How do the aims of behavioural experiments (1) differ to the aims of cognitive therapy (2)
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
List some methods for reappraising/changing assumptions and core beliefs (5)
- 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
List and outline what happens withins the 4 stages of cognitive restructuring. (4;3;3;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
What are the 2 stages of cognitive restructuring for a BE?
- What is the precise prediction that I am testing and wanting to change?
- How can it be disproved?
What is the most powerful method for bringing about change in cognitive therapy? Why?
BEs - disorders don’t arise from events per se, but to the meanings individuals give to these events
Describe the cognitive vs. behavioural perspective regarding behavioural experiments.
- “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
What is the empirical evidence for BEs? (2)
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)
Identify the cognitive, affective, and behavioural components of BEs. (6)
- 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
Identify steps in the process of devising effective BEs. (4;1;3;3;1)
- 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
Identify 3 purpose that BEs can be used for
- Elaborating formulation
- Testing negative cognitions
- Conducting and testing new perspectives
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)
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
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)
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
Identify and define the 3 types of hypothesis-testing BEs.
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
Define discovery BEs.
Give an example in relation to a SAD person who self-monitors excessively
- 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
Identify and describe the 2 types of BEs
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
How do you go about step 1 of planning a BE?
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
How do you go about step 2 of doing a BE? (1; 3; 2; 2; 3; 1; 1; 1)
- 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?
How do you go about step 3 of doing a BE - e.g., what should you be observing? (7; 4; 2)
- 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?)
What is involved in step 4 of BE? (1; 4; 4)
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?
What is involved in step 5 of BE? (4)
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?
What are some common pitfalls in BE? (4)
- 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)
What are some good practice principles for BE? (5)
- 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
What are some common challenges in implementations generally? (4)
- 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?
What are some common challenges when implementing BE for depression?
- 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)
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2) The CBT Model35
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3/4) CB Assessment and Formulation26
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6a) Cognitive Therapy techniques55
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6b) Core beliefs25
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5a) Exposure therapies - Principles and Applications41
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5b) Imaginal desensitisation18
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4) Psychoeducation and Preparing Clients for CBT23
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7) Interoceptive Exposure55
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9a) Behavioural Activation19
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9B) HW in clinical practice19
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10) Cognitive Therapy: Techniques and applications26
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12) Behavioural Experiments24
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13a) Other CBT techniques28
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13b) CBT in practice - additional cognitive techniques11
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14) New CB Therapies13
