Intermediate Beliefs

What an intermediate belief is

An intermediate belief is a rule a person lives by, and it falls between the deep beliefs a person holds and the thoughts that arrive under pressure. Most of the time it is not recognised as a belief at all, because to the person holding it the rule is simply common sense.

Within the cognitive model of depression, intermediate beliefs are usually interpreted as rules of living. They are usually expressed as if-then sentences.¹ "If I ask for help, people will think less of me" is one. So is "I should cope on my own."

The rule is not the mood, and it is not the memory; it is the instruction underneath both. Much of the work of cognitive therapy is aimed at finding it.

Who proposed the three levels

Kaplan and Sadock's textbook credits Aaron Beck and, later, Judith Beck. Between them they proposed a division into three levels: automatic thoughts, intermediate beliefs, and cognitive schemata.² Schemata is the plural of schema.

The distinction matters clinically, because the middle level contains the rules, and those rules are what a session can reach and work on directly.

One student, traced through all three levels

One case from the textbook traces a single student through all three levels.

A student sits down to study. The thought that arrives is familiar to her: she will never understand this. That is the top level, and it is the one she is aware of.²

Beneath that level are the assumptions. She believed she was not competent, and not good enough. She saw the world, in her case professors and classmates, as attacking and critical, and she anticipated that the future would be filled with failure.²

When things went well, she was not unduly distressed.² The assumptions were not active the whole time, and something in the situation had to activate them.

In depression, automatic thoughts often reflect the cognitive triad, which is a negative view of oneself, the world and the future.¹

Below them are the schemas, which are underlying cognitive structures. They help the brain organise information in memory, guide awareness and predispose action.³ That is the deepest of the three.

What they sound like

Rules of living take a few recognisable forms: the wording differs from person to person, but the structure of the sentence tends to repeat.

The if-then form is the clearest: "If I say no, they will drop me." Shoulds and musts do the same work in a plainer construction, as in "I should always be the one who copes."

Some rules are never said out loud, and they show instead in what a person stops doing: an invitation declined, an application never sent. A rule of that kind is easier to notice from the outside than to put into words.

Surfacing one in a session: the downward arrow

The downward arrow is one of the traditional cognitive therapy procedures. The therapist keeps asking for greater clarification, and each answer is taken a step further down.⁴ The name describes the direction of the questioning, from the surface thought towards the rule underneath it.

An illustrative exchange, written for this article. It is a composite and not a real patient.

Client: I could not send the report. I kept going back over it.

Therapist: And if you had sent it, with the mistake still in it?

Client: Then they would all see that I do not know what I am doing.

Therapist: Suppose they did see that. What would it mean about you?

Client: That I am not good enough for the job.

Therapist: And if that were so, what would you have to do?

Client: Be perfect. Then nobody finds out.

The last line is the rule; almost nobody could state it at a first session. It came out because one question was put again, and then again.

Pressing for a rule too early, or too briskly, can leave a person exposed rather than helped. Pacing is a clinical judgement, and it is one of the things training is for.

How they are tested and loosened

Three procedures are named as the most common traditional ones.⁴

• Socratic dialogue. The therapist uses a series of questions.⁴ These help a person identify and challenge unhelpful beliefs, or uncover evidence that disconfirms a fear.⁴
• The downward-arrow technique. Repeated requests for clarification, until the deeper belief and its meaning become clear.⁴
• Thought records. The person writes down automatic beliefs and lists the evidence on both sides.⁴ Cognitive errors are reviewed, then more realistic and helpful beliefs are written.⁴

Behavioural experiments are often listed alongside these three, though they belong to a later development. The three procedures can be run formally, in the traditional way. They can also be used within exposure work, which is more typical in contemporary cognitive behavioural therapy, or CBT.⁴

A behavioural experiment tests beliefs about the nature and probability of feared consequences. The conditions are arranged so that disconfirming information, meaning evidence against the belief, is met and taken in.⁴

Beck and colleagues emphasised a collaborative approach between the therapist and the patient. They called it collaborative empiricism. Sessions were structured in discrete 10 to 20 minute segments.³

The segments served a purpose: a person could give feedback and express reservations. Socratic questioning ran through the same collaborative process, and the person practised the techniques.³

How they are measured, and what a score does not tell you

Beck's model linked vulnerability to depression to deeper forms of cognition, including dysfunctional attitudes and schema.³ Attitudes of that kind have been measured in research. One instrument is the Dysfunctional Attitude Scale, in a revised form A, studied in a Dutch community sample.⁵

Measures of this kind belong to research and to clinical assessment. They are not self-tests. No items, no norms and no cut-off scores are reproduced on this page.

A score describes a pattern of attitudes at the time of asking. It is not a diagnosis, and it does not settle what is wrong or what would help. A clinician reads it alongside everything else a person brings.

What the evidence does and does not show

Beck's view of depression holds that people who are vulnerable carry maladaptive schemas. These remain dormant until stressful life events trigger them, and dysfunctional beliefs reflect their content.⁵ Maladaptive means the pattern works against the person who holds it.

Whether it has been demonstrated is a separate question, and in the past many studies were unsuccessful in demonstrating this cognitive vulnerability.⁵

Dysfunctional beliefs seemed to covary with depressive symptoms, meaning they rose and fell together, which suggested state dependency rather than vulnerability.⁵ On that reading the beliefs follow the mood instead of being present before it.

Teasdale then suggested a refinement. In people who are vulnerable, dysfunctional beliefs could only be measured with a trigger present, and the trigger he had in mind was a low mood state.⁵

In the first episode of depression an association is created, between dysfunctional beliefs and depressed mood. The beliefs can then be easily activated during a later low mood.⁵

The three levels are a model of how cognition is organised. The stronger claim, that these beliefs are present as a standing vulnerability, has been harder to establish.⁵

Where this way of working has its limits

Not every difficulty is best met at the level of rules. Sometimes the pressing thing is sleep, safety, money, or a body that is unwell, and belief work assumes a certain steadiness to start from.

People who can understand and label their feelings and emotions generally respond better to CBT.¹ That is a matter of fit rather than of effort or worth.

The cognitive model is also one account among several. Other traditions describe the same difficulties in their own terms, and they do not always agree with one another.

Surfacing a rule can be uncomfortable: some of the beliefs that come up are harsh, and hearing one said out loud is painful. That is a reason to do this work with someone, rather than alone with a worksheet.

If you recognise yourself in these rules

You may find one of your own sentences here. Recognising a rule is a useful starting point. It is not a diagnosis, and it does not mean anything is wrong with you.

Rules learned early can be examined and questioned, and they can loosen. How far that goes, and how fast, cannot be promised in advance.

If you want to take it further, start with our guide on how to find the right therapist.

If anything here leaves you feeling unsafe, please use the crisis numbers at the top of this page.

This article is for general information and is not a substitute for professional assessment or care. If this is affecting your life, consider reaching out to a qualified mental health professional.

References

1. [1] Gautam M, Tripathi A, Deshmukh D, Gaur M. Cognitive Behavioral Therapy for Depression. Indian Journal of Psychiatry, Clinical Practice Guidelines (2020): the CBT model levels, with intermediate beliefs as if-then rules of living. pmc.ncbi.nlm.nih.gov/articles/PMC7001356.
2. [2] Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed. (2017), §13.8 Mood Disorders: Psychotherapy, pp. 4367 to 4374: the three levels of cognition, credited to Aaron Beck and, later, Judith Beck.
3. [3] Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed. (2017), §33.3 Behavior Therapy, pp. 6884 to 6907: collaborative empiricism and Socratic questioning as the working method.
4. [4] Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed. (2017), §33.16 Individual Psychodynamic Psychotherapy and Cognitive Behavioral Therapy, pp. 7323 to 7362: the downward-arrow technique, Socratic dialogue and thought records.
5. [5] de Graaf, Roelofs & Huibers (PMC2712063), Cognitive Therapy and Research: maladaptive schemas lie dormant until stress triggers them, and studies long struggled to demonstrate that vulnerability pmc.ncbi.nlm.nih.gov/articles/PMC2712063.