CBT Methods: Behavioural Experiments
CBT Methods: Behavioural Experiments
Behavioural Experiments
Client examples made up, anonymised beyond recognition or classics used very frequently with many clients.
What are they?
Behavioural experiments (BEs) are experiential activities undertaken in or between sessions. They are designed based on a cognitive formulation of a problem. The primary purpose is to gather information which tests the validity of the client’s beliefs, develop or test new beliefs or develop the formulation (Bennett-Levy et al., 2004).
BEs are amongst the most powerful tools available in CBT. They enable the client to actively engage in the process in a way that purely verbal methods cannot. Clients (and therapists) get to see it, hear it, feel it, smell it and touch it. This creates a much deeper level of information processing. Adult learning theories stress the importance of both experience and reflection in creating the most effective learning experiences (e.g. Kolb’s learning cycle). By combining BEs with time spent reflecting and discussing the process, clients are able to process information on both emotional and cognitive levels, thereby maximising the learning experience.
How do you design a good one?
-Experiential Methods
A well timed spontaneous experiment early on in therapy can help socialise the client to the active and collaborative approach to learning that is at the heart of CBT. For example, the famous hyperventilation/over-breathing experiments with people who experience panic, the ‘white bear’ experiment (which goes something like, ‘For the next minute I want you to do your very best to not think about white bears. It is very important that you do not think of them so do all you can to push them from you mind’) can help the client recognise that pushing unwanted thoughts away makes them come back with vengeance.
Another more spontaneous example was a client who asked, “Is my mind really powerful enough to make me feel something in my body just because I’m thinking about it?” I could have said, “Yes” but that’s nowhere near as convincing as. “Well let’s find out shall we? Why don’t you close your eyes, right, now I want you to focus your mind on your stomach…” And of course, the client was suddenly aware of all kinds of sensations and gurgles and was able to conclude that their mind was very powerful and that focusing on something can create or heighten physical sensations that they were not aware of before.
-Planned Behavioural Experiments
It is important to pin down the key cognitions for the individual client. What do they really need to find out about to get a different perspective on their problems or dilemmas. BEs can and should be as creative and as individualised as our clients are.
-Surveys
A well designed survey can be both a lot of fun to conduct and an extremely rich source of information for clients and therapists. A number have been conducted on clinpsy and clinpsy members can be a juicy source of material to normalise OCD and psychotic symptoms like this one. Internet surveys like this can be very helpful if you want to get a lot of data or you want to use a particular group of people (some of my clients see psychologists as somewhat superior people who never have problems – so clinpsy data can be extremely helpful to dispel this myth!) However, on the whole, I find that the best surveys are those conducted with a digi-recorder in hand, the recording then given to the client to listen to and reflect on both in the session and as a homework task.
Examples I have done include:
-Interviewing doctors about a specific set of symptoms and asking whether they think it is possible that these are caused by anxiety
-Asking for people’s reactions to a someone acting in a particular way (e.g. avoiding eye contact or covering their face with their hair) thereby giving the client some feedback on how they come across to people who know nothing about them other than the safety behaviours they display in social situations
-Taking a photograph of something about a client’s body they are particularly bothered by and asking for reactions (Gok Wan eat your heart out!) (Obviously get consent for this, consider anonymity and if the client is recogniseable in the photograph, keep it within services if at all possible).
I always make a point of asking clients if they think staff members will have a different reaction than members of the public. If they think they do, then it may be necessary to recruit family and friends to participate in surveys. This can be very helpful. However, people will inevitably be curious about what you are doing. It’s not that often you get some psychologist shoving a microphone in your face and asking a load of obscure questions. So plan in advance how you will explain yourself in a way that is acceptable to you and to your clients and that doesn’t breach confidentiality. Also a note about staff - make sure you explain you're looking for their personal reaction. In my experience this is especially important for students who might see this as a test of their knowledge and present a lot of diagnostic possibilities or professional sounding advice.
If you do use recorded surveys, they will take a fair amount of your time and effort to collect information. Sometimes clients will do their own (e.g. I’ve had clients go and survey people they know to find out if they’ve ever heard their voices) but a lot of the time, the therapist will need to do the leg work because they have access to appropriate people and the courage to ask wacky questions. So be realistic with your client about how many people you will be able to survey and how long it will take you to do this. Also – you’ve put in a lot of effort so milk it for all it is worth. Listen to the recordings in sessions with your client, pause the tape, take time to reflect and get all the juice out of the experience.
-More active experiments
As you get to know the client and you both start to identify they key beliefs and assumptions that need to be explored, more individualised, creative and slightly unusual experiments can be conducted. These can range from good old classics like fainting in the supermarket or attempting to record someone’s voices or thoughts to see whether they are being broadcast to others to highly individualised experiments tailored to very specific predictions of that individual.
There are forms available (such as this one) that can be very helpful to work through with the client. Not only does this help to keep the experiment structured and collaborative, it also gives the client the tools to plan and conduct their own experiments in the future.
Remember – this is not exposure. The aim is not to habituate to an anxiety provoking situation (although that might happen), the aim is to test out a client’s predictions and learn something new. And this is an anonymised example of the process:
BELIEF
Unless I wash every hour, I will smell absolutely disgusting. This is due to sweating in my arm pits which will also be on my clothes.
EXPERIMENT
Therapist recruits a few stooges (and offers up her own services) who agree to bring a change of top to work that day. Just before the client’s appointment the stooges change top. The client also changes their top. Then another group of staff who do not know whose top is whose are asked for smell ratings.
PREDICTION
If I shower in the morning before my therapy appointment in the afternoon but not wash between times, I will smell dreadful. The smell will be in my clothes and people will find them utterly replusive. People will rate other peoples tops as about 2/10 on smelliness and mine as at least 9 or 10 with one being doesn’t smell bad at all and 10 being worst smell ever.
OUTCOME
Client and stooges rated all tops between 1 and 3 including mine.
WHAT I’VE LEARNED
My clothes don’t smell bad to other people. I may not smell as bad as I think I do.
Behavioural Experiments for Therapists
And finally - behavioural experiments are not just for clients! They can be a very helpful way for therapists to test out their predictions about what is happening in therapy or in other workplace situations. I had a belief that if I interrupted clients they would feel very invalidated. This meant that with some very talkative clients my sessions were becoming very unstructured and unfocussed. I experimented, I deliberately interrupted clients and recorded the client’s feedback about the session and well as my own perception. My sessions became more structured, my client’s feedback actually got better and I was also happier with the process.
I also hate complaining, thinking this will provoke an angry response in shop assistants, waiting staff etc. This was a silly
thing to confess to in a workshop on BEs on my CBT training course…of course I had to go and make an outrageous complaint to find out if they did roll their eyes or tell me not to be so unreasonable. (They didn’t, they were very polite and gave me a refund on the perfectly nice cake I claimed was stale!!!)
If you’re not sure about BEs, it can be very helpful to try out a few of your own maybe with a colleague or friend and then you can mutually experiment and see what the experience is like. BEs are an experiential method and the value of doing them for yourself cannot be understated.
Trouble shooting
Vicky_R asked some great questions in livechat discussing this wiki so I've attempted to answer them here
- What happens when a BE, or series of BEs, actually supports the core belief you set out to challenge?
A BE may not be to test to core belief - in fact, they're more commonly used to test intermediary beliefs (also known as assumptions, also known as rules for living). The point of experimenting is to stay open, so this is a possibility. This has happened to clients of mine who are having difficulties with colleagues at work, thinking they don't want to hear their contribution! Turned out their colleagues didn't. When this happens, you need to think about what it means - is the client useless or is there something negative to be said about their colleagues? Does no-one want to hear what they say or are there other people who value the client's contributions? Sometimes you have to switch to problem solving (e.g. finding a new job) and learning to live with difficult circumstances (e.g. preserving ones self-esteem in the presence of such charming coworkers). The chances are a belief isn't true in all circumstances at all times or that although you might not get a straight forward answer, at the very least, a series of BEs will give you a multitude of ideas and possibilities to consider. That is the beauty of them in my view - it's seldom black and white and allows both you and the client to work with complexity. In my view that is more accurate and prevents a pollyannish approach to CBT which doesn't help anyone!
- What do you do if a client continuously twists the result of a BE to support their core belief?
Now this is common - very common in fact! Time to introduce the client to Padesky's model of schema as self-prejudice and to move to core belief level work. (We'll try to develop a wiki on this soon).
- How do you approach a situation where the core belief might in fact be true (particularly if it is a negative one about the self)?
I've never encountered a core belief that is true in all circumstances at all times. I tend to see core beliefs as coming in pairs. So most of us have a belief that we are incompetent sometimes, but we also have a belief that we are competent. I believe some people are untrustworthy but I also believe others are mostly trustworthy. When clients have problems with core beliefs, it is usually because the negative belief is massively over developed and the alternative positive belief is underdeveloped or completely absent. Core belief work is seldom about challenging core beliefs and more about developing the alternative.
- Is it more difficult to challenge a core belief when it is focussed inwards (i.e. is about the self, e.g. "I am a failure") rather than externally (e.g. "everyone is out to get me")?
Not in my experience - they're just different. Not sure if anyone else has a view on this?
Further Reading
The Oxford Guide to Behavioural Experiments in Cognitive Therapy (Bennett-Levy et al., 2004) is a classic and it is worth every penny. It also has a wealth of stories of when experiments didn’t go exactly to plan which are sure to amuse.
Note: If you have a suggestion about how to improve or add to this wiki please post it here. If you want to discuss this post please post a new thread in the forum. There is information about the structure, rules and copyright of the wiki here.
Content checked by qualified Clinical Psychologist on 12/02/2018
Last modified on 12/02/2018
Client examples made up, anonymised beyond recognition or classics used very frequently with many clients.
What are they?
Behavioural experiments (BEs) are experiential activities undertaken in or between sessions. They are designed based on a cognitive formulation of a problem. The primary purpose is to gather information which tests the validity of the client’s beliefs, develop or test new beliefs or develop the formulation (Bennett-Levy et al., 2004).
BEs are amongst the most powerful tools available in CBT. They enable the client to actively engage in the process in a way that purely verbal methods cannot. Clients (and therapists) get to see it, hear it, feel it, smell it and touch it. This creates a much deeper level of information processing. Adult learning theories stress the importance of both experience and reflection in creating the most effective learning experiences (e.g. Kolb’s learning cycle). By combining BEs with time spent reflecting and discussing the process, clients are able to process information on both emotional and cognitive levels, thereby maximising the learning experience.
How do you design a good one?
-Experiential Methods
A well timed spontaneous experiment early on in therapy can help socialise the client to the active and collaborative approach to learning that is at the heart of CBT. For example, the famous hyperventilation/over-breathing experiments with people who experience panic, the ‘white bear’ experiment (which goes something like, ‘For the next minute I want you to do your very best to not think about white bears. It is very important that you do not think of them so do all you can to push them from you mind’) can help the client recognise that pushing unwanted thoughts away makes them come back with vengeance.
Another more spontaneous example was a client who asked, “Is my mind really powerful enough to make me feel something in my body just because I’m thinking about it?” I could have said, “Yes” but that’s nowhere near as convincing as. “Well let’s find out shall we? Why don’t you close your eyes, right, now I want you to focus your mind on your stomach…” And of course, the client was suddenly aware of all kinds of sensations and gurgles and was able to conclude that their mind was very powerful and that focusing on something can create or heighten physical sensations that they were not aware of before.
-Planned Behavioural Experiments
It is important to pin down the key cognitions for the individual client. What do they really need to find out about to get a different perspective on their problems or dilemmas. BEs can and should be as creative and as individualised as our clients are.
-Surveys
A well designed survey can be both a lot of fun to conduct and an extremely rich source of information for clients and therapists. A number have been conducted on clinpsy and clinpsy members can be a juicy source of material to normalise OCD and psychotic symptoms like this one. Internet surveys like this can be very helpful if you want to get a lot of data or you want to use a particular group of people (some of my clients see psychologists as somewhat superior people who never have problems – so clinpsy data can be extremely helpful to dispel this myth!) However, on the whole, I find that the best surveys are those conducted with a digi-recorder in hand, the recording then given to the client to listen to and reflect on both in the session and as a homework task.
Examples I have done include:
-Interviewing doctors about a specific set of symptoms and asking whether they think it is possible that these are caused by anxiety
-Asking for people’s reactions to a someone acting in a particular way (e.g. avoiding eye contact or covering their face with their hair) thereby giving the client some feedback on how they come across to people who know nothing about them other than the safety behaviours they display in social situations
-Taking a photograph of something about a client’s body they are particularly bothered by and asking for reactions (Gok Wan eat your heart out!) (Obviously get consent for this, consider anonymity and if the client is recogniseable in the photograph, keep it within services if at all possible).
I always make a point of asking clients if they think staff members will have a different reaction than members of the public. If they think they do, then it may be necessary to recruit family and friends to participate in surveys. This can be very helpful. However, people will inevitably be curious about what you are doing. It’s not that often you get some psychologist shoving a microphone in your face and asking a load of obscure questions. So plan in advance how you will explain yourself in a way that is acceptable to you and to your clients and that doesn’t breach confidentiality. Also a note about staff - make sure you explain you're looking for their personal reaction. In my experience this is especially important for students who might see this as a test of their knowledge and present a lot of diagnostic possibilities or professional sounding advice.
If you do use recorded surveys, they will take a fair amount of your time and effort to collect information. Sometimes clients will do their own (e.g. I’ve had clients go and survey people they know to find out if they’ve ever heard their voices) but a lot of the time, the therapist will need to do the leg work because they have access to appropriate people and the courage to ask wacky questions. So be realistic with your client about how many people you will be able to survey and how long it will take you to do this. Also – you’ve put in a lot of effort so milk it for all it is worth. Listen to the recordings in sessions with your client, pause the tape, take time to reflect and get all the juice out of the experience.
-More active experiments
As you get to know the client and you both start to identify they key beliefs and assumptions that need to be explored, more individualised, creative and slightly unusual experiments can be conducted. These can range from good old classics like fainting in the supermarket or attempting to record someone’s voices or thoughts to see whether they are being broadcast to others to highly individualised experiments tailored to very specific predictions of that individual.
There are forms available (such as this one) that can be very helpful to work through with the client. Not only does this help to keep the experiment structured and collaborative, it also gives the client the tools to plan and conduct their own experiments in the future.
Remember – this is not exposure. The aim is not to habituate to an anxiety provoking situation (although that might happen), the aim is to test out a client’s predictions and learn something new. And this is an anonymised example of the process:
BELIEF
Unless I wash every hour, I will smell absolutely disgusting. This is due to sweating in my arm pits which will also be on my clothes.
EXPERIMENT
Therapist recruits a few stooges (and offers up her own services) who agree to bring a change of top to work that day. Just before the client’s appointment the stooges change top. The client also changes their top. Then another group of staff who do not know whose top is whose are asked for smell ratings.
PREDICTION
If I shower in the morning before my therapy appointment in the afternoon but not wash between times, I will smell dreadful. The smell will be in my clothes and people will find them utterly replusive. People will rate other peoples tops as about 2/10 on smelliness and mine as at least 9 or 10 with one being doesn’t smell bad at all and 10 being worst smell ever.
OUTCOME
Client and stooges rated all tops between 1 and 3 including mine.
WHAT I’VE LEARNED
My clothes don’t smell bad to other people. I may not smell as bad as I think I do.
Behavioural Experiments for Therapists
And finally - behavioural experiments are not just for clients! They can be a very helpful way for therapists to test out their predictions about what is happening in therapy or in other workplace situations. I had a belief that if I interrupted clients they would feel very invalidated. This meant that with some very talkative clients my sessions were becoming very unstructured and unfocussed. I experimented, I deliberately interrupted clients and recorded the client’s feedback about the session and well as my own perception. My sessions became more structured, my client’s feedback actually got better and I was also happier with the process.
I also hate complaining, thinking this will provoke an angry response in shop assistants, waiting staff etc. This was a silly
thing to confess to in a workshop on BEs on my CBT training course…of course I had to go and make an outrageous complaint to find out if they did roll their eyes or tell me not to be so unreasonable. (They didn’t, they were very polite and gave me a refund on the perfectly nice cake I claimed was stale!!!)
If you’re not sure about BEs, it can be very helpful to try out a few of your own maybe with a colleague or friend and then you can mutually experiment and see what the experience is like. BEs are an experiential method and the value of doing them for yourself cannot be understated.
Trouble shooting
Vicky_R asked some great questions in livechat discussing this wiki so I've attempted to answer them here
- What happens when a BE, or series of BEs, actually supports the core belief you set out to challenge?
A BE may not be to test to core belief - in fact, they're more commonly used to test intermediary beliefs (also known as assumptions, also known as rules for living). The point of experimenting is to stay open, so this is a possibility. This has happened to clients of mine who are having difficulties with colleagues at work, thinking they don't want to hear their contribution! Turned out their colleagues didn't. When this happens, you need to think about what it means - is the client useless or is there something negative to be said about their colleagues? Does no-one want to hear what they say or are there other people who value the client's contributions? Sometimes you have to switch to problem solving (e.g. finding a new job) and learning to live with difficult circumstances (e.g. preserving ones self-esteem in the presence of such charming coworkers). The chances are a belief isn't true in all circumstances at all times or that although you might not get a straight forward answer, at the very least, a series of BEs will give you a multitude of ideas and possibilities to consider. That is the beauty of them in my view - it's seldom black and white and allows both you and the client to work with complexity. In my view that is more accurate and prevents a pollyannish approach to CBT which doesn't help anyone!
- What do you do if a client continuously twists the result of a BE to support their core belief?
Now this is common - very common in fact! Time to introduce the client to Padesky's model of schema as self-prejudice and to move to core belief level work. (We'll try to develop a wiki on this soon).
- How do you approach a situation where the core belief might in fact be true (particularly if it is a negative one about the self)?
I've never encountered a core belief that is true in all circumstances at all times. I tend to see core beliefs as coming in pairs. So most of us have a belief that we are incompetent sometimes, but we also have a belief that we are competent. I believe some people are untrustworthy but I also believe others are mostly trustworthy. When clients have problems with core beliefs, it is usually because the negative belief is massively over developed and the alternative positive belief is underdeveloped or completely absent. Core belief work is seldom about challenging core beliefs and more about developing the alternative.
- Is it more difficult to challenge a core belief when it is focussed inwards (i.e. is about the self, e.g. "I am a failure") rather than externally (e.g. "everyone is out to get me")?
Not in my experience - they're just different. Not sure if anyone else has a view on this?
Further Reading
The Oxford Guide to Behavioural Experiments in Cognitive Therapy (Bennett-Levy et al., 2004) is a classic and it is worth every penny. It also has a wealth of stories of when experiments didn’t go exactly to plan which are sure to amuse.
Note: If you have a suggestion about how to improve or add to this wiki please post it here. If you want to discuss this post please post a new thread in the forum. There is information about the structure, rules and copyright of the wiki here.
Content checked by qualified Clinical Psychologist on 12/02/2018
Last modified on 12/02/2018
If God invented marathons to keep people from doing anything more stupid, the triathlon must have taken Him completely by surprise.
Re: CBT Methods: Behavioural Experiments
Great wiki, Ruthie!
As requested, my questions from chat earlier:
- What happens when a BE, or series of BEs, actually supports the core belief you set out to challenge?
- What do you do if a client continuously twists the result of a BE to support their core belief?
- How do you approach a situation where the core belief might in fact be true (particularly if it is a negative one about the self)?
- Is it more difficult to challenge a core belief when it is focussed inwards (i.e. is about the self, e.g. "I am a failure") rather than externally (e.g. "everyone is out to get me")?
:) Vicky
As requested, my questions from chat earlier:
- What happens when a BE, or series of BEs, actually supports the core belief you set out to challenge?
- What do you do if a client continuously twists the result of a BE to support their core belief?
- How do you approach a situation where the core belief might in fact be true (particularly if it is a negative one about the self)?
- Is it more difficult to challenge a core belief when it is focussed inwards (i.e. is about the self, e.g. "I am a failure") rather than externally (e.g. "everyone is out to get me")?
:) Vicky
Re: CBT Methods: Behavioural Experiments
Brilliant post Ruthie, but is the second clickable (the one below) meant to be the same as the first one?? I think you meant to link it somewhere else....
Mod (not Ruthie!) - I have fixed it, you just need to un-tick the 'Disable BBCode' option in the Options panel underneath the box where you write your message
ps Im sorry the quote isn't working properly, i think it may be because my bb code is off (?) but I can't for the life of me work out how to change it, i've tried reading about it, but i seem to be being a bit dumb today!Ruthie wrote:There are forms available (such as this one) that can be very helpful to work through with the client. Not only does this help to keep the experiment structured and collaborative, it also gives the client the tools to plan and conduct their own experiments in the future.
Mod (not Ruthie!) - I have fixed it, you just need to un-tick the 'Disable BBCode' option in the Options panel underneath the box where you write your message
Re: CBT Methods: Behavioural Experiments
Well spotted - fixed!han10 wrote:Brilliant post Ruthie, but is the second clickable (the one below) meant to be the same as the first one?? I think you meant to link it somewhere else....
If God invented marathons to keep people from doing anything more stupid, the triathlon must have taken Him completely by surprise.
Re: CBT Methods: Behavioural Experiments
thank you! but i don't have that option in the options box, the only two I have are: 'do not automatically parse URLs' and 'notify me when a reply is posted'....maybe this is something i should take to the problems with the new format thread....
Re: CBT Methods: Behavioural Experiments
Fair play Ruthie, that's a cracking Wiki. Really accessible!
Re: CBT Methods: Behavioural Experiments
You are welcome - I aims to pleaseBaneen03 wrote:Fair play Ruthie, that's a cracking Wiki. Really accessible!
!Any requestion for CBT-101 articles send them my way and I will hassle baa to write them
!If God invented marathons to keep people from doing anything more stupid, the triathlon must have taken Him completely by surprise.
CBT Methods: Behavioural Experiments
Behavioural Experiments
Client examples made up, anonymised beyond recognition or classics used very frequently with many clients.
What are they?
Behavioural experiments (BEs) are experiential activities undertaken in or between sessions. They are designed based on a cognitive formulation of a problem. The primary purpose is to gather information which tests the validity of the client’s beliefs, develop or test new beliefs or develop the formulation (Bennett-Levy et al., 2004).
BEs are amongst the most powerful tools available in CBT. They enable the client to actively engage in the process in a way that purely verbal methods cannot. Clients (and therapists) get to see it, hear it, feel it, smell it and touch it. This creates a much deeper level of information processing. Adult learning theories stress the importance of both experience and reflection in creating the most effective learning experiences (e.g. Kolb’s learning cycle). By combining BEs with time spent reflecting and discussing the process, clients are able to process information on both emotional and cognitive levels, thereby maximising the learning experience.
How do you design a good one?
-Experiential Methods
A well timed spontaneous experiment early on in therapy can help socialise the client to the active and collaborative approach to learning that is at the heart of CBT. For example, the famous hyperventilation/over-breathing experiments with people who experience panic, the ‘white bear’ experiment (which goes something like, ‘For the next minute I want you to do your very best to not think about white bears. It is very important that you do not think of them so do all you can to push them from you mind’) can help the client recognise that pushing unwanted thoughts away makes them come back with vengeance.
Another more spontaneous example was a client who asked, “Is my mind really powerful enough to make me feel something in my body just because I’m thinking about it?” I could have said, “Yes” but that’s nowhere near as convincing as. “Well let’s find out shall we? Why don’t you close your eyes, right, now I want you to focus your mind on your stomach…” And of course, the client was suddenly aware of all kinds of sensations and gurgles and was able to conclude that their mind was very powerful and that focusing on something can create or heighten physical sensations that they were not aware of before.
-Planned Behavioural Experiments
It is important to pin down the key cognitions for the individual client. What do they really need to find out about to get a different perspective on their problems or dilemmas. BEs can and should be as creative and as individualised as our clients are.
-Surveys
A well designed survey can be both a lot of fun to conduct and an extremely rich source of information for clients and therapists. A number have been conducted on clinpsy and clinpsy members can be a juicy source of material to normalise OCD and psychotic symptoms like this one. Internet surveys like this can be very helpful if you want to get a lot of data or you want to use a particular group of people (some of my clients see psychologists as somewhat superior people who never have problems – so clinpsy data can be extremely helpful to dispel this myth!) However, on the whole, I find that the best surveys are those conducted with a digi-recorder in hand, the recording then given to the client to listen to and reflect on both in the session and as a homework task.
Examples I have done include:
-Interviewing doctors about a specific set of symptoms and asking whether they think it is possible that these are caused by anxiety
-Asking for people’s reactions to a someone acting in a particular way (e.g. avoiding eye contact or covering their face with their hair) thereby giving the client some feedback on how they come across to people who know nothing about them other than the safety behaviours they display in social situations
-Taking a photograph of something about a client’s body they are particularly bothered by and asking for reactions (Gok Wan eat your heart out!) (Obviously get consent for this, consider anonymity and if the client is recogniseable in the photograph, keep it within services if at all possible).
I always make a point of asking clients if they think staff members will have a different reaction than members of the public. If they think they do, then it may be necessary to recruit family and friends to participate in surveys. This can be very helpful. However, people will inevitably be curious about what you are doing. It’s not that often you get some psychologist shoving a microphone in your face and asking a load of obscure questions. So plan in advance how you will explain yourself in a way that is acceptable to you and to your clients and that doesn’t breach confidentiality. Also a note about staff - make sure you explain you're looking for their personal reaction. In my experience this is especially important for students who might see this as a test of their knowledge and present a lot of diagnostic possibilities or professional sounding advice.
If you do use recorded surveys, they will take a fair amount of your time and effort to collect information. Sometimes clients will do their own (e.g. I’ve had clients go and survey people they know to find out if they’ve ever heard their voices) but a lot of the time, the therapist will need to do the leg work because they have access to appropriate people and the courage to ask wacky questions. So be realistic with your client about how many people you will be able to survey and how long it will take you to do this. Also – you’ve put in a lot of effort so milk it for all it is worth. Listen to the recordings in sessions with your client, pause the tape, take time to reflect and get all the juice out of the experience.
-More active experiments
As you get to know the client and you both start to identify they key beliefs and assumptions that need to be explored, more individualised, creative and slightly unusual experiments can be conducted. These can range from good old classics like fainting in the supermarket or attempting to record someone’s voices or thoughts to see whether they are being broadcast to others to highly individualised experiments tailored to very specific predictions of that individual.
There are forms available (such as this one) that can be very helpful to work through with the client. Not only does this help to keep the experiment structured and collaborative, it also gives the client the tools to plan and conduct their own experiments in the future.
Remember – this is not exposure. The aim is not to habituate to an anxiety provoking situation (although that might happen), the aim is to test out a client’s predictions and learn something new. And this is an anonymised example of the process:
BELIEF
Unless I wash every hour, I will smell absolutely disgusting. This is due to sweating in my arm pits which will also be on my clothes.
EXPERIMENT
Therapist recruits a few stooges (and offers up her own services) who agree to bring a change of top to work that day. Just before the client’s appointment the stooges change top. The client also changes their top. Then another group of staff who do not know whose top is whose are asked for smell ratings.
PREDICTION
If I shower in the morning before my therapy appointment in the afternoon but not wash between times, I will smell dreadful. The smell will be in my clothes and people will find them utterly replusive. People will rate other peoples tops as about 2/10 on smelliness and mine as at least 9 or 10 with one being doesn’t smell bad at all and 10 being worst smell ever.
OUTCOME
Client and stooges rated all tops between 1 and 3 including mine.
WHAT I’VE LEARNED
My clothes don’t smell bad to other people. I may not smell as bad as I think I do.
Behavioural Experiments for Therapists
And finally - behavioural experiments are not just for clients! They can be a very helpful way for therapists to test out their predictions about what is happening in therapy or in other workplace situations. I had a belief that if I interrupted clients they would feel very invalidated. This meant that with some very talkative clients my sessions were becoming very unstructured and unfocussed. I experimented, I deliberately interrupted clients and recorded the client’s feedback about the session and well as my own perception. My sessions became more structured, my client’s feedback actually got better and I was also happier with the process.
I also hate complaining, thinking this will provoke an angry response in shop assistants, waiting staff etc. This was a silly
thing to confess to in a workshop on BEs on my CBT training course…of course I had to go and make an outrageous complaint to find out if they did roll their eyes or tell me not to be so unreasonable. (They didn’t, they were very polite and gave me a refund on the perfectly nice cake I claimed was stale!!!)
If you’re not sure about BEs, it can be very helpful to try out a few of your own maybe with a colleague or friend and then you can mutually experiment and see what the experience is like. BEs are an experiential method and the value of doing them for yourself cannot be understated.
Trouble shooting
Vicky_R asked some great questions in livechat discussing this wiki so I've attempted to answer them here
- What happens when a BE, or series of BEs, actually supports the core belief you set out to challenge?
A BE may not be to test to core belief - in fact, they're more commonly used to test intermediary beliefs (also known as assumptions, also known as rules for living). The point of experimenting is to stay open, so this is a possibility. This has happened to clients of mine who are having difficulties with colleagues at work, thinking they don't want to hear their contribution! Turned out their colleagues didn't. When this happens, you need to think about what it means - is the client useless or is there something negative to be said about their colleagues? Does no-one want to hear what they say or are there other people who value the client's contributions? Sometimes you have to switch to problem solving (e.g. finding a new job) and learning to live with difficult circumstances (e.g. preserving ones self-esteem in the presence of such charming coworkers). The chances are a belief isn't true in all circumstances at all times or that although you might not get a straight forward answer, at the very least, a series of BEs will give you a multitude of ideas and possibilities to consider. That is the beauty of them in my view - it's seldom black and white and allows both you and the client to work with complexity. In my view that is more accurate and prevents a pollyannish approach to CBT which doesn't help anyone!
- What do you do if a client continuously twists the result of a BE to support their core belief?
Now this is common - very common in fact! Time to introduce the client to Padesky's model of schema as self-prejudice and to move to core belief level work. (We'll try to develop a wiki on this soon).
- How do you approach a situation where the core belief might in fact be true (particularly if it is a negative one about the self)?
I've never encountered a core belief that is true in all circumstances at all times. I tend to see core beliefs as coming in pairs. So most of us have a belief that we are incompetent sometimes, but we also have a belief that we are competent. I believe some people are untrustworthy but I also believe others are mostly trustworthy. When clients have problems with core beliefs, it is usually because the negative belief is massively over developed and the alternative positive belief is underdeveloped or completely absent. Core belief work is seldom about challenging core beliefs and more about developing the alternative.
- Is it more difficult to challenge a core belief when it is focussed inwards (i.e. is about the self, e.g. "I am a failure") rather than externally (e.g. "everyone is out to get me")?
Not in my experience - they're just different. Not sure if anyone else has a view on this?
Further Reading
The Oxford Guide to Behavioural Experiments in Cognitive Therapy (Bennett-Levy et al., 2004) is a classic and it is worth every penny. It also has a wealth of stories of when experiments didn’t go exactly to plan which are sure to amuse.
Note: If you have a suggestion about how to improve or add to this wiki please post it here. If you want to discuss this post please post a new thread in the forum. There is information about the structure, rules and copyright of the wiki here.
Content checked on 05/10/2022
Last modified on 05/10/2022
Client examples made up, anonymised beyond recognition or classics used very frequently with many clients.
What are they?
Behavioural experiments (BEs) are experiential activities undertaken in or between sessions. They are designed based on a cognitive formulation of a problem. The primary purpose is to gather information which tests the validity of the client’s beliefs, develop or test new beliefs or develop the formulation (Bennett-Levy et al., 2004).
BEs are amongst the most powerful tools available in CBT. They enable the client to actively engage in the process in a way that purely verbal methods cannot. Clients (and therapists) get to see it, hear it, feel it, smell it and touch it. This creates a much deeper level of information processing. Adult learning theories stress the importance of both experience and reflection in creating the most effective learning experiences (e.g. Kolb’s learning cycle). By combining BEs with time spent reflecting and discussing the process, clients are able to process information on both emotional and cognitive levels, thereby maximising the learning experience.
How do you design a good one?
-Experiential Methods
A well timed spontaneous experiment early on in therapy can help socialise the client to the active and collaborative approach to learning that is at the heart of CBT. For example, the famous hyperventilation/over-breathing experiments with people who experience panic, the ‘white bear’ experiment (which goes something like, ‘For the next minute I want you to do your very best to not think about white bears. It is very important that you do not think of them so do all you can to push them from you mind’) can help the client recognise that pushing unwanted thoughts away makes them come back with vengeance.
Another more spontaneous example was a client who asked, “Is my mind really powerful enough to make me feel something in my body just because I’m thinking about it?” I could have said, “Yes” but that’s nowhere near as convincing as. “Well let’s find out shall we? Why don’t you close your eyes, right, now I want you to focus your mind on your stomach…” And of course, the client was suddenly aware of all kinds of sensations and gurgles and was able to conclude that their mind was very powerful and that focusing on something can create or heighten physical sensations that they were not aware of before.
-Planned Behavioural Experiments
It is important to pin down the key cognitions for the individual client. What do they really need to find out about to get a different perspective on their problems or dilemmas. BEs can and should be as creative and as individualised as our clients are.
-Surveys
A well designed survey can be both a lot of fun to conduct and an extremely rich source of information for clients and therapists. A number have been conducted on clinpsy and clinpsy members can be a juicy source of material to normalise OCD and psychotic symptoms like this one. Internet surveys like this can be very helpful if you want to get a lot of data or you want to use a particular group of people (some of my clients see psychologists as somewhat superior people who never have problems – so clinpsy data can be extremely helpful to dispel this myth!) However, on the whole, I find that the best surveys are those conducted with a digi-recorder in hand, the recording then given to the client to listen to and reflect on both in the session and as a homework task.
Examples I have done include:
-Interviewing doctors about a specific set of symptoms and asking whether they think it is possible that these are caused by anxiety
-Asking for people’s reactions to a someone acting in a particular way (e.g. avoiding eye contact or covering their face with their hair) thereby giving the client some feedback on how they come across to people who know nothing about them other than the safety behaviours they display in social situations
-Taking a photograph of something about a client’s body they are particularly bothered by and asking for reactions (Gok Wan eat your heart out!) (Obviously get consent for this, consider anonymity and if the client is recogniseable in the photograph, keep it within services if at all possible).
I always make a point of asking clients if they think staff members will have a different reaction than members of the public. If they think they do, then it may be necessary to recruit family and friends to participate in surveys. This can be very helpful. However, people will inevitably be curious about what you are doing. It’s not that often you get some psychologist shoving a microphone in your face and asking a load of obscure questions. So plan in advance how you will explain yourself in a way that is acceptable to you and to your clients and that doesn’t breach confidentiality. Also a note about staff - make sure you explain you're looking for their personal reaction. In my experience this is especially important for students who might see this as a test of their knowledge and present a lot of diagnostic possibilities or professional sounding advice.
If you do use recorded surveys, they will take a fair amount of your time and effort to collect information. Sometimes clients will do their own (e.g. I’ve had clients go and survey people they know to find out if they’ve ever heard their voices) but a lot of the time, the therapist will need to do the leg work because they have access to appropriate people and the courage to ask wacky questions. So be realistic with your client about how many people you will be able to survey and how long it will take you to do this. Also – you’ve put in a lot of effort so milk it for all it is worth. Listen to the recordings in sessions with your client, pause the tape, take time to reflect and get all the juice out of the experience.
-More active experiments
As you get to know the client and you both start to identify they key beliefs and assumptions that need to be explored, more individualised, creative and slightly unusual experiments can be conducted. These can range from good old classics like fainting in the supermarket or attempting to record someone’s voices or thoughts to see whether they are being broadcast to others to highly individualised experiments tailored to very specific predictions of that individual.
There are forms available (such as this one) that can be very helpful to work through with the client. Not only does this help to keep the experiment structured and collaborative, it also gives the client the tools to plan and conduct their own experiments in the future.
Remember – this is not exposure. The aim is not to habituate to an anxiety provoking situation (although that might happen), the aim is to test out a client’s predictions and learn something new. And this is an anonymised example of the process:
BELIEF
Unless I wash every hour, I will smell absolutely disgusting. This is due to sweating in my arm pits which will also be on my clothes.
EXPERIMENT
Therapist recruits a few stooges (and offers up her own services) who agree to bring a change of top to work that day. Just before the client’s appointment the stooges change top. The client also changes their top. Then another group of staff who do not know whose top is whose are asked for smell ratings.
PREDICTION
If I shower in the morning before my therapy appointment in the afternoon but not wash between times, I will smell dreadful. The smell will be in my clothes and people will find them utterly replusive. People will rate other peoples tops as about 2/10 on smelliness and mine as at least 9 or 10 with one being doesn’t smell bad at all and 10 being worst smell ever.
OUTCOME
Client and stooges rated all tops between 1 and 3 including mine.
WHAT I’VE LEARNED
My clothes don’t smell bad to other people. I may not smell as bad as I think I do.
Behavioural Experiments for Therapists
And finally - behavioural experiments are not just for clients! They can be a very helpful way for therapists to test out their predictions about what is happening in therapy or in other workplace situations. I had a belief that if I interrupted clients they would feel very invalidated. This meant that with some very talkative clients my sessions were becoming very unstructured and unfocussed. I experimented, I deliberately interrupted clients and recorded the client’s feedback about the session and well as my own perception. My sessions became more structured, my client’s feedback actually got better and I was also happier with the process.
I also hate complaining, thinking this will provoke an angry response in shop assistants, waiting staff etc. This was a silly
thing to confess to in a workshop on BEs on my CBT training course…of course I had to go and make an outrageous complaint to find out if they did roll their eyes or tell me not to be so unreasonable. (They didn’t, they were very polite and gave me a refund on the perfectly nice cake I claimed was stale!!!)
If you’re not sure about BEs, it can be very helpful to try out a few of your own maybe with a colleague or friend and then you can mutually experiment and see what the experience is like. BEs are an experiential method and the value of doing them for yourself cannot be understated.
Trouble shooting
Vicky_R asked some great questions in livechat discussing this wiki so I've attempted to answer them here
- What happens when a BE, or series of BEs, actually supports the core belief you set out to challenge?
A BE may not be to test to core belief - in fact, they're more commonly used to test intermediary beliefs (also known as assumptions, also known as rules for living). The point of experimenting is to stay open, so this is a possibility. This has happened to clients of mine who are having difficulties with colleagues at work, thinking they don't want to hear their contribution! Turned out their colleagues didn't. When this happens, you need to think about what it means - is the client useless or is there something negative to be said about their colleagues? Does no-one want to hear what they say or are there other people who value the client's contributions? Sometimes you have to switch to problem solving (e.g. finding a new job) and learning to live with difficult circumstances (e.g. preserving ones self-esteem in the presence of such charming coworkers). The chances are a belief isn't true in all circumstances at all times or that although you might not get a straight forward answer, at the very least, a series of BEs will give you a multitude of ideas and possibilities to consider. That is the beauty of them in my view - it's seldom black and white and allows both you and the client to work with complexity. In my view that is more accurate and prevents a pollyannish approach to CBT which doesn't help anyone!
- What do you do if a client continuously twists the result of a BE to support their core belief?
Now this is common - very common in fact! Time to introduce the client to Padesky's model of schema as self-prejudice and to move to core belief level work. (We'll try to develop a wiki on this soon).
- How do you approach a situation where the core belief might in fact be true (particularly if it is a negative one about the self)?
I've never encountered a core belief that is true in all circumstances at all times. I tend to see core beliefs as coming in pairs. So most of us have a belief that we are incompetent sometimes, but we also have a belief that we are competent. I believe some people are untrustworthy but I also believe others are mostly trustworthy. When clients have problems with core beliefs, it is usually because the negative belief is massively over developed and the alternative positive belief is underdeveloped or completely absent. Core belief work is seldom about challenging core beliefs and more about developing the alternative.
- Is it more difficult to challenge a core belief when it is focussed inwards (i.e. is about the self, e.g. "I am a failure") rather than externally (e.g. "everyone is out to get me")?
Not in my experience - they're just different. Not sure if anyone else has a view on this?
Further Reading
The Oxford Guide to Behavioural Experiments in Cognitive Therapy (Bennett-Levy et al., 2004) is a classic and it is worth every penny. It also has a wealth of stories of when experiments didn’t go exactly to plan which are sure to amuse.
Note: If you have a suggestion about how to improve or add to this wiki please post it here. If you want to discuss this post please post a new thread in the forum. There is information about the structure, rules and copyright of the wiki here.
Content checked on 05/10/2022
Last modified on 05/10/2022
