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