Oxford Guide to behavioural experiments in Cognitive Therapy: Fennell, Westbrook et al Chapters 1-5

Oxford Guide to behavioural experiments in Cognitive Therapy: Fennell, Westbrook et al

Contents
Chapter 1 Behavioural experiments: historical and conceptual underpinnings    2
Chapter 2 Devising effective behavioural experiments    3
1.    A typology of behavioural experiments    3
Design of behavioural experiments    3
2.    The learning circle: maximizing the opportunities to learn from behavioural experiments    4
3.    Planning: designing behavioural experiments    4
4.    Experience: the experiment itself    5
5.    Observation: examining what happened    5
6.    Reflection: making sense of the experiment    6
7.    Planning: following up the experiment    6
Chapter 3 Panic disorder and agoraphobia    6
Cognitive model    6
Behavioural experiments    7
Agoraphobia    9
Safety behaviours    9
Behavioural experiments    9
Determining the reactions of others    9
Experiments    9
Chapter 4 Health anxiety    10
Key Cognitions    11
Behavioural Experiments    12
Chapter 5 OCD    15
Cognitive model of OCD    15
Key cognitions in OCD    16
Behavioural experiments    16
Thought action fusion    16
Inflated responsibility    18
Controllability of thoughts    18
Over estimation of threat    19
Intolerance of Uncertainty    19
Distinctive difficulties in OCD    20
Reluctance to report    20
Unclear feared consequences    20
Far future catastrophes    20
Chapter 8 Specific phobias    21
Cognitive model    21
Development    21
Maintenance    21
Key cognitions    21
Behavioural experiments    22

Chapter 1 Behavioural experiments: historical and conceptual underpinnings

There are two aspects to thinking the content and the process. The process refers to how quickly we can move from one mode of processing to another or how we might get stuck in it, in say rumination.  There is the argument by Teesdale that there are two types of informational processing system within humans, one which is linked with the intellectual and the other linked with the emotional, the former is a slower response system the latter a faster one, and that you can have beliefs in both, i.e. there can be a rational thought and a felt sense\belief. When you do behavioural experiments you are targeting the latter. Teesdale named these two systems the propositional and implicational systems.

Heightened emotions enhances recollection but not the accuracy of recollection.  Memory is better for self-performed actions than those of others. If something is learned emotionally and behaviourally it has a stronger impact than if something is learnt verbally.

There are declarative and procedural contents of memory, Brazil won the world cup, to get a good night’s sleep drink cocoa.  To make change you have to change both and the latter can be changed by behavioural experiments.

The Lewin\Kolb learning model is Reflect=>Plan=>Experience=>Observe=>Reflect and on.

Chapter 2 Devising effective behavioural experiments

A behavioural experiment should only come out of a formulation and be used to test one aspect of it.

1.     A typology of behavioural experiments

A behavioural experiment has 3 main purposes

1.       Elaborate the formulation

2.       Test negative cognitions

3.       Construct more adaptive beliefs

The key aspect is not to modify cognitions per se, but through modifying cognitions transform emotional state and facilitate problem solving.

A behavioural experiment is a strong force in reducing the credibility of outdated NAT, rules and assumptions and core beliefs.

Don’t forget behavioural experiments can be observational!

Design of behavioural experiments

Hypothesis testing experiments

So establish hypothesis, when I go into a social situation x will happen, then test it. So for a person with a panic attack, they might get one and think they are having a heart attack. Then test this hypothesis with an in session hyperventilation test. The therapist should do this first.

Discovery experiments

Find out what happens when you act in a different way, with no idea of how it might turn out.

Active experiments

Here patients take the lead role, once an unhelpful cognition or pattern of behaviour has been identified, then this can be tested with different behaviour in a situation, e.g. thinking if I express disapproval I will be rejected, so role play expressing disapproval and see how you can deal with it

Observational experiments

These are useful when direct action is too anxiety provoking and when more information is required before planning an experiment.

Direct observation

This is modelling, so if a patient is scared of spiders, then the therapist can pick one up.

Surveys

Here the aim is to gather a broad range of opinions.  So a patient with a vomit phobia, might be relieved to find out that most people don’t like the smell of vomit.  Before carrying out the experiment it is useful to get the client to predict how other people will respond.  It is best to specify demographic aspects of the survey group before surveying them.

2.     The learning circle: maximizing the opportunities to learn from behavioural experiments

As much as there is the Lewin and Kolb model of plan, experience, observe and reflect, so there is the PETS model, prepare, expose, test and summarise.

You need to experience, experiments, what you think, feel, how you behave and what goes on in your body. Then you need reflect on how these new experiences relate to prior and possibly future experiences.

There can be any entry point to the circle, so you can have an unpleasant experience, which would be the experience section, or a powerful belief which would be reflection.  Again a common entry point can be distress, which you can then observe, and understand.

Experience: green rabbit experiment

Observation: trying not to think of them brings them to mind

Reflection= old belief is I cannot control thoughts, new belief through trying to control I’m making them worse

Planning=work out how to respond differently

Experience 2=try new way of dealing with thoughts

3.     Planning: designing behavioural experiments

Checklist for planning

·         Is the purpose of the experiment clear

·         Have you specified the target cognition and the predicted outcome of the experiment

·         Decide on the details of the experiment, where, how when etc.

·         Describe the type of experiment

·         Work out how this will be a no lose experiment

·         Is the experiment at an appropriate level, i.e. challenging but attainable

As you define the target cognition it is important to rate the degree of belief, as it is more than possible that the experiment will only change the degree of belief someone has.

To generate alternative perspectives, ask what would be another way of looking at that. How might a person that cared about you understand this?

Behavioural experiments help with emotionally grounded change, clients come to change their emotions not their thinking!!

You must make sure subtle safety behaviours are not used during an experiment, nor that behaviour that confirms dysfunctional beliefs are used.

When a patient does an experiment they will receive the results with a perceptional bias from their habitual distress, working through the results with the therapist can provide for new and slightly more objective data.

When involving others in the experiment, to start off with its important to build up a client’s confidence and do it with benign people.

If you tell a client next week that they are going to do an experiment they fear you can create anticipatory anxiety, if you spring it on them, then they could feel a breach of trust so you need to find a balance.

If you invest heavily in one outcome from an experiment it may not happen, so prepare a no lose scenario and be prepared for the unexpected!

Embarking on experiments is also a stimulus for a patients interest and curiosity, stimulating energy and inventiveness, thus it is an intervention in itself!

The level of the experiment needs to be discussed so that it is between too challenging and not challenging enough.

There are some beliefs that are hard to test, ones that happen rarely, e.g. job interviews, ones that only happen after many years or those that happen after death. In this case you could test causality, you might also do significant cognitive work before approaching an experiment.

4.     Experience: the experiment itself

For experiments to work a client must be fully immersed in them, for instance if you like golf but play golf thinking oh I’m so bad at golf then your mental behaviour is going to prevent you from enjoying it, so you need to make sure that there aren’t going to be any NAT’s getting in the way.

It is worth monitoring the patient’s emotional state through an experiment if they are highly anxious it might be worth taking a rest before resuming, if they are calm and cheerful then it might be worth seeing if the experiment wasn’t demanding enough or they are engaging in safety behaviours.  There should also be emotional change when there is cognitive change, so you can see whether or not the experiment has bitten.

If an experiment goes wrong then it is useful for the therapist to be there, it is also useful to revisit the formulation so you might well find out that a core belief is stronger than was thought, it is important that the client doesn’t feel demoralised from the experiment.

So how should the therapist be when taking a bus with the client to the site, where there are not the usual boundaries of the therapy room?

5.     Observation: examining what happened

Observation means finding out what happened in the experiment, not what it means, thus it’s pure, well as pure as is possible description. It involves describing what happens externally and internally, so events, cognitions and emotions.  So you need a 5 aspect, you also need to know what the expected 5 aspect was to see if there is a change.

Conceivably as soon after the experiment then a description of what happened is needed.

Use of safety behaviours can be noticed when the client reports a near miss, i.e. it was ok this time, but next time it could be a problem.  So ask was there anything that you did to stop the worst happening.  If a client is still using safety behaviours then they may well have a very strong belief in their NAT so it can be useful to generate alternative views so that they can dispense with the safety behaviour, as safety behaviour is a logical response given the strength of belief in their NAT.

Sometimes you get intellectual shift but not emotional, this can happen if you use observational experiments, in which case move to active ones. It can happen in the face of a long held belief, so repeated experiments could be needed, or more intense ones.  A clients processing bias, may well discount the positives in terms of the negatives so you should be on the lookout for this as they observe. Also look out for self-fulfilling prophecies, i.e. fearing x and acting as if x is happening and therefore making it more likely.

6.     Reflection: making sense of the experiment

So now we move beyond description to find out the meaning of the experiment, has it challenged old beliefs, does it create any new beliefs.  So what does it say about the situation, about herself about other people, about the world?

Common pitfalls

Rushing, so not getting full observation or reflection.

Assuming once is enough, if you have an entrenched belief it’s not going to change with one DTR or one BE, really!

7.     Planning: following up the experiment

Look to see what is still left to be done, is the dysfunctional thought still believed in part, or maybe addressing one dysfunctional thought leads to another, so I realise I’m not going to be rejected by people but am I going to be liked?

Chapter 3 Panic disorder and agoraphobia

DSM4 defines a panic attack as a sudden increase in anxiety accompanied by four of more in a list of symptoms, such as palpitations, breathlessness and dizziness. Panic disorder is where there are recurrent panic attacks, some of which are unexpected.

Cognitive model

Clark (1986) is the best known panic disorder model who sees a panic attack as misinterpreting bodily sensations. Safety behaviours and selective attention maintain this disorder.  People with panic attacks fear imminent catastrophe, be it mental, going mad, or physical having a heart attack. The safety behaviours used are holding on to things, or people, deliberate changing in breathing pattern, people who fear insanity may try distraction techniques.  Triggers for panic attacks derive from the hypsensitivity which clients regard their bodies or minds.  The initial symptom may be spotted so quickly then the panic attack ensue that it may seem like the panic attack comes out of the blue.  So people with panic disorders use both safety behaviours and avoidance to manage their symptoms.

Part of the problem with a panic disorder is that the panic comes from an unknown source and therefore is understood by catastrophic interpretation.

When doing a behavioural experiment then you get the patient to evoke their symptoms, maybe by hyperventilating, however this is from a known source and may not seem like a panic attack. You should not do hyperventilation with someone who suffers from epilepsy, asthma, cardiac complaints or is pregnant.

Behavioural experiments

1.       Discover the true cause of frightening symptoms

2.       Discover the effects of not carrying out safety behaviours

3.       Discover what happens if symptoms are exaggerated

4.       Test whether safety behaviours make things worse

1.       Discover the true cause of frightening cognitions

a.       Target cognition

                                                               i.      High heart rate means heart attack

b.      Alternative cognition

                                                               i.      Could be an increase in activity

c.       Experiment

                                                               i.      Increase heart rate by running up and down stairs

d.      Rationale

                                                               i.      Increases in heart rate are due to increase in activity. When the fight or flight response is created then adrenaline is created and the heart beats faster to enable this.

Symptom	Test
Dizzy and lightheaded	Hyperventilate
Chest pain	Hold in some breath, then breathe in and out rapidly
Sudden rush of symptoms	Repeat paired words of symptom and catastrophe
Disturbance in visual field	Stare at visual grid at move it gently

2.       Discover the effects of not carrying out safety behaviour

a.       People use safety behaviour to protect from feared consequences and then when they don’t come they attribute the lack of feared consequences to the safety behaviour as opposed to the fact the feared consequences didn’t come, as they weren’t going to come anyway

b.      Target cognition

                                                               i.      When I feel wobbly I will fall over unless I hold onto someone

c.       Alternative cognition

                                                               i.      The wobbliness is just a feeling and I won’t fall over

d.      Predication

                                                               i.      If I let go of my shopping trolley when I feel panicky I will fall over

e.      Experiment

                                                               i.      Go to place supermarket where you feel panicky, then don’t use the trolley and see what happens

Prediction	Safety behaviour	Test
Could go crazy from thoughts	Distraction and mind control	Let thoughts race
Could suffocate from dry throat	Eat sweets and drink water	Don’t eat sweets and drink water
If I don’t wear dark glasses I will collapse	Wear dark glasses	Don’t wear dark glasses
If I don’t take deep breaths when anxious I will collapse	Take lots of deep breaths	Don’t alter breathing pattern

3.       Discovering what happens if symptoms are deliberately exaggerated

a.       Get the client to the point where they see the worst will not happen, but they may well still be left with a nagging doubt.  The client would show this by saying they got away with it, just.

b.      Target cognition

                                                               i.      I will feel lightheaded and I will faint, the longer I feel this way I will faint

c.       Alternative perspective

                                                               i.      Feeling light headed is cause by breathing more quickly or deeply than usual and is triggered by the fight or flight response

d.      Experiment, hyperventilate for 5 minutes

Prediction	Test
When hot I will faint	Stand in hot room
Feeling breathless when anxious, I will stop breathing unless I force air in	Hold breath as long as possible
Feeling faint in stuffy rooms, I will run out of air	Create a stuffy room
Feeling wobbly I will fall down, so I must slow down or	Get anxious then walk quickly

4.       Testing if safety behaviours make it worse

a.       Target cognition, I may collapse unless I tense my legs

b.      Alternative cognition, tensing your legs may make it worse

c.       Experiment

                                                               i.      Tense legs and walk around

                                                             ii.      Don’t tense legs and walk around

Safety behaviour	Test
Thought control	Pink rabbit
Swallowing repeatedly to stop throat closing	Try swallowing repeatedly

Agoraphobia

Agoraphobics are more likely to fear fainting than less avoidant panic patients as they have distorted views of how others would react, being totally ignored or attracting a huge embarrassing crowd.  There is also the sense of not being able to cope by themselves.  They are likely to suffer from separation anxiety.

Safety behaviours

The most typical safety behaviour is avoidance of places from which escape might be embarrassing, or the need for a companion or a mobile phone.  They may have little experience of asking strangers for help or asserting themselves when appropriate.

Behavioural experiments

1.       Discover how others would react in the event of physical or mental catastrophe

2.       Experiment to see how well the client would react in the event of physical or mental catastrophe

3.       Experiments to determine the extent of rescue factors

Determining the reactions of others

In the classic experiment the therapist accompanies the patient to a public place then pretends to be going through the feared catastrophe. It is helpful to have two therapists present one to perform the catastrophe and one to support the client.

Experiments

1.       Test bladder control

a.       Target cognition: if I wet myself then I will be ridiculed and might end up in a psychiatric hospital

b.      Alternative perspective: no one will notice me

c.       Experiment

                                                               i.      Therapist pours water on themselves to fake having wet themselves and walks through shopping centre

                                                             ii.      Then when the predicted outcome doesn’t happen then the client does it

2.       Test bladder control

a.       Do a survey to women and ask how many have lost control of their bladder and what the outcome was

3.       Test the reaction of others to fainting

a.       Target cognition

                                                               i.      people will ridicule me

b.      Experiment

                                                               i.      First therapist does it, then client

4.       Test ability to cope with being lost

a.       Target cognition:

                                                               i.      if I get anxious and lost I will not be able to ask for directions

b.      Experiment

                                                               i.      Feign being lost and ask people for directions

Catastrophe	Tips for therapist
Vomiting	Spit out some soup whilst retching
Wobbly walk	Sway around and stagger whilst walking
Lose control	Wander about talking to oneself and doing odd things
Fall down	Trip oneself up and fall to the floor

Chapter 4 Health anxiety

This is the misinterpretation of bodily symptoms to a serious medical conditions. Seeking reassurance makes it worse and the DSM classification says that this must be the case for more than 6 months

The HA person fears their serious medical condition and doubts their ability to cope with it. There is a similarity with panic disorder but with panic disorder the feared catastrophe is immediate where with health anxiety it is in the future.

Specific assumptions about health behaviour comes from past experience from self and from friends and family, i.e. a bump could mean cancer. Likewise stories from the internet about medical mismanagement mean that the medical profession can be doubted and it increases anxiety. Likewise the proliferation of health scare stories in the media can raise the levels of anxiety.

A number of different factors maintain health anxiety

1.       Bodily hypervigilance

2.       Reassurance seeking

3.       Cognitive avoidance

4.       Rumination

5.       Bodily sensation misinterpretation

6.       Thinking errors

Exaggerated beliefs, arbitrary inference, e.g. I have a red patch therefore its cancer, selective attention, i.e. general good health but out of breath walking up stairs, can provide a perceptual confirmatory bias to justify the clients negative beliefs. Repeated checking of the body, can cause irritation that then provides more justification to the idea that something is wrong.

There is avoidant behaviour, in terms of avoiding doctors or health programmes, which in  turns seeks to maintain their dysfunctional beliefs.

Key Cognitions

1.       Fear of missing something important

a.       Patients believe they have to take responsibility for their health as doctors often miss something important and through going often they can help prevent something serious happening to them

2.       Seeking medical information

a.       I must keep abreast of medical information, the internet can show me the best way of keeping abreast of information

3.       Seeking medical assessment

a.       Detailed tests are the only way to be sure. If a doctor sends me for a test it is because he thinks there is something wrong

4.       Checking behaviour

a.       I must check continually for signs of symptoms

5.       A healthy body does not have symptoms

a.       Bodily changes are always a sign that something is wrong

b.      The body should be symmetrical

c.       You can know with absolute certainty that one is not ill

d.      Symptoms are always explainable

6.       Increase vulnerability

a.       People in my family always get ill

7.       The cost of illness

a.       If I die my mother’s life will be ruined

b.      If I am ill no one will care about me

c.       Death will be lonely

8.       Anxiety can kill

9.       If I think about cancer I can get it

The therapeutic alliance with a patient with health anxiety can be difficult. The therapist aims to help the client with their anxiety, the patient wants the therapist to support their position that they have a physical problem.  Again the patient might be resentful being referred to a psychological treatment rather than a physical one, as their problems aren’t being taken seriously.

It is important to build a strong alliance or the patient will drop out. If the therapist focuses on what is maintaining the anxiety this can be useful in ending up in a polarised position between physical and psychological interpretations. Likewise you shouldn’t challenge beliefs until a good alliance is created as often the patient doesn’t feel like they are being understood or taken seriously.

One way to approach the client is in terms of treating therapy as a behavioural experiment between two hypotheses, one that they have a serious and undetected problem, and two that their worrying and concern is a major concern and this can be approached psychologically.

Some patients believe they must always be vigilant for treatment to be effective, this can get in the way of behavioural experiments that delay self-monitoring. This being the case then these beliefs need to be explored.

There are three categories of test

1.       Beliefs about the need to be responsible for your health which maintain preoccupation and worry

2.       Beliefs about health, illness and death

3.       Beliefs about the effects of anxiety and worry

Beliefs about the need to be responsible for your health which maintain preoccupation and worry

Behavioural Experiments

Experiment 4.1

Fear of missing something important

Problem=self-checking

Target cognitions= if I have an unusual sensation it is the sign of something being wrong

Alternative perspective= focussing on a symptom can blow it out of proportion and make it worse

Prediction=if I do not pay attention to a symptom I  will miss something important, I will get more anxious, therefore checking reduces anxiety

Experiment:  On one day, keep a diary of all the times the thoughts about illness come to mind and  check all you want, and rate your anxiety throughout the day. On the next day then keep a diary of all the times the thoughts about illness come to mind and then to rate anxiety every hour.  At the end of the day rate the thought I may have a serious illness

Experiment 4.2 Delaying visits to the GP

Problem=repeated visits to the GP

Target cognition= if I don’t get the doctor to investigate my symptoms then I will undergo a period of suffering due to illness and die

Prediction= If I delay a visit to the doctor anxiety will be unbearable and I will be consumed by health concerns

Operationalize predictions=delay visits to the doctor for two weeks and measure levels of anxiety and presence of symptoms

Experiment=delay visits to a doctor for 2 weeks and rate levels of anxiety and levels of belief that I have a serious illness

Experiment 4.3 symptom focussing

Target cognition=if I don’t monitor then my symptom will get worse and if it goes undiagnosed then I will be at risk of serious injury

Alternative perspective= paying attention to any part of my body can result in identification of normal sensations that could be seen to be symptoms.

Prediction= if I don’t monitor my symptoms they will get worse and my anxiety about getting a serious disease will get worse.

Experiment= hypothesis one= I have a serious disease hypothesis two focussing on any part of the body will turn a normal sensation into a symptom. So pick a part of the body focus on that repeatedly and see if you can create something that feels like a symptom.

Quite often people with health anxiety can use this to mask another problem they may be having. When the health anxiety reduces this primary problem may well surface.

Experiment 4.4 testing whether safety behaviour increases symptoms

Problem= swallowing repeatedly to avert a threat of your throat seizing up, or having throat cancer

Target cognitions=the difficulties that I have in swallowing means that I have throat cancer

Alternative perspective= the difficulty that I have in swallowing is related to my anxiety and the fact that I am constantly checking up on how my throat is feeling by repeatedly swallowing

Prediction= I keep monitoring the symptoms to make sure it is not getting any worse, it would be foolish to ignore as it is important to have these things diagnosed as quickly as possible

Experiment= Do an exaggerated version of safety behaviour, so in this instance swallow repeatedly seven times to see how it makes you feel. The therapist should do this as well to report of their sensation as well.

Experiment 4.6 Over informing the GP

Problem= frequent visits to the GP with long list of problems that the patient feels the GP doesn’t listen to or take seriously

Target cognition= I need to tell the GP every minute detail of all my symptoms otherwise he won’t understand my problem

Alternative cognition GPs are trained to find out what is important in making a diagnosis. Sessions are only 10 minutes long, so the GP will interrupt what he considers irrelevant details and this gets me frustrated which makes for a bad consultation.

Prediction=if I don’t tell the GP every detail he may miss something important

Experiment= make an appointment for specific problem, before seeing the doctor role play it with the therapist only telling him the main details.

The aim here is to get the patient to be more effective at seeking reassurance.

Beliefs about health, illness and death

Experiment 4.7

Problem=believing that you have an undiagnosed illness due to the symptoms that you have

Target cognitions=symptoms are signs of illness

Alternative perspective symptoms are normal for most healthy people

Prediction other people will not experience symptoms because they are healthy and I am not

Experiment=conduct a survey amongst friends and family asking if they have similar symptoms and how they would explain them.

Experiment 4.8 quick in session discovery experiments to look at alternative explanations of symptoms

My body is not functioning properly=Experiment, hold arms at right angle to the body and note the symptoms it produces, see how pain can simply result from using the body in unusual ways.

Dizziness is evidence of brain tumour=get up and down from their chair rapidly to produce dizziness. Then open up a discussion to show how dizziness can be induced and how it can be ignored unless a person is anxious about them.

Experiment 4.9 beliefs about the cost of illness or death

Problem: If I die someone won’t be able to cope

Target cognition= when I die my husband won’t be able to cope and the kids will end up in care

Alternative perspective=if I died my children would be looked after by the family

Prediction=if I asked my husband what he would do if I died, he would say he wouldn’t give up work

Experiment: devise a questionnaire to give to friends and family as to how they would respond to the patient’s death

Beliefs about the effects of anxiety and worry, thought action fusion

Experiment 4.10 controlling worrying thoughts

Problem= worrying about an illness

Target cognition, if I don’t control my thoughts I will go mad

Prediction=if I let the thoughts go and don’t control them then they will spiral out of control and I will go mad

Experiment: therapist and client understand what going mad looks like, and then try to lose control of their thoughts.  Then think repeatedly about the feared thought and see what happens

Experiment 4.11 If I think I will be ill, then I will be

Experiment, set aside a particular time of the day, think about a specific illness say eczema and see if you get it

Distinctive difficulties in working with health anxiety

People with health anxiety have difficulty in changing their beliefs as they believe their lives depend on it.  So there are two ways to approach this, decatastrophise and to cognitively restructure the symptoms that are indicative of it. It is important not to set up experiments to show the absence of a disease or certainty about the future, as you can’t.  Rather what you need to do is to show the client that their current behaviours are increasing their anxiety and are more likely to experience unpleasant symptoms.

Chapter 5 OCD

Obsession is intrusive thoughts, images or impulses which causes marked distress. Compulsions are repetitive behaviours to deal with the obsession. DSM definition is OCD must last for more than an hour a day, interfere with the persons functioning, are seen by the client as unreasonable and cause significant distress.

The most common form of OCD is

1.       Contamination fear that they will become ill

2.       Fear something bad will happen if they do not check they have done something right

3.       Thoughts that are feared will mean that they will do something immoral

Cognitive model of OCD

Salkovskis proposed that the problem occurs in the way the OCD patient interprets the normal intrusive thought. The interpretation is that they may be responsible for harm or its prevention.  This negative interpretation leads to anxiety, which then neutralising behaviours, compulsion, avoidance,  seek to reduce.  There are also attentional issues with OCD where there is overestimation of threat, personalisation, intolerance of uncertainty and perfectionism.

Key cognitions in OCD

1.       Thought action fusion

a.       His can take two forms where a person thinks because they have a bad thought they are likely to do something bad.  The second is where having a bad thought will mean something will happen to someone else, e.g. car crash.

2.       Inflated responsibility

3.       An exaggerated belief that one has the power to create or prevent negative outcomes.

4.       Belief about the controllability of thought

5.       Perfectionism

6.       Overestimation of threat

7.       Intolerance of uncertainty

Behavioural experiments

The main thrust here, is the patient believes there is a real risk and their actions reduce the risk. The therapist sees this as maintaining their fear, and they have an exaggerated sense of risk

There are two types of experiment one to test out the reality of the risk, and one to test out whether their actions maintain their fear.

Thought action fusion

Experiment 5.1 thought leading to action

Problem thought leads to action

Target cognitions: if I have these thoughts, then I must want to do them

Alternative cognition: thoughts can’t make me do anything. I only have them as they are so repugnant to me

Prediction: if I am close to my feared object I won’t be able to help but do a bad thing with it

Experiment: test this in the office

Experiment 5.2 thoughts cause events to happen

Problem If I think something bad will happen to someone then it will

Target cognitions, If I think something bad will happen to someone then it will unless I take preventative measures

Alternative perspective: a thought is just a thought and doesn’t make anything happen

Prediction: if I think something bad it will happen, and my anxiety will get so bad I will be unable to do anything to neutralise it

Operationalising the problem: think something bad about the therapist and see if it happens. Does the event happen or just create anxiety

Experiment: start thinking bad thoughts about the therapist, then extend to closer relations. Rate anxiety whilst having thought, then afterwards when it doesn’t happen, ensure that no safety behaviours are used. Start in session and then spread the net out further You might want to start off with good outcomes, e.g. winning the lottery, then neutral examples, such as colour of socks, then bad stuff

Experiment 5.3 fear of harming due to loss of cause (internal cause)

Problem: intrusive thoughts show madness is impending and the patient might act on them in spite of themselves

Target cognition: if I have these thoughts, it shows I am going mad and I might do it in spite of myself

Alternative perspective: these thoughts only keep coming as they are so appalling to me, they are only thoughts and cannot make me do anything

Prediction

If I have these thoughts I might act on them, so I need to avoid the situations in which I could do them

Experiment:  so be around the feared object for a short time and repeat the thoughts, rate her anxiety at the beginning and at the end of the short time.

Be careful to ensure that the thoughts are ego dystonic and are neutralised as this indicates OCD as opposed to another distress.

Experiment 5.4 fear of harming due to loss of control (external control)

Problem: fear of losing control and doing something bad to someone by being put in a trance\hypnotised state.

Target cognition: any visually repetitive stimulus will result in me becoming hypnotised against my will and I will do something bad

Alternative cognition: I am very frightened of losing control, but I cannot be hypnotised against my will

Prediction: If I see a repetitive stimulus then I will be hypnotised and do something against my will

Operationalising the problem: You need to establish what would show you weren’t hypnotised, e.g. answering a questionnaire.  Likewise you may need to see that you are not under the therapists power by the therapist telling the patient to do things and the patient to ignore them

Experiment: get a pendant and wave slowly in front of their face and test if they are hypnotised, test anxiety levels before and after.  You may also want to get the patient to understand what the emotion of anxiety is so that if they feel it they then don’t think they have been hypnotised.

Inflated responsibility

Problem: repeat checking behaviour, of taps, electricity etc.

Target cognition: I cannot risk leaving without checking or there will be an accident

Alternative cognition: The risk is not height, but my sensitivity to responsibility is making me feel this way

Prediction: I will not be able to resist checking even if someone else takes over. If I do resist my anxiety will be so high I will not be able to resist

Experiment: the therapist writes a letter saying they will take over all responsibility for anything that happens as a result of the patient not checking.   Remember to take the letter back afterwards or it could operate as a safety behaviour.

Experiment 5.6 responsibility for bad comments from others

Problem: client feels overly responsible if someone around her said something bad.

Get bad will happen and I will be responsible for something bad happening

Alternative perspective: if someone says something bad then nothing bad will happen as a result of what was said and I will not be responsible for any consequences

Prediction: if something bad is said, something bad will happen, and if I don’t get them to take it back, then my anxiety levels will go through the roof and I may go mad

Experiment: in the office say something bad and see if it happens, monitor anxiety before and afterwards, then increase the scope outside of the office

Controllability of thoughts

Problem: If I have a bad thought it could happen so I must keep tight control of my thoughts

Target cognition: I need to and should be able to control my thoughts

Alternative perspective: nothing bad will happen if I don’t control my thoughts

Prediction: If I do not control my thoughts, I will be overwhelmed by anxiety and I will do something bad

Operationalise the problem: What does it mean to lose control, have you ever done this before.

Experiment: spend one day trying to control your thoughts and monitor the anxiety, then one day not and just monitoring them monitor the anxiety.  Take the thought as a cue to do something monitor it, or just be aware of it, and this will help manage the anxiety.

Experiment 5.8 perfectionism

Target cognition if I don’t wash then I’ll be dirty and others will reject me

Alternative perspective If I reduce my washing no one will notice

Prediction: if I don’t wash as frequently I will get anxious thinking I’m dirty and ones will notice that I am smelly

Preparation for experiment

Question the black and white thinking by looking at how others behave and whether you reject them

Experiment

Make yourself deliberately dirty, put a stain on your clothes and see how others behave.

Over estimation of threat

Experiment 5.9 overestimation of threat (contamination)

Target cognition: if I touch anything I believe to be contaminated I will become ill and I will get uncontrollable anxiety

Alternative cognition: if I do not wash nothing dreadful will happen

Experiment: touch something dodgy in session and don’t wash, then rate anxiety every ten minutes, then make a sandwich when you get home and see if anyone gets sick

Experiment 5.10 overestimation of threat (harming)

Problem:  Fear that an external action is happening when it’s not, e.g. walking past women and touching them inappropriately

Target Cognitions: I touch women at every opportunity, I am a menace to women

Prediction: I will not be able to walk down the street without touching women, the anxiety will get so bad I will have to cross the road to avoid them

Experiment: therapist follows client as he walks up the street, and see him brushing past women without molesting them, monitor anxiety and see how with repeated practice the anxiety reduces.

Intolerance of Uncertainty

Experiment 5.11 Intolerance of uncertainty

Problem= needing absolute certainty

Target cognition= only if I have absolute certainty can I know something has been done

Alternative perspective= you can have done things without having absolute certainty

Prediction= everyone else remembers that they have turned the taps off and are absolutely certain

Experiment= Survey people if they remember with absolute certainty that they have turned the taps off

Experiment 5.12 Inappropriate criteria-waiting till it feels right

Problem= don’t stop doing something until it feels right, so check that you have turned off the tap until it feels right

Target cognition: I need to check until it feels right, if I don’t I will be overwhelmed by anxiety all day

Prediction: if I stop before it feels right then I will be anxious all day and not be able to cope

Operationalising the problem, test the outcome of checking all the time on anxiety and checking once and turning away

Experiment: do checking until it feels right, test the amount of time taken and the anxiety levels. Then check only once and check his anxiety levels. Do this again, over three days what you will find is that the more that you check, the more doubt is introduced so the higher the level of anxiety

Experiment 5.13 establishing what is normal

Sometimes OCD sufferers have acted like this for so long they don’t know what is normal. So what you need to do is to shadow another person to see how they behave, and compare it with their own behaviour.

Distinctive difficulties in OCD

Reluctance to report

To devise an experiment you must have cognition to test. Now with OCD people are reluctant to divulge their cognitions, due to embarrassment, or fear of being seen to be mad.  It can be useful for the therapist to suggest common cognitions to show that they are familiar with them.  You can also reduce the significance of OCD in comparison to psychosis.

Unclear feared consequences

Because OCD clients neutralise their fears very quickly then their fears never become conscious so they don’t know what they are conscious of. So in this instance you may need not to work with an unknown fear and look to make most use of alternative perspectives. Um how is the question on my mind.

Far future catastrophes

If I touch this door knob I will get cancer in 10 years’ time.  IN this instance it might be more useful building up benign perspectives.

Chapter 8 Specific phobias

Specific phobia is defined as persistent fear of an object, situation, exposure to which leads to immediate anxiety even panic. Anticipatory anxiety is a central feature. Levels of fear depend on the proximity of the object and the ability to escape it.

5 sub types of phobia

1.       Animals

2.       Natural environment

3.       Blood and injections

4.       Situational e.g. lifts

5.       Atypical phobias, e.g. noise

A further category is fear of fear which crosses all other boundaries, the first fear is of the phobic stimulus the second is fear of that fear reaction.  Specific phobias may coexist with health anxiety, OCD and PTSD. Depression, hopelessness and low self-esteem may be secondary problems.

Cognitive model

Exposure with relapse prevention until habituation occurs has been seen to be effective in many clinical trials.  However Salkovskis showed that content of harm cognitions correlates with the level of phobic anxiety levels and avoidance patterns. It has been argued that exposure is only effective if cognitions change.

Cognitive therapy shows that phobic anxiety is constructed as a rational response to situations that are seen as dangerous as a result of biases in perception, interpretation and memory. Carefully targeted interventions on cognitions can facilitate an understanding that feared stimuli are not as fearful as they seem and need not be avoided.

Development

Classical conditioning accounts for the development of specific phobia, where a conditioned stimulus is paired an unconditioned stimulus. Phobias can also be learnt vicariously and through the prepared fears that exist in a society.

Maintenance

1.       Anticipatory anxiety, based on exaggerated beliefs

2.       Physiological arousal

3.       Hypervigilance

4.       Safety behaviours

Key cognitions

The cognitive process overestimates the danger and underestimates the coping resources.

Overestimation of the probability of harm

Overestimation of the consequence of harm

Underestimates of rescue factors, e.g. medical services

Secondary cognitions

1.       I am weak

2.       My life is wasted

Secondary cognitions can lead to depression, hopelessness and loss of confidence.

Behavioural experiments

Animal Phobias

Experiment 8.1 fear of anxiety symptoms

Target cognitions, I will become anxious and pass out

Alternative perspective: I may experience anxiety symptoms but I will not pass out

Experiment: start with inducing small amounts of anxiety without safety behaviour and gradually increase.

Experiment 8.2 overestimate of harm

Target cognition: I will be harmed

Alternative cognition: I will not be

Experiment: again start with small exposure and work up, testing cognition as you go

Natural environment

Experiment 8.4 effect of safety behaviour on overestimate of harm

Target cognition I need to do my safety behaviours to keep safe

Alternative perspective: the less I do my safety behaviours the less I will worry about my fears

Blood injury

Experiment 8.6 needle phobia, using modelling

Blood phobias are different from other phobias as negative predictions are often true. Using applied tension is a recognised treatment option. To do this first teach applied tension, then model getting an injection, then get the client to do it.

Height phobias

Clients can be exposed and retain high anxiety levels due to catastrophic images. In this instance repeat the exposure with a transformed image that the client comes up with. Doing ratings in situ can provide temporary distancing from anxiety. If a client really struggles with exposure then some level of distraction can be temporarily useful finish

Distinctive difficulties

Asking patients to face their fears takes courage.  The aim with these experiments is to test out hypothesis not do graded exposure, so you can go far more slowly than with graded exposure. If you have to deal with very high levels of anxiety, then you can use some distraction techniques or relaxation techniques but these should be dropped as soon as possible. Some clients avoid affect and you should be aware of this in the experiment as if they do, they won’t get the benefit from it.