I have been asked to discussed how behavioural experiments, homework, self-monitoring, Socratic questioning and systematic desensitisation are used in cognitive behavioural therapy (CBT), I will explore each of these individually before summarising.
Behavioural Experiments in CBT are said to be one of the most significant factors of the therapy. They are experiential activities designed to test or challenge cognitions or beliefs of individuals seeking therapeutic change for certain specific issues. They are used to recognise thoughts, challenge them, adapt existing beliefs and test newly formed ones. These activities use experimentation or observation to obtain new evidence or information to help clients reach positive, self-controlled change. To help clients revaluate negative automatic thoughts (NAT’s) and assumptions and encourage conscious process and give step by step guidance to acquire new skills.
This is done identifying the issue, cognition, behaviour or belief that client feels is causing difficulty, it helps is the problem is precise, and if the strength of the cognition is known. Then an experiment is designed with the client and carried out, this is then reviewed with the therapist and results are analysed and check against original cognition, if it is positive results it is discussed how this positive development may be sustained, if not it is seem as developmental learning and a new experiment based on this learning is devised. The pattern followed is engagement of client in therapy, activity design and scheduling, testing/experimenting, review and future planning.
Some of the types of experiment are as follows: hypothesis testing e.g. doing the opposite to the cognition to see what will happen; discovery e.g. when a specific cognition is unknown but a behaviour is known see if you can find the thought by recreating behaviour; observational e.g. watch others do something and see if this helps you change cognition; survey or research e.g. ask others if they feel the same or what they feel about you.
It tends to follow this pattern ‘Thought – If I do X then Y will happen’, sometimes added is a safety behaviour ‘Thought – If I do X then Y will happen, so I do Z’. To fill this in with an example ‘If I walk into a shop everyone looks at me, so I always try to look inconspicuous, rush to only what I need and leave’. The experiment here would be threefold first the therapist would explore the human nature concept that people look at anyone entering a room out of nosiness and safety; second they would get the client to observe others entering a shop or room and see that everyone gets looked at; thirdly they would use the practical experience of walking into a shop slowly just to browse and prove to the client by review afterwards that nothing bad happens if they don’t do their safety behaviour of rushing out again.
Homework in CBT is a method of helping the client to develop outside the therapy room. Studies show that clients who complete their homework are far more likely to achieve better results from their therapy (www.goodtherapy.org), thus it is believed that homework in CBT should not be optional for this reason. The Beck Institute have recently suggested that homework has negative connotations and have suggested a move to calling it Action Plan to help those clients who struggle with homework (www.beckinstitute.org). The bulk of work happens between sessions during homework and can be crucial for the next session because it can provided information to base new behavioural experiments on, it can help the client feel calmer and it can create evidence to prove to the client therapy is working. Homework can be breathing or meditation exercises, exercise, diet, journaling, behavioural experiments, record keeping of thoughts and actions association. Homework should be varied and tailored to suit the client’s needs and style, e.g. creative or scientific, with teaching or learning aids if needed, but it should aim to push the client slightly (but safely) out of their comfort zone or to make progress towards their goal and but suited to the stage of CBT the client is at.
Self-Monitoring in CBT can be part of the collaborative homework set by the therapist for the client. It should be routinely monitored to ensure that it does not cause additional anxiety, stress or negative feedback to the client during the recording process or upon analysis of the results. It can be in many forms, but its aim is to help change thoughts, emotions and behaviours of the client. Self-monitoring techniques focus mainly on the cognitive triangle in CBT which looks at the links between thoughts, actions/behaviours and emotions/feelings. It then allows the client and counsellor to be aware of a pattern and make adjustments in one of these areas to improve the clients presenting issue, tis adjustment can be in the form of a behavioural experiment discussed above. Types of Self-monitoring techniques are; making a daily diary, recording audio or visual images (photo or video), tables of the three cognitive triangle components (thoughts, emotions and behaviours), phone apps, fit bits, heart rate monitors etc, tally charts of incidents or feelings. It can help clients to recognise NAT’s, behavioural reinforcement actions, and allow the therapy to move forward when the results are evaluated in therapy sessions.
Socratic questioning in CBT can be used at different stages of the therapy to help challenge irrational or negative thoughts, in homework, to help gather information during formulation, and to help assess the outcomes of behavioural experiments. They can be used by the therapist to gain information or by the client to challenge their own negative thoughts. They are a set of guiding questions aimed at discovering, identifying, or defining a problem/thought/emotion/action/response. Psychologytools.com lists types of Socratic questions as those that – “identify their cognition and try to really understand their basis for it …ask questions to identify all the reasons their behaviour made sense at the time … and …expand their view of other causes and responsible parties.” (https://www.psychologytools.com)
It helps us to understand how types of questions are useful in CBT by looking at where they stem from, Socrates belief that by questioning assumptions, thoughts and well known beliefs we can reach our own conclusions and developed understanding. It is believed the questions are meant to reveal something the clients does not already consciously know about themselves or have previously overlooked and thus make new connections and conclusions based on answers. Good Socratic questions intend to reveal new perspectives or information. They help with problem solving, revealing new information, and educating the client about themselves. If the client learns the skill it is something they can take away from therapy to continue to use in their future preventing relapse.
Finally I shall discuss Systematic Desensitisation within CBT. This is the process of exposing the client to a fear or phobia while linking a good, calm or positive emotional or physical response to the same fear. It is based on the psychological technique of classical conditioning, and aims to remove a fear response and replace it with a new one. To do this the client must learn calming or relaxation techniques such as breathing exercises, meditation, muscle relaxation. Once the client has learnt these a hierarchy of the clients fears/phobias is drafted, least fearful first increasing in fear until phobia to be addressed is reached. This hierarchy is addressed one by one starting with the least fearful, and the client is asked to use the as breathing exercises, meditation, or muscle relaxation techniques while in the presence of the stimulus to help alter or replace the fear response and become desensitised to the fear or phobia. Then the next fear or phobia in the hierarchy is address and systemically the technique moves up the hierarchy until the clients address the issue that brought them to therapy. This technique needs to be carried out carefully so as not to traumatise the client more or to condition them in a negative way. It can be used as a homework technique or done within sessions.
These are all methods that can be used within CBT to help the client progress through their therapy and reach a positive conclusion, they can be built into the therapy plan between the client and therapist to produce progress.
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