At this point, we have elicited a measurable prediction and ran behavioral experiments to refute it. The next step is to build confidence in the results. This step is both simple and very difficult. It’s simple because we are essentially going to repeat the experiments, altering them based on the continual updating of the prediction. It’s difficult because momentum is a powerful thing. A single refutation is rarely enough to alter the course in a lasting way.
We’ve typically thought of this stage as a gradual progression, and rightfully so. It usually takes a graded form. But, there are suggestions that it doesn’t need to be. It can jump around instead of strictly climbing a hierarchy. In the Craske review on maximizing exposure based care, they mention letting the patient decide what is important to them to deal with next and letting that guide the order of progression as opposed to some strict hierarchy.
An example of what this stage may look like:
Initial prediction: Bending forward OR lifting more than 20 lbs will damage the back.
Behavioral experiment: Demonstration of the patient getting into trunk flexion in other positions, like quadruped, leading to squatting position that raises into a forward bent position, followed by forward bending. They repeat many repetitions that day and over the next few days, continuing to strengthen confidence that the finding was not by chance.
New prediction: Bending forward AND lift 20 lbs will damage the back
Behavioral experiment: Demonstration of the patient carrying 50# in an upright position (confront with strength). Patient demonstrating the ability to squat 100 lbs through a partial range (confront with strength). Patient starts off seated holding 20 lbs and sets it on the floor. They are then shown how the back is being subjected to the same forces during this maneuver. They then lift 20 lbs. from a chair. They repeat many repetitions that day and over the next few days, continuing to strengthen confidence that the finding was not by chance.
Some important things to note here.
- First is that the prediction is not staying static. It gets updated based on the new information. We have a role here in continuing to elicit the changes in the predictions in a measurable way.
- Next, the repeating of the process allows a building of confidence in the trustworthiness of the results.
- Also, it is likely that there will be occasional times that the result is not good. The more confidence and experience that is gained with achieving the refutation result, the less likely they will trust this negative result!
- Repeat the process in varying contexts. This builds confidence that the result is not bound to one particular set of circumstances.
What is very cool is that we can teach this process of “predict -> test -> repeat” as a skill to our patients. We can help them use their creativity to come up with ways to test and progress on their own.