Chapter 8: Cognitive Beliefs
1. Introduction to Cognitive Beliefs
Definition: Refers to an individual's perspective and beliefs (optimistic/pessimistic) about themselves, others, the world, and the future.
Metaphor: "Glass half full or half empty" illustrates multiple ways to perceive, think, feel, and behave based on beliefs.
Occupational Therapy Context (Rosenfeld, 1997): An OTP's collaborative approach, focusing on a patient's negative thinking post-hip replacement, helped modify beliefs and improve mood, effort, and occupational performance through cognitive behavioral strategies.
2. Cognitive Beliefs and Occupational Performance
OTPF-IV Definition: "something that is accepted, considered to be true, or held as an opinion" (AOTA, 2020, p. 51).
Classification: A person factor residing within the client, influencing performance in occupations.
Affected by: Illness, disease, deprivation, disability, life stages, and experiences.
Influence: Along with values and spirituality, beliefs impact motivation for occupations and life meaning.
Identification: Should be part of the occupational profile, measured in performance analysis, and addressed in intervention.
Impact: Positively or negatively influence occupational performance and quality of life.
3. The Nature of Cognitive Beliefs
Core Assumptions (Box 8-1):
Core beliefs at a deep structural level influence surface thoughts, emotions, behavior, and physiological arousal.
Beliefs dynamically interact with behavior (including occupational performance), emotions, physiological reactions, and the environment to comprise human functioning.
Instrumental in perception, appraisal, and meaning-making of internal and external information.
Often act as self-fulfilling prophecies.
Develop from early childhood and continue throughout adulthood.
Affect relationships, group affiliations, and society, while social contexts also affect beliefs.
Levels of Beliefs (Continuum):
Automatic Thoughts: Surface level; words, images, self-talk reacting to situations; most accessible, flexible, situational.
Example (Poor Test): "I'm a failure" vs. "I did poorly because I didn't prepare."
Example (Job Rejection): "I am a loser" vs. "I didn't do my best, but now I have some experience."
Assumptions or Rules for Living (Intermediate): Conditional "if…then" format; easier to test; arise from core beliefs.
Example (Poor Test): "If I don't do good on a test, then I must not be smart enough." vs. "If I work hard, then I can be successful."
Example (Job Rejection): "If I get rejected, then I must not be good enough." vs. "If I keep preparing, then I will get a good job."
Core Beliefs or Schemas (Deepest): Fundamental philosophies, templates of absolutes about self, others, world, future; operate outside conscious awareness; rigid, entrenched, global.
Example (Poor Test): "I am incompetent" vs. "I am competent."
Example (Job Rejection): "I am incapable" vs. "I am capable."
Dynamic Relationship: Core beliefs generate intermediate and surface thoughts; surface thoughts offer a window to underlying rules and core beliefs; surface/intermediate thoughts reinforce core beliefs.
4. Dynamic Interaction of Beliefs
Interplay: Internal personal factors (beliefs, emotions, physiological states), behavior (actions, performance), and external environmental factors (contexts) dynamically influence each other (A. T. Beck, 1976).
Trauma: Can significantly challenge assumptions and rules for living.
5. Beliefs and Information Processing
Filtering: Beliefs, stored in memory, act as filters for perceiving, appraising, interpreting, and attaching meaning to information and experiences. This triggers emotional, behavioral, and physiological responses.
Determinant: How individuals perceive and process situations, largely determined by beliefs (often subconsciously), dictates feelings and actions.
6. Beliefs as Self-Fulfilling Prophecies
Nature: Beliefs are alternatives, not facts, but often carry the weight of facts.
Consistency: People seek consistency between life experiences and beliefs, often ignoring counterexamples.
Entrenchment: Verified beliefs become more entrenched, leading to self-fulfillment (e.g., Joe predicting a lousy day, acting irritably, and thus having one).
7. Development of Beliefs
Early Childhood: Infants absorb experiences from interactions, forming core beliefs/schemas (e.g., "You are dumb" vs. "You can achieve"), which shape personality and adult views.
Adulthood: Beliefs continue to form and change through family, role models, cultural values, trauma, spiritual orientation, and environments. Adults can modify or replace beliefs when no longer serving their needs.
8. Beliefs, Social Contexts, and Relationships
Reciprocal Influence: Humans function in various social contexts (family, friends, communities) that impart cultural, spiritual, political beliefs. One's beliefs also influence affiliations.
Example (Student Readers): Reader A (competent core belief) is excited and productive; Reader B (incompetent core belief) is anxious, overwhelmed, procrastinates, reinforcing the belief.
9. Cognitive Beliefs and Psychiatric Conditions
Cognitive Model (Aaron Beck, 1967): Emotions and behavior are influenced by distorted beliefs, information processing biases, and interpretations of experiences, creating vulnerability to disorders.
Substance Use Disorders: Beliefs strengthen urges and cravings.
Anticipatory: Expectation of reward (e.g., "Party will be a blast with booze").
Relief-Oriented: Assumption substance alleviates discomfort (e.g., "Drink will relieve stress").
Facilitative: Permissive view, acceptable despite consequences (e.g., "Just one won't hurt").
Tailored Interventions: Recognize individual differences in core beliefs due to contexts and person factors.
10. Cognitive Belief-Oriented Practice Models: CBT and ACT
10.1 Cognitive Behavioral Therapy (CBT)
Overview: Widely used and researched model for addressing cognitive beliefs.
Assumptions: Thinking/cognition (including beliefs) is accessible, evaluable, monitorable, changeable, and strongly influences behavior and emotions.
Focus:
Traditional CBT: Aims to restructure (alter) the content of dysfunctional thoughts, attitudes, and beliefs.
Belief-oriented CBT: Emphasizes theories and therapies that directly address beliefs.
Indicators of Change: Cognition and behavior are primary; emotions and physiological states are secondary.
Shared Principles with OT: Present-oriented, time-limited, solution-focused, person-centered, collaborative, grounded in theory and evidence, combines education/empirical processes, values meaningful activity.
10.2 Acceptance and Commitment Therapy (ACT)
Overview: Newer form of CBT (Steven Hayes), uses mindfulness and acceptance to address beliefs.
Philosophical Roots: Functional contextualism (behavior functions in context) and Relational Frame Theory (RFT - language based on contextual relationships).
Psychological Inflexibility: Rigid attempts to control discomfort, leading to experiential avoidance (avoiding thoughts/feelings) and being "stuck."
Difference from Traditional CBT:
Traditional CBT: Dysfunctional thought is the problem; attempts to restructure/alter thought.
ACT: Struggle with dysfunctional thought is the problem, not the thought itself; attempts to alter the person's relationship with thoughts.
Goal: Increase psychological flexibility (ability to contact the present moment fully, change/persist in behavior based on values).
Core Processes (Hexaflex): Six interconnected skills working through mindfulness.
Acceptance: Alternative to experiential avoidance; opening up to unpleasant feelings/sensations without struggling. It's an action, not resignation.
Cognitive Defusion: Taking a step back, looking at thoughts rather than from thoughts; recognizing thoughts as just words/pictures, not objective truths. Techniques: "I'm having the thought that…", singing thoughts, thanking mind, silly voices.
Contact with the Present Moment (Mindfulness): Full awareness of the here-and-now with openness and receptiveness; engaging fully in actions. "Dropping Anchor" exercise: Acknowledge thoughts/feelings (A), Come back into body (C), Engage in the world (E).
Self-as-Context: Recognizing oneself as the consciousness observing thoughts/feelings, not the content of them; a safe psychological space.
Values: How a person wants to behave/act; used for inspiration, motivation, guidance. Aligned with OT (values, beliefs, spirituality influence motivation). Greater consistency between values and actions leads to increased well-being.
Committed Action: Developing effective actions linked to chosen values; flexible action. Resembles traditional behavior therapy (graded exposure, goal setting).
ACT Triflex: Simplified core processes: opening up (acceptance, defusion), being present (contact with present moment, self-as-context), doing what matters (values, committed action).
The Choice Point: An ACT tool to map problems, identify suffering sources, and formulate ACT approach. Illustrates "away moves" (ineffective, values-incongruent actions) vs. "toward moves" (values-congruent actions).
11. Evidence for CBT and ACT
CBT: Extensive research supports effectiveness for anxiety disorders, bipolar disorder, depression, eating disorders, PTSD, substance abuse. Limited effect on schizophrenia symptoms, but may help specific functioning areas.
ACT: Growing evidence, over 1,000 randomized controlled trials. Effective for depression, anxiety, substance use, eating disorders, stress; improves quality of life, psychological flexibility, well-being, functioning, disability.
12. Assessment of Cognitive Beliefs (OT Perspective)
Approach: Individualized, collaborative, focused on identifying triggers and influence on behavior/emotions, and performance strengths/deficits.
OT Role: OTPs contribute valuable assessment information on occupational/skill performance, conduct task analysis, and provide training.
12.1 Structured Assessments
Psychometric Tools (Research Focused): Questionnaires, self-report inventories for validating constructs, identifying beliefs with diagnoses, evaluating outcomes. (e.g., PSEQ, COPM, Self-Efficacy Gauge).
ACT-Congruent Questionnaires: Measure psychological flexibility/inflexibility, experiential avoidance. (e.g., AAQ-II, BEAQ, MPFI, PIPS, CPAQ-R, BIPIS).
12.2 Semistructured Assessments
Clinical Utility: Incorporated into collaborative interactions.
Socratic Questioning with Guided Discovery: Series of open-ended questions promoting reflection and self-awareness.
Four Phases: 1. Informational, 2. Empathic listening/summarizing, 3. Drawing attention to relevant info, 4. Analytic/synthesizing questions.
Three-Question Technique: Guides reframing and discovery of helpfulness of beliefs (e.g., evidence for/against belief, alternative explanations, real implications).
Thought Records (J. S. Beck, 2011): Worksheet to organize/evaluate thoughts, beliefs, emotional responses (situation, emotions, automatic thoughts, distortions, alternative response, outcome).
TIC-TOC Technique (Burns, 1993): Identifies Task-Interfering Cognitions (TICs), thought distortions, and replaces with Task-Oriented Cognitions (TOCs).
Ellis's ABC Model (Ellis, 1994): Identifies Activating events (A), irrational Beliefs (B), and Emotional/Behavioral Consequences (C) of distress.
12.3 Unstructured Assessments
Real-time: Embedded within ongoing intervention, focusing on concurrent thoughts/beliefs as they arise.
13. Interventions to Address Cognitive Beliefs
Synergistic Approach: Integrates cognitive, behavioral, and social cognitive theories for effective outcomes.
Goal: Modify cognitive beliefs or the relationship with them, leading to different behaviors and self-enhancing beliefs.
13.1 Cognitive Restructuring with CBT Methods
A. T. Beck’s Cognitive Therapy: Collaborative reflection to revise/create new beliefs, testing with behavioral experiments. Relies on Socratic questioning and guided discovery.
Cognitive Distortions (Thinking Errors): All-or-nothing, magnifying/minimizing, catastrophizing, mental filter, emotionalizing, personalizing.
Thought Records: Worksheets to identify situations, emotions, automatic thoughts, distortions, and alternative responses.
TIC-TOC Technique: Identify tasks avoided, TICs, distortions, and reframe into TOCs (e.g., Estele's fear of falling).
Self-Talk and Affirmations: Positive self-talk (TOCs) and affirmations (written/oral statements confirming truth) to counteract negative self-scripts.
Ellis’s Rational Emotive Behavior Therapy (REBT): Based on ABC Model; challenges irrational beliefs about "musts" and "shoulds" that cause unhappiness.
13.2 Behavior/Learning-Oriented CBT Methods
Behavioral Experiments: Collaboratively test thoughts, attitudes, beliefs, and behaviors to discover validity.
Behavioral Activation and Activity Scheduling: Counter inactivity associated with negative beliefs by increasing positive reinforcement through engaging in scheduled activities.
Self-Monitoring: Deliberate attention to beliefs, emotions, behavior (recording frequency, ratings of mastery/pleasure). (e.g., Occupational Experience Profile, OEP).
13.3 Brief ACT Interventions (Core Processes)
Acceptance: Taught as an alternative to experiential avoidance; opening up to unpleasant experiences without struggling. "Tug-of-War" metaphor.
Cognitive Defusion: "Deliteralization"; seeing thoughts as thoughts, not objective truths. "Hands as Thoughts and Feelings" metaphor, saying "I'm having the thought that…"
Contact with the Present Moment (Mindfulness): Full awareness of the here-and-now. "Dropping Anchor" exercise (Acknowledge, Come back into body, Engage in the world) to stay grounded amidst emotional storms.
Values Clarification: Helping individuals identify how they want to behave/act; using a "magic wand" question to explore ideal life/behaviors.
Committed Action: Translating values into effective patterns of occupational engagement through goal setting, planning, skills training, graded exposure.
13.4 Self-Efficacy Beliefs and Performance (Bandura)
Social Cognitive Theory: Emphasizes social/cognitive factors, behavior, environment. Self-efficacy beliefs influence effort, persistence, feelings, success.
OT Intervention: Design interventions for occupational performance successes to raise self-efficacy; failures affirm dysfunctional beliefs.
Sources of Influence: Mastery experiences, vicarious experiences, social modeling, social persuasion.
13.5 Other Educational/Learning Methods
Psychoeducation: Teaching relevant psychological principles, knowledge, skills (e.g., concepts of cognitive restructuring, defusion) to facilitate self-management.
Homework: Assignments outside therapy (e.g., reading, data collection, behavioral experiments, defusion practice, activity scheduling) to apply and practice skills.
14. Other Assessment and Intervention Considerations
Metacognitive Demands: Cognitive restructuring requires reflective abilities. For individuals with metacognitive limitations or psychosis, behavioral strategies or ACT-based approaches may be more appropriate.
Culture: CBT research focused on European American perspectives. ACT is flexible for diverse cultural identities due to its focus on individual values and experiential nature.
15. Key Takeaways
Cognitive beliefs are internal and often held as true, developing from childhood in overlapping layers from surface thoughts to deep core beliefs.
These beliefs dynamically interact with emotions, physiological states, behavior, and social environments.
Distorted processing leads to dysfunctional, self-fulfilling beliefs.
Dysfunctional beliefs and the struggle with them are linked to psychiatric conditions and interfere with recovery.
CBT and ACT are evidence-based, OT-compatible approaches: CBT restructures thought content, while ACT changes the relationship with unhelpful thoughts to foster psychological flexibility.
Effective interventions integrate cognitive, behavioral, and social cognitive methods, requiring observable changes in behavior and cognition.
OT assessment should include cognitive beliefs to evaluate their impact on mental health, occupational performance, and participation.
OTPs can use various CBT and ACT interventions to address cognitive beliefs and achieve desired occupational performance outcomes.