Cognitive Beliefs

What are cognitive beliefs?

• convictions held as true

• influence and influenced by occupational, personal, and environmental factors

• OTPs can address cognitive beliefs to positively influence occupational participation and performances

• ex. the principle of hope in the recovery process, perceived locus of control

Theoretical Assumptions about Cognitive Beliefs

1. deeply held core beliefs influence our thoughts, emotions, behavior, and physiological arousal

2. beliefs and their dynamic interaction with behavior, emotions, physiological states, and the environment comprise human functioning

3. beliefs are instrumental in how we perceive, appraise, and attach meaning to information from ourself and the environment (our beliefs are our filter)

4. beliefs that are true or held to be true often act as self-fulfilling prophecies

5. beliefs develop from childhood through adulthood

6. beliefs affect relationships, group affiliations, and society, and these social contexts also affect beliefs

Levels of beliefs

• Automatic thoughts: surface level, spontaneous, flexible, situational, arise from core beliefs

• Assumptions/rules for living: intermediate assumptions, values, conditional rules, arise from core beliefs

• Core beliefs or schemas: deepest level, templates of absolutes about self, others, or the world; rigid; global

Exist in a dynamic feedback loop where core beliefs generate intermediate and surface level thoughts, and intermediate and surface level thoughts reinforce core beliefs

Depression and cognitive beliefs

• cognitive triad of negative beliefs

  • self

  • the world or environment

  • the future

• may lead to a pessimistic world-view, self-deprecation, unpleasant feelings, maladaptive behaviors

Anxiety disorders and cognitive beliefs

• beliefs tend to focus on threats and catastrophic interpretations of situations

• intolerance of uncertainty model

• in ocd, distorted beliefs lead to inflated responsibility for negative events and need for control

• in ptsd, distorted beliefs center around self-blame

Eating disorders and cognitive beliefs

• distorted beliefs about self and eating

• emphasis on appearance and eating habits on self-worth

Substance use disorders and cognitive beliefs

• anticipatory beliefs: expectation of reward

• relief-oriented beliefs: using will alleviate discomfort

• facilitative beliefs: permissive in spite of potential consequences

Schizophrenia and cognitive beliefs

• defeatist beliefs

• self-stigma

Cognitive beliefs and stigma

• stigma is rooted in personal and public beliefs

• experiencing stigmatized beliefs from others and/or holding stigmatizing beliefs about oneself may hinder recovery

• restructuring beliefs about mental illness to focus on hope and the ability to live a successful, meaningful life can support recovery

Assessing structured cognitive beliefs

• Pain self-efficacy questionnaire

  • for adults with chronic pain, 10 item likert scale survey measuring confidence in ability to perform daily tasks with pain

• Self-efficacy gauge

  • for adults with occupational performance dysfunction

  • 27-item likert scale survey measuring confidence to perform occupational performance tasks

Assessing semi-structured cognitive beliefs

• socratic questioning

• dysfunctional thought records

• TIC-TOC

• ABC

Cognitive Belief-Oriented Practice Models

• Cognitive behavioral therapy: thoughts create feelings, feelings create behavior, behavior reinforces thoughts

• Acceptance and commitment therapy: acceptance, cognitive defusion, being present, self as context, values, commitment

Cognitive Behavioral Therapy (CBT)

Assumes that cognitions and beliefs are accessible and can be evaluated, monitored, and changed to improve how we feel and behave

CBT is effective in:

• reducing anxiety

• improving mood and reducing relapse rates in bipolar disorder

• decreasing symptoms of depression

• targeting underlying pathology associated with eating disorders

• substance use treatment, particularly when combined with motivational and skill-building approaches

• addressing some aspects of functioning in schizophrenia

Cognitive Restructuring: Socratic Questioning

• open-ended, guided questions that avoid interpretation

  • informational questions

  • questions that reflect empathetic listening

  • questions that draw the client’s attention to relevant information

  • analytic or synthesizing questions

Cognitive Restructuring: Guided discovery

• process between client and therapist that leads to uncovering information about and options for addressing an issue

Cognitive restructuring: TIC-TOC

• focuses on identifying and reframing cognitions that interfere with tasks (task-interfering cognitions —> task- oriented cognitions)

  • identify task-interfering cognitions (TICs)

  • identify the associated thought distortions

  • reframe to task-oriented cognition (TOCs)

Cognitive restructuring: Self-Talk and Affirmations

• self-talk is the process of talking to oneself out loud or through inner dialogue

• positive self-talk can be done in the form of affirmations, written statements, or oral statements that reinforce something as true

Cognitive restructuring: thought records

• worksheet to organize and evaluate thoughts, beliefs, and emotional responses during distress

• may help to challenge cognitive distortions

  • all or nothing: viewing situation as black or white

  • magnifying or minimizing: exaggerating things way out of proportion or assuming things are less important than they are

  • catastrophisizing or fortune-telling: arbitrarily predicting the worst case scenario without considering what is most likely to occur

  • mental filter: focusing only one the negative and ignoring the positive

  • emotionalizing or emotional reasoning: presuming feelings as facts and ignoring evidence to the contrary

  • personalizing: blaming self for everything even without evidence

Cognitive restructuring: Coordinated Anxiety Learning and Management (CALM)

• model for treating anxiety in primary care settings

• 8-week computer-guided program with educational videos, opportunities to practice new skills, and homework

Cognitive restructuring: Ellis’s Rational Emotive Behavior Therapy (REBT)

• Core tenet: irrational beliefs about how things “must” and “should” be for people to be happy actually lead them to make themselves miserable

• participants first identify, evaluate, and challenge irrational beliefs, and then restructure and replace these beliefs using a graded approach

• ABC model:

  • Activating event

  • Irrational Beliefs

  • Emotional and behavioral consequences

Behavioral Experiments

• collaborative strategy where client has opportunities to test thoughts, attitudes, beliefs, and behaviors

• involves developing a hypothesis, predicting the outcome, engaging in the behavior, evaluating results, and revising beliefs and behaviors

Behavioral Activation and Activity Scheduling

• inactivity/avoidance may result from negative beliefs

• behavioral activation aims to increase activity, counteract avoidance behavior, increase access to positive resources

• may include activity scheduling like making a list, chart, or calendar of activities to increase commitment and engagement

Self-monitoring

• a self-regulatory or self-management process that involves attending to aspects of one’s beliefs, emotions, or behaviors

• may involve tallying frequency or rating degree of pleasure associated with the belief or behavior

• use this information to guide participation

Acceptance and Commitment Therapy (ACT)

• falls under the CBT umbrella

• uses a variety of strategies to address cognitive beliefs

  • become “unstuck” from rigid cognitive beliefs

  • reduce experiential avoidance

  • act in alignment with personal values

• focus on increasing psychological flexibility by helping individuals change their relationship with difficult thoughts and feelings (rather than eliminating them) so they can take meaningful action in the context of their life and values

The ACT triflex model of psychological flexibility

• Be present

  • self-as concept

  • commited action

• Do what matters

  • values

  • acceptance

• Open-up

  • defusion

  • contact with the present moment

ACT: Core processes

1. Acceptance: I can approach problems instead of avoid them

2. Cognitive Defusion: It is just a though, let is pass

3. Contact with the present moment: focusing on and engaging fully in whatever I am doing

4. Self-as context: what am i thinking and doing?

5. Values: what do i stand for? what is important to me?

6. Committed action: i can do what matters to me, even if it is difficult

ACT interventions: Ways of speaking

• But vs. And

• Want vs. Willing

• I’m having the thought…

• Thanks, mind!

ACT interventions: defusion metaphors

thoughts are like leaves and sticks floating down a stream, you don’t have to dive in, you can watch from a bridge

thoughts are like guests entering a hotel, you can be the doorman, you greet the guests, but you don’t follow them into their rooms

ACT interventions: mindfulness

• observing anxiety with mindfulness and compassion

  • recall a situation where you experienced significant anxiety

  • now imagine you are looking at yourself 10 years in the future

• Five sense exercise

  • notice 5 things you can see, 4 things you can feel, 3 things you can hear, 2 things you can smell, 1 thing you can taste

ACT interventions: values clarification

• Life deviation

  • rank valued life domains from 1-10 based on importance and fulfillment

  • subtract the fulfillment score from the important score to find the deviation

• birthday party speech

  • imagine its your 80th bday, all the people you care about have prepared speeches

    • what do you hope they say about you, what do you hope is remembered about you, what kind of person do you want to be in their eyes, what values do these reflections reveal

• Reflect: how do your current behaviors and goals align with these hopes and values?

Social Learning Theory

Considers how environmental and cognitive factors interact to influence human learning and behavior

Mastery Experiences

• performance successes and accomplishments help increase self-efficacy

• low self-efficacy beliefs can be compounded by difficulties with problem-solving, coping, assertiveness, and stress management

• need to understand strengths and deficits in addition to clients’ belief about their strengths and deficits to guide treatment planning

Vicarious Experience

gaining experience or knowledge from someone else

Social Modeling

witnessing other people perform tasks, achieve goals, and express related beliefs

Social Persuasion

direct encouragement from someone else

Psychoeducation

• process of teaching relevant psychological principles, knowledge, and skills

• can include information about cognitive beliefs and why modifying distorted beliefs can improve mental health and behavioral problems

• can utilize a didactic approach, workbooks, or reading materials

Homework

• doing assignments outside of sessions

• encourages clients to apply, practice, and supplement what is addressed in therapy

• might include data collection, reviewing materials, practicing skills, carrying out activities, planning for next session

Metacognitive Demands

• cognitive restructuring requires the ability to reflect on one’s thinking, identify and evaluate one’s beliefs, differentiate between beliefs and reality, and consider the influence of beliefs on feelings and behavior

• for people with difficulty employing metacognition, behavioral or social cognitive strategies may be more effective

Cultural considerations

• CBT research has primarily focused on European American perspectives and assumptions

• many beliefs and behaviors are rooted in culture

• the more we understand a client’s cultural beliefs and behaviors, the better we can support effective and meaningful change