Depression Protocol – Module 5

Module 5: Assertiveness Training

Depression is sometimes maintained by a passive or passive-aggressive communication style and a lack of assertiveness.  This passivity often leads to a failure to communicate needs and desires and thus failing to have those needs and desires satisfied.  Over time, the person lives a deeply unfulfilling and resentful life.

 The Main Goals for Phase 5 include:

  • Identifying your communication style using the aggressive, passive, passive-aggressive and assertive framework.
  • Education on assertiveness and identifying the underlying beliefs that prevent the client from being assertive.
  • Educating the client on other communication skills that include: active listening techniques and understanding body language.
  • Homework: Using assertiveness scripts and worksheets to practice being more assertive.

Depression Protocol – Module 4

Phase 4: Core Belief Work

After you are educated on cognitive restructuring tools and themes have been identified in thought records you can shift towards beginning to challenge those core beliefs.  If the therapist has not identified the salient core belief, then ask for a core belief list and try to identify any that resonate with you.  The therapist can also use the downward arrow technique more deliberately to identify core beliefs.

Here are some examples of using the downward arrow to arrive at core beliefs. The initial thought as recorded on a thought record is followed by responses to the therapist promptings.

  1. “My belief that marriage lasts forever has been challenged by my separation.” –>” This means that what I believe about marriage isn’t true.” → “If what I believe about marriage isn’t true, what else am I wrong about?” → “I am a foolish person.”
  2. “My wife wants to go to bed early tonight.”–>”She must not value spending time with me.” → “I am not worthy of her time.” → “I am unlovable.”
  3. “I am a bad cook.” –> “I cannot fulfill my role obligations.” → “I am a failure.”
  4. “I am never going to get a job.” → “I will not be able to provide for my family.” → “I am a failure. “

You will know when you have identified a core belief because that belief will be extremely resistant to change.  Core beliefs are those most strongly held beliefs, opinions and points of view that tend to be very rigid, resistant to change and distorted.  They are often formed in childhood and maintained through systematic information processing biases and distortions.

There are four categories of core beliefs that we are most interested in:

  • Core Beliefs about the Self: I am bad / I am strong / I am sinful / I am perfect / I am unlovable / I am entitled / I deserve bad things
  • Core Beliefs About Others: Others will hurt me / Others are my potential friends / Others are out for themselves only / Others need me, and I need them
  • Core Beliefs About the World: The world is safe / The word is my oyster / The world is mean / The world is beautiful / The world is a palette
  • Core Beliefs About the Future: Terrible things are destined to happen to me/ my future is bright / My future is grim / I believe I can achieve my important goals / I will never achieve my goals.

The most common Core Beliefs that those suffering with depression report are: “I am unlovable”; “I am incompetent”; “I don’t like other people” and “There is no hope for my future.”  Many variations of these themes manifest so that a client may use slightly different language such as: “I am bad” or “I am a failure” or “People suck.”  The overarching theme seems to be believing one is hopeless to have intrinsic needs met.

Core beliefs are identified so that they can be challenged.  There are four general steps for challenging core beliefs:

  1. Step 1: Find evidence that the belief isn’t true ALL the time. Your therapist can help you brainstorm and create a list of exceptions.  For example, if you have a belief that you are a failure then brainstorming successes or helping you recognize past successes can aid in changing the belief.  Remember, that due to the mental filter, this will be a difficult exercise for you to complete and will rely on skillful questioning from the therapist.
  2. Step 2: Develop an alternative core belief and look for evidence that this is true. The new core belief should not be unrealistic but should be a balanced recognition of strengths and weaknesses. For example, the core belief: “I am perfect just the way I am” may be unrealistic so an alternative may be: “I have the capacity to learn, grow and have my needs met.” As with the first step, you can brainstorm with your therapist to find evidence that proves the balanced core belief is true.
  3. Step 3: Finally, for very rigid core beliefs an examination of the past may be necessary. This can be a time-consuming process as it involves analyzing pivotal events in your history that you believe proves the belief is true.   It is important to analyze these pivotal moments, identify how they were interpreted and reframe them using cognitive restructuring techniques.
  4. Step 4: Changing core beliefs is a difficult and time-consuming process that takes a lot of effort and persistence. In order to successfully change a core belief, it is often necessary for you to repeatedly and purposefully look for new evidence to support your  budding new balanced beliefs.  The positive data log is a tool that asks you to record evidence everyday that supports the new belief.  This is a crucial step and ensures gains are maintained and that the brain is slowly rewired over time.

The Main Goals for Phase 4 include:

  • Identifying and determining the most relevant core beliefs to begin changing.
  • Education on what core beliefs are and how they are maintained.
  • Creating a list of exceptions to the problematic core belief.
  • Doing a historical analysis of the core belief, if needed, to reframe pivotal life experiences and reprocess them as an adult.
  • Creating a new balanced core belief to be reinforced over time.
  • Homework: Utilizing positive data logs every day to reinforce the new balanced core belief.

Depression Protocol – Module 3

Module 3: Cognitive Restructuring

The third phase of a depression protocol involves using standard cognitive restructuring techniques to identify maladaptive beliefs that can become targets for change.

This phase begins with some psychoeducation on the CBT Iceberg, the automatic nature of thoughts and the differences between the conscious and unconscious systems of the brain.  You will then be educated on cognitive distortions and asked to identify examples in your own life.  This is facilitated by describing a recent situation that caused you to feel depressed and then identifying a thought to be used to identify distortions.

After this psychoeducation, you will then be introduced to the thought record in session and then asked to begin filling out the first three columns for homework whenever you notice a large decrease in mood. Subsequent sessions involve education  on the validity and utility of thoughts and doing homework to ensure you are practicing using these new tools.

  • Validity Techniques: Evidence technique, cognitive distortions, cognitive continuum, responsibility pie, best friend technique.
  • Utility Techniques: Cost/Benefit Analysis, behavioral experiments, best-friend technique, maladaptive consequences.

If you determine that a belief is valid and not distorted, then a shift towards problem solving can be helpful. Not all beliefs are distorted and sometimes you truly are in non-responsive environments that need to be changed. The specifics of problem solving training are covered in another post.

Over time, the main objective of this phase is to begin to identify themes and patterns in the thought records that you complete in session and for homework.  Once these themes are identified then core belief work can begin.

Thought Records

Thought records form the foundation of the new house of thought (and therefore mood) that we are developing. Thought records are like training wheels when learning to ride a new bike.  They guide a certain process of thinking that is meant to be internalized and eventually done automatically on one’s own without the need for any paperwork.  CBT is learned line upon line and this is the tool to one of the most important lines for clients to know.  The Thought record is simply the five factor model rearranged with a few more columns added to help you challenge and reconstruct your beliefs.

When you first fill out a the thought record  it can be overwhelming to so you only have to fill out the first few columns at first.  You are to use the thought record whenever you notice a shift in mood and you are to record the situation you are in, what emotion you are feeling, what you are doing and finally what you are thinking.  After you have written down all of your thoughts you are to identify your “hot thought” or the thought that hurts you the most.  If you are struggling to identify the hot thought ask yourself: “If you could get rid of only of these thoughts, which one would it be?” It is important you identify which thought is most harmful because that thought will be the focus of the rest of the thought record.

Here are some pointers for how to fill out each of these columns:

  • Situation: Ideally, you want to confine a situation to a 30 minute period in your day. You want to answer the 4 W’s: Who, What, When and Where.  The 30 minute period to look at should begin when the client noticed a shift in their mood.
  • Mood/Emotion: In this column, you want to list only emotions and sensations and not thoughts or interpretations. Many clients struggle with differentiating between thoughts and emotions.  Commonly, clients will say things like “Hurt” or “Alone” which are not emotions but they probably mean “Sad” or “Scared.”  You can use emotion lists to help with emotional vocabulary and you can get some psychoeducation on what emotions are, how to recognize them and what their functions are.  This thought record provides the basic emotions that you simply need to circle and then rate how strongly you feel these emotions on a SUDS scale (1-10).
  • Thoughts: In this column, write down everything that you are thinking, no matter how stupid you might think those thoughts are. It is very important that you are honest here and do not censor yourself.  After writing down everything you were thinking you need to identify and write down the thought that is most painful to you (hot thought) so that it can be the focus of analysis and possible change in the following columns.
  • Behaviors: In this column simply record what you did or didn’t do in response or reaction to the situation. This will help us identify maladaptive coping responses that may be the target for future change.

After you have practiced filling out the first few columns you can move to the next columns.

  1. Distortions: In this column, simply identify how your hot thought is distorted using this post as a guide.
  2. Evidence: In this column, outline evidence for and against your belief.  You can use this post as a guide.
  3. Utility: In this column, determine how useful this belief is and whether it is helping you meet your goals.
  4. Balanced Belief: Create a new balanced belief that acknowledges the negatives but balances those negatives with positives.  A simple formula you can use is: “While x negative thing is true y positive thing is also true.”

Best Friend Technique

The Best Friend Technique is a simple Socratic question designed to help you gain some objectivity and take the perspective of someone else who cares about you.  It helps you escape your limited perspective and should induce some self-compassion and empathy.  The Best Friend Technique involves some variation of the following question:  “If your best friend was in this situation, what would you say to them? If you have a really wise and loving best friend, what would they say to you if you told them your thoughts? What would I/a therapist say?”  The thought record provided even gives you a column where you can ask yourself this question and fill in the answer.

Coping Cards

To make Coping Cards simply take the balanced beliefs produced through thought records and write them down on a cue card.  Next, place those cue cards in areas that are likely to trigger distorted thoughts so that you can be reminded of the new belief you are trying to reinforce.  Cue Cards should be read daily so that you can be reminded to practice reinforcing more balanced perspectives.

The Main Goals for Phase 3 include:

  • Providing psychoeducation on the CBT Iceberg, automatic thoughts & conscious/unconscious brain system.
  • Education on cognitive distortions and identifying them in sample beliefs.
  • Introducing the thought record and teaching about validity and utility techniques.
  • Homework: Collecting thought records to identify themes and core beliefs to be challenged.

Resources

Thought Record

Evidence Technique

Disputing Questions

Depression Protocol – Module 2

Module 2: Behavioral Activation

In the second phase of treatment, you will begin addressing the behavioral causes of depression by deliberately trying to “activate” yourself through vision casting, goal setting and monitoring behavior.

You begin by analyzing the weekly monitoring worksheets assigned for homework in the first phase of therapy.  These monitoring sheets ask you to record what a typical day/week looks like and to rate your mood throughout the day.  It is also useful to record your subjective experience of “pleasure” and “mastery” on a scale from 1-10.  Monitoring behavior is a potent tool for promoting self-awareness  but it also gives your therapist data that can help draw connections between certain behaviors/situations and moods.  This data can be useful when helping you set goals which is the next task of behavioral activation.

After introducing monitoring and collecting data, an examination of core values is often helpful to set the stage for setting meaningful life goals.  The research confirms that setting goals concordant with your values leads to a range of positive outcomes.  For example, see the following study which suggests self-concordant goals leads to better academic outcomes:

https://www.ncbi.nlm.nih.gov/pubmed/11195887

However, self-awareness appears to be relatively rare in the population and especially rare in those suffering with mental health disorders.  There is often a large disconnect between what clients say they value and how they are behaving.  Many depressed clients have given up on pursuing a life they would value as they do not believe it can be achieved and settle for unrewarding lives.  It is important to determine your top values before setting goals in order to ensure those goals are line with who you want to be. You can use a list of common values and go through that list to identify which ones stand out if you are unsure.

After determining what you value, some variation of the “miracle question” is helpful to allow you to begin dreaming of a life that excites you.  Ask: “If a miracle happened today and you had the life that you desired what would that look like?”  It can be difficult thinking about what your relationships/career/hobbies/family/spirituality/achievements/health would look like but keep persisting. It is important that you do not hold back out of fear but that you are honest about your deepest hopes and desires.  In the business world, Jim Collins calls this process of vision casting setting your “Big Hairy Audacious Goal” or BHAG.  It is a crucial process for engaging in a life of pleasure and meaning.

If you are struggling to visualize the future or to determine what would excite you then try asking yourself the following questions:  “Before you were depressed, what did you like to do?” What do friends/neighbors like to do?” Can I suggest some things and see if any of them sound good?”  “Consult a pleasurable activities list and see which ones stand out to me.”

After determining core values and setting your “BHAGs” you are now ready to begin breaking down what you need to do in order to make this dream a reality.  Set SMART goals that can be accomplished and measured each week.  In order to avoid overwhelming yourself, begin by only setting 2-3 goals a week and then as you build a record of success continue adding onto those goals.

For the rest of therapy, the therapist will check in with you each session concerning goal monitoring and progress.  For many clients, being “reactivated” is often enough to drastically reduce symptoms of depression but for others they need to address deeply ingrained core beliefs.

The main goals for phase 2 include:  

  • Collecting and analyzing data from monitoring worksheets.
  • Determining your core values and setting self-concordant goals.
  • Setting Big Hairy Audacious Goals by answering the miracle question.
  • Homework: Setting and following up on weekly goals that lead to accomplishing the dream.

Depression Protocol – Module 1

Module 1: Intake & Socializing to the Cognitive Model

In the initial phase of treatment, the therapist will educate you on the symptoms, epidemiology and etiology of the disorder.  The therapist will use her standard intake questions and if she determines that you are struggling with depression then she will rule out differential diagnoses such as grief, dysthymia, post-partum dysphoria and seasonal affective disorder.  The therapist will also educate you on the cognitive model using metaphors and five-factor model worksheets to ensure you understand the reciprocal nature of the human matrix.

The therapist will then set treatment goals and determine how those goals will be measured.  Most therapists use a combination of subjective self-reports on mood and more objective depression inventories such as the Beck Depression Inventory to measure progress.

It is during this phase that the therapist begins building the therapeutic relationship which remains paramount above any information/technique that is to be provided. Do not ignore rapport building and establishing a therapeutic relationship by focusing too much on technique.

The main goals for the initial phase Include:

  • Education on the symptoms, epidemiology and etiology of Depression.
  • Education on the cognitive model using metaphor and worksheets.
  • Setting treatment goals and how you will measure progress towards those goals.
  • Build the therapeutic relationship and prioritize it above technique/information.
  • Homework: Five Factor Model Worksheets & Weekly Monitoring Worksheet

Major Depression: An Overview

Major Depressive Disorder: DSM V Criteria

While you cannot diagnose mental health disorders, you should be familiar with their symptoms, as outlined in the DSM V.  According to the DSM V, a diagnosis of Major Depressive Disorder must meet the following criteria:

Specific symptoms, at least 5 of these 9, present nearly every day.

  1. Depressed mood or irritable most of the day
  2. Decreased interest or pleasure in most activities, most of each day
  3. Significant weight change (5 %) or change in appetite
  4. Change in sleep: Insomnia or hypersomnia.
  5. Change in activity: Psychomotor agitation or retardation.
  6. Fatigue or loss of energy
  7. Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt
  8. Concentration: diminished ability to think or concentrate, or more indecisiveness
  9. Suicidality: Thoughts of death or suicide, or has suicide plan.

Source: Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Arlington, VA: American Psychiatric Association.

Differential Diagnoses

Before proceeding with a depression protocol, you should rule out a few differential diagnoses.  Two common disorders that are often mistaken for depression are Seasonal Affective Disorder and Dysthymia.

According to the DSM V, a diagnosis of Seasonal Affective Disorder must meet the following criteria:

  1. The person must have had at least two episodes of depression in the past 2 years occurring at the same time of the year (most commonly, fall winter), and full remission must also have occurred at the same time of the year (most commonly, the spring).
  2. In addition, the person cannot have had other, nonseasonal depressive episodes in the same 2-year period, and many of the person’s lifetime depressive episodes must have been of the seasonal variety.

You should attempt to determine whether the symptoms are seasonal in nature (usually during the fall/winter) and whether the symptoms clear up during spring/summer. Prevalence rates suggest that winter seasonal affective disorder is more common for people living at higher latitudes (northern climates) and in younger people.

If you suspect that you may show symptoms of SAD, then a referral to a clinician who specializes in light box therapy may be necessary.  For more information on bright light therapy, please see the following article from the Harvard Health Blog: https://www.health.harvard.edu/blog/seasonal-affective-disorder-bring-on-the-light-201212215663

Another common disorder that shows a lot of overlap with Major Depressive Disorder is Dysthymia.  Dysthymia is a mood disorder that can best be understood as a chronic (longer lasting) low-grade (lower intensity) form of depression.  Thus, clients with Dysthymia will have a longer history of a less intense form of depression (2 years or more).

Another common presenting issue that is often mistaken for depression is complicated grief.  Grief and depression have many overlapping symptoms, but the major difference is that grief does not lead to a loss of self-esteem while depression does.  Depression can eventually result from complicated grief, but it calls for a very different treatment protocol.

And finally, major depressive disorder should also be differentiated from postpartum dysphoria in which 50-70% of women report symptoms of depression shortly after giving birth.

Source: Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Arlington, VA: American Psychiatric Association.

Epidemiology

The Prevalence of a disorder refers to the proportion of cases in a given population and is a measure of how widespread a disorder is.  The incidence of a disorder refers to the rate of new cases each year and is a measure of the risk in developing/contracting a disorder.

The National Institute of Mental Health’s epidemiological survey in 2016 indicated the following:

  • Prevalence: 7% of the American Population had at least one episode of depression in that year.
  • Lifetime Prevalence: The Lifetime prevalence of mood disorders is estimated to be around 20%.
  • Gender: Major depressive episodes were higher in females (8.5%) compared to males (4.8%). Women are known to have higher rates of trait neuroticism which may account for these gender differences.  The roles many women fulfill also tend to give them less control and research confirms that women are more likely to ruminate which exacerbates depression.
  • Age: Major Depressive Disorder was highest among those ages 18-25 (10.9%).
  • Prognosis: The World Health Organization ranked depression the 4th leading cause of disability. By 2020, it will be the second leading cause.

Source: Major Depression. (n.d.). Retrieved March 20, 2018, from https://www.nimh.nih.gov/health/statistics/major-depression.shtml

Causes

There are multiple causal pathways to depression with many of the causes likely being sufficient but not necessary for onset to occur.

The Biological causes of depression

  • Genes: Twin studies show a moderate genetic influence. One promising candidate is the serotonin‐transporter gene—a gene involved in the transmission and reuptake of serotonin, which is one of the key neurotransmitters involved in depression. One can either have 2 short alleles, 2 long alleles or 1 of each to form three genotypes.  Some research suggests that those with 2 short alleles are at a genetic risk for developing depression when faced with stressful life situations.
  • HPA Axis Abnormalities: Some research suggests that Blood plasma levels are elevated in 20-40% of depressed patients and in 60-80% of severely depressed hospitalized patients. Trauma and intense stress in childhood can increase the reactivity of the HPA axis which becomes a vulnerability to depression later in life.
  • Hypothyroidism: Depression is correlated with low thyroid levels. If your client has been diagnosed with hypothyroidism work collaboratively with her doctor to set the course for treatment.
  • Neurological Differences: Depressed patients show lower left-side prefrontal cortex activity which is associated with approach behaviors and reward seeking.  The relatively higher right-side prefrontal cortex activity is associated with increased negative affect and hyper-vigilant behaviors.   Depressed patients also show increased amygdala activity.
  • Circadian Rhythms: Research with depressed patients also indicates that circadian rhythms become desynchronized and the size and magnitude of these rhythms is diminished. Depression may therefore sometimes be caused or exacerbated by circadian rhythm abnormalities.

The Psychological causes of Depression

  • Attributional Style: Attributional style refers to what you typically attribute the cause of a behavior or event to.  Attributional styles vary along three dimensions:  internal-external, global-specific and stable-unstable.  Depression is associated with an attributional style of internal, stable and global causes.  This means that depressed people tend to attribute negative events to individual causes (internal) that cannot be changed (stable) and that affect many different areas of life (global). This contrasts with explanatory styles that are external, specific and unstable.  This means that negative events are typically seen as being externally caused, changeable and being confined to certain domains of life.
  • Beck’s Cognitive Triad: Aaron T. Beck observed that depressed people tend to have 3 types of negative thoughts. These include negative thoughts about the self, other people and about the future.  Depressed peopled tend to see themselves as failures and as possessing unique flaws that make them unlovable. They also tend to have negative views about people in general and thus have little hope for the future.
  • Cognitive Distortions: Depression is maintained by systematic information processing biases. In level 1 we examined distortions in detail which are negative misrepresentations of reality.
  • Hopelessness Theory: Depression can also result when one perceives a lack of control over a negative outcome which makes the person feel hopeless. However, signs may begin to arise that control is possible, so depression shifts into anxiety as the person attempts to gain control.  The person then vacillates between beliefs that control is possible (anxiety) and that control is not possible (depression).   Anxiety surfaces when some hope returns. This is one possible explanation for the high degree of comorbidity that occurs between depression and anxiety.

The Social causes of Depression

  • Lack of Social Support and Social Skills: Depressed individuals have smaller and less supportive social networks, and many have a passive or passive-aggressive communication style which leads to unmet needs.  Depressed people therefore have less resources to utilize for dealing with life stressors and typically have fewer connections which leads to fewer opportunities. This creates a vicious cycle that maintains the disorder.
  • Interpersonal effects: Depressed people can become burdensome to others as those around them feel the need to provide sympathy, support and care on an ongoing basis. This can lead to resentment or simply fatigue and further strains the already weakened support network and fuels the cycle of isolation.

The Behavioral Causes of Depression

  • Learned Helplessness: Seligman did a series of experiments in which he exposed dogs to uncontrollable shocks and then put them in aversive situations where escape was possible. However, after being exposed to the shocks the dogs lost the drive to even attempt escape.  It was as if they had learned a sense of helplessness that had generalized and prevented future attempts at control even when control was available.  The dogs serve as an analogy for those people who experience uncontrollable stressors (often in youth) and learn a sense of helplessness that generalizes to become the dominant mode of being.  This general sense of helplessness is similar to the symptoms and beliefs that many depressed people experience.
  • Lack of Rewards: From a behavioral perspective, depression is also sometimes caused by an unresponsive environment or a lack of experiences that cause feelings of pleasure and accomplishment.  The passive and hopeless beliefs that depressed people adopt cause them to withdraw and cease to have rewarding experiences.

Source: Hooley, J. M., Butcher, J. N., Nock, M., & Mineka, S. (2017). Abnormal psychology. Boston: Pearson.

The Brain and Depression
In a landmark study done in 1999 by the Archives of Internal Medicine concluded that exercise was just as effective in treating depression as medication is. 156 participants were divided into three
groups: the medication group, the exercise group and a group that exercised and received medication. After 16 weeks there were no significant differences between the groups as around 65% of people were no longer depressed. While the medication group became less depressed faster, after a certain amount of time exercise yields the same results.

Researchers did a follow up study with 133 of the original participants six months after the study and found that those who continued exercising had much lower rates of depression compared to everyone else.  This means exercise seems to work slower but has longer-lasting effects compared to medication.  Exercise seems to increase endorphin release which numbs the pain that depressed people feel. Exercise releases endogenous morphine as opposed to drugs that mimic the effects of endorphins.

Depression is also associated with a malfunctioning arousal-regulation system. When you are depressed your arousal system is tuned too low. In a highly stimulating environment the brain down-regulates its responsiveness too much and in a low-stimulation environment your brain doesn’t up-regulate enough. Neurotransmitters like Serotonin are thought to be involved in these processes and depressed people show deficiencies here.  Brain scans reveal that those who suffer from major depression have substantially fewer serotonin receptors in their midbrain than do non-depressed people.  The midbrain contains the hypothalamus and the limbic system and is associated with mood regulation. Depression is associated with reduced sensitivity to serotonin in these regions of the brain.

One emerging theory suggests that the key to overcoming depression is to stimulate neurogenesis or making new neurons in the brain. Research confirms that people who suffer from depression for several months have smaller hippocampus regions.

People who suffer from inflammation-related diseases are also more likely to suffer from depression. There may be a link between inflammation and depression but right now the relationship is correlational.   Some research suggests that eating fermented foods can help you with depression. Fermentation involves exposing foods to a type of bacteria called lactobacilli. These bacteria convert the sugars in foods into lactic acid which tastes sour. Some examples of fermented foods include: kimchi, sauerkraut, yogurt, sourdough bread, tempeh and miso.  Some research suggests that the incidence of depression is lower in people who eat fermented foods but right now this is correlational and we aren’t sure why.

Source: Outsmart Yourself

Core Beliefs

Overview

In this module, we will be examining the deepest part of the CBT Iceberg: Core Beliefs.  Core beliefs are the most deeply held and strongest beliefs that people have.  They form the foundation of who a person is and guide all of our goals, plans and behaviors.  We will begin by examining their characteristics and when to begin addressing them in therapy.  Afterwards, our focus will turn to how socialize and educate clients on core beliefs and then we will look at how to identify core beliefs in therapy.  After learning how to identify these beliefs, we will discuss how to challenge and change those core beliefs.  We will then put all levels of the iceberg together and look at schemas in general and the module will end with a brief discussion on termination and booster sessions.

Core Belief Characteristics

Core beliefs, as previously mentioned, are our most strongly held opinions, points of view and beliefs about ourselves, other people and the world within which we live.  At the core of many mental health disorders are distorted core beliefs that fuel and maintain the disorder. CBT therapists seek to identify maladaptive core beliefs and eliminate them by replacing them with more adaptive core beliefs.  There are certain Core beliefs have certain typical characteristics that include:

  • Rigid and Resistant to change: Core beliefs tend to be deeply held and are infused with strong emotional content. They tend to be very difficult to challenge and change and often require great effort to do so.
  • Tend to be polarized and over-simplified: Core beliefs often reflect all-or-nothing thinking and frequently contain words such as “all, every, none or nobody.” Negative core beliefs tend not to recognize nuance and tend to be over simplified.
  • Formed in Childhood: Core beliefs are often formed in childhood during really important events. For example, being bullied by another student in grade school may cause a core belief: “I don’t belong anywhere” to form and exist subconsciously into adulthood.  Core beliefs are often problematic because they are often unconscious and unexamined.  However, not all core beliefs are formed in childhood as they can be formed during any pivotal life event. For example, experiencing a trauma as an adult, such as being raped, can alter core beliefs about how safe the world is.
  • Maintained through distortions and biases: Core beliefs, once formed, are difficult to change because cognitive distortions, filters and confirmation bias tend to maintain them.  For example, if a client believes she is incompetent then she will ignore evidence that contradicts this and be hyper-focused on signals that might confirm this belief.  Other distortions such as overgeneralizing or disqualifying the positive will act to strengthen and maintain these beliefs.  Distortions need to be identified and corrected for in order to change core beliefs.
  • Are not necessarily true: People often hold their core beliefs as absolute truths and yet they are not necessarily true.  Core beliefs can be maintained despite overwhelming evidence that they are not true and thus can be irrational.  They are often based on partial truths but do not accurately capture the totality of a concept.
  • Can be tested and evaluated: Core beliefs are often taken for granted and are not subjected to rigorous testing or evaluation.  However, we can take a core belief and develop a test to determine its accuracy.  For example, if a person has a core belief: “Nobody can be trusted” then we can identify a series of tests to determine if this is true.  This may involve first defining trust and then having the client do something that requires trust in another person.  The core belief will either be supported or challenged based upon the results.

Core Belief Socializing

You can use the “all roads lead to Rome” analogy to help clients understand that all of their thoughts and rules flow from their core beliefs.  Their core beliefs are like the city Rome and the roads are comparable to their automatic thoughts and rules for living.

Another popular metaphor is of the blind men and the elephant.  A group of blind men each touch different parts of an elephant such as the tusks, trunk, leg, ears and body.  However, since each blind man only has experience with one aspect of the elephant it distorts his entire view of the creature.  In the same way, core beliefs can form based upon a distorted experience of reality.  The elephant is comparable to reality and the blind man is the client whose entire view has been distorted by a selective focus on only part of the whole.

Of course, you can also understand core beliefs using the metaphor of the partially submerged iceberg that we have already discussed and that you probably already know very well by now.

Another popular analogy is to compare the mind to a tree and each of the trees component parts to different levels of the mind.  The roots of the tree are the core beliefs, the trunk is the rules for living and the branches are the automatic thoughts that flow from the tree and yield a certain kind of fruit.  If the roots of the tree (core beliefs) are malnourished then the rest of the tree begins to die.  You can also use this analogy to help yourself understand the utility of your core beliefs.  Good core beliefs will yield good fruit from the branches of the tree while bad core beliefs can be known by the bitter fruit they produce.  You need to learn to care for your mind by nourishing its roots and pruning away rotten branches.

One final metaphor to consider is that of the magnet.  This metaphor is used to help you understand how core beliefs are maintained.  Core beliefs are like magnets because they attract any evidence that supports them while repelling any evidence that does not.

From a neurological perspective, Core Beliefs are neural pathways that have established themselves through connections and highways in the brain. They are stored bodies of knowledge or structures that interact with incoming information to influence selected attention and memory search.  Genetic predispositions can also contribute to the formation of Core Beliefs.  Genetics can provide a predisposition to negative emotions which can then combine with certain environmental triggers to cause the onset of negative core beliefs.”

Judith Beck also provides a useful list of common core beliefs that you can examine.  Recall that there are three major types of core beliefs:

  1. Beliefs about the Self: I am worthy/unworthy, good/bad, lovable/unlovable, success/failure, and competence/incompetence.
  2. Beliefs about Others: others are trustworthy/untrustworthy, others have certain group characteristics.
  3. Beliefs about the World: The world is safe/unsafe, beautiful/ugly, just/unjust.

Common Core Beliefs about the Self

i.) Helpless

  • I am inadequate, ineffective, incompetent, can’t cope.
  • I am powerless, out of control, trapped.
  • I am vulnerable, weak, needy, a victim, likely to be hurt.
  • I am inferior, a failure, a loser, defective, not good enough, don’t measure up.

ii.) Unlovable

  • I am unlikable, unwanted, will be rejected or abandoned, always be alone.
  • I am undesirable, ugly, unattractive, boring, have nothing to offer
  • I am different, flawed, defective, not good enough to be loved by others.

iii.) Worthless

  • I am worthless, unacceptable, bad, crazy, broken, nothing, a waste.
  • I am hurtful, dangerous, toxic, evil.
  • I don’t deserve to live.

The theme across all of these negative core beliefs about the self appears to be: “I am incapable of having intrinsic needs met.”  If a client believes she is helpless then she believes she does not have the capacity to handle life problems to meet important goals.  If she believes she is unlovable then she believes she lacks the capacity to be loved.  If she believes she is worthless, again she believes she lacks the capacity to contribute in any meaningful way.  The overall theme is about not having the capacity to have important needs met.

Identifying Core Beliefs

There are many sources of data that you can draw upon to identify key maladaptive core beliefs.  Some of the major sources include:

  1. Themes in Thought Records: Once you have done enough thought records, you can begin comparing them to identify common themes. While situations or surface thoughts might change, you will probably be able to identify common core beliefs that do not change across thought records.  If you see a belief continually popping up in thought records, this is a good indication that it is a core belief.
  2. List of Core Beliefs: A therapist can also give a client a list of core beliefs (like Judith Beck’s list) and have the client select which ones resonate. This is useful to use with clients who have a hard time articulating themselves or who may say they have no idea what their core beliefs are.
  3. Client reports: You can also simply ask yourself what you believe your core beliefs are.  Describe pivotal events in your life and then look for how those events changed your view of either yourself, the world or other people.
  4. Fears: Fears can also be a good source of core beliefs.  Negative core beliefs elicit a lot of fear and people are constantly on guard to protect against the core belief activating.  Ask  yourself what you fear is true about yourself, the world or other people.
  5. Judith Beck’s Case Conceptualization: Judith Beck provides a good worksheet for you to help fill in the blanks of the client’s cognitive map.  If you are struggling with core beliefs, fill out the rest of the form and you should be able to make an educated inference on what the core beliefs are.  It has been provided below for your convenience.

The Downward Arrow

The Downward arrow technique is an especially useful tool for identifying core beliefs.  It involves starting with a surface level thought and probing for implications of the thought.  Clients typically go no deeper than their surface thought but the downward arrow technique prompts them to examine the implications of their surface thoughts until we arrive at the true core belief being masked.

The general question for the downward arrow technique is: “And if that were true, what would that mean to you?”  This is an incredibly powerful question and is one that you may need to stick with until you can provide an answer.  It isn’t’ unusual that you  might think: “I don’t know” so you may need to stick with it until you can answer it.

Here are some examples of using the downward arrow technique to go from surface thought to core belief:

  1. “I can’t accept that my husband is gone for good.” (If that were true what would it mean?)
  • That would mean what I believe about marriage isn’t true.
  • If what I believe about marriage isn’t true, what else am I wrong about?
  • I am a foolish person.
  1. “It’s 11 pm and my wife isn’t home yet.” (If that were true what would it mean?)
  • She must not value spending time with me.
  • I am not worth of her time
  • I am unlovable.
  1. “The soup I made is terrible.” (If that were true what would it mean?)
  • I am a bad cook.
  • I cannot fulfill my role obligations.
  • I am a failure.
  1. “I didn’t get a call back from the job I applied to.” (If that were true what would it mean?)
  • I am never going to get a job.
  • I will not be able to provide for my family.
  • I am a failure.

Restructuring Core Beliefs

After educating yourself on core beliefs and identifying the key core beliefs that are maintaining the presenting issue it’s time to begin challenging and restructuring those core beliefs.  You can begin challenging core beliefs in the same way that you would challenge normal thoughts or rules for living, including generating evidence and identifying distortions.  You can begin by listing any evidence at all that might indicate this belief is not always true.   If this isn’t enough (it often isn’t) then you can turn to a few new techniques to help challenge these problematic beliefs including: cognitive continuum’s, behavioral experiments, a historical review of data and the positive data log.  We have already discussed continuum and experiments so we will turn our focus now to the historical data review and the positive data log.

Since core beliefs form during pivotal events that often occur in childhood, we may need to analyze those pivotal events to allow you to reprocess them and interpret them from what is usually a more mature perspective (adult self vs. child self).  A historical review of the data simply involves listing all of the key pivotal events that you believe are reasons why the core beliefs are true and then doing thought records around them and coming to balanced interpretations of those events.  This can be time consuming but also very powerful as it can defuse emotional memories that are holding you hostage.  You treat these memories just like you would situations that you analyze with thought records every week.  Identify what the situation meant , whether the interpretation was distorted and what evidence there is that this is the best interpretation possible.  Construct a new balanced interpretation of the memory for each of the memories you list.  A worksheet developed by Judith Beck has been provided below that illustrates this technique.

Another important tool for changing core beliefs is the positive data log.  This is a relatively simple intervention to understand but is often difficult to practice.  It simply involves taking the balanced core belief that you are trying to adopt and then listing evidence every day that supports the new belief.  It’s important to understand that you have had a lot of practice (sometimes decades) rehearsing your old core beliefs and that we need to create new connections in the brain by rehearsing new beliefs.  If you have trouble doing this as homework then do it in session until you become better at adopting alternative perspectives.

In summary, core belief work progresses in the following way:

Step 1: Educate yourself on core beliefs.

Step 2:  Identify key core beliefs.

Step 3: Develop balanced alterations of the core belief using CB techniques.

Step 4:  Implement new core belief in new situations.

Step 5: Pay attention to new evidence and reinforce new balanced belief.

Putting it all together: Schemas

One final term that you may come into contact with in the CBT literature is that of the schema.  Going back to the iceberg analogy, the schema can simply be thought of as encompassing the entire iceberg and includes all levels of mental life.  Thus a singular schema may consist of a core belief, the rules for living and then the automatic thoughts that flow out of that core belief.  In cognitive therapy, we seek to identify maladaptive schemas and replace them with adaptive schemas.  Below are some example of both adaptive and maladaptive schemas in certain situations.

  1. Situation: A friend doesn’t talk to the client at a party.

a.) Adaptive Schema

CB: I am a generally likable person

RFL: If I mingle, I might have a new friend at the end

AT: “Wow! My friend is busy tonight!”

Embedded memory: simply of last year’s party.

b.) Maladaptive Schema

CB: Others are more interesting than I am

RFL: If I am not interesting, I will be ignored

AT:
My friend doesn’t really like me

Embedded memory: Rejection

  1. Situation: Husband doesn’t remember what the wife told him earlier.

a.) Adaptive Schema

CB: Husband cares about me.

RFL: If my husband forgets what I told him, it doesn’t mean he doesn’t love me.

AT: “He has a lot on his mind.”

Embedded memory: conversation with husband.

b.) Maladaptive Schema

CB: Husband doesn’t care about me.

RFL: If my husband forgets what I told him its proof he doesn’t love me.

AT: I can’t believe my husband forgot this.

Embedded memory: Rejection and isolation.

  1. Situation: A man who was mugged 5 years ago won’t leave his house.

a.) Adaptive schema

CB: The world can be dangerous at certain places and times but where I live it is mostly safe.

RFL: If I take precautions and be reasonable, I will be safe.

AT: “It’s dark out so I should be safe.”

Embedded memory: feeling in control.

b.) Maladaptive schema

CB: The world is dangerous.

RFL: If I don’t leave my house I can’t get hurt.
AT: I can’t leave my house.

Embedded memory: Fear and powerlessness.

Resources

Core Belief Worksheets

Rules for Living & Behavioral Experiments

Overview

In this post, we are going to focus on an important part of the CBT Iceberg and look at the intermediate level of beliefs: Rules for Living.  As we go beneath the iceberg it will become more difficult but also more rewarding and life changing to restructure these aspects of your cognitive maps.  Remember that resistance will be natural and typical as this is a level of change that takes time and perseverance.  This level of change is “life work.” Rules for living are more difficult to challenge and change than automatic thoughts but less difficult than core beliefs.

After we examine the characteristics of rules for living we will turn to the next behavioral intervention designed to tackle these rules: Behavioral Experiments.  Behavioral experiments involve challenging rules by changing the “if” part of the rule to test whether new “then” conclusions can be made.

Rules for Living

Rules for living are sometimes referred to as “intermediate beliefs” or “compensatory strategies” in the CBT jargon.  They are “intermediate” between automatic thoughts and core beliefs and they often lead to ways of compensating for core beliefs.  For example, if someone has a core belief: “I am inadequate and will be rejected” then they may compensate for this belief by developing a rule: “If I stick to myself then I can’t be rejected.”  The rule is designed to protect against the core belief becoming activated.

We all have rules and we would not be able to function without them.  These rules exist implicitly even if a person cannot explicitly articulate what they are.  Rules are ever present, even if they are not immediately obvious.  For example, even the belief: “I do not believe in rules” is a rule!  Stated differently, this belief in rule form would look like: “Always reject rules and never stick to a consistent principle.”  There is, therefore, no way of getting around the fact that we all have rules that we follow whether we are aware of them or not.  These rules often exist on a subconscious level (below the water line on the CBT iceberg) and need to be brought to consciousness for evaluation.

Rules are learned and are not genetically hardwired, though genetics may predispose us to adopt certain rules easier than others.  Rules are thus heavily influenced by sociocultural factors and by our families of origin.  Rules tend to be transmitted from parents to children and form the rationale for many of the behaviors we adopt.  It is difficult to change behavior without understanding the rule that drives that behavior.  Rules therefore tend to be stubborn and resistant to change as we wouldn’t adopt rules that we didn’t think made us safe or functional in some way.

When starting to examine rules, it is easiest to translate them to an “If….then” framework.  For example, a couple may come to therapy to talk about their constant conflict with each other and an inability to repair their relationship.  They may simply report: “We fight a lot and drift apart afterwards” but a skilled CBT therapist may identify a maladaptive rule in the background such as: “If I say sorry then I’ll appear weak.”  As you can see, the rule is probably at the heart of the couples troubles but it is often not articulated immediately as: “If…then.”  With skillful probing, a therapist needs to be able to take vague statements and put them into the “if…then” rule framework so that clients can more easily understand their psychological world.

If…then rules also contain lots of unexamined implicit assumptions that need to be analyzed.  For example, “If I say sorry then I will appear weak” can also be understood as a set of assumptions.  This rule implies a certain definition of weakness, assumes that others share this view and assumes that denying weakness is desirable and valuable.  In many cases, the person will simply not have examined this rule in such depth and will probably not be aware of the assumptions that fall apart upon examination.  In some cases the rule may be more entrenched so the assumptions can become targets for standard CBT challenging techniques such as identifying distortions or the evidence technique.

Rules can also be thought of as contingency plans.  A contingency is something that occurs when a given condition is met.  For example: “If I am put in a new situation…then I remain quiet” can be thought of a contingency.  The condition of “new situation” triggers the contingent behavior of silence.  Contingencies are similar to the “compensatory strategies” we listed earlier.  They are planned ways of achieving goals when certain situations arise.

Rules for living are important because they organize and coordinate our daily existence.  They can also be viewed as “coping strategies” that help individuals deal with stress.  For example, if a person is terrified of rejection they may develop the rule: “If I’m nice to everyone then they’ll like me.”  Being nice becomes a coping strategy for preventing the feared outcome of rejection.  This rule is probably useful in many situations but there are others where this rule would lead to a person becoming unassertive and avoiding healthy conflict.  This leads us to the next skill therapists need to develop: how to tell helpful from unhelpful rules.

Helpful vs. Unhelpful Rules

Since we all have rules it’s important to be able to distinguish between maladaptive and adaptive aspects of rules.  There are certain typical characteristics of helpful rules that include:

  • Being Realistic: Helpful rules will reflect a realistic view of reality and will not be distorted too much in any one direction. These rules will be realistic to achieve and will not reflect impossible standards.  For example, the rule: “I must be perfect at everything” is clearly unrealistic because it is not achievable by anybody.  A healthy approximation of this might be: “I do my best when focusing on things important to me.”  This is a much more realistic rule that is capable of being achieved.
  • Flexible over time, experience and learning: Helpful rules are not too rigid and are able to be adapted when new learning or experience calls for change.  For example, the rule: “I shouldn’t trust new people” may be developed in high school and may be based upon experiences of being bullied.  However, this rule may cease to be useful later in life and would become maladaptive if it could not be changed to suit new circumstances.
  • Intelligent: Helpful rules make accurate distinctions between what we can and cannot control.  They focus on process rather than outcomes since outcomes are often out of our control.  For example, the rule: “If I study hard then I will always get 100%” is outside of the person’s control and is therefore unhelpful.  Changing this rule to: “If I have a test then I study until I know the material” is a much more helpful rule since it focuses on what the person can control (studying) rather than the outcome that depends upon another person’s judgment which is outside of the student’s control.
  • Meaningful: Helpful rules are necessary and meaningful to the individual and are not superfluous or not needed.  For example, a person may be taught the rule: “Always knock on wood when speaking of your own good fortune” but not really believe in it. Since this rule isn’t meaningful, it is probably unhelpful in the grand scheme of things.
  • Tend to lead to behaviour patterns that “work.” We can judge the efficacy of rules by judging the behaviors that they lead to. If a rule leads to dysfunctional or maladaptive behaviors then the rule itself is probably unhelpful.  Helpful rules will lead to behaviors that facilitate beneficial goal achievement and will not hinder those goals.

In contrast to helpful rules, unhelpful rules have the following inverse characteristics:

  • Unrealistic: These rules reflect a distorted view of reality and set impossible standards that cannot reasonably be maintained.
  • Rigid: These rules are inflexible and completely resistant to change even when new data reveals their inadequacy. For Example: “If I enroll my kids in many activities, then I am a good parent” may be rigid when new evidence (child exhaustion) fails to modify the rule.
  • Unreasonable: These rules focus on what is outside of a person’s control rather than what they can control. They focus on outcomes rather than processes.
  • Unnecessary: These rules are often safety behaviors that don’t really keep the person safe. For example, knocking on wood doesn’t really keep a person safe but the person may believe it does.
  • Lead to dysfunctional behaviors: A rule can be determined to be maladaptive simply because it leads to maladaptive behaviors.

Below are some examples of common rules for living that form the cognitive map for certain DSM diagnoses:

  • “If I say something dumb at a party then people will think I am stupid.” (Social Anxiety)
  • “If people hurt me, then they should never be trusted again.” (Attachment Disorder)
  • “If I think about something terrible, then it will happen.” (OCD)
  • “If this job doesn’t work out, then I am a failure.” (Depression)

Identifying Rules for Living

As has been previously mentioned, Rules for Living are not always explicitly articulated by people and need to be skillfully identified.  There are many different sources that you can look to when determining your rules for living that include:

  • Thought Records: Your rules are sometimes listed directly as automatic thoughts in a thought record. They can also emerge from multiple thought records after identifying general themes in them.
  • Socratic Dialogue: Sometimes rules are identified in conversation with the client. For example, if a therapist gives a suggestion and the client resists there may be an underlying rule you’ve identified.  A therapist may say: “I wonder if saying sorry would solve the problem” and a client may respond: “That’s out of the question.”  A little more probing may identify a general rule that the client has about apologies in general.
  • Client value judgments or anger: Another good source for identifying rules is when you notice yourself responding with judgment or anger to certain people or situations. Judgments and anger are both frequent responses to rule violations.  For example, if you are angry with your husband, ask him what rule he broke that is causing this response.
  • Shoulds, Oughts and Musts: People will also frequently frame rules with words like: “should” “ought” or “must.” Pay attention when these words are used as they are good hints that you are probably dealing with a rule for living that needs examination.
  • Society and Culture: Having knowledge of certain subcultures may provide good hints for a therapist trying to identify rules.  For example, a person who comes from a Christian background will probably have rules that reflect that worldview.  Similarly, a person with a Muslim background will probably have rules influenced by that religion.

Challenging Rules for Living

Rules for Living can be challenged using standard cognitive restructuring techniques or they can be challenged using behavioral experiments. We will first briefly discuss cognitive restructuring techniques and then look at behavioral experiments in more depth afterwards.

Just like automatic thoughts, Rules for Living can be taken through the process of identifying distortions, generating evidence and creating balanced rules.  For example, if you identify the rule: “If I am not the top in my class then I am nothing” then you can examine its validity and utility.  This rule clearly reflects all-or-nothing thinking, over-generalizing and a host of other distortions.  Examining the evidence a client has for this belief may reveal where this rule came from and whether it is realistic, reasonable and flexible.  This rule can also be examined for its utility: “What effects does this rule have on your life?” and for double standards: “What would you tell a best friend who was not the top in their class?”  After going through this process, you may be able to generate a balanced rule: “If I do my best in class then I can be satisfied with the results.”

Whenever a person reasons using rules, they are using certain patterns of inference to justify those rules.  Rules are claims that: “If x situation occurs then y response is necessary or forbidden.”  The rule mediates between what is claimed as fact and what the client claims needs to be done about that fact. Reasoning with rules also frequently involves reasoning with analogies as the person says: “X should be done in Y situation.”  “My rule is activated because this new situation is similar enough to situation x to justify this y response.”

However, this line of reasoning is subject to certain tests to ensure sound reasoning is occurring.

  • Do the facts of the situation justify activating the rule? This test ensures that the essential requirements of the rule are met before it’s activated.  For example, if a client has a rule: “If someone is rude to me then I must be rude back” we need to ensure the essential facts of the situation justify the rule activation.  We need to determine if the person really was being rude or whether there was some other explanation for the behavior.  Clients may be activating rules in situations that don’t meet the essential requirements of the rule.
  • Have all relevant aspects of the situation been considered? Ensure that a client considers all aspects of a situation before activating his rule. For example: “If my child misbehaves then he should be disciplined” should only be activated if all aspects of the situation have been considered.  Is the child really misbehaving or is there some other explanation that would cause this rule to be deactivated?
  • Is the rule itself based upon sound principles? Clients should reflect on why they believe a rule is useful and the evidence base needs to be examined. For example, the rule: “If my husband is upset then I must do everything to please him” may be based on examples from past relationships.  This general rule may have been formed based on inadequate data

A general process for challenging rules is listed below:

  1. Identify the unhelpful rule First identify the rule using the sources we have already discussed.
  2. Work out where it came from: Try and understand what role this rule has served in the clients life and whether it was once useful or not.
  3. Ask: Is the rule realistic, reasonable or achievable? Examine the rule according to the criteria discussed about helpful and unhelpful rules.
  4. “Name” the negative consequences of having and keeping this rule: Examine the rules utility and usefulness in the client’s life.
  5. Identify a more helpful rule, if there were one: Generate a balanced rule that can be experimented with.
  6. Plan how to adjust life with new rule: Troubleshoot and debrief rule changes with the client at subsequent sessions to solidify gains.

Behavioral Experiments

Cognitive Restructuring is sometimes not enough to challenge resistant rules for living. When these tools are not enough, behavioral experiments are powerful interventions for challenging rules for living.  As mentioned earlier, behavioral experiments challenge rules by manipulating the: “if…” part of a rule to challenge the “then” conclusions that clients have.  The rule is based upon the foundation that “if” will reliably lead to “then” and the behavioral experiment is designed to cast doubt on this assumption.

For example, the rule: “If I speak up in class then I will be ridiculed” can be tested through a behavioral experiment.  The client needs to speak up in class in order to test whether the rule is accurate or not.  Now, usually, the rule is based upon a few isolated experiences that the client has had so you will need to make sure the experiment is done with new situations that are likely to yield a difference outcome.  Ideally, testing this rule in a variety of circumstances will be more beneficial rather than just doing it once.

Behavioral experiments are a perfect bridge between cognitive and behavioral interventions.  They help us gather data/evidence against our most influencing negative assumptions.  They are designed like an experiment to test the predictions or validity of our conclusions by exposing us to new information.  They can be done in session, but they are also often designed in session and then done as homework between sessions.

Behavioral experiments are often confused with exposure work but they are different interventions.  While exposures are done to reduce fear/anxiety, behavioral experiments can be used for a variety of reasons, such as changing a rule or testing a new idea.  Also, behavioral experiments do not involve prolonged toleration of anxiety but instead simply involve a changed behavioral response and then reflecting upon the data generated.  While exposures usually need to be repeated over and over, behavioral experiments usually only need to be done a few times until the client shifts the initial conclusion.  Instead, behavioral experiments are uniquely designed events aimed at testing a hypothesis (or rule).  Behavioral experiments can include conducting surveys, introducing new behaviors/thoughts and monitoring the results of those changes.

A step-by-step guide for conducting behavioral experiments is included below for your convenience:

Steps to Doing Behavioral Experiments

Phase 1: Pre-Experiment Work

Step 1: Write down the assumption, rule or expectation that you want to test.  For example, the belief: “If I speak up in class I will be ridiculed” might be recorded here.

Step 2: Design an Experiment that will accurately test whether this prediction will come true or not.  Answer the following questions: how are you going to measure this? How many times? Determine specifics to your plan: what, when, where, who and how?  The experiment usually flows naturally from the rule.  For the above example, the series of experiments might include: “I will speak up in math class on Monday, science on Wednesday and Art on Friday.”

Step 3: Make your predictions about what the likely outcomes of the experiment are and rate how likely you think each outcome is to happen out of 100. Also, write down alternative predictions that you might not think are likely. For example, the client may predict: “When I speak up, I will be made fun of” or “When I speak up people will be surprised.”

Step 4: Problem solve barriers by anticipating what could go wrong and then creating a contingency plan to deal with it.  For example, the student about to speak up in class might anticipate that looking at everyone’s faces before doing so might scare her.  She may then resolve to purposely avoid doing so until she has spoken up.  She might also develop coping statements she can use in the moment when her fear becomes heightened.

Phase 2: Conduct the Experiment

Step 5: Conduct the Experiment that was planned, ensuring all of the details that were planned were followed through on.

Phase 3: Post-Experiment Work

Step 6: Review outcomes to determine if your predictions were confirmed.  Does the new data justify a new rule or hypothesis? Determine if you need to do a re-test or to gather more data.  If your hypothesis was confirmed brainstorm why it may have been.

Step 7: Revision and New Experiments.  If your hypothesis was not confirmed and you feel you have enough data to adapt a healthy rule, you don’t need to do any more experiments.  You may want to anyways, to solidify gains but that’s up to the therapist and client.  If your predictions were accurate, new behavioral experiments need to be designed that will be more likely to yield positive outcomes.  Determine what characteristics of the situation led to the negative outcome and then try and eliminate them on subsequent experiments.  The client will need to learn how to differentiate between contexts that suit the rule and contexts that do not.

You can also do behavioral experiments much more informally by reducing them to their core components. For example, you can design something relatively quickly for a client with social anxiety that might look like this:

  • Prediction: Thought, “I will do something dumb and everyone will laugh” (90% confidence)
  • Task: Go to mall, drop change on floor
  • Record: How many people stop and laugh, how that makes me feel
  • Bring back: What (actually) happened, how you felt, how “right” you were about prediction

Resources

Rules for Living and Behavioral Experiments

 

Behavioral Activation & Goal Setting

Behavioral Activation & Goal Setting

The next behavioral intervention that we will examine is called “behavioral activation.” This intervention simply involves planning and monitoring new behaviors that are designed to accomplish your therapeutic goals.  This intervention is one of the first things that you would do if you are struggling with depression.  Some research suggests that behavioral activation is all that is needed in many cases of depression, and that cognitive work is not even necessary.  However for others, a combination of both cognitive and behavioral interventions is required.

You can also use behavioral activation tools to accomplish general lifestyle and behavior modification changes.  Behavioral activation also serves to reinforce cognitive gains and can provide the experience necessary for shifting perspectives.  Behavior change also interrupts perpetuating cycles and introduces new cognitions (Ex. “I begin exercising daily and meeting my goals so I think “I am healthy”, which may in turn create new healthy core belief cycles).  Behavioral activation is also useful when cognitive work doesn’t appear to be working.  Changed behaviors will result in changed environments and thus provides new data for the client to interpret that may challenge old beliefs.

Behavioral Activation involves 4 major steps:

i.) Identifying Values: This is a step that is often overlooked but is very important to establish before goal setting. People are often unaware of their values or they set goals that are inconsistent with those values.  In order to ensure that you set the right goals for yourself, it is helpful to brainstorm what your top 10 values in life are. Consult a list of common values and select 10 of them and prioritize the most important ones.  For example, if your really value family but the goals you have set are all about improving your career then those goals are unlikely to be fulfilling in the long-term.  Identifying these values first will help ensure that the goals you set reflect those values and will lead to lasting fulfillment.

ii.) Vision casting:  After identifying values, it’s important to engage in vision casting.  This can involve asking some variation of the miracle question: “If a miracle occurred and you had the perfect life, what would it look like?”  Dream big and hold nothing back.  Too often, people dedicate themselves to pursuing lesser causes because they are afraid to commit themselves to their biggest dreams.  Write out and envision this future in detail and to be specific.  Be sure to include family, work, recreation, spirituality, health, environment, activities and hobbies, volunteering etc…Creating this vision will also serve as a strong motivating force and give purpose to the mundane planning and monitoring work that will need to occur for this to come true.  Remember that work without vision is drudgery so people need to vision cast to give their lives meaning.

iii.) Creating Goals:  After identifying values and vision casting comes goal creation.  Most people are familiar with the concept of SMART goals but a brief review here will be provided.  SMART goals are:

  • Specific: They are clear and concise and avoid vague statements like “I will feel better or be happy.” A specific version of this goal might be: “I will do 2 activities a week that make me happy.”
  • Measurable: Goals needs to be defined or operationalized in a way that they can be measured. For example, the goal: “I want to feel better” is not really measurable while: “I want to score 10 points lower on the BDI” is measurable.
  • Achievable: Goals must be realistic and within your scope of competence to accomplish.  For example, a man with no musical training should not set a goal: “I will get a record deal in 6 months.”  Instead, a more realistic goal might be: “I will practice every day for the next 6 months so that one day I can get a record deal.”
  • Relevant: Goals should also be focused on that which you value most.  Setting goals around things you don’t really care about but think you should care about will not be helpful.
  • Timed: All goals need to have a deadline.  If there is no deadline then it is unlikely that goal will be achieved.  For example, saying: “I will become a teacher sometime in my life” will not be as effective as: “I will enter teachers college in the next 2 years.”

Ensure that the goals you set  are calculated to achieve the grand vision set forth and that they are reflective of the values you have chosen.  Create a list of goals in at least the following categories: Family relationship, social and community relations, education and career, Hobbies and Recreation, Volunteer Work, Spirituality, environment and physical health.

iv.) Planning and Monitoring Goal Progress:  And finally, after identifying values, vision casting and setting long-term goals you need to plan out your week in advance, scheduling in activities that will help her meet those goals.  For example, if the client has a goal of “I will lose 10 pounds” then she should schedule exercise time on 4 days in the coming week.  The client similarly plans out activities for the coming week that will help her meet her goals in all of the categories listed above.  Attached below is a “behavior checkout” worksheet that you can give to your clients to help them schedule and monitor activities consistent with their goals.

Resources

Behavioral Activation Worksheet