9/25/20

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SKILLS CLASS:

Supercharging the effectiveness

ofBehavioural Experiments

Emma Warnock-Parkesemma.warnock-parkes@psy.ox.ac.uk

@DrEmmaWParkes

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With thanks to

OxCADAT team:• David Clark

• Anke Ehlers

• Jennifer Wild

• Nick Grey

• Alice Kerr

• Graham Thew

• Hannah Murray

• CADAT, London

• Paul Salkovskis, Jack Rachman

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(Mini) skills class plan

Building skills: video demos, brief reflective

1. How can we do effective BEs remotely?2. What makes BEs so powerful?3. How can we supercharge learning? 4. Roadblocks to effective BEs (briefly)

5. Questions/Discussion

Share thoughts, ideas, questions on chat – Jen can address during talk too

“I hear and I forget. I see and I remember.

I do and I understand” (Confucius)

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Key read ing /resources

• www.oxcadatresources.com

• Video role-plays PTSD, SAD, Panic

• Papers, clinical guides

• COVID-19 resources

• Bennett-Levy et al., (Eds) (2004) Oxford Guide to Behavioural Experiments in CT. Oxford University Press

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What are behavioural experiments(Bennett- levy et a l , 2004)

• Formulation driven experiential activity

• Powerful method belief change, emotional shifts• Test unhelpful beliefs, construct or test new

beliefs, contribute to/verify formulation• Learning cycle (Lewin 1946/Kolb 84):

Plan…Experience…Observe…Reflect…Plan

• In sessions (in room/world outside),homework

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Exper iment ing remote ly

• Experiments possible remotely

- Together webcam (in house, add colleagues to call, making a call)

- With the patient leaving home, therapist on webcam/phone

- Set up for homework (screen share BE logs)

• COVID restrictions may impact (see Warnock-Parkes et al., 2020; Wild et al., 2020 papers on remote working in SAD/PTSD)

Video coming soon: oxcadatresources.comCOVID-19 resources

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VIDEO: REMOTE EXPERIMENTSNote down any key take home points or questions

Full video and more : www.oxcadatresources.com, under COVID-19 resources

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REMOTE CONSIDERATIONS

Build relationship & loosen beliefs

Practical issues: Suitable environment? Sufficient time? Wifi/reception

More verbal check ins (check SB use, belief ratings)

Lots encouragement

Do together when possible

Do share any key tips to the chat!

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W hat makes BE so power fu l ?(Bennett-levy et al., 04)

• Teasdale’s Interacting cognitive subsystems model, 2 levels process information, Bes impact on both:

1. Specific level – propositional code (language, e.g. I am an idiot)

2. Generic level – implicational code (felt sense/feeling)

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W hy are some exper iments more power fu l than others?

• Oxford guide to BE (Bennet Levy et al., 2004) ‘remarkably little written about BEs’ (pg1) in 2004

• Called for more research on mechanisms of change in BE

• Little published since then – do share on chat if you know of any papers of interest

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Reflection exercise

• Consider a BE done that was particularly powerful. • Identify anything that gave that BE its extra power? • Or use video shown

If you can summarize it as one word, please share this at www.pollev.com and enter username: emmawarnockp349

Or add to Zoom chat

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The power o f more : CT-SAD

• CT-SAD (Clark et al) BEs most sessions & homework

• Snowballs belief change

• Out of office BE great for this

• More BE= better outcome in SAD-iCT(Clark et al., In Prep).

• Clement, Lin & Stangier(2019) hypothesize better outcomes UK trials as more BEs than German/Swedish trials.

• Sudden gains study: greater number BE wk prior to sudden gain (compare to control wk) (Thew et al, In Prep)

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GENERALIZE TO SUPERCHARGE!

• Thew et al (In prep) CT-SAD greater generalising in pre-sudden gain sessions compared to control sessions • Generalizing = reflecting what learnt beyond the specific

situation• Ensure generalize back to the heart of the problem • In SAD: fundamentally acceptable as I am.• This step needs sufficient time & therapist guidance

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W hat are h i t t ing the hear t o f the prob lem w ith our BEs?

• Case exploration (n=5 good and 5 poor response to iCT-SAD).• 126 experiment record sheets analyzed blind. • Small exploratory study to generate hypotheses• Better responders, double number BEs, more experiments

addressed patients’ negative self-images/impressions (57% v 19%)(Warnock-Parkes, Thew, Smith, Wild, Stott & Clark (In prep). • SAD negative & distorted self-images (Clark & Wells, 95)• We look for cognitions to target in BEs, sometimes miss the core

target?• Shame sometimes means people hold back about self-imagery

e.g. ‘robot face’, ‘gurning face’, ‘smirking mouth’

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The power o f chang ing se l f - imager y

• “After treatment I see myself totally differently, like a normal, acceptable woman” – Liz, now recovered from SAD

• Lusia Stopa (2009): emphasizes importance changing images in SAD that may represent self-concept

• Arnoud Arntz (2020) images are key part of patient’s mental representations about themselves and the world and these need to be changed in treatment to prevent relapse. If not changed “the underlying representation can be easily activated again.”

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Using v ideo /s t i l l image feedback

• CT-SAD video/still image feedback helps supercharge learning, generalize and consolidate it

• BE recorded, predictions compared before/after video

• Warnock-Parkes et al (2017) & McManus et al (2009): video feedback further shift in belief & greater reduction in social anxiety.

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Video feedback br ie f i l lu s tra t ion

Full video: www.oxcadatresources.com, ‘General principles of Video Feedback’

After a BE meeting a stranger Elizabeth worries she blushed during the chat

Note down any key take home points or questions

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St i l l image f la shcards

• Update negative images, generalize learning, consolidate• Can add to positive data log targeting unconditional self beliefs

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Using stil l images to consolidate learning across presenting problems

• Anybody tried using still image flashcards capturing key moments in BEs to help consolidate learning in any other anxiety/mood problems we work with? Please share!

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Using BEs to update traumat ic memor ies (SAD)

• Can be used to aid imagery rescripting (Wild & Clark, 2011)• Bring in photos or other learning from BEs to help update

traumatic memories and show the patient how things are different now

Then I was bullied and teased when I stood up in class and I felt I looked inferior. NOW I’m accepted by my friends and colleagueswhen I speak up and nobody bullies me. I’m a competent woman.

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Using BEs to update traumat ic memor ies (PTSD)

• CT-PTSD (Ehlers & Clark) during updating memories procedure, can bring in BE learning (relive relevant hotspot or update narrative). Photo/video taken during BE can help info sink in:

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Video: BE updating trauma memory/negative imagery

Please note, some content on blood/injury in video. Full video: oxcadatresources.com

Note down any key take home points or questions

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Identify road blocks = key

•Activate detective mode!• Check model, questionnaires• Shame can mean things are missed• Block may be therapist’s– examine cognitions • Identify blocking belief or process (e.g. traumatic

memory, self-criticism, low mood, etc.)

•Address block e.g. stimulus discrimination used live during BE to help process present not past (PTSD/SAD video examples oxcadatresources)

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KEY POINTS

• BE powerful & can be done remotely!

• More experiments snowballs belief change

• Generalizing & consolidating =key

• Video/still images can help

• Use to update negative imagery/memories if relevant• When faced with blocks…get into detective mode

Take a moment to write down any key take home points from today & how you could bring into clinical practice.

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Thank you!

Emma Warnock-Parkesemma.warnock-parkes@psy.ox.ac.uk

@DrEmmaWParkes

Time to share our ideas, thoughts and any questions

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