CBT – Intermediate Beliefs

Intermediate Beliefs are different from core beliefs and encorporate rules, attitudes and assumptions. We formulate these gradually through treatment, not right from the start. 

It can help to explain that different people have different beliefs because of different personalities and experiences, and that they may make things hard for us but that we can unlearn them. 

Examples are:

Rule: I should do things myself

Attitude: it’s terrible to ask for help

Assumption: if i ask for help I’m incompetent”

To uncover them, we would normally start with the Hot Cross Bun or Five Areas model but would also start to ask ‘what does this mean’  when we’re exploring a clients negative thoughts.

We might ask what childhood events might be related to the core beliefs ? What events might have initiated and maintained the core belief?

Then we might ask “how did you cope with this painful core belief?” i.e. which intermediate beliefs such as assumptions,  rules and attitudes have you developed in response to the painful core beliefs? 

When thinking of how to elicit intermediate beliefs we can:

• Ask outright “what is your belief about X?”or do you have a rule about that?

• Look for themes and ask them if their belief is X

• Use the downward arrow technique to dig further into the issue by repeating similar questions such as ‘what does that mean?’ / ‘what does that mean about you?’  / ‘what’s the worst part about X?’ / ‘what’s so bad about X?’   / ‘if that’s true so what?’ 

• Start first half of a sentence and ask the client to finish it, such as “ if I haven’t done this properly then it means I am…”

• They might come in the form of Negative Automatic Thoughts (NATS) 

It’s important only to work on beliefs that are distressing and believable by client, and so in order to uncover those out can help to get them to rate its distress level. 

Easier to challenge intermediate beliefs

Typical coping strategies for dealing with these core beliefs are detailed below and are paired together to illustrate how we might use the extreme opposite coping strategy:

• Avoid negative emotion, or display high levels of emotions

• Be perfectionist, appear helpless

• Be responsible, avoid responsibility

• Avoid intimacy, seek intimacy

• Seek validation, avoid attention

• Avoid conflict, provoke it

• Control situations, abdicate

• Be childlike, authoritarian

• Please others, distance self, be selfish

It is worth looking at the advantages and disadvantages of holding the belief, before challenging them. 

Then, when the client decides to work on then it can help for the clinician to plan it first by writing some new alternative beliefs for the client before they start doing their own. The clinician can be more persuasive than collaborative now than with challenging NATS. 

When challenging beliefs, clinicians should ask patients how much they believe it on an intellectual and then on an emotional / gut level.

Ways of challenging beliefs:

1. Socratic questioning:

Is there another way of viewing X?

If I did X in this (similar situation) would I still be Y?

Is it possible that in doing X I can be z?

If we have 2 people, 1 does X and one does y but the consequence is z, which is more positive?

2. Behavioural Experiments 

3. Cognitive continuum:

Useful for all or nothing thinking. Put things on a scale from 0% to 100%,  i.e I’m a failure. So put self at 0% initially. Then ask if there’s anyone doing worse than you. Put them at 0. Then ask whether there’s someone doing even worse than them, or who doesn’t try or who doesn’t turn up or who couldn’t be bothered to enrol at uni even and add those onto the scale then reevaluate where client sits on scale.
4. Intellectual / emotional role plays:

They play part of emotional brain, you play part of intellectual and argue both sides of the belief. Then swap over so hey have to be the intellectual side of things
5. Using others as a reference point:

A)Talk about someone else who doesn’t mind for example if they don’t get all As. Ask what client thinks their belief is. Ask if the client agrees with this belief about the other person. Ask whether the belief could apply to the client too. Ask if there is anything different about the other person vs client that makes the rule inapplicable?

B) talk about someone who has the same belief and whether the client would agree with their belief about themselves and how they would guide them to think differently

C) role play where client has to convince someone else that the belief isn’t right

D) imagine they had a child or are speaking to a child, what would they want the child to believe? How does that apply to them?

6. Acting as if:

Ask the client what they would do if they didn’t believe it at all, what would they do differently. Ask them to act as if they didn’t believe and then report back.
7. Self disclosure:

Say,  “ X happened to me but I don’t think that makes me y, do you?”

As homework, ask them to read the beliefs and new beliefs and re-rate them for believability every day. Get them to stop when they’re below 30%. 
www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

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