respond with ‘I don’t know’. If this is the case, the job of the therapist and young person is to work out how we could get to know the answer. This is one role of behavioural experiments.
• The therapist works with the young person to explore their beliefs and assumptions and examine alternatives through Socratic questioning.
• They are encouraged to think about the evidence for their old belief versus an alternative viewpoint.
Figure 2.3
Questioning beliefs
28
Creswell and Waite
Behavioural experiments
The purpose of behavioural experiments is to test thoughts to assess their validity and utility. This can be necessary when there is not enough available evidence to fully evaluate a thought, or when the available evidence is just not convincing to the young person (‘I know I shouldn’t think it, but I still do’ or ‘I know it, but I don’t feel it’). Experiments must have a clear hypothesis to be tested and alternative explanations for possible results need to be taken into account from the start, so that the results cannot be discounted after the experiment has taken place. Following the experiment, the results need to be considered with explicit reference to the initial thought being tested.
There are various types of behavioural experiments, ranging from active experiments, such as real situations or role play, to observational experiments, such as the young person observing the therapist performing an experiment, carrying out surveys or gathering information from other sources.
In OCD, active experiments are essential for challenging the young person’s beliefs, such as the likelihood of harm occurring or to test the idea that thinking something can make it happen. Historically, exposure and response prevention (ERP) has been used to treat OCD, where the young person is encouraged to experience the intrusive thought without carrying out the compulsion. For example, if the young person is worried about contamination, they may be encouraged to touch a door handle without then washing their hands. With a more cognitive approach, ERP may still be used but this would always be specifically as a behavioural experiment to test out a particular cognition. For example, if the young person’s belief is ‘If I touch the door handle without washing my hands I could get ill’, then the experiment may involve ERP. However, if the belief is ‘If I touch the door handle, I will be so anxious that I will go mad’, then the experiment may involve the young person touching the door handle and then allowing a sufficient amount of time to pass so that they are able to learn that the anxiety eventually remits.
In this case, they could wash their hands afterwards without affecting the outcome of the experiment. Rather than designing a graded hierarchy of exposure tasks for the young person to work through, behavioural experiments are set up as a way of finding out how the world really works, and as a result they are designed in an idiosyncratic way according to the young person’s beliefs. Other information such as that provided by surveys can also be helpful to find out that other people have intrusive thoughts, to consider how often other people are able to achieve perfection or a ‘just right’ feeling or to find out about other people’s experiences of anxiety.
As much as possible, the young person should be encouraged to take the leading role in designing the experiment. Where this is not possible, for example, if the therapist suggests an in-session experiment, the young person must have clear permission to say no. To encourage young people to get involved in the design of experiments, again it will be necessary to be creative and have fun. For example, when carrying out experiments to find out whether thinking something can make it happen, the therapist could encourage the young person to begin by thinking something funny rather The use of CBT with children and adolescents 29
than anxiety
• The therapist works with the young person to explore their beliefs and assumptions and examine alternatives through Socratic questioning.
• They are encouraged to think about the evidence for their old belief versus an alternative viewpoint.
Figure 2.3
Questioning beliefs
28
Creswell and Waite
Behavioural experiments
The purpose of behavioural experiments is to test thoughts to assess their validity and utility. This can be necessary when there is not enough available evidence to fully evaluate a thought, or when the available evidence is just not convincing to the young person (‘I know I shouldn’t think it, but I still do’ or ‘I know it, but I don’t feel it’). Experiments must have a clear hypothesis to be tested and alternative explanations for possible results need to be taken into account from the start, so that the results cannot be discounted after the experiment has taken place. Following the experiment, the results need to be considered with explicit reference to the initial thought being tested.
There are various types of behavioural experiments, ranging from active experiments, such as real situations or role play, to observational experiments, such as the young person observing the therapist performing an experiment, carrying out surveys or gathering information from other sources.
In OCD, active experiments are essential for challenging the young person’s beliefs, such as the likelihood of harm occurring or to test the idea that thinking something can make it happen. Historically, exposure and response prevention (ERP) has been used to treat OCD, where the young person is encouraged to experience the intrusive thought without carrying out the compulsion. For example, if the young person is worried about contamination, they may be encouraged to touch a door handle without then washing their hands. With a more cognitive approach, ERP may still be used but this would always be specifically as a behavioural experiment to test out a particular cognition. For example, if the young person’s belief is ‘If I touch the door handle without washing my hands I could get ill’, then the experiment may involve ERP. However, if the belief is ‘If I touch the door handle, I will be so anxious that I will go mad’, then the experiment may involve the young person touching the door handle and then allowing a sufficient amount of time to pass so that they are able to learn that the anxiety eventually remits.
In this case, they could wash their hands afterwards without affecting the outcome of the experiment. Rather than designing a graded hierarchy of exposure tasks for the young person to work through, behavioural experiments are set up as a way of finding out how the world really works, and as a result they are designed in an idiosyncratic way according to the young person’s beliefs. Other information such as that provided by surveys can also be helpful to find out that other people have intrusive thoughts, to consider how often other people are able to achieve perfection or a ‘just right’ feeling or to find out about other people’s experiences of anxiety.
As much as possible, the young person should be encouraged to take the leading role in designing the experiment. Where this is not possible, for example, if the therapist suggests an in-session experiment, the young person must have clear permission to say no. To encourage young people to get involved in the design of experiments, again it will be necessary to be creative and have fun. For example, when carrying out experiments to find out whether thinking something can make it happen, the therapist could encourage the young person to begin by thinking something funny rather The use of CBT with children and adolescents 29
than anxiety
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