CBT – Core Beliefs

Core beliefs in CBT

We all have central beliefs are about ourselves and our relations to others; they are like short cuts to which we revert, time after time. The problem arises when they become maladaptive, and in which case they often highlight an underlying belief about us being one of three things: unlovable, helpless or worthless.

They often originate in our childhood experiences, and can be related to our personality. For example, a child whose siblings are cruel to them and whose mother does not defend them, may start to believe that they are worthless. If their personality is perhaps more introvert, then they may never speak of their feelings to their mother which means they might never get the ‘your safety and wellbeing is important to me’ response which would quash the thought that they are worthless. So the belief continues.

These beliefs surface during times of psychological distress when they become activated. At times like this we will start to see, in the world around us, only the information which supports the core belief; we almost start to build a case for it being true.

What is hard, particularly when working as a therapist with such clients, is that these beliefs are not often articulated or easily articulated. If this is the case then we can follow the following structure:

  1. Hypothesise which category of core belief they fall into
  2. Present this idea to the client
  3. Educate the client about core beliefs
  4. Understanding the childhood origin of the belief
  5. Understand what maintained it through time
  6. Understand how it contributes to difficulties currently
  7. Monitor its activation in the present

We would call them ideas at the first stage and explain that there are two options, either they ARE incompetent (or unlovable or worthless) or they BELIEVE they are incompetent (or unlovable or worthless) and thus act incompetently. We would then explain about how core beliefs stop the good stuff getting through and illustrate this by asking them for an example of when this happened in the last week, i.e. when some evidence to the contrary happened but they wrote it off.

We would then help them gather information to strengthen a more accurate core belief by:

  • Ask them what their core belief was before they got depressed
  • Ask what their strengths are
  • Notice data and label that as strengths
  • Ask for positive experiences from last week
  • Keep a credit list of things that the client is doing ok on or receiving love for
  • Ask them for contrary evidence continually
  • When they are displaying positive behaviours ask what that means about them and what it is about them which makes this happen
  • Give positive feedback about their skills and behaviours
  • Ask them to gather evidence too (they might need a reminder to do this; a bracelet, a post it, reminder in phone)

Of course there are ways of doing this and I’d like to explain this in a bit more detail.

We might get the client to fill out a Core Belief worksheet which comprises the evidence supporting the new core belief of (for example) “I’m competent but human” and also the evidence supporting the old core belief of (for example)“I’m incompetent” BUT with a reframe afterwards which allows them to broaden the perspective.

I would also use an extreme example of an incompetent (for example) person that they know and ask what that person is doing. I would then ask how they are different from that person.

I might use a story or an example of someone famous to illustrate similarities between them and elicit how the wouldn’t judge the example unfavourably so illustrating how it is not logical why they should judge themselves in such a way i.e. Cinderella wasn’t bad just because she got abused.

It is also possible to use the emotion a client displays in session. So when the client is emotional, we might explore why and what the core belief is behind it and then ask about where they feel it in the body. Then we might ask them to remember a time when they were younger when they experienced this same feeling. Then we would discuss it and ask about how the other people in the situation were behaving and whether their actions were right. We might also ask why they and others might have acted that way. Then we might role play the situation with you, the therapist, as the young client and the client as the other person in the memory.

We could also do the same as above but using imagery instead. I might interview the younger client, getting them to imagine the scene when they were young, asking for details and ask for thoughts, feelings and behaviours, so that it intensifies the effect. Then I would ask if the older version of them can come into the scene to talk to them. I would get them to choose where they should stand and whether they’re holding hands etc. Then I might get the client to talk to themselves as the old client to young client, talking them through the conversation, i.e. saying older client, ask the younger client what’s wrong, now what would young client say? etc.

I would stop when the client is feeling a bit better and ask them to rate how believable (emotionally and intellectually) the old belief is and now the new belief. I would then take them back to the present day exercise and ask them how the same principle applies.

More Techniques

There are other CBT techniques which can also be used alongside this to help the client both manage real problems,and  help them cope with core beliefs and overcome some core beliefs:

  • Problem solving
  • Making decisions using a decisional matrix
  • Asking them how they refocus away from their core beliefs and onto their daily life
  • Distraction (such as walk, tv, newspaper, music, call someone, email someone, clean, do finances, go to the shop, bath, prayer)
  • Complete thought records
  • Measure mood intensity during activities to find patterns and to show that things do fluctuate
  • Relaxation
  • Mindfulness
  • Graded tasks of overcoming fears bit by bit
  • Role playing to learn social skills and practice beforehand
  • Draw a pie chart to show the imbalance of time spent on things they don’t want to be doing vs ideally what they’d like to be doing (in arenas of fun, social, work, hobbies etc) and then ask how they feel about adjusting, then asking them to test their prediction.
  • Determining their responsibility for success, i.e. Get them to identify other reasons for failure (such as luck, other people’s actions, weather, lack of resources and training) and put this in a pie chart and then re-evaluate the core belief after this
  • Ask them to compare themself to themself at their worst rather than comparing themselves to others (by explaining that it’s not reasonable to compare to others without depression for example)
  • Get them to write a credit list through the week of positive activities or things which were hard but ‘I pushed through anyway’

Imagery

Clients might not relate to the idea of core beliefs as thoughts but might call them memories, mental pictures, imaginings, fantasies, images, visual ideas.

Techniques which we use with images differ slightly:

  • Completion: I would explain that the image normally stops at the worst point, and get the client to imagine what happens next and after that and again and so on and try to guide them to see themselves coping, can say “what do you want to imagine happens next?”. If it ends in catastrophe, then we might ask for the meaning of this and this might highlight another core belief.
  • Jumping ahead: I would ask them to jump to the completion of the event they are imagining and imagine the detail of it and ask how it feels once they’ve done this
  • Coping: I might ask them to go through the image again and imagine themselves coping the next time
  • Changing the image: I would explain they’re the director of the upsetting scene and ask them to imagine how they wish it would happen next. I would then discuss what they could do behaviourally to make this more likely.
  • Reality test the image, using evidence to critique it
  • Repeat the image and ask how it changes every time
  • Substitute the image, as if it was on TV and then change the channel or volume or colour

We can also induce images to help us challenge a thought, for example:

  • Imagine a year from now what will you be doing, ask them for details from when they wake up and notice how the thought doesn’t often appear
  • Imagine the prediction and then ask them to imagine what they will do to help themselves cope
  • Imagine the consequences or what life will be like in 6m, a year, 5 years
  • Get them to imagine more encouraging surroundings and faces and equipment around them

Hopefully, this article will have given you more of an understanding of core beliefs within a CBT framework, but more importantly how, as therapists or individuals, we can challenge the unhelpful ones to help us live happier lives.

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.

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.

CBT – Negative Automatic Thoughts and Thought Challenging 

We all have negative thoughts from time to time; they are often what make us feel low or anxious. 

The thoughts themselves can be distorted or the conclusion from the thoughts may also be distorted i.e. I didn’t remember calling my friend back therefore I am a nasty person.  Or our thoughts may simply be unhelpful, i.e. ‘this will take me til 3am to finish’ might be accurate, but focussing on it makes us feel worse.

To identify the negative thoughts, simply ask yourself “what was going through my mind?”. Clinicians might ask this when there is an emotion change and this can help us get to the unhelpful thinking patterns. 

If stuck identifying them, a therapist might:

  • Suggest opposite thoughts to the ones they think you might predict so that you become clear on what you’re not thinking 
  • Ask for the meaning of the situation
  • Ask for an image that you might be imagining 
  • Ask for more detail of the situation as this might get more thoughts to come out
  • Ask you to role play it with you to do the same
  • Ask you to identify where in the body you were feeling it and that can get you in the feeling again and then they may ask again what was going through your mind

If there is a discrepancy between your emotions and your thoughts then they might help you dig deeper into it to find out what other thoughts occur and whether there are other emotions involved. 

In addition, labelling the intensity of our emotions can help us prioritise which situations to focus on. Asking how intense that feeling feels now / later can help us understand whether it’s worth focussing on now or whether you’re over it, and if you’re over it then we can look at what behaviours or tools you used to do this as they might be useful in the future. 

Once we’ve identified the negative thoughts it can then help lift our mood to challenge them. 

How to challenge thoughts:

  • When challenging thoughts, imagine how taking your thoughts to court; look at evidence (not opinions) on both sides
  • You might be given a testing thoughts worksheet to use
  • ask “is there an alternative explanation for what has happened?”
  • If (the worst) happened, ask how would you cope? What else could you do?
  • Ask what the impact of the negative automatic thought is on your emotion
  • Ask what you’d advise a friend to do

Other questions can help us flush out practical, alternative ways of thinking about the situation. 

This can be illustrated with an example:

  • How bad is it in the grand scheme of things if your mother is upset?
  • How hurt is she?
  • How long was she hurt for?
  • Has she been hurt before and got over it?
  • Is she hurt now?
  • Is it possible for you to spare her hurting all the time?
  • If she wants to see you all the time, is it possible to ever do something for you and it not result in her hurting?
  • What would you have to give up yourself in order to do that? 

Sometimes or negative thoughts aren’t biased or inaccurate, they’re true.  In this case it can help to:

  • Problem solve
  • Challenge the meaning of them
  • Work toward acceptance

After a while you may be able to come up with an alternative more helpful way of thinking without going through the evidence.

Your clinician may ask you to read your therapy notes every day and when needed,  and it helps if you have your revised thoughts written down on card for later, to look at and repeat in order for the message to sink in. 

Of course,  you don’t have to challenge your thoughts, you can:

  • Problem solve
  • Distract yourself 
  • Use relaxation techniques 
  • Label the situation for what it is and accept it

If you want to do this then you can use the acronym AWARE: 

  • Accept emotion
  • Watch without judgement
  • Act as if not anxious
  • Repeat
  • Expect the best

Thought challenging may not work if there are core beliefs in the way, or if not all evidence is brought to the fore. 
In addition,  your clinician might not always challenge your thoughts if you’re too distressed, if they think that you don’t feel supported by them or aren’t on your side or if there are other important matters to focus on.
www.happii.uk is a website providing  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.