Cognitive-Behavioral Therapy: Theory, Techniques, and Applications, 3rd Edition _ _____________________
C: I wouldn’t be happy. I wouldn’t get to catch up with friends and enjoy a night out. I would really like to go out with my friends. [Client’s face visibly brightens.] T: And how would you feel if you let go of that thought and instead were to go out? C: Better, relaxed, it would be nice to laugh a little. I might feel a little bad for my boyfriend, but I don’t think there’s anything wrong with me having some fun once in a while. Technique: Advice for a Friend Through this technique, the client is asked to put a friend in their position and to assume the friend is having the same thoughts that they are having. The client is then asked to give advice to the friend. Example: T: You had the thought, “I won’t recover from this divorce; I will be lonely forever,” and this made you feel depressed. C: Right. It’s been three years, and nothing has changed. I want to just give up trying and become a hermit some- times. T: What if Sandy [a friend the client has previously identified] were in your situation? Would you tell her to give up? C: No! Of course not. I’d tell her she’s pretty and fun to be around. Finding a companion just takes time. Technique: Thought Records (e.g., Beck et al., 1979; J. S. Beck, 2020) The therapist introduces the client to the concept of record- ing and addressing their thoughts on paper. Additionally, this record prompts the client to record the situation, emotion, and outcome associated with specific thoughts. This can be done using a template “thought record.” The therapist provides instructions on how to use the record and may assign comple- tion of the thought record as homework. See the Appendix for an example of a thought record. Techniques for Addressing Intermediate Beliefs Cognitive therapy typically begins by addressing automatic thoughts in an effort to produce some symptom relief, as automatic thoughts are situation specific and often easier to evaluate and/or change. It is often wise to ensure that the client can identify and challenge automatic thoughts success- fully before shifting the focus of therapy. Depending on the treatment plan, the next step may be to identify and address the individual’s intermediate/underlying beliefs to facilitate a shift in how the client perceives events. This produces more lasting change than is attained by attending only to automatic thoughts (J. S. Beck, 2020). Intermediate beliefs are not as easily modified as automatic thoughts but are more easily modified than core beliefs (J. S. Beck, 2020).
As mentioned earlier, intermediate beliefs comprise an indi- vidual’s attitudes, assumptions, and rules (J. S. Beck, 2020). For example, an attitude may be “It is awful to be vulnerable.” An assumption could be, “If I act tough, then I will be OK,” or “If I don’t act tough, then I will be hurt.” A rule may consist of “I should always protect myself.” Intermediate beliefs are often expressed using if-then statements, as well as “should,” “must,” and “have to” (Leahy, 2017). Once an intermediate belief is identified, the therapist must determine whether it should be addressed during therapy. Again, the key to answering this question will draw from the case conceptualization, the strength of the belief, and the degree to which the belief affects the client’s life. A sample of techniques that are commonly used to identify and modify intermediate beliefs, with illustrative examples, follows. Evaluating cognitive distortions is one of the most central techniques of cognitive therapy, and therefore techniques described earlier for identifying automatic thoughts can be used to address intermediate beliefs as well. Similarly, many techniques described here can also be used in identifying and modifying core beliefs. Technique: Recognize an Intermediate Belief Expressed as an Automatic Thought (J. S. Beck, 2020) Sometimes clients express automatic thoughts that are actually intermediate beliefs. Example: T: What did you think to yourself when your art project received the “C” grade? C: I should have done a better job on it [rule]. If I had worked harder, then I would have gotten a better grade [assumption]. Technique: Downward Arrow (J. S. Beck, 2020) The therapist guides the client to identify a belief underlying an automatic thought. This underlying belief may emerge as an intermediate belief or lead directly to a core belief, as illustrated in the example. Example: T: You were working out at the track and had the thought, “I’ll never win the competition.” If you would, please try to complete this sentence: “Losing the competi- tion means that. …” C: I’d look ridiculous. It’s just terrible to look ridiculous [attitude]. T: And, if you look ridiculous, then that would mean … C: I’m a terrible athlete. T: And if you are a terrible athlete, what would that mean about you? C: I’m a failure [core belief].
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