CHAPTER 21
Behavioural experiments: at the crossroads
Christine Padesky
Do not go where the path may lead,
go instead where there is no path and leave a trail.
Ralph Waldo Emerson
The crossroads are where all paths meet, traditionally a place for assembly, social interchange, and exchange of knowledge and goods. Today, they are often highways, heavily travelled because of their utility and speedy convenience. This chapter highlights how behavioural experiments are the crossroads of cognitive therapy. They are prime opportunities for exchanging knowledge and speedy paths to therapeutic change. Crossroads also can be a point of divergence from which new trails are blazed. Speculation on the future of behavioural experiments within cognitive therapy points to trails yet lightly travelled.
Behavioural experiments as the crossroads
Professional and personal science
This text beautifully illustrates the empirical nature of cognitive therapy. Succinct summaries in each chapter provide readers with a digest of current theoretical and empirical knowledge regarding each problem focus. Cognitive therapy treatment protocols are detailed that mark the leading edge of empirical knowledge regarding each topic. For therapists, these chapter reviews ground the described behavioural experiments within a broader scientific framework.
For patients, however, behavioural experiments are the science. Patients bring the healthy scepticism to experiments that true experimental science requires. They, more than therapists, are likely to question conclusions formed and press for more data before toppling a tightly held theory. Informed by a therapist’s understanding of psychology’s scientific knowledge base, behavioural experiments are designed to help patients use their own life as a laboratory, so they can
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derive personal scientific knowledge from analysis of life events. In these ways, behavioural experiments form the crossroads of professional and personal science.
Analytical and experiential knowledge
As highlighted in Chapter 1, behavioural experiments provide a meeting ground for discourse between knowledge derived from the rational mind and from the more intuitive, emotional mind (that is grounded in subjective phenomenological experience). Cognitive therapists sometime err in giving too much weight in therapy discussions to rational arguments (‘head’). Patients often err in anchoring their conclusions in subjective experience filtered through biases in information processing and distortions of memory (‘heart’). The four-stage learning model outlined in Chapter 2 and illustrated throughout the book provides a frame that can help ensure therapists and patients balance and value both types of information.
The importance of helping ‘head’ and ‘heart’ to reach consensus is highlighted by findings in experiments conducted by Epstein and his colleagues. When the emotional consequences of decisions and behaviours are increased, rational processing of information takes a back seat to experiential processing. The first thoughts that occur to people in times of misfortune are most likely to rise from the experiential mind. And when there is a conflict between ‘head’ and ‘heart’, information that comes from the heart is generally more compelling (Epstein 1994). Thus, to help ensure lasting change, it is important the experiential mind is truly convinced of new beliefs. Case examples throughout this book eloquently demonstrate how repeated experiments can and must be done to explore and answer all the reservations of the experiential mind.
Old and new beliefs, behaviours, emotional responses
Behavioural experiments create an intersection for old and new beliefs. Similarly, behavioural experiments often mark the transition between old and new behaviours as well as old and new emotional responses to events. As is clear in preceding chapters, cognitive therapists hope that a patient who enters a series of behavioural experiments following the path of old beliefs emerges on a different path of new belief. The quality of the new beliefs, behaviours, and emotional reactions derived will be affected by the relevance of the experiments designed and the care with which therapist and patient analyse and extract learning from what is observed.
The authors of the Oxford Guide provide excellent models for how to design behavioural experiments to test pivotal beliefs, rather than tangential beliefs. As is clear, behavioural experiments can involve great time and perceived risk for
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patients, and sometimes therapists too. Thus, it is important to choose experiments that are likely to make a relevant and significant difference for the patient’s well-being. Each chapter offers meaningful help to therapists by identifying common cognitive themes and beliefs that are central to the problem discussed. Readers are encouraged to examine these cognitions to see if any appear pivotal to the maintenance of a particular patient’s problems.
In addition, therapists are challenged to develop their guided discovery skills. As illustrated in each chapter, skilful and dogged guided discovery can uncover invaluable patient observations. Focusing patient attention on the relevant details revealed can lead to evidence palpable enough to convince the experiential mind. One is left with the impression that several behavioural experiments, expertly designed and debriefed, significantly influence learning more than dozens of experiments half-heartedly designed and inadequately analysed.
Therapist as collaborative ally
Cognitive therapy has long championed the idea that therapist and patient should be active collaborative partners in therapy (Beck et al. 1979). Therapists often coach patients to do behavioural experiments on their own, between sessions. As described in this book, behavioural experiments can challenge therapists to collaborate with patients by crossing the invisible line between therapy office and broader world. The Oxford group encourages therapists to leave the office and become experimental allies whenever adopting this role facilitates learning.
Each therapist needs to judge the professional boundaries appropriate to his or her own community, professional affiliations, and legal restrictions, and to each patient relationship. Yet a powerful picture emerges from case examples that observation of therapist experiments in the real world can pave the way for rapid patient learning and subsequent patient risk taking. Audiotaped thera- pist-conducted surveys provide patients with normative information they might hesitate to gather on their own. Therapist activities such as these can provide a positive or negative crossroad in the therapy relationship. A therapist stance of curiosity, empirical interest, and compassionate exploration of patient beliefs contribute to patient perception of these experiences as therapeutic rather than boundary crossings.
New trails ahead
Individual therapists
The most promising trails often go unrecognized until explored. The Oxford Guide shows cognitive therapists new ways to design and debrief behavioural experiments. The vivid samples offered should encourage them to use
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behavioural experiments more often, with greater precision, and with more thorough examination of patient observations and learning. Therapist readers now need to do their own behavioural experiments to test whatever reservations or questions linger about the utility of this powerful therapy tool.
Several chapters in this book specifically address use of behavioural experiments with patients diagnosed with personality disorders. In addition to treating problems associated with particular personality disorders (e.g. avoidance, self-injurious behaviours, interpersonal difficulties), there is a growing literature that suggests cognitive therapy can effectively treat the personality disorder itself (Beck et al. 2003). Behavioural experiments play a key role in this treatment (Beck et al. 2003; Mooney and Padesky 2000; Padesky 1995). As modelled in previous chapters, cognitive therapists help patients with personality disorders to identify alternative beliefs prior to embarking on behavioural experiments. This is particularly important because the absence of viable alternative beliefs is considered a maintenance factor of these disorders (Padesky 1994).
Behavioural experiments have a clear advantage over purely verbal interventions when treatment focus is a personality disorder. Target symptoms are interpersonal behaviour patterns maintained by beliefs deeply grounded in emotionally laden experiences. Patients with personality disorders are generally certain that their central maintaining beliefs are absolutely true. Thus, verbal questioning of beliefs can be construed as a sign that the therapist does not understand or care about the patient’s welfare. The curious, experimental approach illustrated in this Oxford Guide can enhance the collaborative relationship considered fundamental to successful transformation of personality. As patients with personality disorders engage fully in behavioural experiments, they learn to adopt more flexible beliefs, behaviours, and strategies that increase interpersonal success.
Cognitive therapy researchers
It is remarkable there is little research on behavioural experiments given the central role they play in treating so many disorders. On the other hand, the paucity of research is a great opportunity for new discovery. Qualitative comparisons of different types of behavioural experiments (e.g. observational, active, discovery) can be made to see if some experiments are associated more strongly than others with positive treatment outcomes. Empirical studies could evaluate what qualities of therapeutic debriefing (e.g. use of guided discovery, focus on patient observations) influence patient learning and change. Patient factors that influence behavioural experiments are also important to
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identify, especially to understand which factors enhance the efficacy of this therapeutic method.
Cognitive therapy: new trails
For a broad spectrum of problems, cognitive therapy offers one of the best roads to recovery and relapse prevention (DeRubeis and Crits–Christoph 1998; Hollon and Beck 2003). As this Oxford Guide suggests, behavioural experiments play a beneficial role in each cognitive therapy application developed to date. What is the future of cognitive therapy? What role will behavioural experiments play in this future?
As long as cognitive therapy is grounded in empiricism, it will evolve (Padesky and Beck 2003b). Cognitive therapy treatments and use of behavioural experiments should improve in upcoming years, hopefully informed by empirical research. There are likely to be more diverse methods for delivering cognitive therapy through print, electronic media, and even video games (Padesky 2002). There will be greater focus on applications for children (c.f. Friedberg and McClure 2002) and modifications for particular cultural groups. In addition to an emphasis on therapy for individuals or couples, new attention is likely to be given to family therapy, group therapy (c.f. White and Freeman 2000), applications within communities (including prevention programmes), and administration of cognitive therapy via guided self-help programmes (c.f. Greenberger and Padesky 1995). Each new or expanded cognitive therapy application is likely to include, or even emphasize, use of behavioural experiments because they potentiate learning and change.
In addition, the topical attention of cognitive therapy is likely to continue to expand beyond its current focus on psychiatric disorders. Seligman, a leading proponent of the positive psychology movement, has challenged psychology to apply its scientific knowledge to enhance positive human qualities rather than simply addressing human problems (cf. Seligman and Csikszentmihalyi 2000). Cognitive therapy is well poised to meet this challenge. Positive psychologists propose that we can build a psychology that will help people become happier, more altruistic, resilient, kind, compassionate, and courageous.
Positive qualities, behaviours, and moods are influenced by beliefs just as surely as negative ones. What better way to develop and refine positive qualities than through behavioural experiments? As cognitive therapy contributes to positive psychology in the years ahead, behavioural experiments will not only test beliefs but also help evaluate the individual and social consequences of behaviours, decisions, and values.
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Conclusion
Readers of this Oxford Guide will gain a broad perspective on the state of the art for the theory, processes, and practical use of behavioural experiments in cognitive therapy. Practitioners who emulate the model articulated will discover, through their own experience, the depth and breadth of learning that can emerge from creative use of behavioural experiments. Hopefully, this book also will inspire researchers. In the history of cognitive therapy, ideas published become ideas researched.
Behavioural experiments provide an intersection for professional and personal science, patients’ analytical and experiential minds, old and new beliefs/ emotions/behaviours, and patient learning inside and outside the therapy office. With such a rich convergence, it is not surprising that behavioural experiments play a central role in cognitive therapy for so many diverse problems. As cognitive therapy continues to evolve, behavioural experiments are likely to be found at the crossroads.