How to Use the Downward Arrow Technique in CBT

Purpose

The downward arrow technique is employed in cognitive-behavioral therapy to access core beliefs. How is it used?

Core beliefs are a critical part of the formulation of many cases in cognitive-behavioral therapy (CBT). As a therapist, if you understand what the core beliefs are, you can better understand the symptoms that need intervention.

This, in turn, enables you to more effectively address those symptoms. Knowledge is power, and knowing a patient’s core beliefs gives you the power, ideally, to select appropriate treatment components. Knowing core beliefs also enables you to better understand which CBT skills will be most helpful.

The problem is that core beliefs are often difficult to discern. More experienced therapists will sometimes be able to surmise core beliefs early in treatment, but certainly not always. Regardless of your level of experience, it’s helpful to accelerate the process of learning a patient’s core beliefs when possible. The downward arrow technique can do that.

When to Use the Downward Arrow Technique

To Expedite Patient Progress

The downward arrow technique is used to facilitate symptom improvement via cognitive restructuring. Sometimes a patient will become quite adept at restructuring various negative automatic thoughts and intermediate beliefs. However, this doesn’t usually translate to an ability to spot core beliefs. To understand how we can use automatic thoughts and intermediate beliefs as a springboard to accessing core beliefs, let’s look at an example. The list below is from a patient with depression:

If a core belief of, e.g., being unlovable, lies behind these intermediate beliefs and automatic thoughts, patient progress may plateau until and unless the unlovability belief is addressed.

To Help the Therapist Improve the Case or Symptom Formulation

Sometimes even after several weeks or months of CBT therapy, areas of the therapist’s formulation of the patient’s problems will be incomplete. This muddles the picture and obstructs efforts to discern which problem or symptom to address in which order.

Using the downward arrow technique, if successful, may reveal to the therapist core beliefs that were not apparent before. In these cases, the therapist need not spend time discussing the importance of a core belief unveiled with the downward arrow technique. The therapist can continue to focus with the patient on the symptoms and problems that warrant attention at that moment. However, the next target may change based on the revised formulation.

How to Use the Downward Arrow Technique

Step One: Get to Know Your Patient
Perhaps this would go without saying, but the downward arrow technique works most effectively after a you’ve arrived at preliminary case formulation. This will take a few sessions regardless of whether you consider them to be assessment, pre-treatment or treatment sessions.

Step Two: Be Prepared – Pick the Right Starter Thought
As you prepare for the session, have in mind the kinds of thoughts and intermediate beliefs you want to listen for. These will be thoughts and beliefs that seem strong, rigidly held or impactful in ways that surprise you. If you’ve prepared in this fashion prior to the session, you’ll be ready when the thoughts come up.

Step Three: Inquire with Purpose
Questions to ask to get at beliefs one level deeper:

And what does that mean?
What does that say about you?
And so what, what if that were true?
What are you worried that might mean?
And why does that bother you?
What does that suggest?

Below is an example of what this part of the session might sound like. The example illustrated here is of a music teacher with depression. His students will be giving a recital next Friday.

Automatic thought (AT): The recital’s going to be a disaster.

Query: Is it? OK. And so what does that mean, if it is?

Belief: It means I’ve failed.

Query: And so what? if you’ve failed, what does that mean?

Belief: It means I’m a bad teacher.

Query: And what does that mean?

Core belief: It means I’m just… incapable.

Cautions

Don’t use try to access core beliefs with this technique too early in treatment. You want the patient to have a good skill base to address whatever belief you find.
Don’t rely on the downward arrow technique as a therapeutic “eureka” moment. Insight is not the goal; information is the goal. Use the information you get to better inform your future work with the patient.
Don’t put words in patients’ mouths. It can be tempting to say something like “and do you think that means you’re incompetent, generally?” during the downward arrow technique. However, the technique is optimally effective when the phrasing comes from the patient. Additionally, you don’t want patients to feel pressured to agree with your hypothesized belief if it doesn’t exactly match their understanding.