01 - 18. Modifying Beliefs

18. Modifying Beliefs

I n the previous chapter, we discussed how to identify important positive and negative beliefs, how to explain beliefs to clients, and how to motivate them to modify their beliefs. When clients are in a maladaptive mode such as depression, it’s important to • develop and strengthen realistically positive beliefs to activate the adaptive mode (which is emphasized to a greater degree in a recovery orientation), and • modify their unrealistic, negative beliefs to deactivate the depressive mode (which is emphasized to a greater degree in traditional CBT). In this chapter, you’ll read about strengthening positive beliefs first and weakening negative beliefs second. In practice, you’ll work on both kinds of beliefs at most sessions, either directly or indirectly. The techniques apply to both intermediate and core beliefs. Here are the questions that you’ll find answers to in this chapter: How do you strengthen adaptive beliefs? How do you modify intermediate and core beliefs? STRENGTHENING ADAPTIVE BELIEFS Most people, unless they have strong personality disorder traits, have reasonably balanced, adaptive, realistic beliefs. But the schemas MODIFYING BELIEFS

containing some of these positive beliefs become deactivated when clients are in the depressive mode. It’s important to reinforce these more positive beliefs (Ingram & Hollon, 1986; Padesky, 1994; Pugh, 2019) throughout treatment by helping clients engage in activities that could bring them a sense of mastery, pleasure, connection, and empowerment. Other important strategies include • eliciting positive data and drawing helpful conclusions about their experiences, • eliciting the advantages of believing adaptive beliefs, • pointing out the meaning of positive data, • referencing other people, • using a chart to collect evidence, • inducing images of current and historical experiences, and • acting “as if.” Eliciting Positive Data and Drawing Conclusions I started identifying and working to strengthen Abe’s positive, adaptive beliefs from the beginning of treatment, in many ways. In the following examples, I primarily address Abe’s core belief of incompetence/ failure. Here’s what I did when we initiated therapy and throughout our treatment: • At the beginning of each session, I asked Abe, “What positive things happened since I saw you last? What positive things did you do? [or “When this week did you feel even a little better?”] Then I asked, “What do you conclude about [these experiences]? What do these experiences say about you?” • I asked Abe to keep a credit list of everything he did each day that was even a little difficult but that he did anyway. • Once we identified an important adaptive belief (“I’m competent, with strengths and weaknesses like everyone else”), I added a question at the beginning of each session: “How strongly do you believe today that you’re competent? When did you believe that most strongly this week? What was going on?” Cognitive Behavior Therapy: Basics and Beyond

Examining Advantages of the Adaptive Belief I also helped Abe examine the advantages of seeing himself as competent. We identified several advantages: It would be more reality based, increase his self-­confidence, make him feel better about himself, improve his mood, motivate him to try things that seemed difficult, and help him accomplish tasks. Pointing Out the Meaning of Positive Data Early in treatment, when we identified one of Abe’s adaptive behaviors, I praised him and often characterized these actions as showing evidence of competence and other related qualities: “It’s so good you helped your neighbor. I think it shows you have a lot of skills—­plus I think it’s another example of how competent you are—do you agree?” “It sounds like your grandson’s soccer coach saw you as a real asset. Do you think that’s right?” “Persevering like that, until you finished the forms, shows how hard working you are, doesn’t it?” “Getting your apartment in order really indicates you’re taking control; do you think so too?” As therapy progressed, I elicited the meanings from Abe. “What does it say about you that you were so helpful at the homeless shelter?” “What does it say about you that Charlie wants you to keep working for him?” Referencing Other People One way to help clients get some distance from their beliefs is to ask them to think about how the adaptive belief might apply to other people or what others’ perspective about them might be. Here are several ways to do that: • Ask clients about people who historically viewed them in a favorable light: “Who in your life believed most strongly that you were competent? Why? Could this person have been right?” • Ask them to think of a specific person and how they would evaluate this person in terms of the adaptive belief: “Abe, who is someone whom you view as competent in most ways? What have you done this week that you would say shows that [this person] is competent if he or she had done it?”

Modifying Beliefs

• Ask them to reflect on whether they would discount positive evidence if they compared what they did to a hypothetical negative model: “Abe, you don’t believe that paying all your bills is a sign of competence. But would a truly incompetent person have been able to do that?” • Ask them to name another person who views them positively: “Abe, who’s someone who knows you pretty well, whose judgment you trust? What would [this person] say you had done this week that’s evidence you’re competent?” or “Abe, what have you done this week that I would consider a sign of competence?” Using a Chart to Collect Evidence An important Action Plan item was for Abe to remind himself to look for data that supported his positive beliefs. Once we agreed to work on his belief that he was competent, we converted his “credit list” into an “Evidence of Competence Chart” (Figure 18.1). I made this chart in session for him. We started it together so I could be sure he understood what to do. I asked him to include evidence about things that not only were even a little difficult but also were easy but nevertheless indicated competence. The chart also elicited his conclusions about these experiences and, especially, what these experiences showed about him. He filled out the chart at home and brought it to therapy so he could add additional examples we discovered during our sessions. A little later in treatment, we used the same chart to collect historic evidence of competence. I asked Abe to take a photograph of as many of these positive experiences as he could (or to look online for an image that represented the experience) to show me at subsequent sessions. Reviewing the photographs gave me the chance to respond to his discounting cognitions; they were a potent reinforcer that his new core belief was accurate. Event/Experience I finished going through all the bills and paying them. Conclusion, or what this says about me I can concentrate better than I thought. Soccer coach thanked me several times again after the game. I can organize people pretty well. I helped Jim fix a leak. I can figure things out. FIGURE 18.1.  Abe’s Evidence of Competence Chart. He also took photographs of the pile of bills he had just finished paying, of the soccer coach and team, and of Jim’s leaky pipe. Cognitive Behavior Therapy: Basics and Beyond

Inducing Images of Current and Historical Experiences Imagery tends to reinforce adaptive beliefs at both the intellectual and the emotional level, especially when clients experience positive affect as they visualize a scene. I asked Abe to tell me about and then visualize both recent and historic memories. Here’s one example: Judith: Can you think about your history? What was a situation in which you felt really competent? . . . Can you imagine this scenario, as if it’s happening right now? . . . Tell me what you see, what you’re thinking, how you’re feeling . . . Abe: (Visualizes and describes the experience of finding out he was getting a promotion at work.) Judith: You know, you’re still the same person now, with the same level of competence. It’s just partially covered over by the depression, which affects what you do, what you think, and how you feel. Acting “As If” Clients are often willing to act as if they believe their adaptive belief—­ and doing so strengthens this belief. Abe and I were discussing an upcoming job interview. I asked Abe to visualize this situation, as if it were happening right now, and to imagine acting as if he believed his positive belief. His Action Plan was then to act that way in the actual situation. “Abe, can you imagine what it would be like if you completely believed you were competent when you went for your job interview? Can you visualize it? . . . How do you feel when you enter the reception area? . . . What are you thinking? . . . Remember, you completely believe you’re competent. When you walk up to the receptionist, what does your posture look like? . . . What does your face look like? . . . What do you say to the receptionist? . . . How are you feeling? . . . What do you do when you meet the interviewer? . . . What do you look like sitting in the chair? . . . What do you say when he asks you about your previous job?”

CLINICAL TIPS When clients have difficulty identifying positive data, you can use the metaphor of the screen from Chapter 17 to remind them that they may be missing or discounting positive evidence. Then discuss what they could do in the coming week to get better at this skill.

Modifying Beliefs

MODIFYING MALADAPTIVE BELIEFS The degree of difficulty in modifying negative beliefs varies from client to client. In general, it’s far easier to modify the negative beliefs of clients with acute disorders whose counterbalancing adaptive beliefs have been activated throughout much of their lives—as compared to clients with personality disorders (J. S. Beck, 2005; Beck et al., 2015; Young et al., 2003). The beliefs of some clients change easily, at least at the intellectual level, but the beliefs of others require considerable effort over time to change at both an intellectual and an emotional level. Clients vary widely in the degree to which they’re able to modify their core beliefs. It’s not possible or realistic for some clients to reduce the strength of these beliefs to 0%. Generally, beliefs have been sufficiently weakened when clients are likely to continue modifying their dysfunctional behavior despite still holding on to a remnant of the belief. Beliefs usually change at the intellectual level first, especially if you’ve been employing only intellectual-­level techniques. Clients may need experiential techniques (including using imagery, doing role playing, using storytelling or metaphors, and engaging in behavioral experiments) to change their beliefs at the emotional level. Cognitions change in the presence of affect, so the best time to work on negative beliefs is when their schemas are activated in session. Clients then generally experience change at both levels as corrective information is received. Gestalt-­type techniques, such as empty-chair work (Pugh, 2019), can be quite useful in exposing clients to painful beliefs and emotions or distressing interpersonal situations. Clients generally learn that they don’t need to protect themselves from upsetting situations; they don’t need to use coping behaviors, such as escape, avoidance, or distraction. Techniques using an extended metaphor of a trial are also helpful in helping clients identify and modify entrenched core beliefs (De Oliveira, 2018). Techniques to Modify Negative Beliefs To change a negative belief, you will educate clients about core beliefs, monitor the activation of their schemas, explain their contribution to clients’ current difficulties, and motivate clients to change them (as described in Chapter 17). You’ll use both intellectual- and emotional-­ level techniques, as described below. Many of the techniques are also used to modify automatic thoughts. Cognitive Behavior Therapy: Basics and Beyond

• Socratic questioning • Reframing • Behavioral experiments • Stories, movies, and metaphors • Cognitive continuum • Using others as a reference point • Self-­disclosure • Intellectual–­emotional role plays • Historical tests • Restructuring the meaning of early memories Socratic Questioning When evaluating Abe’s beliefs, I use the same kinds of questions as I used in evaluating his automatic thoughts. Even when I identify a general belief, I help Abe evaluate it in the context of specific situations. This specificity helps make the evaluation more concrete and meaningful, and less abstract and intellectual. Judith: [summarizing what Abe learned from the just-­completed downward arrow technique] Okay, so you believe about 90% that if you ask for help, it means you’re incompetent. Is that right? Abe: Yes. Judith: Could there be another way of viewing asking for help? Abe: I’m not sure. Judith: Take therapy, for example. Are you incompetent because you came for help here? Abe: A little, maybe. Judith: Hmm. That’s interesting. I usually view it in the opposite way. Is it possible it’s actually a sign of strength and competence that you came to therapy? Because what would have happened if you hadn’t? Abe: I’d probably be much worse. Judith: Are you suggesting that asking for appropriate help when you have an illness like depression is a more competent thing to do than remaining depressed? Abe: Yeah . . . I guess so. Judith: Well, you tell me. Let’s say we have two depressed people. One

Modifying Beliefs

seeks treatment, works hard, and overcomes his depression. The other person refuses therapy and continues to have depressive symptoms. Whom do you consider more competent? Abe: Well, the one who goes for help. Judith: Now how about another situation you’ve mentioned, volunteering at the homeless shelter? Again, we have two people. They’re not sure how to deal with an aggressive person because they’ve never had to do it before. One asks the staff what to do. The other doesn’t and continues to struggle. Who’s the more competent? Abe: (hesitantly) The one who goes for help? Judith: Are you sure? Abe: (Thinks for a moment.) Yeah. It’s not a sign of competence to just struggle if you could get help and do better. Judith: How much do you believe that? Abe: Pretty much. Judith: And do these two situations—­therapy and help at the shelter—­ apply to you? Abe: I guess they do. Here I used Socratic questioning in the context of two specific situations to help Abe evaluate his dysfunctional belief. I judged that the standard questions of examining the evidence and evaluating outcomes would be less effective than asking leading questions. Note that when you’re evaluating beliefs, you may need to ask questions that are more persuasive and less evenhanded than when evaluating more malleable cognitions at the automatic thought level. Reframing You can hand draw a chart to help clients track and reframe evidence that seems to support their dysfunctional beliefs (Figure 18.2). Judith: [summarizing] So it was difficult for you to come to therapy and talk to a supervisor at the homeless shelter because of your belief “If I ask for help, it shows I’m incompetent or a failure.” Is that right? Abe: Yes. Judith: Now that we’ve discussed it, how do you see it? Abe: If I ask for help, I’m not incompetent? Judith: You don’t sound convinced. Let’s see. Do you want to phrase it like this: “Asking for help when I need it is a sign of competence”? Cognitive Behavior Therapy: Basics and Beyond

Abe: Yes. Judith: How much do you believe this new idea now? Abe: A lot . . . (Reads and ponders the new belief.) Judith: Would you be willing to keep a chart in which you write down evidence that you initially think supports the idea that you’re incompetent? Abe: Yes. Judith: Then you can counter it with a more realistic perspective, which we can call the “alternative view” or “reframe” or something else. What do you want to call it? Abe: I like “reframe.” I then draw the chart in Figure 18.2. I ask Abe to think of another item that belongs on the chart, and he writes it down. He agrees to an Action Plan item to continue filling in the chart at home. I advise him that it may be difficult at first to think of a reframe but that we can fill in the right side of the chart together at subsequent sessions. I also ask him to keep this chart in front of him during our sessions, so he can add to it when the topic we’re discussing is relevant to his negative core belief. Next, I suggest an Action Plan to help reinforce the new, more adaptive belief. (You read about this acting “as if” technique earlier in this chapter.) Judith: Also, could you be on the lookout for other situations this week where you could reasonably ask for help? That is, let’s imagine that you believe the new belief 100%, that asking for reasonable help is a sign of competence. When during this coming week might you ask for help? Can you think of anything now? Abe: Well, yesterday I tried to rewire a lamp, but I couldn’t. I was going to keep trying . . . but I suppose I could ask my neighbor for help. FIGURE 18.2.  Abe’s Reframes of Competence Belief Chart. Event/Experience Asking for help at homeless shelter Reframe Competent people ask for help when they need it. Going to therapy It’s a sign of strength and competence to get treatment. Lost my job Boss changed my job and didn’t provide training.

Modifying Beliefs

Judith: Perfect. If you can think of any other reasonable opportunities to ask for help, could you do that? Abe: Okay. Judith: And when you do ask, make sure to give yourself enormous credit—­because you’ll be doing something hard, something that goes against your grain but is really, really important. Once you’ve introduced both the Evidence of [the Adaptive Belief] Chart and the Reframes of [the Negative Belief] Chart, you can consolidate them into the Belief Change Worksheet (Figure 18.3). Behavioral Experiments As with automatic thoughts, you can help clients devise behavioral tests to evaluate the validity of a belief. Behavioral experiments, when properly designed and carried out, can modify a client’s beliefs more powerfully than verbal techniques, at both the emotional and the intellectual level. Judith: [summarizing] It sounds as if this belief, “If I ask others for help, they’ll be critical of me,” got in the way this week? FIGURE 18.3.  Abe’s Belief Change Worksheet. Copyright © 2018 CBT Worksheet Packet. Beck Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania. Event/experience that supports my new belief “I am competent            .” What does this say about me? Event/experience with reframes of my old belief “I am incompetent        .” • Figured out how to work [son’s] drone, which shows I’m competent. • Fixed bookshelf for daughter when my son-in-law couldn’t—evidence of competence. • Balanced checkbook—most people can do this, but it’s still a sign of competence. • Helped put up drywall for Charlie—I was competent. • Had trouble understanding article on economic trends, but most people probably would. • Couldn’t figure out how to fix the brakes in my car, but I’m not a trained mechanic. • Got a parking ticket, but the sign was ambiguous. • Dinner I made tasted terrible, but that means I’m incompetent at cooking that meal, not that I’m incompetent as a person. Cognitive Behavior Therapy: Basics and Beyond

Abe: Yeah, that’s why I didn’t ask my neighbor. Judith: How much do you believe that? Abe: I don’t know—a lot. Judith: Well, you came to me for help, and I haven’t actually criticized you, have I? Abe: No, of course not. But that’s your job, to help people. Judith: True, but it would be useful to find out if other people, in general, are more like me or not. How could you find out? Abe: I’d have to ask them for help. In the next part, I find out whether asking his neighbor for help would be a good behavioral experiment. Judith: Okay, can we talk about your neighbor? What evidence do you have that he’d be critical of you if you ask for help to wire the lamp? Abe: (Thinks.) Well, he’s a nice guy. I guess he wouldn’t criticize me. Judith: Has he helped you before? Abe: You know, I almost forgot about this. But yeah, there was one time when my grandson brought his dog over and the dog ran away. My neighbor helped us look for him, and he was actually the one who found him. Judith: Did he seem to be critical? Abe: No, he seemed happy to help. Judith: Then he might not criticize you now either? Abe: No, no, I guess he wouldn’t. I don’t know why I didn’t think of that. Judith: Well, I think your depression is still affecting you. Abe: I think I’ll go knock on his door after dinner tonight. Judith: Good. We can add that to your Action Plan. (pause) Next, we discuss how Abe could cope if it turned out his neighbor was critical. Then I ask, “Now, is there anything else you’ve avoided asking for help with—­because you thought you might be criticized?” It’s very important that clients change their behavior by decreasing their avoidance and entering into situations they’ve been avoiding. Otherwise, they won’t have the actual experience of having their beliefs disconfirmed. For an extensive description and discussion of behavioral experiments, see Bennett-­Levy and colleagues (2004).

Modifying Beliefs

Using Stories, Movies, and Metaphors You can help clients develop a different idea about themselves by encouraging them to reflect on their view of characters or people who share the same negative core belief that they themselves have. When clients experience vivid examples of how others’ very strong beliefs are invalid, or mostly invalid, they begin to understand how they too could have a powerful core belief that isn’t accurate. Maria was sure she was bad because her mother had been physically and emotionally abusive to her, often telling Maria how bad she was. It was helpful for Maria to reflect on the story of Cinderella, in which a wicked stepmother treats a youth quite badly without the youth’s being at fault. For additional common metaphors used in CBT, see Stott and colleagues (2010) and De Oliveira (2018). Cognitive Continuum This technique is useful to modify both automatic thoughts and beliefs that reflect polarized thinking, that is, when the client sees something in all-or-­nothing terms. A cognitive continuum helped Abe see that there’s a middle ground between being a success and a failure. Judith: [summarizing] So when you found out that you had bounced a check, you thought, “I’m a failure.” Can we see how that looks on a scale? (Draws a number line.) So 100%—that would represent someone who’s a complete success. And 0%—that’s someone who’s 0% successful, in other words, a failure. (pause) Now, where on this scale do you belong? 0% Successful/ Failure 20% 40% 60%     90%  100% Successful Abe: Well, I’m almost out of money, and I don’t have a real job. I’m at 0. Judith: Though you do volunteer—­even though you’re depressed. And you are looking for work, right? Abe: I guess so. Maybe I’m 20%. Judith: Is there anyone else who’s between you and someone who isn’t working at all? Abe: Umm . . . Maybe this guy, I know. Jeremy. He works as little as he Cognitive Behavior Therapy: Basics and Beyond

possibly can. He’d much rather just sit back and collect unemployment. Judith: Okay. Where does Jeremy go? Abe: About 20%. Judith: And you? Abe: About 30%. At least I’m trying to get a job. Judith: And when you did work, what was your work ethic like? Abe: Oh, I always worked hard. Judith: Let’s take a look at another guy who never works. Let’s say he keeps borrowing money from family members. He could work, but he never wants to, so he never does. Is this the kind of guy who’s at zero? Abe: Probably. Judith: Now, how about a person who never works, lives off his family’s money, and actually does harm to others. Abe: That person would be a worse failure. Judith: So if he’s 0%, where is the guy with family money who isn’t hurting anyone? Abe: (Thinks.) Oh, I guess 20%. He’s not a failure in every way. Judith: And Jeremy and you? Abe: Let’s see. He’d be 40%, and I’d be . . . I’m not sure. Judith: Well, if you were working now, where would you be? Abe: Hmm. Maybe 90%? Because I don’t think I could ever be 100% successful. Judith: So does that put you now between 40% and 90%? Abe: (sounding unconvinced) I guess so . . . Judith: Let me ask you this: Why don’t you have a paid job? Is it because you’re just lazy or because you have a bad work ethic? Or is it because the depression has been affecting you? Abe: It’s the depression. Judith: Are you sure? Abe: Well, I know I’m not lazy when I’m not depressed, and I do have a good work ethic—and I’m looking for a job now . . . So I guess I’d be at 60%. Judith: How accurate is it to call someone a failure—0% successful—­ who is at the 60% mark? Abe: Not very.

Modifying Beliefs

Judith: Maybe the worst thing you can say is that he or she is 60% successful. Abe: Yeah. (Brightens visibly.) Judith: And once you’ve been in a new paid job for say 6 months, where do you think you’ll be? Abe: It depends on the job, but I hope I’ll be 90% successful. Judith: Let me ask you another question: What has been the effect of labeling yourself as a failure? Abe: It makes me feel more depressed. Judith: Yes. And according to your own scale, it’s not even true. So can you put in your own words what you’ve learned from this scale? Abe: That I’m not a failure. I guess at worst, I’m a 60% success and I’m working my way back to being a 90% success. Judith: That’s excellent. Let’s get that down in writing. And I’d like you to look at this scale every morning and whenever you start feeling like a failure again. Never works, harms others Lives off family money Jeremy Abe Abe with job 0% Successful/ Failure 20% 40% 60% 90%     100% Successful As with many of these belief modification techniques, you will probably find that clients change their thinking at both an emotional and an intellectual level if their negative emotions are heightened in the session. If their distress is low, you may get some change, but it will probably be only at the intellectual level. And you can directly teach clients how to use this kind of technique themselves between sessions. “Abe, let’s review what we did here. We identified an all-or-­nothing error in your thinking. Then we drew a number line to see whether there were really only two categories—­success and failure—­or whether it’s more accurate to consider degrees of success. Can you think of anything else that you see in only two categories, something that distresses you?” Using Other People as a Reference Point When clients consider other people’s circumstances and beliefs, they often obtain psychological distance from their own dysfunctional Cognitive Behavior Therapy: Basics and Beyond

beliefs. They begin to see an inconsistency between what they believe is true or right for themselves and what they more objectively believe is true about other people. In this first example, Abe disagrees with his cousin’s core belief, and I help him apply this perspective to himself. Judith: Abe, you mentioned last week that you think one of your cousins is depressed too? Abe: Yeah. She called me last week. She’s had a lot of trouble. First, she got fired from her job. Then her boyfriend broke up with her, and she had to move in with my aunt. Judith: How do you think she sees herself? Abe: When she called the other night, she said she feels like a failure. Judith: What did you say to her? Abe: That she’s not a failure. That she’s just going through a hard time right now. Judith: Could that be true for you too? Abe: (Thinks.) I’m not sure. Judith: Is there something different about your cousin that makes her okay if she’s depressed and doesn’t have a job, but not you? Abe: (Thinks for a moment.) No. I guess not. I hadn’t really thought of it that way. Judith: Do you want to write something down about this? Finally, many clients can get distance from a belief by using a child as a reference point, someone they feel compassion for. This may be their own child or grandchild or another child they feel close to. Or they can imagine that they themselves have a child. Judith: Abe, so you believe that if you don’t do as well as everyone else, then you’ve failed? Abe: Yeah. Judith: I wonder, can you imagine that your granddaughter is now grown up? She’s 50 years old and she’s very upset because she’s just lost her job. Would you want her to believe that she’s a failure? Abe: No, of course not. Judith: Why not? . . . What would you like her to believe? (Abe responds.) Now how does what you’ve just said apply to you?

Modifying Beliefs

Using Self‑Disclosure Using appropriate and judicious self-­disclosure can help some clients view their problems or beliefs in a different way. The self-­disclosure, of course, needs to be genuine and relevant: Judith: You know, Abe, when I started working full time, I was overloaded. And so was my husband. But I was hesitant to ask anyone for help at home. I thought I should be able to manage on my own. Ultimately, I did get someone to help me. What do you think it meant about me that I needed help? Did it mean I was incompetent? Abe: No, not at all. You probably did have too much to do. Judith: So, someone can need help but not be incompetent? Abe: I see what you mean. Judith: Can you spell it out? Abe: Maybe the fact that I need help now doesn’t necessarily mean I’m incompetent. Judith: What could it mean? Abe: Like we talked about last week. That I’m depressed. That I wouldn’t judge myself so harshly if I were on crutches and needed help. Intellectual–Emotional Role Plays This technique, also called “point–­counterpoint” (Young, 1999), is usually employed after you have tried other techniques, such as those described in this chapter. It’s particularly useful when clients say that intellectually they can see a belief is dysfunctional but that emotionally or in their gut it still “feels” true. You first provide a rationale for asking clients to play the “emotional” part of their mind that strongly endorses the dysfunctional belief, while you play the “intellectual” part. Then you switch roles. Note in both segments you and clients both speak as the client; that is, you both use the word “I.” Judith: It sounds from what you’re saying that you still believe to some extent that you’re incompetent. Abe: Yeah. Judith: I’d like to get a better sense of what evidence you still have that supports your belief, if that’s okay. Abe: Sure. Cognitive Behavior Therapy: Basics and Beyond

Judith: Can we do a role play? I’ll play the “intellectual” part of your mind that intellectually knows you’re not incompetent through and through. I’d like you to play the emotional part of your mind, that voice from your gut that still believes you are incompetent. I want you to argue against me as hard as you can, so I can really see what’s maintaining the belief. Okay? Abe: Yeah. Judith: Okay, you start. Say “I’m incompetent because . . . ” Abe: I’m incompetent because I lost my job. Judith: No, I’m not. I have a belief that I’m incompetent, but I am reasonably competent most of the time. Abe: No, I’m not. If I were truly competent, I would have done really well in the job. Judith: That’s not true. I didn’t do well on the job because my boss changed my responsibilities and didn’t train me well enough. Abe: Well, Emilio had done well in inventory. That shows I was incompetent. Judith: That’s not right either. Emilio had strengths in the skills needed for inventory, and I had other strengths. The worst thing you can say is that I was incompetent in doing inventory. But I am competent in lots of other things. Abe: But I haven’t been acting very competently in the last year or two. Judith: That’s true; though as my depression has gotten better, I’ve been acting a lot more competently recently. Abe: But a truly competent person wouldn’t become depressed in the first place. Judith: Actually, even truly competent people get depressed. There isn’t a connection between those two things. And when truly competent people get depressed, their concentration and motivation definitely suffer, and they don’t perform as well as usual. But that doesn’t mean they’re incompetent through and through. Abe: I guess that’s true. They’re just depressed. Judith: You’re right, but you’re out of role. Any more evidence that you’re completely incompetent? Abe: (Thinks for a moment.) No, I guess not. Judith: Well, how about if we trade roles now, and this time you be the “intellectual” part who responds back to my “emotional” part? And I’ll use your same arguments. Abe: Okay. Judith: I’ll start. “I’m incompetent because I because I lost my job.”

Modifying Beliefs

Switching roles provides clients with an opportunity to speak with the intellectual voice that you’ve just modeled. You use the same emotional reasoning and the same words that they used. Using their own words and not introducing new material help clients to respond more precisely to their specific concerns. CLINICAL TIPS If clients are unable to formulate a response while in the intellectual role, you can either switch roles temporarily or come out of role to discuss the stuck point. As with any belief modification technique, you will evaluate both its effectiveness and the degree to which clients need further work on the belief. You do so by asking clients to rate how strong their belief is before and after the intervention. Many clients find the intellectual–­emotional role play useful. A few, however, feel uncomfortable doing it. As with any intervention, the decision to use it should be collaborative. Because it is a slightly confrontational technique, take special note of clients’ nonverbal reactions during the role play. Also take care to ensure that clients do not feel criticized or denigrated by the elevation of the intellectual part of their mind over the emotional part. Historical Tests Modifying dysfunctional beliefs by reframing relevant current experience or using current material as examples is sufficient for many clients. Others benefit from discussing how and when a negative core belief originated and became maintained and why it made sense for the client to believe it at the time. Maria’s belief that she was unlikeable stemmed from childhood. I asked her, “What memories do you have in which you believed you were unlikeable? Let’s start with your elementary school years, so when you were about 6 to 11.” Next, I asked her for relevant memories when she was an adolescent. (She didn’t have any pertinent memories as a very young child.) Then we used Socratic questioning to reframe the meaning she put to each of these experiences. Finally, I asked Maria to record a summary of her new understanding of herself from the most salient time periods. Here’s what she concluded about elementary school: “I was basically likeable. I had a best friend, and I was friendly with some other girls. I was bullied by a group of kids who picked on people to make themselves feel superior. That says something negative about them but not about me.” I asked Maria to read this therapy note every day. Cognitive Behavior Therapy: Basics and Beyond

Restructuring the Meaning of Early Memories To modify the meaning of significantly negative events (from childhood or later) at the emotional level, some clients may also need experiential techniques in which they “relive” the experiences in session with you and, in the presence of significant affect, use role play or imagery to reframe the meaning at the emotional level. (See Appendix D.) SUMMARY Strengthening adaptive beliefs and restructuring maladaptive beliefs require consistent, systematic work over time. Techniques applicable to restructuring automatic thoughts and intermediate beliefs may be used along with more specialized techniques oriented specifically toward core beliefs. Additional strategies to modify core beliefs can be found in multiple sources, including J. S. Beck (2005), Beck and colleagues (2015), McEvoy and colleagues (2018), Pugh (2019), and Young (1999). REFLECTION QUES TIONS How can you strengthen adaptive beliefs and modify maladaptive beliefs? How do beliefs become strengthened over time? PRACTICE EXERCISE Imagine that you have a core belief that you are inferior, unlovable, or worthless. Think of a corresponding adaptive core belief and fill out the Belief Change Worksheet.

Modifying Beliefs