Changing core beliefs

[MrFlyGuy]

Hi all,

I'm just your standard PGY-3 going through therapy training and wanted to bring up a therapy case I have (without any patient details). Basically the patient has core beliefs that stem from negative self-esteem ("I'm never going to be good enough." "I have to please everyone around so that they don't abandon me/I don't get fired"). What is your general therapeutic approach for changing core beliefs?

My struggle has been CBT has felt at times too rigid and almost boring to me but I think it might be because my patient presents thoughts that are actually true and there's no real cognitive restructuring that needs to be done. I would also like to hear from a psychoanalytical perspective as I've become recently curious about taking on a psychodynamic case.

- MrFlyGuy

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[Lexanoob]

I'm just a fourth-year but at a therapy-heavy training program with a psychoanalytic slant. I think the consensus is that in the end all of the various "types" of therapy all end up talking and doing the same thing but just with different starting principles/guidelines/frameworks. One of my supervisors mentioned that if they take experts of all the various types of therapy from CBT to psychodynamic, and have an observer try to figure out the method being used, people usually get it wrong.

The framework that I use a lot of psychodynamic having been really impressed by Nancy McWilliams book Psychodynamic Psychotherapy. She also is a contributor to the PDM-2 which kind of breaks down a lot of what she states in the book in more of a DSM-5 like format, and in one part, basically connects individuals "core beliefs" with defenses/ other patterns of thinking, and then suggests recommended ways of engaging with the patient therapeutically. This is kind of good intro and framework to start at, which was helpful before going into the original papers of various thought leaders if you're interested.

To share a bit of my thinking on this case (based on the very small snippet shared), and I think my style is more "eclectic," I wonder if this patient has/is dealing with a lot of issues around depressive/narcissistic/self-defeating personality structures/ ways of coping.
- I would try to understand more about where these beliefs came from, thinking that these beliefs helped them at some point in their life (likely early on) deal with difficult affects that they were experiencing in the world, and became continuously reinforced as they experienced life. However, now, in a different environment, these beliefs aren't helpful and might be leading to self-defeating behaviors. In discussing this and bringing greater understanding, a few of my patients have found greater self-compassion for themselves in this process which they found helpful.
- I would also be curious about what this belief or thought is helping them avoid/ what is missing. What emotion do they feel when they shared this thought, and what do you sense there is a lack of ability to access in certain emotions? (For example, maybe this patient is comfortable with feeling sad/anxious, but this may be because they are uncomfortable with feeling angry.) Emotions can be a tool that can help people see what they want and get what they want.

Anyway, I don't know if this is helpful, and can share more via PM if you'd like. I think psychodynamic therapy uses the relationship and therapist more explicitly as a "tool"/"therapy" to help the patient, as you're making a real connection with them!

 

[tr]

Hi all,

I'm just your standard PGY-3 going through therapy training and wanted to bring up a therapy case I have (without any patient details). Basically the patient has core beliefs that stem from negative self-esteem ("I'm never going to be good enough." "I have to please everyone around so that they don't abandon me/I don't get fired"). What is your general therapeutic approach for changing core beliefs?

My struggle has been CBT has felt at times too rigid and almost boring to me but I think it might be because my patient presents thoughts that are actually true and there's no real cognitive restructuring that needs to be done. I would also like to hear from a psychoanalytical perspective as I've become recently curious about taking on a psychodynamic case.

- MrFlyGuy

Wait what? Their core beliefs that "they will never be good enough/must please others to avoid being abandoned" are *true* according to you??? And don't require restructuring??

 

[MrFlyGuy]

Wait what? Their core beliefs that "they will never be good enough/must please others to avoid being abandoned" are *true* according to you??? And don't require restructuring??

Sorry, I should have worded that better. These aren't the conscious thoughts that she presents to me, they are more set beliefs that she herself unknowingly reinforces throughout her life.

When I say thoughts that are true some examples include, "my husband will freak out if I tell him how anxious he is making me." In the situation she presents to me I actually do believe that he would do this. Another example would be, "my step daughter is immature and lazy." From what she tells me that seems to be true but there is always two sides to every story but it's difficult for me to restructure that thought because it could be true?

 

[ObsequiousAplomb]

What did your psychotherapy supervisor say when you brought this up during supervision? It doesn't sound like this was one isolated hour, so it most likely would have been a topic for supervision on multiple occasions.

Given what your supervisor said when you mentioned this (several times, I imagine), what is leading you to seek second opinions from us?

 

[smalltownpsych]

Sorry, I should have worded that better. These aren't the conscious thoughts that she presents to me, they are more set beliefs that she herself unknowingly reinforces throughout her life.

When I say thoughts that are true some examples include, "my husband will freak out if I tell him how anxious he is making me." In the situation she presents to me I actually do believe that he would do this. Another example would be, "my step daughter is immature and lazy." From what she tells me that seems to be true but there is always two sides to every story but it's difficult for me to restructure that thought because it could be true?

Sounds like she is too anxious to say that he makes her anxious. Seriously though, I tend to think its important to help her start connecting the dots as to where these core beliefs originated from and opening up the layers of it and begin challenging them. Also, if she has such a passive stance, the process is going to be slower than what the CBT manuals would lead one to believe. She could be pulling for you to fix things and newer therapists get sucked into that rescuer/victim enactment pretty easily because we legitimately want to be helpful.

 

[surfguy84]

She could be pulling for you to fix things and newer therapists get sucked into that rescuer/victim enactment pretty easily because we legitimately want to be helpful.

I find myself falling into this trap at times. Any tips to avoid this, or what your approach is when the patient routinely presents as passive/woe is me?

 

[annoyedpsychiatrist]

I think the key is getting patients to discover the answers themselves as well as guiding them on cognitive flexibility by asking "why" and forcing the patient to elaborate and dig deep, rather than just overgeneralizing . This is pretty hard as an attending when you get around 20 mins for f/us to do brief therapy, so my therapy is mainly supportive and challenging cognitive distortions because self discovery isnt exactly easy in 20 minutes. If her step daugther is lazy, why does she feel that she is lazy? How does her perception of her stepdaugther influence her own thoughts/feelings and how does that relate to her? What is good enough? Who is good enough? How does someone obtain being good enough? What would YOU change about yourself if you could change three things? How would you go about changing these things? Why do you feel you need to change these things/what would these changes lead to? Guided self discovery

But im no expert at therapy, like some of the other people here. As an attending i find it harder to remember tidbits i learned in residency and probably should brush up on my CBT

 

[WisNeuro]

Well, first step is delineating automatic thoughts, intermediate beliefs, and core beliefs. There seems to be some conflating of all of these here.

 

[smalltownpsych]

I find myself falling into this trap at times. Any tips to avoid this, or what your approach is when the patient routinely presents as passive/woe is me?

Rogerian empathic reflections is one way. My trainee was doing a really good job of that in recorded session with this type of patient yesterday. By reflecting back some of the negative thoughts and beliefs, they will almost always begin to moderate or challenge them a bit and then you reflect that back to them. Then as you are dictating them about CBT works you have their own examples to illustrate. Good reflective listening skills are essential to implementation of most of our techniques and sometimes get a little glossed over as they are assumed to be there. Also, I have to be ok with their woe is me to an extent. Meeting the patient where they are at in the stages of change and using some MI techniques can also be helpful. When I find myself trying to convince them they need to or should do anything then i know I’m in the enactment. It literally happens almost every day. 😁 That’s when I recognize that I need to take a step back, slow down, and explore their thoughts and emotions about where they are at a bit more.

It is pretty tough because I am also very open about the process of psychotherapy and improvement and will be pretty directive about what would be helpful for them. I just have to make sure that there is space for them to do or not do things in their on time and assist them with it being their choice. I also try to stick with generalities more than specifics. For example, engaging in pleasurable activities is important and I will tell patients that. When the negative response is I can’t do anything, I resists the urge to suggest things to do or explain why they should do it. Instead I might ask if they used to do fun things and tell me more about those. I might also just reflect back the problem of you want to be less depressed or anxious or feel better, and part of that is doing fun things, but you aren’t able to see yourself doing anything.

 

[Bartelby]

Let's say "my stepdaughter is immature and lazy" is true. Okay, so what? Plenty of people have stepdaughters who are immature and lazy and yet are not clinically depressed or anxious. Having a lazy stepdaughter does not inevitably lead to anxiety or depression. So why does it in your patient's case?

You need to explore how your patient perceives the situation. Do they catastrophize, believing that because their 13 year old is a B-student that she will end up homeless? Do they view the situation in all-or-nothing terms, believing that their stepdaughter is all bad because she is not fully meeting their expectations? Do they filter the incoming information, ignoring many of the positive accomplishments their stepdaughter has achieved, or positives in their relationship? Do they engage in frequent mind-reading, viewing actions that may be benign as holding serious ill intent?

Most people have some seriously stressful experiences in their lives, and yet most people do not develop a mental illness in response to any given stressor. Part of your job as therapist is to empathize with and understand what are often very real stressful experiences, while avoiding colluding with the patient's hopelessness or helplessness around these issues.

 

[smalltownpsych]

Let's say "my stepdaughter is immature and lazy is true." Okay, so what? Plenty of people have stepdaughters who are immature and lazy and yet are not clinically depressed or anxious. Having a lazy stepdaughter does not inevitably lead to anxiety or depression. So why does it in your patient's case?

You need to explore how your patient perceives the situation. Do they catastrophize, believing that because their 13 year old is a B-student that she will end up homeless? Do they view the situation in all-or-nothing terms, believing that their stepdaughter is all bad because she is not fully meeting their expectations? Do they filter the incoming information, ignoring many of the positive accomplishments their stepdaughter has achieved, or positives in their relationship? Do they engage in frequent mind-reading, viewing actions that may be benign as holding serious ill intent?

Most people have some seriously stressful experiences in their lives, and yet most people do not develop a mental illness in response to any given stressor. Part of your job as therapist is to empathize with and understand what are often very real stressful experiences, while avoiding colluding with the patient's hopelessness or helplessness around these issues.

That stepdaughter issue stood out to me to and my immediate thought was the same. So? 😁
One thing I will add is that in that type of ”my problems are because of someone else”, I will often use the Columbo technique. “I’m confused, lots of people have annoying or worse step-daughters, why does her life problems bother you?” “I still don’t get it, help me understand how this relates to what you want to do in your life?” Depending on responses to this I might be very direct that it is easier to focus on wishful thinking that I would be happier of other people did things I wanted them to do as opposed to focusing on the harder work of changing themselves.

 

[surfguy84]

Depending on responses to this I might be very direct that it is easier to focus on wishful thinking that I would be happier of other people did things I wanted them to do as opposed to focusing on the harder work of changing themselves.

This is where I usually try to introduce the idea of radical acceptance. Seems to provide a different perspective for some that opens the door to improving their distress tolerance.

 

[watto]

I sometimes bring this list of codependent traits up with this type of patient - when they have some context for the type of work they need to do, the barriers they need to focus on, you get a straighter path to treatment:

• Feeling responsible for solving others' problems.
• Offering advice even if it isn't asked for.
• Poor communication regarding feelings, wants, or needs.
• Difficulty adjusting to change.
• Expecting others to do as you say.
• Difficulty making decisions.
• Chronic anger.
• Feeling used and underappreciated.

 

[tr]

Sorry, I should have worded that better. These aren't the conscious thoughts that she presents to me, they are more set beliefs that she herself unknowingly reinforces throughout her life.

When I say thoughts that are true some examples include, "my husband will freak out if I tell him how anxious he is making me." In the situation she presents to me I actually do believe that he would do this. Another example would be, "my step daughter is immature and lazy." From what she tells me that seems to be true but there is always two sides to every story

I think some of the terminology used in CBT can contribute to the misapprehension that positive reframing of negative thoughts/cognitive distortions requires a rejection or repudiation of the thought.

Many negative thoughts have some kernel of truth to them. It's not helpful to try to convince the patient that they are 'false.' I prefer to present it as, is this thought pattern helpful to you or harmful? If it is not helping you, can we find another way to think about it that is more helpful? Some negative thoughts can be repudiated, but others can be reframed in other ways.

"My stepdaughter is immature and lazy" isn't a statement of fact, it's just labeling (i.e. a nicer word for name-calling).

https://arfamiliesfirst.com/wp-content/uploads/2013/05/Cognitive-Distortions.pdf

What are the specific behaviors that bother your patient about her stepdaughter? Why might she be behaving that way? How does framing the stepdaughter as "immature and lazy" help the patient in her own life? Is there another way she could frame/react to her stepdaughter's behaviors that might have a more positive result?

but it's difficult for me to restructure that thought because it could be true?

Hold on there. Are you trying to restructure the thought *for* the patient? That's not usually helpful. The patient needs to work on restructuring their own thought for the exercise to be useful. It's always more effective for one to convince oneself of something new. Restructuring the thought yourself and then presenting it to the patient just invites an automatic rejection.

 

[tr]

Sorry, I should have worded that better. These aren't the conscious thoughts that she presents to me, they are more set beliefs that she herself unknowingly reinforces throughout her life.

When I say thoughts that are true some examples include, "my husband will freak out if I tell him how anxious he is making me." In the situation she presents to me I actually do believe that he would do this. Another example would be, "my step daughter is immature and lazy." From what she tells me that seems to be true but there is always two sides to every story but it's difficult for me to restructure that thought because it could be true?

Negative thought: "My husband will freak out if I tell him how anxious he is making me"

Distortions: Mind-reading, fortune-telling

Possible reframes: (**Patient should come up with reframe. Not therapist**)

- My husband cares for me and doesn't want to see me anxious. At the same time, some of his behaviors really do make me anxious. Perhaps he and I can discuss this problem and find a better way for both of us to react

- Actually last time I revealed my anxiety he was very understanding, so I think he has the capacity to understand my concern and be helpful

- My husband has his own worries and sometimes we interact in ways that amplify each other's anxieties. We might both be better off if we find ways to manage our anxieties individually instead of feeding them to each other

- What does it mean to "freak out"? ("Freak out" is broadly pejorative and not very descriptive. Getting more specific about what the response is and why it bothers her may help the patient to contain her own reaction)

etc.

 

[tr]

That stepdaughter issue stood out to me to and my immediate thought was the same. So? 😁
One thing I will add is that in that type of ”my problems are because of someone else”, I will often use the Columbo technique. “I’m confused, lots of people have annoying or worse step-daughters, why does her life problems bother you?” “I still don’t get it, help me understand how this relates to what you want to do in your life?” Depending on responses to this I might be very direct that it is easier to focus on wishful thinking that I would be happier of other people did things I wanted them to do as opposed to focusing on the harder work of changing themselves.

Yes! It's so common for people to expect others to change to make them happy that I make a habit of addressing this issue right up front, during the Agenda Setting portion of the therapy. When we are setting a therapy goal I am always very explicit that the patient is the only one in the room with me and therefore we can only work on changing the patient's feelings, reactions, and behaviors. We cannot change anybody who is not in the room.

This sounds obvious but making direct reference to it during goal setting and again during the therapy as needed really helps keep things on track. The patient in the OP's example sounds like she might be doing a lot of Other-Blame, which suggests it could be useful to make this point more explicitly.

 

[tr]

I find myself falling into this trap at times. Any tips to avoid this, or what your approach is when the patient routinely presents as passive/woe is me?

It's important to constantly reiterate and reinforce to the patient that their reactions are their own choice and their own responsibility. You are just there as a guide to helping them get to where they want to be.

A passive/woe-is-me patient often has some underlying resistance to the stated therapy goal. This should be addressed explicitly, up front, ideally in the beginning of the therapy, but if you are already knee-deep and finding yourself engaged in this struggle where you are trying to convince the patient of something and they are resisting, you need to back up and return to Agenda Setting/identification of any underlying resistance.

This feeling of tug-of-war with the patient is a huge red flag that things are not going right, and it always means you need to let go of your end of the rope.

Here's a sample generic approach, but it really has to be tailored to the specific patient and their issue. But in general Agenda Setting follows the principles of Motivational Interviewing.

"It sounds like you are really unhappy with the way things are going in your life right now; and at the same time, there are some good reasons why you might not really want to change them. Is there anything [your negative thoughts] are doing for you? Are they helping you in some way? When you think about possibly changing them, is anything holding you back?"

 

[Candidate2017]

When I say thoughts that are true some examples include, "my husband will freak out if I tell him how anxious he is making me." In the situation she presents to me I actually do believe that he would do this. Another example would be, "my step daughter is immature and lazy." From what she tells me that seems to be true but there is always two sides to every story but it's difficult for me to restructure that thought because it could be true?

What difference does it make if the patient's statements are true or not? Why do you feel the need to change her core beliefs? How long have you seen this patient? Why do you assume to know her actual beliefs?

It takes a long time (for the patient, and you) to understand what kind of picture they are painting, in order for you (and the patient) to determine if that picture is accurate. The simple statement, "my husband will freak out if I tell him how anxious he is making me," has at least several components that will take at least one session each to unpack.

The goal is to help her help herself expound upon singular, offhand statements about her husband or stepdaughter. To get her to voice her opinions and fill in the blanks, while you throw in a question here and there as a reality check for her to hopefully reflect upon and find some truth.

 

[smalltownpsych]

Just wanted to say that I love some of the strong therapeutic wisdom and advice that I hear coming from this thread. One downside to more structured treatments such as CBT is that some of the more core aspects of therapeutic technique can get overlooked. Also, if you have a narrower focus of training or perspective then might miss strategies or ways of conceptualizing that will work best for you as a clinician.