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Cognitive Behavioral Therapy Lecture 6 Page: 1

Lecture 6
Cognitive Behavioral Therapy
Paul Linden, Psy. D.

Chapter 10: Identifying and Modifying Intermediate Beliefs”


I. Cognitive Conceptualization
A. Beginning in the 1st session the therapist begins to formulate a
conceptualization, which logically connects automatic thoughts
to the deeper-level beliefs.
B. If the therapist fails to see the larger picture he/she will be less
likely to direct therapy in an effective way.
C. The Cognitive Conceptualization Diagram is designed to
demonstrate how things connect to each other.
D. The Cognitive conceptualization is develop from the bottom
upward
E. The meaning of automatic thoughts for each situation should be
logically connected with Core Belief box near the top of the
diagram.
F. At the top of form, is a section designed to answer the question
how did the core belief originate and become maintained
G. Situations linked to core beliefs may be obvious, or subtle.
Evaluating how the patient coped with these situations, is
critical in understanding the functional elements as well as the
dysfunctional element
H. There are likely to be many different intermediate attitudes and
key assumptions that support the core belief
I. Key assumptions often link the compensatory strategies to the
core belief, note: compensatory strategies are normal behaviors
that people engage in, may be over used or used at the expense
of some more adaptive strategy.
II. Identifying Intermediate Beliefs
A. Recognizing when a belief is expressed as an automatic thought
i. Statement which generalized across situations
ii. Statement that answers the question “Who am I?”
B. Providing the first part of an assumption
i. And if I don’t work as hard as possible--?
ii. Does this sound familiar
iii. Assessing how wide spread the belief is
C. Directly eliciting a rule or attitude
i. Do you have a rule about that?
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D. Using the Downward Arrow Technique


i. First identify a key automatic thought which you
suspect is connected to a belief
ii. Ask the patient for the meaning of this cognition,
assuming that the thought were true (Do you think
this is really how things work?)
iii. Asking what a thought means to a patient often
elicits and intermediate belief, asking what is means
about or says about the patient elicits a core belief.
iv. Sometimes therapist can get stuck when pt. responds
with a feeling rather than a belief
E. Examining the Patient’s automatic thoughts and looking for
common themes.
i. Automatic thoughts are frequently logically
connected and can lead to understanding beliefs,
rules and assumptions.
ii. Look for important a reoccurring themes
F. Reviewing a belief questionnaire completed by the patient.
i. Asking for specific beliefs, particularly if you have
several automatic thoughts that seem logically
connected (or related to the same type of situation)
ii. There are some published Dysfunctional Attitude
Scales or belief questionnaires that can be used to
directly assess intermediate thoughts and core
beliefs.
III. Deciding whether to modify a Belief
A. Determine which beliefs are central to the patients problems
B. Much like deciding which automatic thoughts to analyze,
looking for How much do you believe this can be a good guide.
C. How strongly is this belief influencing the patient’s behavior,
and emotional difficulties?
IV. Educating Patient about Beliefs
A. Festinger 1954 Cognitive Dissonance Theory
i. All people have some sense of “Who am I?”, and it
is our perception of ourselves being consistent over
time the substantially determines the sense of “who
am I?”
ii. When we behave in ways that conflict with our
sense of who am I, were experience a state of
internal tension “cognitive dissonance.”
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iii.
Often without conscious awareness, we make
choices or take actions to confirm our sense of
ourselves, and to reduce any tension caused by
cognitive dissonance.
V. Changing Rules Attitudes into Assumption Form.
i. Logical evaluation of this conditional assumption
through questioning or other methods (downward
arrow, role play, distancing or depersonalizing)
often creates greater cognitive dissonance than does
evaluation of the rule or attitude.
ii. Examining the Utility, advantages and
disadvantages of a belief.

VI. Formulating a New Belief


i. Therapist needs to first formulate to himself a new
more adaptive belief
ii. Constructing a new belief is a collaborative process,
however the therapist formulates a range of more
reasonable beliefs so he can appropriately choose
strategies to change the old belief
iii. Selecting Beliefs to change
a. Central, strongly belief
b. Formulate a more functional, less rigid belief
c. Select belief related to they dysfunctional one
d. Therapist does not impose this belief on the patient
e. Use Socratic method to question and then construct an
alternative belief
f. Educate patient about the nature of beliefs (in particular
that beliefs feel like absolute rules but are not
necessarily truths, are learned, and can be unlearned,
and they can be evaluated and modified)

VII. Modifying Beliefs (both intermediate and core beliefs)


i. Some beliefs may change easily but many (core
beliefs in particular) take concerted effort over a
period of time.
ii. Not necessary nor particularly desirable to reduce
the degree of belief to 0%
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iii. Have the patient keep track of beliefs through there


therapy notes (writing down the old belief as well as
the new belief)
iv. Seven strategies to change beliefs
a. Socratic questioning
b. Behavioral experiments
c. Cognitive continuum (applied in particular to all or
none distortions)
d. Rational-emotional role-plays
e. Using others as a reference point
f. Acting “as if”
g. Self-disclosure (from the therapist)

Chapter 11: Core Beliefs


• Core beliefs are one’s most central ideas about the self.
• Schemas are cognitive structures within the mind, the specific content
of which are core beliefs
• Negative core beliefs essentially fall into two broad categories; those
associated with helplessness and those associated with unlovability.
• Core beliefs develop in childhood
• For most of our lives most people may maintain relatively positive
core beliefs
• Negative core beliefs may surface only during times of psychological
distress
• Unlike automatic thoughts the core beliefs that patients “know” to be
true about themselves is not fully articulated until the therapist peels
back the layers by continuing to ask for the meaning of the patient’s
thoughts as in a downward arrow exercise.
• Patients may also have negative core beliefs about other people and
their worlds.
• Negative core beliefs are usually global, overgeneralized, and absolute
• Therapist develops a case conceptualization early; eventually the
therapist needs to share the conceptualization with the client.
a. How strong is the therapeutic alliance?
b. How strongly does the patient believe in the cognitive model?
c. How activated are the core beliefs in the session?
d. How much insight does the client have?
e. How concrete is the clients thinking?
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f. How successful has the client been at evaluating automatic thoughts,


and intermediate thoughts (prior to moving to core beliefs)
• Patients who are under significant emotional distress will have more
motivation and will more easily modify core beliefs
• It is far easier to modify the negative core beliefs of Axis I patients
than it is to modify core beliefs in Axis II character disordered
patients
• Five steps the therapist needs to take to identify and modify core
beliefs
a. Mentally hypothesized from which category or core beliefs the
specific automatic thought appears to have arisen
b. Specifies the core belief using the same techniques he uses to
identify the patent’s intermediate beliefs
c. Presents his hypothesis about core belief(s) to the patient, asking
for confirmation or disconfirmation
d. Educates the patient about core beliefs in general and about his/her
specific core belief

• Categorizing Core Beliefs


Helpless Core Beliefs
I am helpless I am inadequate
I am powerless I am ineffective
I am out of control I am incompetent
I am weak I am a failure
I am vulnerable I am disrespected
I am needy I am defective
I am trapped I am not good enough

Unlovable Core Beliefs


I am unlovable I am unworthy
I am unlikable I am different
I am undesirable I am defective
I am unattractive I am not good enough
I am unwanted I am bound to be rejected
I am uncared for I am bound to be abandoned
I am bad I am bound to be alone

• Identifying Core Beliefs


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a. The therapist uses the same technique to identify the patient’s specific
core belief that he uses to identify intermediate beliefs (downward
error, asking about the meaning of an automatic thought, what does
this say about you as a person)
b. Look for central themes in the patient’s automatic thoughts
c. Note: attempts to evaluate core beliefs too early in therapy are likely
to be ineffective

• Presenting Core Beliefs


a. Tentatively poses conceptualization to the client to confirm or
disconfirm
b. Obtain historical data regarding where the core belief possible came
from helps to establish the reasonableness or understandability of the
belief

• Educating the Patient about Core Beliefs and Monitoring their


Operation
a. That it is an idea, not necessarily a truth
b. She can believe it quite strongly even “feel” it to be true and yet
have it be mostly or entirely untrue
c. That as an idea, it can be tested
d. That it is rooted in childhood events: that may or may not have
been true at the time she first came to believe it.
e. That it continues to be maintained through the operation of her
schemas, in which she readily recognizes data that support the core
belief while ignoring or discounting data to the contrary
f. That she and the therapist working together can use a variety of
strategies over time to change this idea so that she can view herself
in a more realistic way

Modifying Core beliefs and Strengthening New Beliefs


a. Mentally devise a new, more realistic and functional belief and guide
the patient toward it.
b. Collaboratively develop a new more adaptive belief
c. Core Belief Work Sheet
d. Gathering Positive Data (goal to disruptive filter created by a
cognitive schema—often distancing by putting the belief in another
person)
e. Using Extreme Contrasts to Modify Core Beliefs (logical implications
of a belief)
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f. Developing Metaphors
g. Historical Tests of the Core Belief (best after patient has begun
monitoring her core belief in the present)
h. Restructuring early memories (Role play, empty chair, writing letters
to the inner child)