CBT Exam 2

Core Belief

• Core Beliefs are:

  • Fundamental

  • inflexible

  • absolute

  • generalized beliefs

• Core beliefs:

  • The central ideas about self and the world

• Inaccurate or unhelpful core beliefs can have a profound effect on a person’s self-concept, sense of self-efficacy, and continued vulnerability to pathology

• MOST CENTRAL, FUNDAMENTAL BELIEFS ABOUT OURSELVES, OTHERS, AND THE WORLD

  •  Absolute and rigid beliefs (+ or ‐) in 1‐2 words

  • example: “I’m worthless.”

• May result in biases in attention, information processing, and memory. Not necessarily accurate or helpful

Intermediate Beliefs

• Attitudes, rules, or assumptions

• Stem from core beliefs

• Fuel automatic thoughts

• Examples of dysfunctional intermediate beliefs:

  • “To be accepted, I should always please others.”

  • “I should be excellent at everything I do to be considered adequate.”

  • “It is best to have as little as possible to do with people.”

Schemas 

• ways in which we view the world that are acquired over time

• rules that give us shortcuts

• Deep-rooted, cognitive frameworks that organize our beliefs, memories, and emotions about ourselves and others

• Schemas are more flexible, and core beliefs are rigid

• Schemas are shortcuts related to how we developed core beliefs

Why Modify Core Beliefs?

• Adds flexibility/sense of self-kindness to a patient’s rules/assumptions

• Decreases likelihood unhelpful or inaccurate automatic thoughts will be activated during stressful or challenging situations

• Decreases extremity of unhelpful information processing biases

• Core belief work is how we really attack automatic thoughts

How to identify core beliefs

• Few patients will be able to articulate their core beliefs early in treatment

• Automatic thoughts that provoke a great deal of affect have the potential to be core beliefs in and of themselves, or be a direct manifestation of a core belief

• Look for themes in thought records across weeks and situations to begin to identify core beliefs

• Be aware of common core beliefs for certain diagnoses

• Downward Arrow Technique

Downward Arrow Technique

Repeatedly ask about the meaning of situational automatic thoughts until you arrive upon a core belief, whose meaning is so fundamental that there is no additional meaning associated with it.

Modifying Core Beliefs Options

• Option 1: Operationalize the components that make up the core belief → define it. Make them aware. Often buy in when you came at belief together

• Option 2: Examine the Evidence → What supports/doesn’t.

  • Through information processing biases → they were probably only looking at data that supports core belief/discounting others 

• Option 3: Restructuring early memories → early memories have an effect on core beliefs. 

  • New perspective, not changing memories just looking at the memories in a different way than you had before

• Option 4: Advantages- Disadvantages analysis → we have new core belief and an old one. What are the advantages and disadvantages of both 

• Step 5: Behavioral Experiments →

  • For example, act as if your core belief is inaccurate and the new one is accurate

    • Ex: Smiling at strangers with social anxiety

• Step 6 Example: “Acting as if”

  • Specific type of behavioral experiment. Patients behave in a manner consistent with a new, healthier belief (even if they are not fully invested in the new belief) and evaluate the effects of this new belief

  • Questions: 

    • What were the effects on my mood (e.g., happier?, less anxious?)

    • How did others respond to me?

    • What negative consequences came from my acting “as if”?

    • What positive consequences came from my acting “as if”?

Cultural Responsiveness

• Cultural effectiveness (the what)

  • starting to recognize whether the treatments available are effective across cultures 

• Cultural humility (the how)

  • can’t all have cultural competence 

Cultural effectiveness is about acquiring knowledge and skills to interact effectively across cultures, while cultural humility is a lifelong, self-reflective process of examining one's own biases and power dynamics. Effectiveness is a goal with a focus on learning about others, whereas humility is a mindset focused on self-critique and continuous learning.

What is ACT?

• Acceptance and Commitment Therapy Action-oriented approach and related to CBT

• Clients learn to stop avoiding, denying, and struggling with their inner emotions

• Instead accept these feelings

• Developed in the 1980s by Steven Hayes, PhD

• "We as a culture seem to be dedicated to the idea that ‘negative’ human emotions need to be fixed, managed, or changed—not experienced as part of a whole life. We are treating our own lives as problems to be solved as if we can sort through our experiences for the ones we like and throw out the rest," Steven Hayes, PhD

ACT vs CBT

• CBT → goal: no symptoms, goals shaped from symptoms and therapy.

  • changing, disputing thoughts

• ACT → goal: valued life, individual values shape the goal, might not necessarily be symptom-free

  • accepting thoughts 

• both:

  • believe experiences come from maladaptive thought but how we go about dealing with these thoughts is different 

  • target improvement in life 

  • use behavior strategies, emphasize a collaborative relationship

  • have relationship building, didactic, experiential learning, behavioral intervention/activation, homework

  • focus on the present and future

Hexaflex!!

• Split into 2 chunks

• Acceptance and Mindfulness Processes

  • Contact with the Present Moment

  • Acceptance

  • Defusion

  • Self as Context

• Commitment and Behavior Changes

  • Contact with the Present Moment 

  • Values 

  • Committed Action

  • Self as Context

• all connected and move toward the goal of psychological flexibility

6 Components of ACT Forman and Herbert

1. Aims to increase psychological acceptance of subjective experiences (e.g., thoughts and feelings) and decrease experiential avoidance

2. Increase psychological awareness of the present moment

3. Teaches patients to defuse from subjective experiences, particularly thoughts

4. Decrease focus on and attachment to the conceptualized self

5. Values clarification

6. Committed Action

Experiential Avoidance

Avoiding internal experiences

Experiential avoidance (EA), or the unwillingness to remain in contact with distressing internal experiences along with the attempts to control or avoid distressing internal experiences, has been associated with a range of psychopathological symptoms across a range of clinical presentations of anxiety and fear

Creative Hopelessness

• You’ve tried just about everything to feel better, get rid of negative emotions, etc...

• “Gold medal” effort

• Could simply “try harder.” But how likely is that to work?

• What if your experience is valid? What if it won’t work because it can’t work?

  • Man in the Hole Metaphor

• It’s not about how hard you’re working if you’re working at the wrong thing

  • Tug of War with Monster

Man in the Hole

You’re stuck in a hole with the nicest shovel ever, but, that’s not the right tool to get out

Creative Hopelessness metaphor to increase buy-in

Control as the Problem

• Why do you keep trying to dig out

  • control/working hard works in other places (studying/practicing…)

  • it works for others

  • you are told it should work

  • It can often work in short term but not long term

• The implications of creative hopelessness:

  • Cognitive and behavioral strategies designed to control our internal experience are unlikely to be effective

  • Control strategies are limiting

    • if you focus too much on one thing, we miss other options that could work

Informed Consent for ACT

• have to be prepared to feel worse before you feel better

• might have some distress but ultimatley it’ll be good for your health and feeling betteryour

• it’s like going to the dentist 

Acceptance

• The alternative to controlling and fighting internal negative experiences is to accept 

• Chocolate Cake Metaphor 

  • The more I tell you not to think about something, the harder it is

• Negative reinforcement of experience avoidance 

• polygraph metaphor (gun to head, if you feel nervous, you will get shot)

  • How ridiculous it is to try to control our thoughts/feelings 

• The more you try to control, the more your brain is working and not doing other things

• manufacture joy → you can try to fight a feeling by telling yourself you’re not upset, but you won’t win

• Are you willing?

  • Not because you want or like it

  • Not because you’ve given up hope that it will get any better

  • But instead, to openly allow the momentary pain to end the long-term suffering?

• The hidden choices

  • Give up “direct control” of your thoughts and emotions to gain control of your life

  • Allow yourself to experience all emotions, so you can also experience “good” emotions

• Acceptance as the Alternative

Tug of War with a Monster

• creative hopelessness 

• our job is not to win tug of war → goal is to drop the rope, let go of the rope

• the monster might still be there, screaming on the other side but what’s the advantage of not holding the rope anymore? 

  • you can do something else, don’t have to focus energy on the rope

  • gives you the freedom to live a valued life, do things that don’t have to do with the monster 

Acceptance of Difficult Content

Giving up the control agenda means:

1. accepting the inevitability of distress; and

2. a willingness to experience that distress in the service of living a valued life

Psychological Acceptance

• The ability and willingness to endure/tolerate aversive internal experiences

• Learning to accept the presence of uncomfortable internal experiences

• Engaging in behaviors even when they produce internal discomfort

Willingness

• accept distress

• active, not passive 

• Is a choice (not a feeling/belief)

• an action (doing, not trying / a jump, not a step) 

• is always in the service of our goals / values and recovery (it’s not a resignation or giving up, it’s just a different strategy)

• The Scales Metaphor 

  • anxiety and willingness on different sides of a scale. We can’t control our anxiety but we can control our willingness 

  • if willingness is 0, your anxiety will never move. You can control your willingness and no matter what your anxiety will move 

• Willingness Worsheet

  • how willing were you throughout the week to experience certain psychological distress?

Can willingness alter the frequency/intensity of internal experiences?

• Short answer: Yes

  • In the long-term, in an overall average kind of way

• But, “rogue waves” and the inability to ever take away all negative feelings

  • Negative experiences are a part of your life

• We can tell clients this directly, but...

  • “trying to pick up the rope”

  • The second you see the goal as taking away your distress, it changes to a goal-focused agenda 

  • don’t want them to keep trying to control

Psychological Acceptance: Distress Tolerance

• Uncoupling

  • Converting “but” language into “and” language

• Willingness:

  • Transforming “only if” statements to “even if” statements

  • Pattern smashing

• Dealing with Dirty Distress

But/and

• Type of distress tolerance. Uncoupling exercises 

• both distress and action can exist at the same time

• Example:

  • I would eat all my meals and snacks today but I am afraid of gaining weight

  • I will eat all my meals and snacks today and I am afraid of gaining weight

Even if, only if

• Has to do with willingness

• Example:

  • I will get go to the social event only if I don’t feel too tired or depressed

  • I will get go to the social event even if I feel tired and depressed.

• once someone starts noticing how distress is impairing their ability to engage in other areas, they can start replacing it

Dirty Distress

• distress that you’re feeling distressed 

• the goal is to shed the 2nd layer of distress and get rid of judgement 

• clean distress”: experiencing the pure distress in the present moment

  • (“I’m sad, this is unpleasant”; “I am in pain”)

• “Dirty distress”:

  • additional feelings about your feelings (e.g. irritated about being sad - “I shouldn’t feel sad – I should just get on with it”).

Cognitive Defusion

• Getting distance

• Our minds are so smooth that we barely even notice it’s working...we get caught up in products of our thinking without noticing the process.

• You can think of this as the first part of Defusion in ACT – the idea of observing and separating from internal experiences

• We are so fused (stuck) with our thoughts, the fusion makes us believe they are true

• Recognizing that an internal experience is an internal experience, e.g., labeling and describing thoughts as thoughts, emotions as emotions, etc.

• Looking at internal experiences, rather than from internal experiences

• notice automatcity of thoughts → fast, happens all the time (Mary had a little … lamb)

Cognitive Fusion and Defusion

• cognitive fusion → you believe your thoughts

  • believing the literal contents of the mind, so one become fused w/ thoughts

• cognitive defusion → opposite, getting distance and separating yourself from your thoughts

  • “Disentangling people from their minds is one of the main aims of ACT”

Cognitive Defusion Exercises

• Observe, Describe, Balance

• Learning to get distance from and Label Thoughts, Feelings, and Physical Sensations

• Balancing Inner and Outer Wisdom

• Word Repetition → when you say the word over and over it loses it’s meaning. The word is just a word, we give it meaning

• Leaves on a Stream

Present Moment Awareness

• ACT & CBT are present and future focused

• nonjudgemental awareness of the present moment 

• A state of full, open, and non-judgmental awareness of your current experience—both internal (thoughts, feelings) and external (sights, sounds, sensations).

• The goal: To be fully engaged in what is happening right now, rather than being lost in rumination about the past or worry about the future.

How do cognitive defusion and present moment awareness work together

• Defusion helps you stop being swept away by your thoughts, and contact with the present is the result — a direct, sensory experience of here and now

• Shifting attention back to the present moment

• Ruminations can feel true, but our thoughts about life are not life. 

  • Our mind can tell us a mouse is a monster. Your mind can keep you safe, but it can also overreact 

Mindful Awareness Skills

• contact with the present moment linked with mindful awareness skills by using mindfulness to be present, engage senses, and observe thoughts and feelings in a nonjudgmental way,

• Observe, Describe, Balance: Increasing awareness of emotions, physical sensations, and thoughts

• shifting attention back to present

• Mindful Decision Making:

  • Each time you notice an external cue, stop and think so you can choose your behavior

  • Slowing the decision-making process can increase awareness and allow you to make more intentional choices 

  • Awareness of immediate experiences

  • Internal : thoughts, feelings, desires, hunger, cravings

  • “External”: sounds, sights, smells

  • Stop, think

Radical Acceptance

the practice of completely accepting reality as it is, without judgment or resistance, to reduce suffering

You’re not giving up hope but giving yourself strength toward it

It's not about approval or giving up, but rather acknowledging the facts without judgment, which then opens the door to finding a better way forward.

Self-as-Concept

• 2 sides 

  • Self as Content → problem 

  • Self as Context → solution

Self-as-Content

• The Story of Me

• Organized into cognitive networks coherent across time and situations

  • Well-elaborated

  • Multi-layered

• Once we have a story, we don’t like how it feels to be

• “wrong” about our story: e.g. cognitive dissonance

• When we take our stories about ourselves to be literally true, we guard and defend them WITH OUR LIVES.

• We work to construct our worlds in a way that confirms the truth of our self-labels.

• Like a documentary

  • our mind is telling you a story but the story is not you.

  • Usually true to a degree, but not the whole truth

  • Scenes are selected to maintain the truth and coherence of the story

Common treatment interfering conceptualized selves

• Over attachment to:

  • Illness as part of identity

  • Victimhood

  • Likability

  • Everyone else is the problem, not me

  • Busyness as a virtue

  • Caretaker roles

  • Success/things come easy to me

Self-as-Context

• This approach involves understanding that one's identity is distinct from thoughts and feelings, fostering a stable sense of self amidst changing internal experiences. This perspective helps individuals maintain a consistent sense of self-identity, even as their thoughts and emotions fluctuate

• The sense of self as perspective

  • You are a person separate from your story

  • Your story can and should grow and change over time

• Not threatened by aversive content

  • Facilitates willingness, compassion, intimacy

• Chess example

  • make space for both positive and negative pieces, but we’re not involved in the game/fighting. We don’t want to be stuck plaing ches,s but we want to be the chess board. I am more than any individual piece. 

  • We can invest time/effort in acting like the person we want to be instead of battling our thoughts and feelings 

Values

• Values 

  • What are the things important to you 

  • freely chosen

  • might be similar to you as the therapist, but it’s ok if they’re totally different

  • like CBT → you are the expert in yourself, only YOU can say what’s important to you 

  • Tombstone or 80th birthday

Values-Based-Decision-Making Skills

• Values-Based-Decision-Making Skills

  • Values Clarity

  • Building a Valued Life

  • Values-Based Decision Making

  • Values Awareness

  • Up Votes and Down Votes

  • Using Values to Address Negative Mood

  • Addressing Competing Values

Values-Based Decision-Making

• Behaviors as choices

  • Consider options/values/goals

  • Engage in behavior congruent with values

• If you rank values and recognize them, balance them, and understand how they shift, you can use your values as a framework for decisions

Up/Down Vote for Values

• Recognize that every decision you make is a vote up or down for your values

• Every decision goes toward (up vote) or against (down vote) for a value

• shift away from psychopathology, instead, how do we work toward life that we want 

Using Values to Address “Negative” Feelings

• Unpleasant feelings can be an important signal that we are about to make a decision about how to behave or act.

  • Negative feelings can be cues that we are going away from our values

• In this way, unpleasant feelings are an important cue that we should use a values-based decision-making skill.

• we let values lead our motivations

• we make decisions based off our values not our feelings 

Barriers to Living a Valued Life

• Why is it so difficult to engage in some behaviors, even when they are consistent with our values?

• you need to do the work, make decisions

• easy to become complacent 

Values Conflict

• 2 options: 

  • can integrate values

  • In other words, we don’t always have to choose one value over the other – we can live by both.

• can rank or prioritize values 

  • what’s more important in the moment 

  • Sometimes hard/impossible to make choice that is consistent with 2 values at the same time.

  • Consider which value is most important to act on (at the moment); prioritize that value

  • Don’t always default to same value!

Goals vs Values

• Values → directions

• goals → mile markers 

Committed Action

• Encourages taking concrete steps toward goals that are consistent with one's values, promoting perseverance and adaptability.

• Setting specific, values-driven goals and pursuing them despite obstacles, thereby enhancing overall life satisfaction and achievement

• Living in line with our values even when we have difficult thoughts and feelings

• Homework

• committed toward ACT even when raw and uncomfortable feelings can come up

• Coin example → pain on one side and values on the other. You don’t get to throw away just the pain. If you care about this, that means the times you stray from your values will hurt. Have to take pain with you to go toward the goal