Normalising a symptom or experience

Surveys can be used to normalise symptoms or experiences which the patient is concerned about and can address catastrophic interpretations such as ‘I am going crazy’ or ‘I am permanently damaged’. For example, symptoms such as dissociation and hallucinations can feel frightening to patients but are actually extremely common, especially in certain situations such as following prolonged sleep loss or after traumatic events. Intrusive thoughts and images (such as jumping off a high place or harming someone vulnerable), often causing high levels of distress and forming part of problems such as obsessive-compulsive disorder (OCD), are a regular occurrence in non-clinical participants (over 90% in some studies, e.g. Radomsky et al., Reference Radomsky, Alcolado, Abramowitz, Alonso, Belloch, Bouvard, Clark, Coles, Doron, Fernández-Álvarezi, Garcia-Soriano, Ghisi, Gomez, Inozuk, Moulding, Shamsm, Sica, Simoso and Wong2014). Sharing this normalising information from surveys can form an important first step of exploring alternative explanations for such experiences.

Often normalisation is linked to the testing of an appraisal. For example, a patient who believes themselves to be a bad mother for experiencing post-natal depression and not feeling instantly connected to their child found it helpful to hear from other women who have a similar experience and realised that this is not evidence of being a bad parent. Another common example are intrusions in grief.

Lena came for treatment following the death of her husband. She told her therapist that she often saw him sitting in his favourite chair or heard his voice around the house that they had shared for 20 years. Lena felt as if she was losing her mind. Lena’s therapist helped her carry out a survey to find out how common these experiences were following a bereavement. To Lena’s surprise, many of the respondents also reported seeing or hearing their loved one after their death. They described a range of responses to this experience, with some finding it disturbing and others reporting it was a comfort or a way of keeping their memory alive. Lena found this information helpful and began to feel less distressed when she saw her husband.

Discovering what behaviour is typical for others

A survey can be helpful to develop a benchmark for what is typical for other people, especially when a patient has had long-term experiences of thinking or behaving in a particular way. Surveys can be a first step in shifting patients’ appraisals about threat and their linked safety behaviours. For example, someone with OCD may use a survey to find out how much time other people spend on certain tasks which they do to excess, such as cleaning, handwashing or checking. Someone with PTSD following repeated exposure to a high threat environment (such as a domestic abuse survivor or military veteran) may use a survey to better understand how much caution others take in certain situations where the patient has historically needed to be extremely careful but needs to update their benchmark for an appropriate level of caution now that they are out of danger.

Hamid experienced panic attacks where he believed he was having a heart attack. He began using many health-related checking behaviours including taking his pulse and blood pressure several times a day. He also avoided activities that might cause his heart to race such as exercising too hard, as he feared it could trigger a heart attack. Hamid conducted a survey to see whether other people used similar precautions and was surprised to learn that most people did not, and in fact believed that deliberately increasing their heart rate was a healthy strategy to reduce, not increase, the chance of a heart attack. This encouraged Hamid to try a behavioural experiment with his therapist where they both deliberately increased their heart rates by running on the spot to test if a heart attack was triggered.

Testing the water

A survey can be useful to ‘test the water’ and discover more information before then deciding a next step, such as disclosing an experience to others. It can also be used to seek opinions on a physical feature, such as scarring, that a patient usually hides, to assess how people would respond. This can lay the groundwork for further behavioural experiments, such as revealing a secret to a trusted person or allowing scars to be visible in public and observing responses.

Jenny was raped as a teenager by an older boy at school. At the time, she pretended to herself that it hadn’t happened and didn’t tell anyone. Many years later, she developed PTSD, triggered by the boy (now an adult) contacting her on Facebook. In treatment, Jenny told her therapist that she was still afraid to tell people about the rape, believing they might think she had somehow invited it or that she should have fought back (Jenny froze at the time). They agreed to carry out a survey, asking people what they would say to a friend who disclosed this experience. The responses were universally supportive, with no one blaming the victim in this scenario (all agreed the perpetrator was 100% to blame), nor endorsing Jenny’s beliefs that she had invited it or should have fought back. The survey results encouraged Jenny to take the risk of disclosing to a close friend that she had been raped. Her friend was compassionate and supportive.

Testing how other people judge one’s appearance, behaviours, symptoms or past experiences

Surveys can be particularly powerful tests of a patient’s beliefs about how others judge them. Concerns often focus on appearance, behaviours, symptoms or past experiences.

Duncan was receiving CBT for social anxiety disorder. He was extremely anxious about blushing, which he had been teased about as a child. He believed that people would think he was effeminate, weak, and pathetic if he visibly blushed, or that women would think he fancied them. As a result, if he began to feel hot and thought he was blushing, Duncan would leave a conversation and walk away. Duncan’s therapist helped him construct a survey to ask people’s opinions about blushing, what they thought of people who blushed and if they ever blushed themselves. No one endorsed Duncan’s predictions that they perceived blushing as signs of being effeminate, weak, pathetic, or fancying someone. Most people ascribed other causes to blushing, such as a person being hot, excited, or embarrassed, and everyone reported blushing themselves. Many people also saw it as a positive and endearing feature in others. The survey gave Duncan the confidence to try further behavioural experiments including staying longer in conversations if he felt himself blushing and watching for signs that others responded no differently to when he didn’t feel hot.

Surveys are powerful tools to discover that other people are less judgemental, and more understanding and compassionate than the patient expects, such as in Jenny’s example. This is especially helpful if a patient is experiencing self-critical thoughts or shame. Many patients with low self-esteem and/or high shame struggle to access self-compassion, particularly where shame has been longstanding, or they have significant experiences of emotional abuse. Receiving compassionate responses from a group of strangers (who presumably are not motivated to be disingenuous) can be hugely powerful in demonstrating that not everyone will hold the same critical stance as the patient or past abusers.

In treatment for depression, Piotr described self-critical thoughts and a long history of low self-worth linked to emotional abuse from his mother in childhood. As an adult, he had experienced two long periods of unemployment related to his depression and his marriage had failed after his wife was repeatedly unfaithful. Piotr believed that these experiences showed that he was ‘a loser’ and ‘useless’. Even though his friends had been supportive, Piotr believed that they secretly saw him as a failure. In his survey, Piotr described this history and asked people to be truthful in their responses. He asked whether respondents would view a man with these experiences as ‘a loser’ and ‘useless’. At the recommendation of his therapist, Piotr included questions about what respondents would say to a good friend with the same history and whether they themselves, or someone close to them, had experienced unemployment or divorce. This prompted compassionate responses, and many respondents shared their own experiences of unemployment and relationships breaking down. Piotr selected some of the compassionate responses and saved them on his phone, looking at them regularly when his thinking became self-critical to remind himself that other people would not judge him as harshly as he judged himself.

Who to ask?

It is important to be mindful of who to approach to ensure responses are as meaningful as possible for patients. Collaboratively discussing who to send the survey to may help reduce the chances of the responses being discounted. Asking the patient about who they think would be most helpful to ask is the first step, without making assumptions. Most patients are happy for the survey to be sent to anyone, but some may wish to hear from specific groups, so considering culture, ethnicity, race, heritage, sex, identified gender, age, LGBTQI+, people with/without disabilities and socioeconomic status is important. For example, a new father experiencing intrusive thoughts about harming his baby is more likely to be interested in hearing about other parents’ experiences of intrusive thoughts, or perhaps only other fathers’ responses. Another example might be a young Asian woman who feels stigmatised for having been sexually assaulted who may be most interested in the views of people with Asian heritage. It is important to include a range of people, rather than only therapists, to avoid the common dismissal, ‘yes, but they are just being nice; they are all therapists’.

Gaining consent to send the survey more widely, while confirming confidentiality and anonymity, is key. As a rough estimate, sending the survey to 10–12 people with the aim of getting 8–10 responses provides enough data without the risk of overwhelming the patient. We also recommend encouraging the patient to complete the survey themselves, being as objective as possible (imagining they are responding about someone else) and/or asking for the patient’s predictions about what others will say.

What to ask?

Surveys may purely consist of questions, present a brief vignette based on the patient’s experience with associated questions, or feature pictures with linked questions. Questions must link to the formulation and specifically target key cognitions and their meanings. Surveys are best kept clear, brief and succinct; restricting the number of questions will encourage as many responses as possible. We usually aim for at least five, but definitely less than ten! It will also help to limit the time required to devise the survey in session – developing a brief survey need only take 10–20 minutes.

Questions are written together in session as collaboratively as possible. Therapists can assist with suggesting or shaping questions so that they target the patient’s specific beliefs. In general, we start with open questions (e.g. ‘Why do you think people stutter?’) and then use more specific questions (‘Would you think badly of someone who stutters?’) directly related to patients’ negative beliefs. The open questions often reveal that people have a range of different views about the things that patients are concerned about. The final closed questions often show that others rarely confirm patients’ negative interpretations. In order to ensure that the survey is convincing, it is useful to encourage respondents to write detailed answers, not just yes/no responses. Belief ratings (0–100) can also sometimes be useful.

It can be helpful to ask questions about others involved, where relevant. For example, where interpersonal trauma has occurred, it can be helpful to ask peoples’ opinions of the perpetrator(s). For other problems, it can also be helpful to gather perspectives on the behaviour of other people towards the patient, e.g. ‘What would you think of someone who was very critical of a person for stumbling over their words?’. This is often something the therapist may need to suggest, particularly where there is excessive self-blame. Finally, we recommend adding in a question towards the end of the survey designed to elicit direct compassion for the patient, such as ‘What would you say to a friend or a loved one who faced this situation?’.

How to get responses?

The easiest and most reliable way of obtaining anonymous, confidential, honest and open responses is to use online platforms, such as Survey Monkey or Google Forms. Ideally, both therapist and patient will send the survey to people they know. If appropriate, audio or video responses may be more emotionally powerful than written responses. These can’t be collected using the same online platforms but can be recorded on the patient or therapist’s phone and saved in an online folder.

How to collate feedback

It can be helpful to collate responses so that all answers to each individual question are grouped together to enable maximum learning to each question. It is essential to read through responses before giving them to patients to be aware of the range of responses. There will likely be variation in opinions, particularly where a broad audience has been approached, and this can be helpful and representative of the general population’s varying viewpoints. See the ‘Trouble-shooting’ section below for how to deal with responses that support the patient’s predictions.

How to share and use responses

Try to keep survey reviews as active as possible: encouraging the patient to make predictions about the responses before looking through them and then updating the predictions. This is similar to using a behavioural experiment record form. If they have completed the survey themselves, comparing their responses to other people’s can also lead to important learning (e.g. that they are more critical of themselves than others are, which may be true more generally as well). It is helpful if patients read responses aloud (unless surveys are particularly long/have many respondents!) to enable reflection on key points. Guided discovery is important when looking at responses: asking what patients made of individual and overall responses and what they have learned about their predictions and in turn their beliefs, re-rating their original predictions as part of this process.

As with all cognitive and behavioural interventions, writing down key learning points is essential (Padesky, Reference Padesky2019). It is then important to discuss how the patient will build on these learning points and take them further, e.g. the survey may be the first step towards telling family members or trusted friends about their particular beliefs, or it could be to start reducing the number of times they spend washing their hands each day in line with other people surveyed, setting up a behavioural experiment to further test beliefs, or providing key information to bring into the updated reliving of a particular hotspot in PTSD. Flashcards of key information can also be used between sessions. There is a video example of preparing and feeding back a survey with a PTSD patient on https://oxcadatresources.com/surveys/

I have short/limited sessions – I don’t have time to do a survey

Surveys need not be very time-consuming, especially once therapists get more confident with the technique and adept at using online survey tools. We often find that a quick survey can take only 10–20 minutes to devise in session, with similar time required to add to an online system and generate a link which can be emailed to colleagues and friends (and to the patient to share if they so wish). Filling in the survey themselves and/or making predictions can be set as a homework task. Discussing the findings in the following session is the next step and may take most of a 60-minute session to fully explore new learning in terms of the patient’s beliefs and plan how to take it forward. CT-PTSD sessions are typically 90 minutes, leaving enough time for additional tasks, such as integrating new information from the survey into memory updates. As we often find that the findings from surveys can be very powerful, we see this as a worthwhile use of session time. It is often experiential techniques like surveys which lead to the biggest cognitive and emotional shifts in treatment and are memorable to patients after therapy ends. As with other behavioural experiments, therapists can seize the opportunity to address key beliefs experientially when they arise in session – these are often more time-efficient interventions than other forms of guided discovery.

My patient is reluctant to try a survey

Patients may have blocking beliefs about surveys which can be identified and addressed in session. For example, they may have concerns about anonymity or negative responses. These may interact with our own concerns as therapists, leading to us holding back. Many concerns can be addressed through mutual agreement about how the survey will be set up (e.g. using an anonymous platform, pseudonyms, sent out by the therapist). We acknowledge that we cannot know the results in advance, and this introduces the risk of some responses that confirm the patient’s appraisals. However, this is rare, and the therapist will be there to support the patient with any upsetting responses. Using ready-made surveys on similar topics if available can also be useful as a precursor to illustrate common responses. In our experience, most patients (and therapists when they are new to the technique) are surprised by how helpful surveys can be.

Some of the responses supported my patient’s beliefs

With responses that support the patient’s predictions, we can help our patients to formulate and view them in context, e.g. One out of 15 people said it is a sign of weakness to blush – 94% said it was not a sign of weakness. What do you make of that? Do most people judge blushing negatively or is this a rare opinion? What do you think about the one response linking blushing to weakness – does it say more about you or them? Is it possible this person had some anxiety about this topic themselves? Similarly, if three out of 12 people said they would think a friend who had been raped is ‘damaged’, it would be important to consider their comments (hence why we ask respondents to comment on their answers), as they might qualify their responses with a sense that their friend would need help and support to overcome their reactions to being raped rather than being a damaged person per se. Discussing any concerns or questions in supervision can be helpful before sharing with the patient.

My patient has discounted the results

Patients sometimes discount the results of surveys, for example saying that people are just being nice, or the results are not representative. There may be some thinking errors at play here which can be addressed through Socratic questioning, for example considering evidence for and against people being dishonest in their responses to an anonymous survey, and asking the patient to imagine they are reading another person’s survey results – would they still think they were biased? It can also be helpful to repeat the survey with different questions or distribute it to a different group if it has not fully addressed the patient’s appraisals.