Topic 8: Core Beliefs & Behavioral Exposure {by 11/3}

[Core Beliefs] – Watch MDD-16: Core Beliefs – Identifying 2 – Core Belief Flowchart-Part A.  Answer the following: (1) In what way was the CBF-A effective in understanding how the clients’ core belief developed? (2) What additional historical information could have been obtained to understand the development of the client’s core belief?

 

[Behavioral Exposure] – There is one reading due this week (Volungis – 1 Chapter).  For this discussion, share at least two main thoughts: (1) Why is behavioral exposure very effective for certain disorders/types of distress?  (2) What are some cautions to consider when implementing behavioral exposure interventions?

 

Your original post should be posted by the beginning of class 11/3.  Have your two replies posted no later than 11/5.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

41 Comments (+add yours?)

  1. Amanda Bara
    Oct 31, 2022 @ 11:51:08

    The CBF-A technique was effective in understanding how the clients’ core belief developed by looking at past events and experiences. Looking into these past events and factors involved in those situations like emotions and thoughts show how the core belief is supported by Mark. Dr. V helps to establish certain individuals that have reinforced Mark’s idea that he is unlikable. Allowing Mark to talk about these individual’s and how they have developed negative thoughts towards himself in relation to events is helpful to see patterns with the core belief. Mark does a good job at identifying how events impact him. He was able to see that his parent’s divorce did not have anything to do with this belief however, his friendships over the course of high school and college definitely did. This technique helps to identify coping strategies in which Mark states that he tends to withdraw and treat others negatively. This has had an impact on his relationship with his girlfriend and progress at work. I found it particularly interesting how Mark struggled to find qualities that he liked about himself in the present. He mentioned that he used to be resilient and more accepting but is not anymore. He also talks about his big accomplishment in life being his college degree. This CBT-A really helped to bring out Mark’s view of himself in regards to relationships, situations, and personal qualities. This helps create a better case formulation and ways to formulate new core beliefs in future therapy sessions.
    Mark brings up certain topics that are important to dig into when understanding the development of his core belief. He mentions that he was an only child growing up and I am wondering how that played an impact on him making friends when he was younger. He also mentions that he never felt “popular” which is something that relates to his core belief of being unlikable. This is something that should be explored and the situations that have developed this idea. Mark specifically talks about how he was able to cope and deal with these thoughts better in high school and college. I am wondering if there is a specific event that has triggered him to cope negatively and what ways he finds it harder to cope now than he did previously. It is also crucial to identify the stressors in Mark’s life that could be impacting his relationships with others. In particular, his job is stressful to him and managing work with trying to establish relationships is daunting for Mark.

    Behavioral exposure is effective for certain disorders and types of stress because it specifically targets areas of distress. For individuals that have developed patterns of short-term relief from their anxiety and fears this technique helps to train the brain to process differently. Exposing someone to what they fear through behavioral exposure helps to identify the patterns of anxiety and how to cope with stress in the moment. Instead of avoiding situations that are going to cause an emotional or physiological reaction the rationale is to confront it head on. Knowing what situations cause distress and negative feelings or thought patterns is important in order to establish relaxation techniques. These techniques can help to manage the negative reactions and anxious distress. It is important to note that behavioral exposure should be used with caution. When putting client’s in the specific situations they fear or avoid there could be negative emotional or physiological reactions including panic attacks. Putting clients in these situations could be harmful for the therapeutic relationship therefore it is important to establish strong rapport with the client before implementing any behavioral technique. Because of the reactions that could arise with exposure it is important to proceed with caution and identify signs of extreme distress therefore there is no harm which would be ethically wrong for the therapist to do.

    Reply

    • Bekah Riley
      Nov 01, 2022 @ 10:54:14

      Hi Amanda,
      I really enjoyed reading your post this week! I really liked how you discussed how the CBF-A was effective in terms of how it helped to uncover where the client’s core beliefs developed. Specifically, you wrote about how helping the client identify who in his life first began to make him feel unlikeable or unwanted was very beneficial in seeing where these core beliefs developed. In watching the session myself, I think that feeling excluded by a close friend in high school as well as in college really contributed to the client carrying this belief that he is unlikeable into adulthood. In addition, I also agree that the client feeling “unpopular” since adolescence should be explored more in terms of how it has contributed to his core beliefs.
      Overall, great post!

      Reply

    • Yoana Catano
      Nov 04, 2022 @ 13:09:14

      Hi Amanda,
      I agree with you in the ability that Mark has shown to identify events that had an impact in his life. I thought at the beginning that his parent’s divorce was going to be significant for this event, but Mark did not consider as associated with it. It is good to see hot the collaborative work is presented in this video. Clients are experts in their own life and we provide the expertise in cognitive modification. Also, challenging Mark about finding qualities on himself, is a good way to start some modifications of his thoughts. Great post!

      Reply

  2. Bekah Riley
    Oct 31, 2022 @ 17:06:43

    This particular client has a few core beliefs around the idea that he is both unlikeable and unwanted in different social settings. When trying to be social by either asking coworkers out to lunch or reaching out to friends in hopes of spending time with them, this client finds himself feeling hurt and often withdraws from his daily activities upon being rejected. In addition, when this client puts himself out there and is rejected, that contributes to the formulation of his core belief around being unlikeable and unwanted. However, by using the Core Belief Flow Chart-Part A (CBF-A), Dr. V is able to gain a deeper understanding on how the client’s core beliefs really developed. To begin the CBF-A, the client responds to his feelings around himself, others and the world in terms of his core beliefs. He describes that generally he views himself as unlikeable or unwanted and occasionally feels that others perceive him that way. As the CBF-A continued, the client began talking about how his depression began in adolescence and one friend in particular, Dave, began to distance himself from the client after years of close friendship. The client identified that he began to feel unlikable as well as unwanted and felt similarly when his coworker Jeff turned down his offer to lunch then continued to go out with other coworkers. As Dr. V continued to go through the flowchart with the client, the client was able to identify that maybe his friendships began to end in high school and college because he is unpopular or unwanted by others. The client also talks about how he was able to process the loss of friendship going through college because he had other friends, but now he feels that the unlikable and unwanted feeling takes more of a toll in terms of how he really ruminates on this core belief. In addition, now living more independently in his adult life, the client finds it easier to withdraw. However, when asking what the client liked about himself in the moment, the client was able to identify that he is both dedicated and caring, despite his core belief. Moving forward, the client talked about questioning if he is doing a good enough job at work and ruminating on that even after leaving work. This may have formulated from the immense pressure the client’s parents put on him growing up. As the CBF-A went on, the client continued to identify that his core belief of being unlikeable, unwanted or even not good enough may have stemmed from this view of himself that formed early on in adolescence. Overall, the CBF-A was helpful in creating an in-depth conceptualization of where the client’s core beliefs began in terms of his experiences in adolescence and how being out of a college setting has led to him ruminating more in his core beliefs as well as withdrawing from his daily activities. Looking back on the session, I would have liked to obtain additional historical information on the client’s initial belief around being unpopular beginning in adolescence and how that has contributed to his core beliefs of being unlikeable and unwanted.

    In terms of different CBT techniques and interventions, when treating certain disorders or types of distress, behavioral exposure may be very effective. More specifically, behavioral exposure may be an effective intervention for a client struggling with anxiety and/or fear. For example, an individual with anxiety will tend to avoid the source or their distress, providing short term relief, but long-term detriment because they will not have developed needed coping skills to manage their distress. By implementing behavioral exposure, it allows the client to confront their source of distress, ultimately breaking a pattern of avoidance and helping clients develop needed coping mechanism to manage that distress. Confronting the source of distress may also be beneficial for clients who have specific fears that lead to patterns of avoidance. However, there are some cautions to consider when providing a behavioral exposure intervention. Specifically, exposing the client to their source of fear or distress may cause different negative physiological and psychological symptoms of distress, potentially increasing the client’s want to avoid such situations. In addition, if the client has a negative experience upon confronting their source of distress, it may turn them away from wanting to continue therapy with the therapist they were currently with or other therapists moving forward. That is why it is important to both build a strong rapport with the client as well as assess the client’s readiness to be exposed to their source of fear or anxiety before implementing behavioral exposure.

    Reply

    • NikkiAnn Ryan
      Nov 03, 2022 @ 14:36:39

      Hi Bekah,

      I think you did a great job thoroughly describing the thoughts and feelings that the client presented while going through the CBF-A. You highlighted a lot of the key points that were discussed during the session including some of the specific terms the client used such as not feeling “popular” and finding it “easier to withdraw” now that he lives independently compared to when he was living at school. These are really important factors to consider when thinking about his core beliefs as well as potential interventions. Great post!

      Reply

    • Tayler Shea
      Nov 05, 2022 @ 23:22:41

      Hi Bekah!

      Great post this week! I like how you started by describing Mark’s core beliefs that he is unlikable and unwanted. It was so interesting to see how well mark reacted to the CBF-A worksheet. I found it interesting how Dave made such a profound impact on Mark’s adult life. You did a great job understanding Mark’s thoughts and feelings before, during, and after the CBF-A. I think Mark has come a long way from where he started! I am also interested in if Mark’s beliefs on his popularity as a child contributed to his negative core beliefs as an adult.

      Reply

  3. Yoana Catano
    Oct 31, 2022 @ 23:48:38

    [Core Beliefs] The CBF-A was effective with Mark because it helped him to identify where his core belief came from considering historical events, as well as feeding events, with the intention to start developing more adaptive core beliefs. The events identified by Mark, are related to negative experiences in high school that brought all-or-nothing statements about himself, in this case, no one likes me, negative feelings, and negative automatic thoughts have developed from that. It is interesting how the CBF-A helps the client to associate events that are similar to the present event, how the responses (emotional and cognitive) are still present, and what validity comes with it.

    For additional historical information, I would like to have more information about family dynamics and how this core belief could have been reinforced by his family. Mark does not identify other events as big “traumatic” events, but it could have been small situations that could have validated his cognitive distortion of being unlikeable.

    [Behavioral Exposure] Behavioral exposure is very effective in anxiety disorders that are using avoidance as a coping response; this is because it comes from the CBT theory of negative reinforcement that maintains the behavior. To modify or break this pattern, it is necessary to diminish the avoidance by exposing the client to the specific situations they are avoiding, this anxiety will disappear if the cognitive anticipation and physical arousal that are future-oriented, turn into more reality-oriented. In the same way that cognitive distortions, such as catastrophizing, need to be moved from the extremes, the client’s behavior needs to be brought to a more functional response.

    Also, anxiety can come from processing negative experiences. Behavioral exposure is also a good technique for psychological trauma since the individual can gradually approach trauma-related memories, images, situations, etc.; the avoidance can be overcome by changing the avoidance pattern, with confrontation to the stimuli that are causing the anticipatory anxiety and that is relatively safe, such as dialogue about the negative event.

    However, it is important to be cautious when implementing behavioral exposure interventions. This technique is confrontational and needs to be achieved gradually, according to the client’s self-hierarchy of some of the most feared situations, graded in severity. In collaborative work, the client will provide information about what they fear and knowing the main goal is to face the most distressful event, even when the therapist should “push” the exposure to prove to the client that it is safe this confrontation, it needs to be under the client’s level of tolerance. The technique is not harmful by itself, but if utilized incorrectly could result in increasing the client’s anxiety and exacerbating the symptoms. Adequate training and ethical responsibility will guarantee the use of this technique as one of the most valuable to treat specific symptoms.

    Reply

    • Bekah Riley
      Nov 01, 2022 @ 11:05:41

      Hi Yoana,
      I thought you had a great post this week! I liked how you described that the client’s negative experiences with friendships in high school contributed to his all or none thinking about his peers not liking him, ultimately contributing to this core belief that he is overall unlikeable. I also think it may be beneficial to gain more information on the client’s family dynamic. In the session, the client talks about feeling a lot of pressure from his parents which may contribute to how hard he is on himself in terms of his relationships with others as well as his work performance. In terms of your description of behavioral exposure, I completely agree that it is not something a therapist and client can just jump right into; it is a gradual process.
      Overall, great post!

      Reply

    • Teresia Maina
      Nov 05, 2022 @ 21:00:59

      Hi Yoana,
      I enjoyed reading your post! I agree, learning more about Mark’s family dynamics could be helpful, especially since he was an only child of divorced parents. I was wondering if, due to these factors, his parents tried to “fix” the uncomfortable social situation. You did a great job discussing behavior exposure. When using behavior exposure, you need to be cautious about how the treatment progresses. You can’t start a client at the most challenging task. You need to start slow and build up as you progress. Great post!

      Reply

  4. NikkiAnn Ryan
    Nov 01, 2022 @ 22:14:36

    Using the CBF-A was helpful for gaining a greater understanding of the client’s core beliefs and how they developed. This client has been working on the core belief of being unlikeable. The CBF-A elicited information from the client about his thoughts, emotions, expectations, and behaviors during different points of his life from childhood to the present day. For instance, the client recalled a time when his college roommate began hanging out with him less and less and began attending other events, such as parties, with friends that the client may have hung out with previously. This event is very similar to another event the client recently discussed in therapy regarding his coworker who declined a request to hang out with the client due to having other plans and the plans turned out to be with coworkers with whom the client would have also hung out. This helps identify a pattern of events and thoughts that contribute to the development of the client’s core belief of being unlikeable. Completing the CBF-A also helped the client identify maladaptive coping strategies that he uses like withdrawing. It also helped him identify some of his positive attributes and what he likes to do, which provided a good opportunity to focus on some of the positive aspects of his life after reviewing some negative moments from his past. I think it may be helpful to follow up on the client’s thoughts about his parents’ expectations of him when he was younger. He mentioned that the expectation was for him to bring home As from school I wonder how much of that was his parents’ expectations and how much of it was the client’s perceived expectations based on the expectations he held for himself. This information may be helpful for understanding the development of his core beliefs. Additionally, it may be helpful to explore some of the other significant relationships from his childhood/adolescence outside of his parents, such as any significant teachers or coaches, and how that influenced his thinking patterns.

    Behavioral exposure is an effective technique for a variety of anxiety-related disorders such as agoraphobia, obsessive-compulsive disorder, panic disorder, and several others. This intervention is effective because it focuses on relieving anxiety-related distress and modifying the specific behaviors, particularly avoidance, associated with distress. Clients who are struggling with anxiety often avoid the source of their distress and experience an initial sense of relief due to their reduced anxiety. However, this comfort does not extend beyond the initial sense of relief because by avoiding the source of distress, they never learn how to cope with it and will continue to experience anxiety when confronted with the source of distress. Moreover, the client will also continue to experience negative automatic thoughts related to their avoidance and anxiety which further contributes to their distress. Behavioral exposure assists with breaking this cycle of negative reinforcement by helping the client learn skills to cope with the source of their distress in an organized, supportive environment, namely, with the therapist’s assistance. Although the client will initially experience heightened levels of anxiety and fear, these emotions will decrease with repeated exposures and the client will learn the skills to cope with their distress. Modifying the maladaptive behavior pattern will also modify negative automatic thoughts and ultimately decrease the client’s distress. There are some cautions to consider when implementing this type of intervention. For instance, it is crucial for the therapist to be aware that the client may initially experience increased anxiety and fear when exposed to the source of their distress and they should also communicate this to the client so that they know what to expect rather than jumping to conclusions about the intervention “not working.”
    Similarly, the client may experience an intense physiological response to the exposure. The therapist should help the client identify these responses, provide psychoeducation when necessary, and assist with implementing relaxation strategies. Notably, the therapist should develop a solid therapeutic relationship before implementing behavioral exposure interventions to foster the client’s sense of trust in the process and to provide support during these anxiety-provoking situations.

    Reply

    • Tuyen Phung
      Nov 04, 2022 @ 19:40:33

      Hi Nikkiann,
      I liked your idea of exploring the extent of the expectation of the client’s parents on him. He mentioned his parents’ high expectations of him, but there was no specific mention of what aspect of his life. This can bring a significant influence on his behavior like withdrawal. Regarding this, I also want to ask him about how his parents expected him in his relationship with other people. As you mentioned that you wanted to know how Mark had a relationship with other people like coaches and teachers, the way the parent expected him in his relationship with these people can influence his present behavior. Also, his parents’ attitude toward making friends can impact significantly his life, especially when he was the only child and had no siblings to interact with.

      Reply

  5. Ashley Torres
    Nov 02, 2022 @ 13:01:48

    The CBF-A is effective in understanding how the clients’ core belief develops because it examines times when the client has felt unlikeable. Giving the client an opportunity to reflect on historic events helped him realize his core belief started back when he was in high school. Mark was able to share his thoughts, emotions, and behaviors during times he felt his negative core belief. Mark mentioned his roommate in college started distancing himself and would go out without him. Here, Mark shared he was unlikeable and that’s exactly how he felt recently when his coworker rejected his request to go out and get lunch. As a result, the CBF-A helped the client understand what causes him to feel the old negative core belief. The client was also able to reflect on his behaviors after feelings of being unlikable like withdrawing from the rest of the group and shutting his door. The CBF-A also helped Mark recall positive experiences he’s had like being able to recover from a negative situation and earning a college degree. This is important to know because it proves that the client can cope with negative experiences and not ruminate about a core belief. Additional information I could obtain to understand the development of the client’s core belief is his relationship with his parents. Mark was expected to get good grades in school which could have put a lot of pressure on him. I would like to ask Mark how that felt and share other experiences where he felt he needed to live up to an expectation.

    Behavior exposure is effective for anxiety disorders because it helps alleviate anxiety related distress like fear. Behavioral exposure is very good at modifying avoidant behaviors because individuals who have anxiety, tend to avoid their stressor. As a result their anxiety continues because they are not learning how to manage their distress but rather running from the problem. This becomes a cycle that behavioral exposure can break and help elevate their distress. The clients will develop coping mechanisms when faced with their anxiety/fear that will alleviate their distress. Panic attacks and other psychological reactions should be considered when implementing behavioral exposure. Some clients may not be ready to participate in behavioral exposure and the therapist should work on building rapport and creating an environment they feel safe in. Having a negative experience with behavioral exposure will also discourage the client from trying further techniques. The client will also learn that they feel the most relief when avoiding the stressor.

    Reply

    • NikkiAnn Ryan
      Nov 03, 2022 @ 15:01:49

      Hi Ashley,

      I liked reading your post this week. I think you did a great job discussing behavioral exposure. I particularly liked the emphasis you placed on developing rapport and creating a safe environment for the client before implementing behavioral exposure methods. I think that you are right about how a negative experience with behavioral exposure may discourage the client from wanting to try the same or other techniques in the future, but building rapport can help mitigate this. Nice post!

      Reply

    • Patricia Ortiz
      Nov 04, 2022 @ 18:34:54

      Hi Ashley, I agree that we should be cautious when implementing behavioral exposure interventions, specifically with panic attacks and other psychological reactions, and should be considered when implementing the technique. I like how you mention that the therapist should work on building rapport and creating a safe and optimal environment for them because having a negative experience with behavioral exposure could discourage the client from trying further techniques. Also, it can make the client not want to continue with the process and do more harm than good.

      Reply

    • Rylee L Ferguson
      Nov 06, 2022 @ 20:22:04

      Hi Ashley I think you made a solid point about the client needing to be ready to engage in behavioral exposure in order for it to be effective. However, I think many times clients will be reluctant even if they truly are ready. That is where the therapeutic rapport you mentioned comes in. The therapist should have a relationship with the client where they know enough to be confident of the client’s capabilities even when the client themselves may be apprehensive.

      Reply

  6. Sam Keller
    Nov 02, 2022 @ 17:36:14

    1A) The CBF-A helps us dive into a client’s past in a structured way to try and find things that might have helped establish this negative core belief. It asks about three separate incidents that might have contributed to the formation of this negative core belief. As far as the ‘old’ core belief, it helps identify if the belief falls into the category of helpless, worthless, or unlovable. It helps us identify whether the client holds this belief in the perspective for the self, others, or the world. It lets us identify significant individuals, such as family members, friends, or significant others, that were central in these incidents. It also has us ask questions about life events, recent contributing stressors that may have been reinforcing these beliefs, and the client’s coping style. This checklist will also let us find out if there are any social-cultural factors that play into this negative belief and if there are any relevant life events that have played a role in these incidents. If we look at all of these factors we might begin to see a pattern about beliefs and life events that lead the client to gain and reinforce these beliefs.

    1B) It is important to try and identify parts of a client’s life that would have compounded that negative core belief or cause it to be incorporated into their thoughts in a major way. It is true that it can only take a single instance for a core belief to develop. However there are other factors that might have left the client more vulnerable to that single or recurring incident. For example, if a person had a bad incident of betrayal by someone who they thought was a friend, an adaptive person might be able to keep from generalizing this if they had other good social experiences and validation. However, if the person didn’t have a good social structure before this incident then that single instance might be enough for the person to incorporate negative beliefs about those events and generalize them. I would be looking for other vulnerabilities in a client’s past that might have layered on top of the inciting incident. I would do this by asking if there had been other similar incidents in the past or by asking them if there was something about their past that made that event especially significant.

    2A) Behavioral exposure can be very effective with certain kinds of issues because it lets the client face the monster in a manageable way. Avoidance tends to be a typical response to anxiety because if you don’t encounter the stressor then you will never have to experience the stress. However if clients continue in this way they will never develop coping skills or distress tolerance. In addition, if we never confront something or actively avoid it it can become a larger threat or problem in our minds then it actually is. For example, a person who procrastinates for hours about a task that will take 15 minutes or less to complete. For phobias, it can let a client face the scary stimulus in a way that is manageable so they can use coping skills effectively. This can help build their confidence because if they have conquered their fear on a smaller scale then they might feel more capable of conquering their fear on a larger scale. It also lets an individual solve problems with a therapist if something goes wrong. For example, in the case of social anxiety it lets the client and their therapist brainstorm about different ways to approach a conversation if one doesn’t work.

    2B) The main caution to consider when doing exposure work is going too fast too soon. If you expose the client to a situation they cannot handle this will result in a step back in their progress. We need to go very very slow in the beginning to make sure we can give the client a few wins to build confidence before challenging them with harder exposure. We should also not put our own opinions into a person’s fear hierarchy. Let the client dictate to you what is easy and what is hard. This will prevent you from making a misstep by assuming that some asp-ect of their fear is the ‘easiest’ to deal with and being in error. We also do not want to flood a client and end up causing harm instead of healing.

    Reply

    • Tuyen Phung
      Nov 04, 2022 @ 20:00:44

      Hi Sam,
      Your post is very interesting for me to read how you dig deeper into understanding clients’ past experiences. Most interesting, I like the way you reason that therapists should be cautious in pushing clients to experience their fear too fast and too soon. Once clients perceive the fearful and anxious stimuli in a more harmful way, it may be harder to push and persuade them to try it again. However, I think that helping clients expose their fearful stimuli also needs consistency. If therapists are hesitant in the decision to let clients try the exposure, it may create reluctance to try it. Overall, moderate and appropriate time of exposure are most important to have effective results.

      Reply

  7. Rachel Marsh
    Nov 02, 2022 @ 21:10:39

    Core Beliefs
    Question 1
    The core belief flowchart is beneficial because it helps explore key individuals, events, and contextual factors that may have contributed to core belief development. Part A of the flowchart focuses on past core beliefs and behaviors that result from a specific core belief, whereas Part B focuses on the actual modification of the maladaptive core belief. For example, in the video, Dr. V and Mark talked about Mark’s core belief of unlikability. They went in depth about some events that Mark experienced from adolescence into adulthood.
    Some past events that he identified as possibly contributing to this belief were being bullied/unpopular growing up, struggling to maintain friendships, and dealing with depression for most of his adolescence and adulthood. One event that came to mind that Mark discussed was not being invited to the game of an individual he perceived as being a close friend. He also had a similar experience with a friend in college. In response to these events, Mark engaged in rumination and isolation. This reminded me of the previous events that we have seen in the videos with Mark talking about Jeff, where he responded the same way.
    Something that has stood out to me in the readings is the importance of looking for themes in events and automatic negative thoughts to pinpoint core beliefs. By understanding this pattern in Mark, it is clear that these patterns went back to his childhood and developed early on in his life. Another thing that stood out to me is when Mark disclosed that he did not have any specific event that he believes has contributed to his beliefs, but rather the accumulation of events. By using the CBF-A, Mark and Dr. V were able to trace these events back to see when Mark began experiencing these thoughts.
    Question 2
    One historical factor that may have been useful is a further exploration of Mark’s parents’ divorce. While Mark mentioned his parents had a divorce, there was not much more exploration of the divorce and how it may have contributed to the development of Mark’s core beliefs. I would have liked to know some of the thoughts, emotions, and behaviors that occurred around this event. Moreover, I would have liked to see the temporal relation to the divorce in relation to the interpersonal difficulties Mark experienced in his adolescence and young adulthood. I am curious to know if the divorce happened before or after Mark began experiencing these difficulties to see if it may have contributed, at least in part, to the development of his core beliefs.
    Additionally, I would have liked to acquire more insight into the relationships between Mark and his “friends” from high school and his former college roommate. I believe it might be beneficial to further explore some of the characteristics of the individuals Mark discussed to see if there is any other underlying pattern. For example, this might include seeing how these individuals interacted with others to see if Mark felt that he was treated the same or different from other people in these significant individuals’ lives. That is, was there something that Mark felt that made him less desirable than other people that resulted in him being treated differently? Mark talks a lot about how he feels unliked by others but does not really identify specific characteristics about himself that make him unlikable. By delving deeper into this, I think understanding this could be a way to help Mark challenge his core belief of unlikability.
    [Behavioral Exposure] – There is one reading due this week (Volungis – 1 Chapter). For this discussion, share at least two main thoughts: (1) Why is behavioral exposure very effective for certain disorders/types of distress? (2) What are some cautions to consider when implementing behavioral exposure interventions?
    Question 1

    Behavioral exposure is beneficial for addressing anxiety and distress for several reasons. Firstly, this can help cultivate positive coping strategies for the client. Part of behavioral exposure includes teaching clients relaxation techniques such as progressive muscle relaxation, diaphragmatic breathing, and visualization. Once the client has developed these skills, they can then apply these skills when engaging in exposure exercises to cope with their anxiety rather than resorting to their safety behaviors. For example, a few weeks ago, we watched a video in class where Lindsey, an individual experiencing agoraphobia, went to Vals **the best restaurant ever** as part of an exposure exercise to encourage her to go to new, unfamiliar places. Lindsey had the goal of walking in to get a menu but ended up staying longer and talking with the restaurant manager. Instead of engaging in her safety behavior of avoidance, Lindsey may have used strategies such as visualizing herself successfully getting a menu from the restaurant or engaging in deep breathing to get her through the experience. With this, she now has a positive coping strategy that she can employ in anxiety-inducing situations rather than engaging in her maladaptive safety behaviors.
    Another way in which behavioral exposure can be useful in addressing anxiety and distress is by teaching clients to directly confront uncomfortable, anxiety-inducing events. The main goal of CBT is to help clients become their own therapists. By performing exposure, the client gradually gains experience directly confronting their anxieties rather than avoiding them. Exposure aims to help clients start with things that provoke less anxiety and work through their hierarchies to the more anxiety-provoking events. At first, they have the therapist to guide them through, but they will eventually progress to doing exposure exercises as homework.
    Overall, exposure can be extremely beneficial to help clients take ownership of their anxiety and directly experience the things that they avoid.

    Question 2

    In the readings, several cautions stood out to me when implementing exposure techniques. Firstly, finding the “just right” challenge regarding the level of anxiety is integral to developing the client’s anxiety hierarchy. If the client has too many events on their hierarchy that they view as extremely anxiety-provoking, the activities will strengthen avoidance patterns. In addition, this would likely discourage the client from future attempts at exposure exercises and may damage the therapeutic alliance. On the opposite end, if the client has too many events on their hierarchy that they view as low anxiety, the exposure activities will not be strong enough to break the client’s cycle of avoidance. Therefore, collaborating with the client to ensure a balance of low, intermediate, and high anxiety activities are included in their hierarchy is integral to ensuring the exposure is effective.
    Another caution that stood out to me related to client readiness. That is, the client needs to demonstrate effective skills to be ready to implement the relaxation techniques. If done incorrectly, the skills can exacerbate the client’s anxiety. This emphasizes the importance of ensuring that clients can successfully execute their coping skills before going into exposure. If the client has strong skills but is hesitant to jump into exposure, it is imperative to motivate the client. One way that I found helpful to achieve this is attempting an imaginal exposure before an in-vivo exposure and re-assessing the client to see if they feel ready for an in-vivo exposure. Another method that stood out to me was to start with a small, simple exposure by breaking the first step on the hierarchy into smaller parts to decrease the level of threat perceived by the client.
    Overall, motivating the client to give exposure a chance and ensuring they possess the skills necessary to do so is integral to ensuring effective exposure techniques.

    Reply

    • Tom Mandozzi
      Nov 06, 2022 @ 00:09:11

      Hi Rachel,

      I liked that you mentioned a balance when collaborating with clients. I agree that it is crucial to ensure a balance of low, intermediate and high anxiety activities to make sure the exposure is effective in working toward treatment goals. Readiness is also a critical aspect to consider where navigating the implementation of behavior exposure with clients. Every client is different and will have varying levels of readiness and intensities when it comes to their anxiety levels. It is important to engage with clients in an individualized way and assess what is appropriate for each individual client. Great point!

      Reply

    • Rylee L Ferguson
      Nov 06, 2022 @ 20:26:54

      Hi Rachel, I thought it was helpful when you mentioned the example of Lindsey’s behavioral exposure in the restaurant. Not only was she able to overcome her anxiety and fear in order to achieve getting the menu, but she ended up going above and beyond. Because she faced the situation instead of avoiding it she made social connections that she otherwise would’ve missed out on. This illustrates how safety behaviors and avoidance can limit people and cause them to miss out on aspects of life, whereas exposure can give them confidence and connect them to new opportunities.

      Reply

  8. Patricia Ortiz
    Nov 02, 2022 @ 21:26:57

    Core Beliefs] – Watch MDD-16: Core Beliefs – Identifying 2 – Core Belief Flowchart-Part A. Answer the following:
    (1) In what way was the CBF-A effective in understanding how the clients’ core belief developed?
    With this exercise, I could understand that this client’s core beliefs started to develop when he was an adolescent and in high school. When he was a sophomore, he stated that he used to hang out with his friend Dave, but in a college event, he felt like his friend did not want to be with him and felt rejected. To this day, he still remembers that day, and when he sees people from that time, he feels uncomfortable.
    In regards to his family members, he does not necessarily feel non-likable, but he feels like his parents were a little hard on him because they had high expectations with grades, and sometimes, he asks himself if he is good or not, for instance, at his job. I believe those situations are hardly related to Mark’s present core beliefs about being non-likable and feelings of rejection; he puts a lot of pressure on himself about other people thinking he is not “good enough” he stated that no one caused harm to him and their intentions were not “malicious” or “openly mean,” is just that he feels terrible about the situations that he went through. This makes me realize that he does not victimize himself, which is a good thing in the therapeutic process, but it is important to note this issue and work with it because he is more prone to internalize events.
    He also states that there is not a single event that changed the view he has of the world, and there is not an event that sticks out, but rather an accumulation of little events that made him feel the way he feels in the present. He talked about how his parent’s divorce did not cause any harm to him, but I would like to dig a little more about that event because usually, parents’ divorce causes some lifetime adverse outcomes.
    In addition, it stuck out to me that he affirms that he was not so popular back then, and people did not want to hang out with him; he was unsure of himself and felt like he did not fit in and instead withdrew himself and went to play video games. This is important because this is a maladaptive coping skill. Another thing that he used as a coping skill was to put some distance between his friends and himself and not communicate those issues with them, which gets to my point about him internalizing things.
    He also stated that he thinks that there are some things about himself that he considers as good qualities; for instance, he is good with going with the flow, is an easygoing person, has been able to handle all the situations thrown at him and sees “the glass half full,” that means he is an optimistic person, and it could help a lot in his process. Also, he says that other people say that he is present and trying to improve and that he is a caring, persistent and dedicated person.

    (2) What additional historical information could have been obtained to understand the development of the client’s core belief?
    As I stated before, I would dig a little more about his parents’ divorce and ask how his family dynamic is right now and how it was back then. How did they handle that situation? After a divorce, if not treated the right way, children could have a low self-concept, social difficulties, and emotional difficulties such as depression, fear, and anxiety. Also, they may feel guilty or develop a fear of being left alone and abandoned. This certainly is not going to fix any present problems, but it could give an insight into his core beliefs and help understand their development.
    Also, maybe help him recap more things that he has accomplished. He stated that he feels that he has not accomplished so much, but I think that even the littlest thing matters in therapy, and just by acknowledging, for example, that he got accepted to college, his job, or that he got a place with his girlfriend are things to be proud of, and that could help him gain confidence and self-efficacy.

    [Behavioral Exposure] – There is one reading due this week (Volungis – 1 Chapter). For this discussion, share at least two main thoughts:
    (1) Why is behavioral exposure very effective for certain disorders/types of distress?
    Behavioral exposure is generally initiated in the early or middle phase of therapy to help relieve anxiety-related distress and cope with related life stressors. Such therapy motivates the patient to “face their fears”; that is, exposing the person to the object or situation that causes anxiety and stress.
    Behavioral exposure is very practical for certain disorders/types of distress, such as anxiety-related distress, because when the patient is exposed to a stimulus that causes discomfort, the phenomenon of habituation generally occurs; in turn, the individual realizes that many of their fears and much of their anticipatory anxiety are excessive compared to the danger they actually pose, that is, it can measure their actual level of threat and achieve a modification in their distressing cognitive interpretations, their reactions and their behaviors. Habituation can help reduce the stimuli that generate anxiety or fear to manageable levels, so it can facilitate adaptation to various situations that represented a problem for the subject. The feeling of self-efficacy that is acquired with the progress of therapeutic sessions serves as motivation to follow through. Emotional and cognitive processing helps to implant more realistic beliefs regarding the objects or circumstances that generate so much anguish or stress; also, clients develop associated behavioral and coping skills to manage possible future distress.

    (2) What are some cautions to consider when implementing behavioral exposure interventions?
    Despite being risk-free, exposure may actually put patients at higher risk than they would be with conventional talk therapy. It’s crucial to reduce risk while using exposure because patients are often requested to perform a variety of “uncomfortable” exercises, for instance, handling animals they do not like and purposefully causing panic symptoms (hyperventilation, etc.). First, the process of obtaining informed consent is essential, is ongoing, and is used to weigh the risks and benefits of exposure as well as to reduce the possibility of harm. Also, it is critical to ensure that the session is long enough to finish an exposure with anxiety reduction. In addition, managing and preparing for unfavorable outcomes is crucial because, although uncommon, exposures could not turn out as expected (accidents could happen). Prior to exposure work, it is essential to address and discuss the probability of those outcomes.

    Reply

    • Ashley Torres
      Nov 03, 2022 @ 12:31:39

      Hi Patricia, I enjoyed reading your response! If I had the opportunity to ask Mark further questions, I would also focus on his parents. His parents went through a divorced and he mentioned he was expected to receive good grades. I would ask Mark how he felt about when he got good and bad grades. I would also ask him why he had those thoughts and if he could recall another time he has felt the same way. It is important to investigate Mark’s relationship with his parents because they were a big influence on him and he has learned to navigate the world through them. Mark cares about his parents therefore his feelings and thoughts regarding them may have an impact on his life.

      Reply

  9. Tayler Shea
    Nov 03, 2022 @ 00:58:25

    The CBF-A technique is effective because it analyzes the client’s past experiences that may have led him to develop negative automatic thoughts. Mark believes that he is unlikable and unwanted in social situations, by his loved ones, and by friends and peers. Dr. V was able to work with the client to identify specific events and individuals who contributed to the development of Marks’s negative core beliefs and automatic thoughts. Mark was able to identify specific individuals who contributed to his negative core beliefs from his early adulthood. Understanding how the negative core beliefs developed is crucial for the therapist to understand to successfully help their client. Dr. V was able to deeply dive into a friendship that Mark had during early adulthood that made him feel very isolated. Mark shared that his friend Dave was a part of the “popular crowd” and he was not. He shared that there were many times that this friend made him feel unwanted like he did not fit in, and like a burden. Mark described this experience as painful and shared that it is now easier for him to withdraw from social situations than to make himself vulnerable to rejection. The CBF-A is a useful tool when trying to investigate where a core belief was developed and what reinforced and maintained those maladaptive cognitions. I would like to ask Mark to dive a little deeper into relationships that he had prior to Melissa and how he thinks Melissa feels regarding his core beliefs. I would also like to hear more about Mark’s familial history and how his parents would feel regarding his core beliefs.

    Behavioral exposure is often a successful therapeutic technique for clients with anxiety-related disorders. Behavioral exposure requires the client to come in contact with or experience the thing that they are the most scared of. By exposing the client to their fear, you will be breaking the cycle of negative reinforcement. The behavior (avoidance) is negatively reinforcing the client’s fear. This exposure often teaches the client that the thing they were most worried about is not that bad. Exposure therapy allows the client to break their cycle of avoidance with the stimuli that they were worried about. Before utilizing exposure therapy, the therapist must build a strong bond with the client. Rapport is a key element of exposure therapy because the client is trusting you, as their therapist enough to expose themselves to what causes them the most distress. Clients are trusting you when you tell them that they will be okay, they can face this stimulus, and that you will support them along the way. The therapist should be cautious about beginning exposure therapy too soon. They need to ensure that they have a strong foundational relationship. Exposure therapy is highly uncomfortable for the client. This may cause them to want to terminate the therapy experience or seek alternative care. The therapist should consider this and utilize psychoeducation surrounding exposure before beginning the therapy.

    Reply

    • Ashley Torres
      Nov 03, 2022 @ 12:25:14

      Hi Taylor, your response was great! I agree with your thinking and I believe the CBF-A is a useful technique when investigating a core belief. It is important to figure out when the core belief developed and how it is reinforced. The client mentioned he had experienced these core beliefs in high school and college but feels like he is now withdrawing from people when he gets distressed. I also think it’s important to look at events where the core belief isn’t reinforced. These sceneries can help the client develop a new core belief later in sessions because it shows that his thinking may not always be accurate.

      Reply

    • Teresia Maina
      Nov 05, 2022 @ 21:15:51

      Hi Tayler,
      I really enjoyed reading your post! For additional information learning more about his previous relationships before Melissa could provide us with more information concerning his core belief. This is a great point that I did not think of. I also wrote something similar about learning more about his family dynamic. You did a great job explaining behavioral exposure and highlighting how having a solid therapeutic relationship is essential to the process.

      Reply

  10. Tuyen Phung
    Nov 03, 2022 @ 08:38:44

    Core beliefs

    In the session between Mark and Dr. V, the CBF-A was effective in understanding how Mark’s core beliefs developed in several ways. First of all, the CBF-A helped both the therapist and the client specify the client’s personal experience of developing the core beliefs as an unlovable person. By exploring the historical development of the core beliefs, the therapist helped him to have a clearer picture of the origin of his core beliefs. Especially, Mark understood more about how his core beliefs in which he saw himself as unlovable formed when he was much younger in high school. As a result, he could understand how the core beliefs reached this high level, leading to his negative consequences in mental health and life satisfaction. Furthermore, Dr. V guided him to relate his experience in his family in which he stated that he was hard on himself since his parents had had high expectations of him, especially from an academic perspective. When Mark had high expectations of himself, he wanted to reach the perfect point in his life, which was the relationship with his colleagues as Jeff. Moreover, the CBF-A was effective by leading Mark to recognize how recent contributing stressors and life events led him to the core belief, including expectations from his bosses.
    Dr. V asked most of the appropriate questions that dig into Mark’s development of the core beliefs. Besides questions regarding the personal historical development of his core beliefs, including his relationship with his parents, and friends, and how he dealt with life events, I would ask him more information about his background factor in which he could describe how he was different from other people in his groups of friends and colleagues. Also, I would also ask how these colleagues whom he invited to go out for lunch and to come home had an attitude toward his invitation. Are there any differences in the way they see the excuse or refusal of the invitation? How was his attitude toward close friendships different from his friends? Asking these questions can help to understand his attitude toward the way of invitation and his friend’s attitudes.

    Behavioral Exposure

    Behavioral exposure is a well-known technique for certain disorders relating to anxiety, OCD, and distress. This technique is effective in helping clients reduce avoidance and fear of the stimuli they are afraid of. When individuals develop disorders or distress, they tend to avoid it to get rid of the fearful, anxious, and even panic feelings. On the one hand, behavioral exposure helps them reduce safety behavior. On the other hand, implementing the exposure encourages them to face their fearful stimuli due to the support of therapists and significant others. Gradually, they do not depend on the safety behaviors and develop coping skills to manage the behaviors in the future.
    During practice the of behavioral exposure, I think that there are some considerations that should be concerned. First, the most vulnerable individuals are those who have PTSD. The individuals are likely to face more severe consequences if they expose to the stimuli. Also, the consistency and observation of therapists are essential to the success of overcoming the stimuli. If therapists are not consistent, the clients may not be persistent with their attempts. Finally, I think that checking the preparation and readiness of clients to expose the stimuli.

    Reply

    • Amanda Bara
      Nov 03, 2022 @ 12:43:09

      Tuyen,
      I really enjoyed reading your post and I think you made some important points in regards to exploring Mark’s core belief development. Specifically, you pointed out how his parents always held high expectations for him academically. I think that this should be further explored because those feelings could have transferred over into relationships which have added on to his belief development. You also did a great job in highlighting how behavioral exposure is good for anxiety and OCD. I think it is particularly useful because there is no beating around the bush and individuals are able to face their fears head on! Great job!

      Reply

    • Patricia Ortiz
      Nov 04, 2022 @ 18:45:51

      Hi Tuyen, I found it essential that you highlighted that people with PTSD may be the most vulnerable individuals when it comes to behavioral exposure and that they are more likely to face more severe consequences if exposed to the stimuli. I think it is critical that the therapist takes time to psychoeducate the client, explaining the different cognitive, emotional, and behavioral reactions after trauma and the problems that come with it. Psychoeducation is also sought to validate the patient’s reactions and give them hope and motivation. Another technique that might be helpful is relaxation techniques/control of emotional arousal, it is an anxiety management strategy that will help them promote relaxation and can be helpful, especially at the beginning of treatment.

      Reply

    • Tayler Shea
      Nov 05, 2022 @ 23:16:46

      Hi Tuyen,

      I really like how you explained behavioral exposure as facing fears. I agree, once fears develop, they are super hard to face, especially when the fear is causing a lot of emotional distress. The development is coping skills is so crucial to our clients facing their fears. I like how you noted that individuals who are most in need of behavioral exposure also tend to be most vulnerable. I agree with you that therapists must be consistent and supportive during exposure therapy. Great post!

      Reply

  11. Rylee L Ferguson
    Nov 03, 2022 @ 11:13:05

    The CBF-A helped illustrate that the client’s core belief appeared to develop over time. According to him, there does not seem to be a big event or turning point that marked the beginning of this thinking pattern. Instead, various smaller events that started in childhood and built up over time eventually led to the client thinking about himself in this manner. The client felt that at first he was able to cope with the situations that made him feel unlikeable, but has since been impacted really negatively by the core belief. The technique also illustrated that this core belief seems to stem largely from social interactions with friends rather than with relatives. The struggle with feeling likable also was exacerbated since the client left college. He has been immersed in his adult life where it can be more difficult to find time to engage and it is easier for him to withdraw. The technique also shows how the core belief could have developed because it was partially valid at the time. The client mentions that while he maintained several friends throughout school, there were instances of close friends drifting apart. While the client may have largely been likable, his core belief may have reflected the few times where he and others did not remain friends. Because there is this evidence supporting the notion behind the core belief, it can make it harder to dismantle, but it explains why the core belief developed and has remained in the client’s life for so long.

    Mark’s relationship with his family and position as an only child has not yet been explored in depth. This could be related to his core belief of being unlikable or other core beliefs. The client may not see how they are related yet but some time could be spent exploring them to see for sure. His parents having such high expectations for him may contribute to him having a different core belief of worthlessness. This belief may be intertwined with unlikability too. If the client has too high of expectations and fails to meet them, he may feel like he is not good enough and therefore it would make sense for his friends to not like him. His feelings of worthlessness might be motivating his tendency to fill in the ambiguities of his friend’s rejections as meaning he is at fault. This possibility is worth exploring by diving in to his family dynamic a bit more.

    Behavioral exposure is effective for certain disorders, specifically anxiety disorders, because it treats the avoidance aspect. People with anxiety disorders often learn to avoid situations that worry them and this is negatively reinforced so the avoidance becomes the standard. In order to return to being able to interact in the situations rather than avoid them, the individuals need to learn to confront the situations. Behavioral exposure helps people confront these anxiety inducing situations but gives them relaxation tools throughout the process to help make it less aversive. If the confrontation was as bad as they feared, it would not help reduce avoidance in the future. Relaxation techniques help the individual remain more calm so they can see the object of their fear is not as daunting in reality. Another reason behavioral exposure is effective is because it involves a hierarchy of feared situations or starting with lesser fears and worries and working towards the larger ones. This way clients can learn the process and start slow as they gain confidence.

    One important caution to give clients is that the process will initially involve them experiencing an increase in anxiety, fear, and physiological arousal as they break the cycle and begin to confront their fearful situations. Ultimately being able to overcome these issues will lead to an overall decrease in anxiety but getting there may take time. Another consideration is the timing of these interventions. Behavioral exposure is usually introduced in middle therapy. This is important because you want to have a good relationship with your client so they can trust you and be willing to put themselves out there. This process can be difficult and having a strong therapeutic rapport can make the client feel more empowered as they confront their fears.

    Reply

    • Amanda Bara
      Nov 03, 2022 @ 12:38:48

      Rylee,
      I think you did a great job at capturing the aspects that have led to Mark developing his core belief. I like how you highlighted how he struggles with friends rather than family members or relatives. I thought it was interesting how he said that his parent’s divorce did not really impact him too heavily. I like how you discussed behavioral exposure in regards to anxiety. You made some key points that show why it is particularly useful with anxiety disorders. Nice job!

      Reply

    • Tom Mandozzi
      Nov 05, 2022 @ 23:48:51

      Hi Rylee,

      I really appreciated what you mentioned about Mark’s relationship with his family and how this might have informed his current automatic thoughts and core beliefs. I think delving more into these relationships would be an important step in the therapeutic process and would provide very helpful insight into what experiences have contributed to the core beliefs that are currently effecting him. Parent expectations and responses to Mark could absolutely have an impact on Mark and how he thinks about himself. Exploring his childhood and experience being an only child would be a great step for reaching a deeper level of understanding of his thoughts and beliefs and this understanding can ultimately support modifying these thoughts. Great post!

      Reply

    • Sarah Kendrick
      Nov 06, 2022 @ 21:49:21

      Hi Rylee! Definitely a nice catch that Mark’s core belief seems to stem from social interactions with friends. It’s acknowledged that his family impacted him in other ways but this makes me wonder if he has had previous romantic relationships and how these impacted him or were impacted by his beliefs…I also liked that you identified that this belief definitely appeared valid at the time, this may definitely be why it’s so difficult to overcome this belief as at one point, it could have indeed been true and it’s hard to recognize that that may have/likely changed.

      Reply

  12. Tom Mandozzi
    Nov 03, 2022 @ 12:13:35

    I thought it was interesting to watch the CBF-A technique utilized in session as a tool to help a client tackle their core beliefs and gain some further insight on them. I think this technique was effective in understanding how core beliefs developed because it allows the client to identify some of the past experiences and thoughts that may have resulted in the development of the maladaptive core beliefs. It has been established that Mark has some core beliefs that are rooted in feeling unlikeable in some current social situations and in the context of peer relationships (i.e. his coworker, friends, etc.) in more recent experiences. However, the CBF-A technique was effective because it took Mark’s understanding of his core beliefs even further by identifying previous relevant experience that shaped these beliefs. Mark was able to recall experiences in his childhood and youth that may have impacted the formation of his beliefs. With prompting from Dr. V, Mark was able to identify experiences with a friend in college in which he went from being close friends with him to then being distant and the friendship kind of dissolving over time. This was an important experience that stuck with Mark and may have informed his core belief that he is unwanted or unlikeable. Mark felt as though there were times that he did not fit in or was not accepted by the popular crowd at school. This core belief may have ultimately affected his behavior in that he began withdrawing from social situations out of fear that he was not likeable to others. Ultimately the CBF-A technique is effective in evaluating and identifying a core belief to develop and more comprehensive understanding of where the belief was developed and what thoughts and behaviors may have been reinforcing it. It allows the client to gain important insight into the events and interpretations that took place in their lives that brought them to the core belief they have now. I think moving forward, I would want to ask Mark more about his previous relationships, in a romantic sense and in terms of family and friendship relationships, to see if any events related to these relationships may have informed this core belief or any others. I think further prompting Mark to delve a little deeper into his previous relationships with others would continue to support identification of experiences that have informed his current core beliefs.

    Behavior exposure is an important technique for many different disorders. This technique is especially important for anxiety related disorders and avoidant behavior for when people are avoiding stressors. Because the client is avoiding these stressors, their behavior perpetuates the fear of engaging in these situations. By engaging the client in behavior exposure interventions, they can confront these fears and ultimately learn skills and strategies to manage overwhelming thoughts and feels. It is important to be aware of some cautions as the therapist implementing behavioral exposure. The client may initially experience and even more heightened level of distress and anxiety when exposed to the stressor. This should be communicated to the client beforehand as something to consider before engaging in the behavioral exposure. The therapist should make sure that the client is ready for behavioral exposure after appropriate rapport building and therapeutic alliance. This reminds me of a current client I work with, who has overwhelming anxiety about going to stores and buying things in public. I have gone to stores with her to help her feel more comfortable engaging in this behavior, and at first, she was even more anxious and emotional about the situation. After repeated exposure, the anxiety levels improved, and the client has shown an increased ability to engage in this behavior. The therapist should have established a comprehensive understanding of the client’s distress and how behavior exposure may be beneficial for the client.

    Reply

    • Yoana Catano
      Nov 04, 2022 @ 12:58:49

      Hi Tom,
      It is interesting how you explain the benefit of utilizing CBF-A with Mark. The fact that he is able to understand what experiences have shaped his core belief and understand the connection in those experiences as a pattern, has set the step to approach change. Mark has a better perception of the importance of modifying those thoughts that have caused more damage that events itself. I also agree in your curiosity about how past romantic relationships have contributed to his core belief.
      For behavior exposure, I completely agree in the need of a good therapeutic relationship to enter this phase as well as a good preparation in therapy.

      Reply

  13. Kristin Blair
    Nov 03, 2022 @ 15:38:52

    The downward arrow technique seemed helpful for Mark to go back and speak on experiences from high school that he probably has not revisited in his mind since. I’m sure that coming back to that memory and speaking about it very openly, much later, can be therapeutic on its own! Being able to “feel” that past event and thinking about it concerning his feelings on his relationships and interactions now allowed Mark to fully come to this realization on his own with the light guide and probing from Dr. V. This showcases the ideal thought process that we as therapists want to facilitate in our clients. When the client forms and connects their thoughts independently and can identify their thoughts and beliefs, it helps bring a firm understanding. Once the client finds their core belief that they connect to their negative automatic thoughts, it becomes the catalyst for change. In the video, you see Mark speak on the poor coping skills he is currently using and has used in the past that he knows may not be the best choice. He can even reflect on things like being an only child, never really being popular in school growing up, and even how, now being more independent and on his own, he finds that withdrawing becomes a much more accessible coping mechanism.
    I think it would be beneficial to delve more into Mark’s childhood and his significant relationships (especially since he puts great influence on not feeling wanted and not being popular etc.). I also think it would be good to know about any significant events in his childhood. 

    I think that a big part of why behavior activation works well is because it has a very personalized feel and approach. This is also why it is a very versatile tool that can be used at virtually any therapeutic stage. It is very personalized because it can be different for every individual. It is not mapping out a specific schedule that the therapist or anyone else deems important or joyful; it is what the client chooses and then examines how they feel about their daily activities. I think that just this simple fact alone makes this approach “attractive” for clients to want to try because someone has to want to engage in an activity for them to receive the full benefits.
    This is partly why it is so effective for treating depression and anxiety. Those who are experiencing depression and or anxiety (they are often comorbid and go together) typically struggle with motivation and, oftentimes, time management. Actively scheduling pleasureful activities to counteract the ones they may find themselves struggling with completing…can be very helpful in getting someone out of a “rut” that they may find themselves experiencing. Touching base and reviewing these ideas and themes weekly with a licensed therapist and having the process validated and examined a great asset when using this approach.

    One very common challenge when using behavioral activation is the level of motivation the client has and the ability to complete and carry out the activity monitoring and scheduling. This is why it may be crucial to start this process more slowly. This can vary from client to client depending on their current mental state and level of motivation. The second challenge is the therapist’s ability to effectively utilize the information they gain from implementing this technique with a client.

    Reply

    • Rachel Marsh
      Nov 05, 2022 @ 16:23:00

      Hey Kristin,

      I enjoyed reading your post! I especially like what you said about making the connection between automatic thoughts and core beliefs. As you stated, Mark made some significant discoveries once this occurred and was able to understand the function of his withdrawal, as well as his social history of interpersonal difficulties and being an only child. The relationship between his automatic thoughts (I.e., Jeff doesn’t want to spend time with me) and his core beliefs (I.e., I am unlikable) is easier for Mark to follow once he made that association between how his automatic thoughts stem from his core beliefs.
      Additionally, I think you make a great point when you discuss the benefit of looking at Mark’s childhood and relationships. As you suggested, this would be a great way to see how his automatic thoughts and core beliefs revolve around unlikability. Through the semester as we have seen videos with Mark, there is a clear theme of his automatic thoughts and core beliefs that always seem to go back to being unpopular when he was younger.
      Overall, great post!

      Reply

    • Sarah Kendrick
      Nov 06, 2022 @ 21:45:21

      Hi Kristin! I like how you identified that this process allowed Mark to fully realize how past situations have affected him throughout all this time. I agree that it can often be therapeutic just to reflect on the past but that making the connections to one’s core beliefs is truly where the change begins. I also agree with your statement about the personalization of behavioral exposure, it definitely is a turning point for a lot of people and it requires a lot of trust in the therapeutic relationship as these situations are not generic and tested for everybody. It definitely is crucial how the therapist utilizes the information gained from this technique!

      Reply

  14. Teresia Maina
    Nov 04, 2022 @ 17:11:43

    [Core Beliefs] CBF-A is effective in understanding how Mark’s core beliefs were developed. Mark was able to examine his core belief of being unlikeable by looking at thoughts, emotions, and behavior from childhood till the present. Mark remembered a time in college when he was in a similar situation as the one his being discussing in therapy about being left out by his coworkers. In college, his friends slowly stopped including him in activities. This past experience has served as a reinforcer in situations where Mark feels left out, strengthening his unlikable core belief. Additional information that may be important to obtain when understanding the development of the client’s core beliefs is family dynamics. Mark mentioned that he is an only child and his parents divorced. I would like to know how being an only child impacted Mark’s social skills and developing friendships, but also if his parents tried to “fix” every distressing situation, Mark went through socially. I wonder if his parents did try to “fix” everything as a child that played into strengthening his core belief.

    [Behavior Exposure] Behavior exposure is effective for specific disorders/types of distress because it helps reduce fear and avoidance. It forces clients to deal with/break their avoidance patterns by exposing them to the thing that causes them anxiety. By breaking their avoidance patterns, clients learn techniques they can use when confronted with maladaptive thoughts and emotions. Before using behavior exposure with a client, it’s essential to have a strong therapeutic relationship. You should also start small and go slow and build up as you progress.

    Reply

    • Rachel Marsh
      Nov 05, 2022 @ 16:11:01

      Hey Teresia,

      I loved reading your post! Specifically, I like what you brought up regarding Mark’s core beliefs. You make a great point when you mention that it might be useful to understand the dynamics of the relationship between Mark and his parents. Looking at how his social skills developed would definitely be beneficial to gain insight into how Mark formed and maintained his earliest relationships. In addition, if his parents did try to “fix” his relationships as you state, this would definitely contribute to the development of his core beliefs of being unlikeable or unloveable.
      I also appreciated your insights pertaining to behavioral exposure. Ensuring there is a strong rapport before initiating exposure technique is integral to ensuring the client trusts the process. It is imperative to ensure the client that you will collaborate with them in the beginning and will be their for support. Though eventually they will be doing this independently, in the earlier stages of exposure this is key.
      Overall, great post!

      Reply

  15. Sarah Kendrick
    Nov 06, 2022 @ 21:37:13

    The CBF-A was effective in understanding how the clients’ core belief developed. As core beliefs typically develop earlier in childhood or later through significant interactions with highly regarded individuals, significant life events, or through genetic and biological vulnerability, the CBF-A helped to explore the possible significant events, relationships, and other factors that may have led to the core belief’s development. Completing the CBF-A includes identifying the category of the core belief(s), the lens through which the individual sees and believes in the idea, significant individuals who may have influenced the belief, significant life events that may have triggered the belief, any recent contributing stressors that further solidify the belief, the individual’s temperament and what they utilize for coping skills, any possible contributing sociocultural factors, and any other relevant activities or life accomplishments. For Mark, it was identified that he believed he was unlikable; that he was the one who viewed it this way (viewing himself as unlikable); that his high school friend, some recent friends, and a college friend helped solidify this belief as the relationships fizzled or as Mark faced rejection; there were no larger-scaled events rather, Mark identified that it’s been the accumulation of smaller events that have caused stress; he utilizes “withdrawing” or creating distance to cope; did not identify any contributing sociocultural factors; and recently, he identified work as being a recent and significant stressor that also reminds him of his parents’ high expectations of him when he was school-aged as well as the effect that his stress from work had on his relationship with his partner. Overall, the CBF-A visually presented Mark’s emotions, behaviors, and negative automatic thoughts as well as other core beliefs, presenting an overall clearer view as to how this one particular core belief developed and how it has impacted his life both throughout his past as well as his current reality. In further challenging Mark’s core belief and to better assist him in identifying that he is likable, Dr. V did well in asking questions that made Mark reflect on what he likes about himself and his accomplishments, identifying specific aspects of himself that he likes and that perhaps by building upon these aspects, Mark can begin to believe that he is likable not only just through having evidence that others do like him, but through evidence that he encompasses what he believes to be likable for himself.

    Regarding other helpful historical information, I would be curious to know more about why Mark thinks he was better able to cope in school. If perhaps it is like Dr. V stated and due to the more “forced” social nature of the environment which made it less available for Mark to create distance, I wonder how this could be applied to his current stage in life (would making more social engagements cause more stress? What if he joined a social club of sorts?). I would definitely be curious about his early home life as it seems his parents’ expectations of him spill over into a few beliefs as well. I’d also be interested to know more about his school life and how this may have further contributed (especially the “unpopular” aspect).

    Behavioral exposure is very effective for certain disorders/types of distress as it requires individuals to face or be exposed to what they find anxiety-producing or generally distressing. Individuals can avoid their anxieties/distress both cognitively and behaviorally and in doing so, feel a sense of relief. This is only short-term relief and allows them to neglect learning appropriate coping skills to manage this or other distress. In exposing individuals to their anxiety/stress, individuals can learn in the moment how to cope and prepare for future situations instead of avoiding them. Regarding cautions to consider when implementing these interventions, it is important not to rush and to fully explain and make the individual aware that they will indeed experience psychological and physical discomfort when confronting the situation. Individuals should have coping skills that they can utilize for this exposure and while they do require a “push,” they should not be forced into the exposure too early or else this negative experience may provide “proof” to them they should indeed avoid this situation (and it may be a lot harder to rebuild rapport with the individual, if they decide to continue treatment with you).

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Adam M. Volungis, PhD, LMHC

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