Identifying and Modifying Intermediate Beliefs

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Cognitive Conceptualization
Generally, you will guide patients to work on automatic thoughts before
directly modifying their beliefs. From the beginning, though, you start
formulating a conceptualization, which logically connects automatic
thoughts to the deeper-level beliefs. If you fail to see this larger picture,
you will be less likely to direct therapy in an effective, efficient way.
You can start filling out a Cognitive Conceptualization Diagram
(Figures 13.1 and 13.2) after the first session with a patient, if you have
collected data in the form of the cognitive model (the bottom part of
the diagram); that is, you have data about the patients typical automatic
thoughts, emotions, behavior, and/or beliefs. This diagram depicts,
among other things, the relationship between core beliefs, intermediate beliefs, and current automatic thoughts. It provides a cognitive map
of the patients psychopathology and helps organize the multitude of
data that the patient presents. The diagram in Figure 13.1 illustrates
the basic questions you will ask yourself to complete the diagram.
When filling in data after the initial session, you should regard
your first efforts as tentative; you have not yet collected enough data
to determine the extent to which the automatic thoughts patients have
expressed are very typical for them. The completed diagram will mislead you if you choose situations in which the themes of patients automatic thoughts are not part of an overall pattern. After three or four
sessions, you should be able to complete the bottom half with more
confidence, as patterns should have emerged.
You share your partial conceptualization with patients verbally
(and sometimes on a blank piece of paper) at every session as you summarize their experience in the form of the cognitive model. Generally
you will not share the worksheet, however, as many patients would find
it confusing (or occasionally demeaning if they interpret the diagram
as your attempt to fit them into boxes).
Initially, you may have data to complete only a portion of the diagram. You either leave the other boxes blank, or fill in items you have
inferred with a question mark to indicate their tentative status. You
will check out missing or inferred items with the patient at future sessions. At some point you will share both the top and bottom parts of
the conceptualization, when your goal for a session is to help patients
understand the broader picture of their difficulties. At that time, you
will review the conceptualization verbally, share a simplified version
on a blank sheet of paper, or (for patients whom you judge will benefit) present a blank conceptualization diagram and fill it out together.
Whenever you present your interpretations, you will do so tentatively
and label them as hypotheses, asking patients whether they ring true.
Correct hypotheses generally resonate with the patient.

Patients name:

Date:

Diagnosis: Axis I

Axis II

Relevant Childhood Data

Which experiences contributed to the development and maintenance of the core belief(s)?

Core Belief(s)
What are the patients most central beliefs about him/herself?

Conditional Assumptions/Beliefs/Rules
Which positive assumption help him/her cope with his/her core belief(s)?
What is the negative counterpart of this assumption?

Compensatory/Coping Strategy(ies)
Which behaviors help him/her cope with the belief(s)?

Situation 1
What was the problematic
situation?

Situation 1

Situation 1

Automatic Thought
What went through his/her mind?

Automatic Thought

Automatic Thought

Meaning of the A.T.

What did the automatic thought
mean to him/her?

Meaning of the A.T.

Meaning of the A.T.

Emotion
What emotion was associated
with the automatic thought?

Emotion

Emotion

Behavior
What did the patient do then?

Behavior

Behavior

FIGURE 13.1. Cognitive Conceptualization Diagram. Adapted from Cognitive behavior

therapy worksheet packet. Copyright 2011 by Judith S. Beck. Bala Cynwyd, PA: Beck Institute
for Cognitive Behavior Therapy.
Reprinted by permission in Cognitive Behavior Therapy: Basics and Beyond, Second Edition, by Judith
S. Beck (Guilford Press, 2011). Permission to photocopy this material is granted to purchasers of
this book for personal use only (see copyright page for details). Purchasers may download a larger
version of this material from www.guilford.com/p/beck4.

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Identifying and Modifying Intermediate Beliefs

201

Usually it is best to start with the bottom half of the conceptualization diagram. You jot down three typical situations in which the
patient became upset. Then, for each situation, fill in the key automatic
thought, its meaning, and the patients subsequent emotion and relevant behavior (if any). If you have not directly asked patients for the
meaning of their automatic thoughts, you either hypothesize (with a
written question mark) or, better still, do the downward arrow technique (pages 206208) at the next session to uncover the meaning for
each thought.
The meaning of the automatic thought for each situation should
be logically connected with the Core Belief box near the top of the
diagram. For example, Sallys diagram (Figure 13.2) clearly shows how
her automatic thoughts, and the meaning of those thoughts are related
to her core belief of incompetence.
To complete the top box of the diagram, ask yourself (and the
patient): How did the core belief originate and become maintained?
What life events (especially those in childhood) did the patient experience that might be related to the development and maintenance of the
belief? Typical relevant childhood data include such significant events
as continual or periodic strife among parents or other family members;
parental divorce; negative interactions with parents, siblings, teachers,
peers, or others in which the child felt blamed, criticized, or otherwise
devalued; serious illness; death of significant others; physical or sexual
abuse; and other adverse life conditions, such as moving frequently,
experiencing trauma, growing up in poverty, or facing chronic discrimination, to name a few.
The relevant childhood data may, however, be more subtle: for
example, childrens perceptions (which may or may not have been
valid) that they did not measure up in important ways to their siblings;
that they were different from or demeaned by peers; that they did not
meet expectations of parents, teachers, or others; or that their parents
favored a sibling over them.
Next ask yourself, How did the patient cope with this painful core
belief? Which intermediate beliefs (i.e., underlying assumptions, rules,
and attitudes) has the patient developed?
Sallys beliefs are depicted hierarchically in Figure 13.3. As Sally
has many intermediate beliefs that could be classified as attitudes or
rules, it is particularly useful to list the key assumptions in the box below
the core belief. (See page 211 on how you can help a patient re-express
an attitude or rule as an assumption.) Sally, for example, developed
an assumption that helped her cope with the painful idea of incompetence: If I work very hard, then I can do okay. Like most patients,
she also had the flip side of the same assumption: If I dont work hard,
then Ill fail. Most Axis I patients tend to operate according to the first

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COGNITIVE BEHAVIOR THER APY: BASIC S AND BE YOND

Patients name:
Diagnosis: Axis I

Sally
Major depressive episode

Date:
Axis II

2/22

None

Relevant Childhood Data

Which experiences contributed to the development and maintenance of the core belief(s)?

Compared self with older brother and peers

Critical mother

Core Belief(s)
What are the patients most central beliefs about him/herself?

Im incompetent.

Conditional Assumptions/Beliefs/Rules
Which positive assumption help him/her cope with his/her core belief(s)?
What is the negative counterpart of this assumption?

(positive) If I work very hard, I can do okay.

(negative) If I dont do great, then Ive failed.
Compensatory/Coping Strategy(ies)
Which behaviors help him/her cope with the belief(s)?

Develop high standards

Work very hard
Overprepare

Situation 1
What was the problematic
situation?

Talking to freshmen about

advanced placement credits

Automatic Thought
What went through his/her mind?

Theyre all smarter than me.

Meaning of the A.T.

What did the automatic thought
mean to him/her?

Im incompetent.
Emotion
What emotion was associated
with the automatic thought?

Sad
Behavior
What did the patient do then?

Kept quiet.

Look for shortcomings and correct

Avoid seeking help

Situation 1

Thinking about course

requirements

Situation 1

Reflecting on difficulty
of textbook

Automatic Thought

Automatic Thought

I wont be able to do it
(research paper).

I wont make it through

the course.

Meaning of the A.T.

Meaning of the A.T.

Im incompetent.

Im incompetent.

Emotion

Emotion

Sad

Sad

Behavior

Cried

Behavior

Closed the book;

stopped studying

FIGURE 13.2. Sallys Cognitive Conceptualization Diagram. Adapted from Cognitive behavior therapy worksheet packet. Copyright 2011 by Judith S. Beck. Bala Cynwyd,
PA: Beck Institute for Cognitive Behavior Therapy.

Identifying and Modifying Intermediate Beliefs

Core belief

Intermediate
beliefs

203

Im incompetent.

1. Attitude:

Its terrible to be incompetent.

2. Assumptions:

If I work extra hard, I can do okay.

If I dont work hard, Ill fail.

Automatic thoughts
when depressed

I cant do this.
This is too hard.
Ill never learn all this.

FIGURE 13.3. Sallys hierarchy of beliefs and automatic thoughts.

assumption, the one phrased in a more positive way, until they become
psychologically distressed, at which time the negative assumption surfaces. Note that the designation positive does not necessarily mean
the belief is adaptive.
To complete the next box, coping strategies, you ask yourself,
Which behavioral strategies did the patient develop to cope with the
painful core belief? Note that the patients broad assumptions often
link the coping strategies to the core belief:
If I [engage in the coping strategy], then [my core belief may
not come true; Ill be okay]. However, if I [do not engage in my
coping strategy], then [my core belief is likely to come true].
Sallys strategies were to develop high standards for herself, work
very hard, overprepare for exams and presentations, remain vigilant
for her shortcomings, and avoid seeking help (especially in situations
in which asking for assistance could, in her mind, expose her incompetence). She believes that engaging in these behaviors will protect her
from failure and the exposure of her incompetence (and that not doing
them could lead to failure and exposure of incompetence).
Another patient might have developed strategies that are the
opposite of Sallys behaviors: avoiding hard work, developing few goals,
underpreparing, and asking for excessive help. Why did Sally develop
a particular set of coping strategies while a second patient developed

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the opposite set? Perhaps nature endowed them with different cognitive and behavioral styles; in interaction with the environment they
developed different intermediate beliefs that reinforced their particular behavioral strategies. The second patient, perhaps because of his
childhood experiences, had the same core belief of incompetence, but
coped with it by developing a different set of beliefs: If I set low goals
for myself Ill be okay, but if I set high goals Ill fail. If I rely on others
Ill be okay, but if I rely on myself Ill fail.
Note that most coping strategies are normal behaviors that everyone engages in at times. The difficulty of patients in distress lies in the
overuse of these strategies at the expense of more functional strategies.
Figure 13.4 lists a few examples of strategies that patients develop to
cope with painful core beliefs.
To summarize, the Cognitive Conceptualization Diagram is based
on data patients present, their actual words. You should regard your
hypotheses as tentative until confirmed by the patient. You will continually reevaluate and refine the diagram as you collect additional data,
and your conceptualization is not complete until the patient terminates
treatment. While you might not show the actual diagram to patients,
you will verbally (and often on paper) conceptualize their experience
from the first session on, to help them make sense of their current reactions to situations. At some point, you will present the larger picture to
patients so they can understand:

Avoid negative emotion

Display high emotion (e.g., to attract attention)

Try to be perfect

Purposely appear incompetent or helpless

Be overly responsible

Avoid responsibility

Avoid intimacy

Seek inappropriate intimacy

Seek recognition

Avoid attention

Avoid confrontation

Provoke others

Try to control situations

Abdicate control to others

Act childlike

Act in an authoritarian manner

Try to please others

Distance self from others or try to please only

oneself

FIGURE 13.4. Typical coping strategies.