate to old beliefs (Hypothesis A) versus new alternatives (B)?
o Does the experiment support a new thought or assumption?

Question 20

What is involved in step 5 of BE? (4)

Answer 20

Planning: Following up BE
* Planning comes directly from what has emerged during learning process
o How can this be translated to day to day basis?
o How carried forward in new experiments?
o What else needs testing?

Question 21

What are some common pitfalls in BE? (4)

Answer 21

• Maintain therapeutic relationship (trust)
• Aiming too high or too low
  o Too threatening or overwhelming, intense emotions can prevent learning
  o Or Not challenging
  o Discuss & feedback from client
• Some predictions hard to test
  o E.g. God is punishing me; If I don’t eat carrots I’ll get cancer in 10 years.
• Physical health issues
  o Overbreathing to induce panic symptoms may be contraindicated for some people (e.g. asthma)

Question 22

What are some good practice principles for BE? (5)

Answer 22

• Experiment must have meaning and impact
  o If the experiment worked out in your favour, would that result in positive progress
• Experiment should have good power
  o Load the dice towards an outcome
• If feasible, identify observations that are unambiguous, don’t lend themselves to multiple/contrary interpretations
• Must be do-able (not overly ambitious)
• Must be collaborative

Question 23

What are some common challenges in implementations generally? (4)

Answer 23

• Some clients are scientifically- minded by nature; others not so
• More challenges with clients with some disorders (e.g., Illness anx, GAD)
• better for Individuals who are: objective data driven, subj experience, ability or inclination to evaluate data, value ascribed to new information (e.g., GAD)
• challenging to test meta-cognitive beliefs
• What impact would the expt have should it prove your predictions wrong?

Question 24

What are some common challenges when implementing BE for depression?

Answer 24

• Pessimism
  o Client (…or yes-but)
  o Therapist contamination
• Cognitive deficits
• Suicidal thoughts/hopelessness
• Environmental reinforcement of negative thinking (yes-but from Others)
• Tailor frequency and level of treatment to
• client (e.g, twice weekly sessions for several weeks, day/in-patient)
• NB: Good coverage of Expts & Challenges by Fennell et al., (Chap 10, handout)