10 Cog interventions: beh exp

Question 1

Ch13

Identifying and modifying intermediate beliefs

Answer 1

Unarticulated ideas or understandings that patients have about themselves, others, and their personal worlds, that give rise to specific automatic thoughts.

• Intermediate beliefs: Intermediate beliefs, while not as easily modifiable as automatic thoughts, are still more malleable than core beliefs.
• Core beliefs

Question 2

CH13

Conceptualization

Answer 2

Unarticulated ideas or understandings that patients have about themselves, others, and their personal worlds, that give rise to specific automatic thoughts.

• Intermediate beliefs: Intermediate beliefs, while not as easily modifiable as automatic thoughts, are still more malleable than core beliefs.
• Core beliefs

Question 3

Ch13

Cognitive conceptualization

Answer 3

From the beginning, though, you start formulating a conceptualization, which logically connects automatic thoughts to the deeper-level beliefs.
You can start filling out a Cognitive Conceptualization Diagram, after the first session with a patient.
• This diagram depicts, among other things, the relationship between core beliefs, intermediate beliefs, and current automatic thoughts. It provides a cognitive map of the patient’s psychopathology and helps organize the multitude of data that the patient presents.
Usually it is best to start with the bottom half of the conceptualization diagram.
The meaning of the automatic thought for each situation should be logically connected with the Core Belief box near the top of the diagram.
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

Question 4

Ch13

Identifying Intermediate and Core Beliefs

Answer 4

1. Recognizing when a belief is expressed as an automatic thought.
2. Providing the first part of an assumption.
3. Directly eliciting a rule or attitude.
4. Using the downward arrow technique.
5. Examining the patient’s automatic thoughts and looking for common themes.
6. Asking the patient directly.
7. Reviewing a belief questionnaire completed by the patient

Question 5

Ch13

Modifying beliefs

Answer 5

1. Socratic questioning.
2. Behavioral experiments.
3. Cognitive continuum.
4. Intellectual–emotional role plays.
5. Using others as a reference point.
6. Acting “as if.”
7. Self-disclosure.

Question 6

Ch14

Core beliefs and schemas

Answer 6

Core beliefs are a person’s most central ideas about the self; they are sometimes called schemas.
Beck: schemas are cognitive structures within the mind, the specific content of which are core beliefs.

Three broad categories of negative core beliefs:
x associated with helplessness x associated with unlovability x associated with worthlessness.

Question 7

Ch14

Early belief modification may fail

Answer 7

x Have core beliefs that are quite rigid and overgeneralized.
x Do not yet believe that cognitions are ideas and not necessarily truths.
x Experience very high levels of affect when beliefs are elicited or questioned.
x Do not have a strong enough alliance with you (not enough trust; misunderstanding of you as a person, invalidated by the process of belief evaluation).

Question 8

CH14

Identifying and modifying core beliefs

Answer 8

1. Mentally hypothesize from which category of core belief (helplessness; unlovability; worthlessness) specific automatic thoughts appear to have arisen.
2. Specify the core belief (to yourself)
3. Present your hypothesis re core belief to patients, asking for (dis)confirmation; refine your hypothesis with additional data about current and childhood situations and their reactions to them.
4. Educate patients about core beliefs in general and about their specific core beliefs; guide patients in monitoring the operation of the core belief in the present.
5. Help patients specify and strengthen a new, more adaptive core belief.
6. Evaluate and modify the negative core belief with patients; examine the childhood origin of the core belief (if applicable), its maintenance through the years, and its contribution to patients’ present difficulties; continue to monitor the activation of the core belief in the present; use both “intellectual” and “emotional” or experiential methods to decrease the strength of the old core belief and to increase the strength of the new core belief.

Question 9

Ch14

Categorizing Core Beliefs

Answer 9

Whenever patients present data (problems, automatic thoughts, emotions, behavior, history), you ‘listen’ for the category of core belief that is activated.
x E.g. inability to concentrate and fears of failing -> helpless category.
x E.g. others not caring, fears of being too different from others to sustain relationship -> core belief category of unlovability.
x E.g. frustrated by inability to get others to listen, in interpersonal situations, does not believe s/he is unlovable
 core belief of helplessness.
x E.g. feels like a worthless human being, morally a bad person -> worthless belief.

Typical core beliefs in the unlovable category:
Themes: being unlikable, undesirable, unappealing, or defective in character so patient thinks sustained love and caring of others is not deserved.

Worthless core beliefs:
Patients feel they are bad, unworthy, or even dangerous to other people.

Question 10

Ch14
Identifying Core Beliefs
Strategies

Answer 10

The same techniques to identify specific core beliefs are used that you used when identifying their intermediate beliefs. So, use the downward arrow technique, look for central themes in patients’ automatic thoughts, watch for core beliefs expressed as automatic thoughts, and directly elicit the core belief.
You will often identify a core belief early in therapy to conceptualize patients and plan treatment. You may gather data about and even try to help patients evaluate their core beliefs early on. Sometimes such early evaluation is ineffective but helps you test the strength, breadth and modifiability of core belief.
The downward arrow technique can be used to identify an idea the therapist has conceptualized as a core belief. The strength, breadth, and modifiability are gently tested. No action may be taken at this time, but the “idea” (it is not necessarily a truth) is marked as a future topic.

Question 11

Ch14

Strengthening New Core Beliefs

Answer 11

1. From the beginning of treatment, (see p 26–27), you deliberately elicit positive data from patients through questioning, and you point out positive data to them—especially when the data contradict the old, negative core belief but support a new, more reality-based belief. You can elicit and point out positive data in several ways
2. When specifically working on strengthening their new core beliefs, you ask patients to examine their experiences in a new way that facilitates their ability to recognize positive data themselves. Help patient adopt a different view of their experiences

Question 12

Ch14

Historical Tests of the Core Belief

Answer 12

Step 1: in session or for homework: recording memories that contributed to the creation or maintenance of the core belief. Reflect on preschool, elementary school, high school, college, their 20s, and succeeding decades.
Step 2: Search for and record evidence that supports the new, positive belief for each period.
Step 3: reframing each piece of negative evidence. Step 4: patients summarize each period.

Question 13

CH14

Restructuring Early Memories

Answer 13

1. Identify a specific situation that is currently quite distressing to the patient and seems linked to an important core belief.
2. Heighten the patient’s affect by focusing on automatic thoughts, emotions, and somatic sensations linked with this situation.
3. Help the patient identify and re-experience a relevant early experience.
4. Talk to the “younger” part of the patient to identify automatic thoughts, emotions, and beliefs.
5. Help the patient develop a different understanding of the experience through guided imagery,
   Socratic questioning, dialogue, and/or role play (for instance, get the adult patient to talk to the ‘younger’ part of the patient, to support her/him). I.e.: ‘Is it okay if we get your older self to come talk to you?’

Question 14

Ch14
Core beliefs
Summary

Answer 14

Core beliefs require consistent, systematic work. A number of techniques applicable to restructuring automatic thoughts and intermediate beliefs may be used along with more specialized techniques oriented specifically toward core beliefs.

Question 15

Lec

Targets of modification

Answer 15

• Automatic thought: Thoughts about external situations and internal events
• Dysfunctional assumption: Cross-situational rules
• Core beliefs: Generalized conclusions about self, others, and the world

Question 16

Lec

Behavioural experiments

Answer 16

• A powerful way to test patients’ beliefs through action
• Not a therapy in themselves: tools to be used in the context of a comprehensive cognitive therapy program
• Close working relationship, key principles:
- Collaborative empiricism
- Guided discovery
• The primary purpose is to obtain new information, which may help to:
o Test the validity of the patients’ beliefs about themselves, others and the world
o construct and/or test new, more adaptive thoughts

• How do we know if the experiment was effective: elicited cognitive change?
o Rate belief/credibility of maladaptive cognition before and after experiment (0-100%)
o Rate belief of adaptive cognition

Question 17

Lec

Crucial components of behavioural experiments

Answer 17

• Identify an assumption/belief/process that plays a role in the (maintenance) of the disorder
• Design an experiment to test the assumption/belief/ process
• Define the hypotheses
• Operationalize the outcomes that would (not) support the hypotheses clearly
• Do the experiment
• Evaluate the experiment carefully

Question 18

Lec

Background behavioral experiments

Answer 18

• Complementing verbal challenging techniques (Automatic Thought Record)
• Using an experiential approach; not just talking, but experiencing
• Activating verbal, emotional and behaviours systems

Question 19

Lec

Types of behavioural experiments

Answer 19

•	Active experiments 
•	Observational experiments 
o	Direct observation (modelling) x
o	Survey 
o	Gathering information from other sources (e.g., internet)

Question 20

Lec

Evaluation

Answer 20

• Of procedure
• Of results concerning H0 and HA (establish new % conviction)

If the credibility doesn’t drop, this provides source of information:
• Experiment not well designed
• Too difficult
• Vague agreed outcome
• This was the exception
• Safety behaviour that prevented really testing the cognition
• Belief is true?

Question 21

Lec

Summary of conducting behavioural experiments

Answer 21

1. . Establish the automatic thought / belief / hypothesis (as concrete as possible)
2. Have patient indicate degree of credibility (in %).
3. Formulate an alternative (but likely/ corresponding) belief.
4. Have patient indicate degree of credibility (in %).
5. Design a convincing experiment in a collaborative manner
6. Patient predicts outcome of the experiment
7. Formulate specific (and concrete) predictions on the experiment’s outcome
8. Have the experiment carried out.
9. Discuss the outcome referring to the original belief / hypothesis.
10. Have patient indicate degree of credibility of the original belief (in %).
11. Have patient indicate degree of credibility of the alternative belief (in %).
12. Encourage the patient to formulate a more realistic belief / hypothesis.