Session aims

Conditional assumptions (rules for living)

Jon Wheatley & Sunjeev Kamboj CNWL & Royal Holloway

To consider the role of conditional

assumptions in cognitive theory and therapy

To provide some strategies for helping clients

identify & evaluate their assumptions

To encourage you to think about some of

your own assumptions (including assumptions about being a cognitive therapist!)

I. What are Conditional Assumptions?

Part of the artistry of cognitive therapy

consists of conveying a sense of adventure in unravelling & ferreting out the origins of the patients beliefs, exploring the meaning of traumatic events

Basic beliefs that predispose the person to

emotional disorder (Beck et al., 1979).

A psychological Achilles heel (Burns, 1980). The connective tissue between NATs & core

Beck et al (1990) Cognitive Therapy of personality disorders

beliefs (Fennell, unpublished)

II. What are Conditional Assumptions?

Implicit understandings we have about self, others

III. What are Conditional Assumptions?

Determine how a person organises

and the world. Abstract rules enabling us to get by. Rules can be designed to cover up perceived flaws

perceptions, sets goals & monitors progress towards them, evaluates & modifies their behaviour, adapts to their environment
Have the force of absolute commands rather

e.g. do everything perfectly to prevent being found out

Inform choice of safety behaviour e.g. social phobic might strive to appear perfectly confident in front of people Leave core beliefs unchanged

than desirable options (I must not I could)

A subsection of these may be dysfunctional

(unhelpful, counter-productive)

I. Examples of How Rules are Expressed

Value Judgements (It is terrible if I hurt people,

II. Examples of Unhelpful Assumptions

How might these be unhelpful? What sort of problems might they lead to?

make a mistake). Statements of contingency (If Athen B; Unless Athen B) e.g. Unless I succeed at everything then Im a failure. Drivers (Shoulds, Musts, Oughts) or else May affect both:

our behaviour (Duck out of challenges if possible) & the conclusions reached from that behaviour (That was lucky, they didnt find me out!)

If I dont fight for myself, then Ill be an easy target. If people see Im nervous, then theyll think Im pathetic. Unless I control my thoughts at all times, I am liable to go mad. I must give everything 100% all of the time or else I will fail.

I. Characteristics
Learned and abstracted. Often culturally reinforced (assumptions of the family, or wider society e.g. about mental illness). Idiosyncratic Often operate outside our awareness. Active in situations which evoke a sense of

II. Characteristics
Rigid/resistant to change. Associated with strong emotions. Excessive: overgeneralised, absolute,

extreme.
Dysfunctional: prevent the achievement of

goals and predispose the client to future difficulties.

vulnerability.

Differences between NATs & CAs 1

Automatic thoughts Situation specific Transient & momentary Variable content Many Relatively accessible via self-observation Conditional assumptions General rule Enduring & stable Constant content Relatively few Relatively inaccessible Observation + inference

Differences between NATs & CAs 2

Automatic thoughts Evidence based Negative impact Relatively swift change (minutes) Affect + Episode linked Conditional assumptions Value judgement Mixed impact Change takes weeks or months Affect ++ Persistent even when well

Levels of cognition: example 1

Negative Automatic Thoughts No-one will want to talk to me Underlying Assumptions If people meet me they wont like me If Im really nice to people, they might not notice how awful I am

Levels of cognition: example 2

Negative Automatic Thoughts I cant make a request or theyll get angry Underlying Assumptions I will be rejected if I put my own needs first

Core Belief Im inferior Core Belief Im unlovable

Process Issues
Assumptions are protective. Need for empathy. Convey a sense of a joint search. Can take several sessions to identify. Use the clients own language

I. Guidelines for Working with Assumptions

Work from problem maintenance towards

general background beliefs

Start with NATs: Less emotive so work with cooler material More immediate results (CT evidence base) A skill that is relatively easy to learn. Promotes meta-learning (Things arent always as I see them, change is possible). Time to develop relationship Valuable source of information

II. Guidelines for Working with Assumptions

Key ideas to communicate:

Therapy Aims
1. Help the client notice when the rule comes

on line.
Assumptions are not necessarily true (even if they feel true). Assumptions are learned and so can be unlearned. They can be evaluated and modified.
2. Explore ways in which the assumption is

unreasonable and unhelpful.

3. Formulate an alternative assumption. 4. Test out if the new rule is more helpful.

I. How to Elicit Assumptions

Direct statements

II. How to Elicit Assumptions

Downward arrow technique (see later) Themes arising across situations and

(But I couldnt do that because) NATs need observation only, UAs need observation + inference

Examine DTR for recurrent themes.

relationships.
Childhood memories and family rules.

(You have to laugh dont be a show-off)

Children might tune into rules that are never

Focus on a current situation: what rule

explains the feelings evoked?

Global evaluations of self and others. What is the client avoiding? e.g. If I do/feel/think that which Im avoiding, then.

put into words

Implicit expectations Notice what is praised/criticised Non-verbal communication e.g. smiles, frowns

Rules about emotional expression

If I talk about my feelings then Ill open the

Family rules (personal reflection)

As a child, what messages did you receive

floodgates & be overwhelmed

Theres no point crying over spilt milk

about how to behave?

Its best to keep a stiff upper lip maybe

throw yourself into your work?

What were you told you should & should not do? What were you punished or criticised for? How did others react when you were naughty or made mistakes? What were you praised or appreciated for? What family sayings or proverbs can you remember?

Downward arrow: some useful questions

What would it mean to you? Whats the worst that might happen? And then? And

Downward arrow technique: example

That was a terrible session we didnt get anywhere Supposing that were true, what would it mean to

then?
How would that be a problem for you? What are the implications of that? What does that tell you about what you expect from

yourself/others/life?
What does that tell you about what you should do or

be in order to:
- - feel good about yourself - - succeed in life - - be accepted/liked/loved by others

you? That the patient wont get better And if that happened, what would that mean to you? That I hadnt done my job properly And if that were true, what would it mean to you? That I was a lousy therapist And if that were true, what would it mean to you? It would show I havent really got what it takes. Sooner or later Ill be found out as a fraud

Deconstructing assumptions 1: Origins

Where did the assumption come from? What experiences in life contributed to

Deconstructing assumptions 2: irrationality

In what ways is the assumption

unreasonable?
How does it fail to reflect the way the world

forming it and keeping it going? Given the clients life experiences, what rules may they have developed? Good reasons: It probably made a lot of sense when you originally developed it but what about now? How do you feel when the rule works? Times of joy/elation. When do you feel best?

works, or go beyond what is realistically possible for an ordinary human being? In what ways are the rules demands excessive or exaggerated? BUT also need to ask what would be the risk of dropping this assumption?

Deconstructing assumptions 3: Pros & Cons

Pros - What are the advantages of believing the

Identifying assumptions Self reflection, then discuss in pairs

1. Reflect on personal assumptions that you

might have:

assumption? How has it helped you in life? What risks are you avoiding by hanging on to it? What would be the risk of dropping your assumptions? Cons - What are the disadvantages of believing this assumption? In what ways does it make life difficult for you? What areas of your life has it adversely affected? Would you recommend it to someone else? If not, why not?

From DTRs Look out for times that something hits a nerve or pushes your buttons Perhaps a problem that you have encountered so far during your CBT training?

Deconstructing assumptions 4: continuum work

1. Use diaries/Socratic method to identify the

Dual continuum (orthogonal)

Aim is also to help clients reduce absolute

all or nothing concept e.g.

thinking
Stages: 1. Clarify assumption 2. Identify dichotomous thinking 3. Tease out the relevant continuua 4. Devise dimensional continuaa that combine both N.B. Humour can be injected into this work!

100% success or total failure 100% in control or totally out of control

2. Illustrate this:

ALL or NOTHING & explore validity of this extreme view 3. Ask client for examples of differing degrees of severity, drawing up a continuum: ALL INTERMEDIATE NOTHING

Dual continuum Example 1: Perfectionism assumption

1. If I dont do everything perfectly then I am

Example 1: Perfectionism assumption Step 4: 2D charting of continuaa

PERFECTION 100%

worthless 2. This reveals both perfection & worth dichotomies SO step 3:

WORTH 0%

100%

0%PERFECT______________________100% 0% WORTH_______________________100%
0%

Example 2: Attractiveness assumption

1. Unless Im thin then I am unattractive 2. Thinness and attractiveness dichotomies 3.

Example 2: attractiveness assumption Step 4: 2D charting

Not fat

FAT 0____________________________100% ATTRACTIVE 0%__________________100% (NOT: Thin_____________________Unattractive)

Attractiveness

100

Very fat

Constructing new assumptions 1

Key Question:

Constructing new assumptions 2

New rules are often more lengthy & elaborate

What alternative rule would be more realistic & helpful to you?

(The opposite isnt always the answer)

than old ones

Helpful rules are more flexible,

allow you to respond to different challenges & circumstances

This is because they allow you to enjoy the payoffs of the old without its disadvantages They will be based on an adults ability to understand how the world works & to take different circumstances into account. Important to retain what the client values most But may capture the essence in a shorthand form

Goals & rules

Make a list of your main values & goals in life, e.g.

Working towards goals

What goals do you have?

to have a satisfying career to make the most of every experience etc

E.g. to feel more comfortable in social situations

Then ask yourself:

Does this rule help me to achieve these goals? Is this the best strategy for getting what I want out of life? What are the payoffs & disadvantages?

What underlying assumption might allow you

to do this?

E.g. that I dont have to be witty and smart all the time, that its okay to be a little anxious, etc

I. Re-evaluating assumptions
Identify someone who appears to have the

II. Re-evaluating assumptions

Using a loved one as a reference point.

same rule:

How accurate do you think it is for her? Do you agree with her rule? If not, how would you view it? What rule would you like her to have? How might this apply to you?

Would you want to pass this rule on to your children? If not, what would you prefer their rule to be? For example: Your child has failed an exam. Would you want him to see himself as a failure? What would you like him to believe? How could you help him see things differently? How could this apply to you?

III. Re-evaluating assumptions

Using a role-model/icon:

Creating flexibility my worth depends on what others think of me

Others judgements not always reliable (Hitler) Chocolate ice cream if someone doesnt

What rule might she have? Do you think her rule is accurate? How would you live life differently if you had this rule, too? How might this rule be relevant to you? What makes it OK for her but not for you?

like it, does that mean its bad? (i.e. you are
what you are, regardless of whether others like you)

How do you judge others close to you? Are

there days when you feel warm towards them & others when they drive you mad? What accounts for these differences?
(your mood & others behaviour influence judgements, opinions change day to day more helpful to judge actions rather than people)

Assumptions flashcard
I hold the belief that It is understandable that I hold this belief

Assumptions flashcard: example

I hold the belief that I must do everything to the

highest possible standard

It is understandable that I hold this belief because

because
The payoffs of obeying this rule are However the belief is unreasonable

because
It is also unhelpful because Given that I have held this belief for some

time, it will take time to change it. What I need to do is: (action plan)

as the oldest I was expected to set a shining example. The payoffs of obeying this rule are that I have achieved a great deal in my life However, the belief is unreasonable because noone could fulfil all its terms all & no-one is perfect It is also unhelpful because it sets an impossible standard that causes excessive stress, misery and sometimes poor performance A more helpful belief is I get pleasure from doing well thats fine. But Im only human & I sometimes make mistakes thats inevitable

Assumptions flashcard: action plan

Since I have held this belief for a long

IV. Re-evaluating assumptions

Acting as if:

time, it will take time to change. What I need to do is: Keep this card handy! Watch out for signs of stress (old ways) Use thought record sheet to deal with NATs Learn to say no practice! Delegate, at home & work Take time for myself (being not doing) Focus on what I achieve not what I fail to do

How might you benefit from acting as if you believe the new rule 100%? What might you do differently over the next week? What positive/negative things might happen? How could you manage these?

Overall aims
We are not aiming to get rid of unhelpful

Retrieval competition account of CBT

Brewin (2006) Perhaps CBT works not by

beliefs, but to:

getting rid of negative memories/beliefs, but:

Reducing the ease with which they are

Reduce their intensity Raise the threshold for their activation Recognise them when they come on-line Consider options (choice) about how to respond Internal attentional shift rather than belief change? (increased awareness) This is why we end therapy with blueprints

accessed
Providing alternative beliefs/memories (e.g.

discussions with my therapist, behavioural experiments) which compete with the original, less helpful beliefs Therapy as constructive rather than rationalist

Putting the B into CBT

Assumptions (rules for living) determine

Learning summary & action plan

behaviour So far have only considered verbal discussion techniques to increase flexibility Behavioural Experiments can be constructed (collaboratively) to test old assumptions or to evaluate new assumptions
To be continued

What was your experience on a personal level? What did you discover about yourself? Where would you like to take this? What could you do now? What was your experience at a professional level? What did you observe as a therapist? What did you learn about CBT practice? What were the practical implications for work with clients? (what? when? who/ how?)

Key references
Beck, J.S. (1995) Cognitive Therapy: Basics &

Acknowledgements
This workshop is prepared with acknowledgement to Dr Melanie Fennell and the Oxford Cognitive Therapy Centre Thanks also to Dr Sarah Corrie, CNWL

beyond. Guildford, New York (Ch. 10 & 11) Brewin, C.R. (2006). Understanding cognitivebehaviour therapy: A retrieval competition account. Behaviour Research and Therapy, 44,765-784. Fennell, M.J.V. (1989) Depression. In K. Hawton et al (Eds) Cognitive behaviour therapy for psychiatric problems. Oxford University Press For clients: Greenberger, D. & Padesky, C.A. (1995) Mind over mood. Guildford, New York (Ch. 9) Fennell (1997) Overcoming low self-esteem (Ch.7)