Блог Анкара

In This Chapter

^ Making sure your Part D coverage works in a nursing home ^ Changing Part D plans if you need to ^ Finding sources of help

7he phrase Long-term care Covers several different living situations. It includes everything from staying in a nursing home through being in various kinds of assisted living facilities (where people can live independently but with access to support services) to living at home with support from personal caregivers and community services.

In most of these situations, the rules for Medicare Part D drug coverage are no different than those described in the rest of this book. But this chapter focuses on some special protections and rights — and things to consider — in regard to Part D for people in two types of long-term care. If one of the following situations applies to you, then you can’t afford to skip this chapter:

You’re living temporarily or permanently in a nursing home or another institutional setting (such as a rehabilitation hospital or unit, long-term care hospital, or psychiatric hospital or unit) that offers round-the-clock nursing care and help with daily activities.

You’re staying in a skilled nursing facility (which may be located in a nursing home or a hospital) for needed care after an illness or injury.

For all these situations, I use the term Nursing home Throughout this chapter. And I need to define another term here, too. That term is You. In this chapter I address "you" (the patient), while understanding that many people going into nursing homes are too frail or sick to be able to cope with Part D issues. So when I say "you," I expect that, in many cases, you (the reader) will actually be a family member, friend, or other personal caregiver helping a patient who’s in a nursing home.

In this chapter, I explain special Part D rules and rights that apply to people in nursing homes when paying for prescriptions or changing plans. I describe a special kind of Medicare health plan that focuses on the needs of people in nursing homes, and another Medicare program that provides comprehensive care designed to keep people out of nursing homes for as long as possible. Finally, I suggest sources of help.

Reviewing Your Drug Coverage When You Enter a Nursing Home

When you first go into a nursing home, it’s likely that the last thing on your mind (or your caregiver’s) is whether you need to do anything about your Part D plan. You have too many other practical and perhaps emotional issues to think about. And if you’re already in a plan, why worry?

Well, you need to consider a few points about Part D, even at this difficult time. In the following sections, I explain why you need to find out how your meds are covered in the nursing home and why, in some circumstances, it may be wise or even necessary to change from your current Part D plan to another.

Understanding how your drugs will be covered

In most cases, while you’re in a nursing home, your meds are covered under the usual conditions of your Medicare Part D plan (or under any alternative drug coverage you have, such as an employer or union health insurance plan; see Chapter 6 for details about different types of drug coverage). The following sections note three exceptions.

Lf you receive the Medicare skilled nursing facility benefit

If you’re receiving the Medicare skilled nursing facility benefit, your prescription drugs are covered under Medicare Part A (hospital insurance) for a certain amount of time, and Your Part D plan isn’t involved.

Many people don’t realize that Medicare does Not Usually cover what the agency calls Custodial care In a nursing home. That means room and board, nursing care, and help with daily living activities. But the Medicare skilled nursing facility (SNF) benefit is an exception. To qualify, you need to be enrolled in Medicare Part A. You must also have spent at least three days as an inpatient in a hospital And Need skilled care for nursing and rehabilitation services related to the illness or injury that put you into the hospital. A

Physician must refer you for SNF care under this benefit and certify that you need it as a matter of medical necessity. For example, a need for intravenous injections and physical therapy are reasons for this kind of continuing care.

If you qualify for this benefit, Medicare Part A covers all of your care in a Medicare-certified skilled nursing facility (either in a nursing home or hospital) for up to 100 days.

For the first 20 days, Medicare Part A pays for all of your care needs — including the cost of your room and board, help with daily living activities, and prescription drugs — and you pay nothing.

From 21 to 100 days in the facility, you’re responsible for a co-pay (up to $128 a day in 2008).

JjttNG/ If you’re still in the SNF after the 100 days are up, you’ll be responsible for all 4^»~3£\ costs, and Medicare pays nothing. (However, a Different Illness or injury that requires skilled care after another three-day stay in the hospital would qualify you for another 100-day benefit period.) So from day 101, if you have Part D drug coverage, you must then get your prescription drugs through your Part D plan. Make sure, well before the SNF benefit runs out, that the plan covers your prescriptions (as explained in the later section "Asking important coverage questions on Day One") to prevent any interruption of treatment.

&UJG/ Just because the SNF benefit lasts for up to 100 days doesn’t mean you can

Choose to stay in the facility that long. Your continuing eligibility to stay there is reviewed regularly and depends on whether your physician and/or other medical professionals (such as physical therapists) consider that further days or weeks at the facility will result in an improvement of your condition. So if your condition reaches a Plateau — a point when the illness or injury isn’t expected to get any better — you lose your eligibility for the SNF benefit and must leave the facility, even if you don’t feel better and actually need continuing care.

4%

If you receive full Medicaid benefits

If your state pays for your medical benefits under the Medicaid program and you’re enrolled in Medicare Part D for your prescription drug coverage, you’re probably already receiving Part D’s Extra Help benefit (as explained in Chapter 5) and paying small co-pays for your meds. After a month in the nursing home, though, you should no longer pay Anything For your meds for the rest of your stay. (In the event that you continue to be charged co-pays, call Medicare at 800-633-4227 or call your plan to get it to correct the mistake. Any undue payments you’ve made must be refunded to you.)

Medicaid also pays most of the costs of Medicaid-certified nursing homes for people with low incomes and few resources. Eligibility varies from state to state. Many patients who enter nursing homes pay the costs themselves or through long-term care insurance, but they become eligible for Medicaid when their savings are used up (or their insurance runs out and they have no

Savings to fall back on). In this situation, you receive a small allowance for personal needs. You’re not expected to pay for prescription drugs out of this allowance — again, your Part D plan must not charge you anything for the drugs it covers. If the plan doesn’t cover all the drugs you need, Medicaid may cover them instead (as explained in Chapter 5).

Ensuring all of your meds are covered when you enter a nursing home

Very often, people go into nursing homes after being in the hospital, where they’re prescribed more or different drugs than they were taking before being hospitalized. For this reason, and so that your treatment isn’t interrupted, your Part D plan must cover all the meds that you’re taking when you first enter the nursing home for at least 90 days — even if the plan normally doesn’t cover some of these drugs or restricts access to them. Some plans extend this transitional period for up to 180 days after their enrollees go into nursing homes. Your plan can tell you how long the transitional period lasts.

Asking important coverage questions on Day One

Physicians who care for people in nursing homes say there are good reasons for patients (or their caregivers) to consider their Part D plan carefully and find out whether it’ll continue to work for them in these changed circumstances As soon as possible after admission, or even before. "Ideally," one physician told me, "they should do this on Day One." These are the questions to ask and why you should ask them:

Are any of the pharmacies that the nursing home uses also in my Part D plan’s pharmacy network? Nursing homes use special long-term care (LTC) pharmacies that dispense prescriptions in special packages — the drugs come in single doses, individually sealed, instead of the usual containers. This is for hygiene and safety reasons in a setting where nurses administer a great many different drugs to many patients. LTC pharmacies may be large companies that supply only nursing homes and other LTC facilities or, in rural areas, local retail pharmacies that can supply properly sealed medicines. All Part D plans must include LTC pharmacies in their networks. But if the ones your nursing home uses are Not In your plan’s network, the plan most likely won’t cover your drugs. The nursing home won’t pay for your meds if your plan doesn’t cover them, even if you can’t afford them.

Does my Part D plan cover the medicines that I’m taking Now? As

Explained earlier in this chapter, your Part D plan must cover all the drugs you’re taking when you first enter the nursing home for at least 90 days. But it’s wise to check whether the plan will continue to cover your prescriptions (especially if they’re new ones) after this transitional supply has run out — and, if necessary, take steps to avoid having to pay full price for them at that time.

You can ask the nursing home administrator or social worker for the names of the long-term care pharmacies it uses; then call your plan and ask whether those pharmacies are in your plan’s network. If you’re not sure, the administrator or social worker can also tell you whether Medicare Part A is covering your stay (and your drugs) under the skilled nursing facility benefit. (I explain this benefit earlier in this chapter.) To find out whether your Part D plan covers your new prescriptions or imposes any conditions restricting your access to them (as explained in Chapter 4) — you should call the plan.

If you’re Not Covered by the Part A skilled nursing benefit (or if it’s run out), you may be facing at least one situation that requires action:

The LTC pharmacy isn’t in your Part D plan’s network. You need to change your plan, as explained in the next section.

Your plan doesn’t cover some or all of the drugs you now need or restricts immediate access to them. You can ask your attending doctor whether any alternative drugs your plan does cover would work as well for you (as explained in Chapters 4 and 16). Or you can ask your attending doctor to request an exception to the plan’s policy (see Chapter 4). In this case, it’s important for the doctor to explain to the plan representative that you’re in a nursing home and to fully describe why this particular drug is medically necessary for you and why an alternative covered by your plan wouldn’t work as well or could cause additional medical problems. Other ways of dealing with this situation may be

• Finding out whether Medicaid (if you’re enrolled in the program) will pay for drugs your plan doesn’t cover. Ask the nursing home social worker or a counselor at your State Health Insurance Assistance Program (SHIP) to help you. (For your local SHIP’s contact information, see Appendix B.)

• Switching to a Part D plan that covers your drugs or imposes no, or fewer, restrictions, as explained in the next section.

Switching to Another Plan

In general, the process of switching plans when you’re in a nursing home is the same as it is for anybody in Part D (see Chapter 17). But when you enter a nursing home, you immediately have rights that most other folks don’t have. In this section, I explain those rights and some additional tips. I also describe two special types of Medicare health plans that are available in some areas: Special Needs Plans and PACE plans.

Knowing your rights for changing plans

You have an absolute right to change your Part D plan, if you wish, when you enter or leave a nursing home, and at any time during your stay there. In other words, you don’t have to wait until the general enrollment period at the end of the year. Instead, you automatically receive a special enrollment period (SEP) to make the change. You don’t have to apply for this SEP or disenroll from your current plan — just enroll in a new plan, explaining the situation.

Recognize, too, that this right to switch plans applies if you’re in any Medicare – or Medicaid-certified Institutional facility — an umbrella term that sounds grim but actually comprises nursing homes, skilled nursing facilities, rehabilitation hospitals or units, long-term care hospitals, psychiatric hospitals or units, or intermediate care facilities for the mentally retarded.

Table 18-1 shows how often you can change Part D plans when you enter, live in, or leave any of the preceding facilities and when your new coverage starts.

Choosing and enrolling

In a new Part D plan

Having the right to switch to a different plan doesn’t overcome the fact that it’s a hassle if you need to do so — especially when you, the patient, are too frail or sick to go through the process. In such circumstances, you’d think that the simplest way would be to ask the nursing home staff or your attending physician to point you to the plan they think would suit you best. But Medicare Prohibits These professionals from doing so. This rule is intended to protect patients and prevent the possibility of doctors and nursing facilities receiving financial kickbacks for steering patients to a particular Part D plan.

But consumer and patient groups, long-term care physicians, and pharmacists point out that the rule lays a burden on many patients at a time when they are at their most vulnerable and unable to cope with it.

So if you’re a family member, friend, or personal caregiver of the patient, you’re likely to be the one helping to choose his new Part D plan. You may be able to choose a new plan by using Medicare’s online Prescription Drug Plan Finder, following the guidance I give in Chapter 10. If you don’t want to go online to compare drug plans, you can call Medicare or any of the other sources of help listed in Chapter 10.

Although nursing home staff, physicians, and pharmacists are banned from steering anybody to any one plan, they may be willing to do an objective search on the Medicare plan finder to identify the three or four plans that would suit the patient’s needs best (according to the drugs needed), and then you can make a final choice from that shortlist.

After you’ve found a suitable plan, the patient needs to be enrolled in it, and he must sign the enrollment application. Or, if the patient is incapable of signing, you (as caregiver) may be able to do so. If you already have Durable power of attorney — the right to make medical and financial decisions on the patient’s behalf, according to the laws of your state — you can sign the enrollment form as explained in Chapter 12.

Checking out two alternative plan options

Two types of Medicare health plans are specially designed for people who are either in nursing homes or are eligible for nursing home care. These plans may be worth considering, according to your circumstances and preferences, if the plans are available in your area.

Special Needs Plans

Special Needs Plans (SNPs) are Medicare private health plans (usually HMOs or PPOs). Each one serves the specific needs of one group of people in three categories (see Chapter 9). One of these categories is for people who have been (or expect to be) in long-term care facilities, such as nursing homes or other institutions, for 90 days or longer.

SNPs, which came into existence in 2004, are still somewhat experimental. In 2008, Congress authorized them to continue through 2010, but also barred any new ones from setting up in 2009 and 2010 until Congress has again reviewed the program and decided whether to continue it. Meanwhile, existing SNPs may accept more enrollees. Only about half of Medicare beneficiaries have access to SNPs that serve nursing home residents.

SNPs for people in nursing homes and other types of long-term care (which include assisted living facilities) are supposed to offer ways to coordinate care and services. For example, an SNP may provide a case worker or care

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Manager who helps patients coordinate Medicare and Medicaid benefits, links patients with needed community services, advises on managing health conditions, and maybe helps solve problems with drug coverage. These services, and their quality, vary a great deal among different plans. By 2010 all SNPs must provide a care management plan for each enrollee.

If you’re considering joining an SNP for nursing home patients, find out not only its costs and benefits, but whether it covers the providers that you prefer — all the factors relating to Medicare health plans that I cover in Chapter 9. The SNP should cover most of the meds commonly used by nursing home patients. But it’ll still have a formulary, so check that it covers the drugs you need.

You can enroll in this type of SNP (if one is available to you) when you enter a nursing home, regardless of the time of year. Your coverage starts on the first day of the month after you enroll. But if your special needs status changes so that you’re no longer eligible for this kind of plan, you can switch to another Medicare health plan with drug coverage or to traditional Medicare and a stand-alone drug plan. This SEP begins in the month your special needs status changes and ends up to three months after you’re disenrolled from the SNP.

You can find out whether there’s an SNP for nursing homes in your area by calling Medicare (800-633-4227) or by going to its online plan finder at www. Medicare. gov. You may also want to take advice from your State Health Insurance Assistance Program (SHIP), as explained in the later section "Getting Help for Yourself or Your Loved One."

Programs of All-Inclusive Care for the Elderly

Programs of All-Inclusive Care for the Elderly (PACE) is a Medicare program that helps people who’d otherwise need nursing home care to continue living in their own homes or with their families in the community for as long as possible. It provides comprehensive medical and social services — including home care, day care, physical therapy, dentistry, meals, social work counseling, transportation, and many other services. It also provides hospital and nursing home care should you need it. You can’t choose your own doctors in a PACE plan. Instead, you’re assigned a primary care physician who is one of a team of healthcare professionals working with you and your family to help maintain your overall health. The team also provides support to your care-givers. PACE programs include Medicare Part D drug coverage, so you don’t have to join a separate drug plan.

You can join a PACE program if You’re 55 or older

You’re certified by your state as being eligible for a nursing home level of care, after an assessment by the PACE plan’s care team

A program serves the area where you live and is accepting new enrollees

You’re enrolled in Medicare Or Medicaid

You’re able to live safely in the community with the help of PACE

PACE has no deductibles or co-payments for any service, care, or prescription drug approved by your care team. Other costs depend on your situation:

I If you qualify for Medicaid, you pay a small monthly payment — and nothing for long-term care if you need it. The PACE plan determines the amount of the payment.

I If you don’t qualify for Medicaid, you pay a monthly premium to cover the long-term care part of the PACE benefit and also a monthly premium for Medicare Part D drugs, in each case paying what the plan requires.

If you’re eligible for an available PACE, you can join it at any time. If you’re enrolled in Medicare, you get a special enrollment period to leave traditional Medicare or a Medicare private health plan to join the program. (You can’t be in either of these programs at the same time as being enrolled in a PACE.) Also, you can leave a PACE any time you want to switch to traditional Medicare or a Medicare health plan.

To find out whether a PACE exists in your area, call Medicare (800-633-4227) or go to Www. cms. hhs. gov/PACE/LPPO/list. asp. If you’re interested in joining it, contact the plan to arrange a home visit with you or your caregiver, or a visit to the PACE center. The plan will schedule a meeting between you and its care team for a medical and social assessment that determines your eligibility for the program. For more on how PACE works, go to the National PACE Association’s Web site at Www. npaonline. org.

Getting Help for Yourself or Your Loved One

Don’t hesitate to get help for yourself or your loved one; some problems you just can’t cope with on your own. Here are some resources:

Your State Health Insurance Assistance Program (SHIP): Whenever you need information or help with a problem with Medicare or Medicaid, including Part D and long-term care issues, your best bet by far is to phone your local SHIP immediately. This way, you get free, personal counseling from experts familiar with your area. For the phone number of your state SHIP, go to Appendix B.

Medicare long-term care information: Medicare’s Web site (www. Medicare. gov) provides detailed information on different types of long-term care. On the home page, click "Long Term Care." The site also has useful info on all nursing homes in the country that are certified by Medicare or Medicaid, including details of how well (or not) they perform. Click "Nursing Home Compare." You can get the same info by calling the Medicare help line at 800-633-4227 and asking the customer service rep to search for details of the nursing homes you’re interested in and send you printouts.

Your state long-term care ombudsman: This is the person to contact if you have complaints or concerns about the care you receive in an LTC facility or are trying to find a facility. The ombudsman is trained to troubleshoot problems on behalf of people in nursing homes, board-and-care homes, and assisted living, and acts as their advocate. Every state, plus the District of Columbia, Puerto Rico, and Guam, has an LTC ombudsman. To find the name and phone number of the ombudsman for your area, go to the National Long-Term Care Ombudsman Resource Center’s Web site at Www. ltcombudsman. org. Or call your state Office of Aging (in the state pages of the telephone directory) for the number.

Your Area Agency on Aging: These public services are provided by the federal Administration on Aging to help older people maintain their independence and remain in their community. Each agency acts as a resource center for linking seniors and caregivers with local services and support groups. Visit the national Web site at Www. aoa. gov/ eldfam/eldfam. aspx or call your local Agency on Aging at the number in the state pages of your phone book.

Family Caregiver Alliance: This long-established organization offers programs at the national, state, and local levels to support families who provide long-term care at home for relatives or friends. Among FCA’s numerous services, check out its Family Caregiver Locator to find many resources for caregivers in every state and its Caregiver Toolkit, a large resource of practical information. Visit its Web site at Www. caregiver.

Org or call 800-445-8106.

National Family Caregivers Association: This group supports, educates, and acts as a national advocate for more than 50 million Americans who care for sick or disabled elderly relatives. It also offers local training for improving at-home caregiving skills. Visit its Web site at www. Nfcacares. org or call 800-896-3650.

AARP’s Caregiver Web site: The world’s largest nonprofit organization for people age 50 and over, AARP maintains a Web site that provides practical information for caregivers of all kinds. Go here for an estimate of costs for nursing homes, assisted living facilities, home health aides, and adult day care in your state. Among many articles and tools, check out "Prepare to Care," a planning guide for new caregivers, and "LongDistance Care-Giving," on what to do if a loved one far away needs help. Visit the Web site at Www. aarp. org/families/caregiving.

Chapter 19

In This Chapter

► Putting your current problems into context Identifying your core beliefs

► Dealing with early experiences

► Developing alternative beliefs

■# our past experiences have an effect on how you think and function now.

Sometimes, you may endure bad experiences and be able to make some good things happen from them. At other times, you may be wounded by unpleasant events and carry that injury with you into your present and future.

This chapter encourages you to examine openly whether your past experiences have led you to develop Core beliefs That may be causing your current emotional difficulties.

People are sometimes surprised to find out that CBT considers the past an important aspect of understanding one’s problems. However, rather than focusing intensively on childhood relationships and experiences, CBT specifically investigates past experiences in order to see how these early events may still be affecting people in their Present Lives.

Exploring Hou/ \lour Past Can Influence \lour Present

We don’t know what your childhood and early adulthood were like, but many people share relatively common past experiences. The following examples highlight various aspects of past experience that may resonate with your life history. Rather than focusing on the differences between these examples and your own experiences, use the examples to identify similar things that have happened to you in your own life.

I Sybil grew up with parents who fought a lot. She learnt to be very quiet and to keep out of the way so that her parents’ anger would not be directed at her. She always tried to be a very good girl and no trouble to anyone.

Rashid had critical parents. The demands Rashid’s parents made on him to be a ‘high achiever’ made it clear to him that he would get their love and approval only when he did well in sports and at school.

Beth had a violent father who would frequently beat her and other family members when he was in a bad mood. At other times, her father was very loving and funny. Beth could never predict accurately what mood her father would be in when he came through the front door.

Milo’s relationships have never lasted for very long. Most of the women he’s dated have been unfaithful to him. Milo’s partners often complain that he is too insecure and suspicious of their friendships with members of the opposite sex.

Mahesh lost the family business and his oldest son in a fire five years ago. His wife has been depressed since the fire, and their marriage seems to be falling apart. Recently, his teenage daughter has been in trouble with the police. No one seems to offer Mahesh support. He feels dogged by bad luck.

Many other different kinds of difficult experiences can contribute to the development of negative core beliefs:

Death of loved ones

Growing up with neglectful, critical, or abusive parents or siblings Divorce

Being bullied at school

Being abandoned by a parent or significant other

Undergoing a trauma, such as rape, life-threatening illness, accidents, or witnessing violent attacks on other people

These are just some examples of the types of events that can have a profound effect on mental health generally. Negative events that contribute to the way you think about yourself, other people, and the world often occur in childhood or early adult life. However, events occurring at any stage of your life can have a significant impact on the way you think about the world.

Identifying \lour Core Beliefs

Your Core beliefs Are enduring ideas or philosophies that you hold very strongly and very deeply. These ideas are usually developed in childhood or early in adult life. Core beliefs are not always negative. Good experiences of life and of other people, generally lead to the development of healthy ideas

About yourself, other people, and the world. In this chapter we deal with negative core beliefs because these are the types of beliefs that cause people’s emotional problems.

Sometimes, the negative core beliefs that are formed during childhood can be reinforced by later experiences, which seem to confirm their validity.

For example, one of Beth’s core beliefs is ‘I’m bad’. She develops this belief to make sense of her father beating her without any real or obvious reason. Later, Beth has a few experiences of being punished unreasonably by teachers at school, which reinforces her belief in her ‘badness’.

Core beliefs are characteristically global and are absolute, like Beth’s ‘I’m bad’. People hold core beliefs to be 100 per cent true under all conditions. You often form your core beliefs when you’re a child to help you make sense of your childhood experiences, and so you may never evaluate whether your core beliefs are the best way to make sense of your adult experiences. As an adult, you may continue to act, think, and feel as though the core beliefs of your childhood are still 100 per cent true.

Your core beliefs are called ‘core’ because they’re your deeply held ideas and they’re at the very centre of your belief system. Core beliefs give rise to rules, demands, or assumptions, which in turn produce Automatic thoughts (thoughts that just pop into your head when you are confronted with a situation). You can think of these three layers of beliefs as a dartboard with core beliefs as the bull’s-eye. Figure 14-1 shows the interrelationship between the three layers, and shows the assumptions and automatic thoughts that surround Beth’s core belief that she’s bad.

Figure 14-1:

The core beliefs dartboard and Beth’s dartboard, showing the three layers of belief.

Core beliefs dartboard

Beth’s dartboard

Another way of describing a core belief is as a lens or filter, through which you interpret all the information you receive from other people and the world around you.

The three camps of core beliefs

Core beliefs fall into three main camps: beliefs about yourself, beliefs about other people, and beliefs about the world.

Beliefs about uourself

Unhelpful negative core beliefs about yourself often have their roots in damaging early experiences. Being bullied or ostracised at school, or experiencing neglect, abuse, or harsh criticism from caregivers, teachers, or siblings can inform the way in which you understand yourself.

For example, Beth’s experiences of physical abuse led her to form the core belief ‘I’m bad’.

Beliefs about other people

Negative core beliefs about others often develop as a result of traumatic incidents involving other people. A traumatic incident can mean personal harm inflicted on you by another person or witnessing harm being done to others. Negative core beliefs can also develop from repeated negative experiences with other people, such as teachers and parents.

For example, because Beth’s father was violent and abusive towards her but also could be funny when he wanted to be, she developed a core belief that ‘people are dangerous and unpredictable’.

Beliefs about the World

People who have experienced trauma, lived with severe deprivation, or survived in harmful, insecure, unpredictable environments are prone to forming negative core beliefs about life and the world.

Beth holds a core belief that ‘the world is full of bad things’, which she developed from her early home situation and events at school later on.

Sometimes, core beliefs from all three camps are taught to you explicitly as a child. Your parents or caregivers may have given you Their Core beliefs. For example, you may have been taught that ‘life’s cruel and unfair’ before you have any experiences that lead you to form such a belief yourself.

Seeing how your cove beliefs internet

Identifying core beliefs about yourself can help you to understand why you keep having the same problems. However, if you can also get to know your fundamental beliefs about other people and the world, you can build a fuller picture of why some situations distress you. For example, Beth may find being yelled at by her boss depressing because it activates her core belief ‘I’m bad’, but the experience also seems to confirm her belief that people are unpredictable and aggressive.

Like many people, you may hold core beliefs that you’re unlovable, unworthy, or inadequate – these beliefs are about your basic worth, goodness, or value. Or perhaps you hold beliefs about your capability to look after yourself or to cope with adversity – these beliefs are about how helpless or powerful you are in relation to other people and the world.

Mahesh, for example, may believe ‘I’m helpless’ because he has experienced tragedy and a lot of bad luck. He may also hold beliefs that ‘the world is against me’ and ‘other people are uncaring’. Looking at these three beliefs together, you can see why Mahesh is feeling depressed.

Detecting \lour Core Beliefs

Because core beliefs are held deeply, you may not think of them or ‘hear’ them as clear statements in your head. You’re probably much more aware of your negative automatic thoughts or your rules than you are of your core beliefs (refer to Figure 14-1).

The following sections show you some methods you can use to really get to the root of your belief system.

Following a downward arrow

One technique to help you pinpoint your problematic core beliefs is the Downward arrow Method, which involves you identifying a situation that causes you to have an unhealthy negative emotion, such as depression or guilt. (For more on healthy and unhealthy negative emotions, check out Chapter 6.)

After you’ve identified a situation that brings up negative emotions, ask yourself what the situation means or says about you (or others, or the world). Your first answer is probably your Negative automatic thought (NAT). Keep asking yourself what your previous answer means or says about you until you reach a global, absolute statement, such as ‘other people are dangerous’ or ‘I am bad’ in Beth’s case.

For example, when Rashid uses the downward arrow method to examine his feelings about failing a university entrance exam, he has the negative automatic thought:

NAT: ‘I’ll never get into a good university.’

What does this NAT mean about me?

‘I’ve disappointed my parents again.’

What does disappointing my parents mean about me?

‘Every time I try to do well at something, I fail.’

What does failing mean about me?

‘I’m a failure.’ (Rashid’s core belief.)

You can use the same downward arrow technique to get to your core beliefs about other people and the world. Just keep asking yourself what your NAT Means about others or the world. Ultimately, you can end up with a conclusive statement that is your core belief. The following is an example of how to do this, using the situation of getting a parking ticket:

NAT: ‘These kinds of things are always happening to me.’

What does this mean about the world?

‘Bad things are always just around the corner.’

What does this mean about the world?

‘The world is full of tragedy and hardship.’

What does this mean about the world?

‘Life is against me.’ (Core belief.)

Picking up clues from your dreaming and screaming

Imagine your worst nightmare. Think of dream scenarios that wake you up screaming. Somewhere in these terrifying scenarios may be one or more of your core beliefs. Some examples of core beliefs that can show themselves in dreams and nightmares include:

Drying up while speaking publicly

Being rejected by your partner for another person

Being criticised in front of work colleagues

Getting lost in a foreign country

Hurting someone’s feelings

Doing something thoughtless and being confronted about it Letting down someone important in your life Being controlled by another person Being at someone else’s mercy

Look for the similarities between your nightmare scenarios and situations that upset you in real life. Ask yourself what a dreaded dream situation may mean about yourself, about other people, or about the world. Keep considering what each of your answers means about yourself, others, or the world until you reach a core belief.

Tracking themes

Another way of journeying to the core of your core beliefs is to look for themes in your automatic thoughts. A good way of doing this is by reviewing your completed ABC forms (which we describe in Chapter 3).

For example, if you find that you often have thoughts related to failure, getting things wrong, or being less capable than other people, you may have a core belief of ‘I’m inadequate’ or ‘I’m incompetent’.

Fitting in the btanks

Another method of eliciting your core beliefs is simply to fill in the blanks. Take a piece of paper, write the following, and fill in the blanks:

Lam_

Other people are_

The world is_

This method sort of requires you to take a wild guess about what your core beliefs are. Ultimately, you’re in a better position than anyone else to take a guess, so the exercise is worth a shot.

You can review written work that you have done, which is a good technique for discovering your core beliefs. Going over what you’ve written again enables you to refine, tweak, or alter your beliefs. Be sure to use language that represents how you truly speak to yourself. Core beliefs are very idiosyncratic. However you choose to articulate them is entirely up to you. The same is true of the healthy alternative beliefs you develop (see the section that covers how to acquire alternatives to your core beliefs, later in this chapter). Make sure that you put alternative beliefs into language that reflects the way that you speak to yourself.

Understanding the Impact of Core Beliefs

Core beliefs are your fundamental and enduring ways of perceiving and making sense of yourself, the world, and other people. Your core beliefs have been around since early in your life. These core beliefs are so typically engrained and unconscious that you’re probably not aware of their impact on your emotions and behaviours.

Spotting When you are acting according to old rules and beliefs

People tend to behave according to the beliefs they hold about themselves, others, and the world. To evaluate whether your core beliefs are unhealthy, you need to pay attention to your corresponding behaviours. Unhealthy core beliefs typically lead to problematic behaviours.

For example, Milo believes that he’s unlovable and that other people cannot be trusted. Therefore, he tends to be passive with his girlfriends, to seek reassurance that they’re not about to leave him, and to become suspicious and jealous of their interactions with other men. Often, Milo’s girlfriends get fed up with his jealousy and insecurity and end the relationship.

Because Milo operates according to his core belief about being unlovable, he behaves in ways that actually tend to drive his partners away from him. Milo doesn’t yet see that his core belief, and corresponding insecurity, is what causes problems in his relationships. Instead, Milo thinks that each time a partner leaves him for someone else, it is further evidence that his core belief of ‘I’m unlovable’ is true.

Sybil believes that she mustn’t draw attention to herself because one of her core beliefs is ‘other people are likely to turn on me’. Therefore, she’s quiet in social situations and is reluctant to assert herself. Her avoidant, self-effacing behaviour means that she doesn’t often get what she wants, which feeds her core belief ‘I’m unimportant’.

Sybil acts in accordance with her core belief that other people are likely to turn on her and, subsequently deprives herself of the opportunity to see that this is not always going to happen. If Sybil and Milo identify their negative core beliefs, they can begin to develop healthier new beliefs and behaviours that can yield better results. We look more closely at how to develop new, more positive core beliefs later in this chapter.

Understanding that unhealthy core beliefs make you prejudiced

When you begin to examine your core beliefs, it may seem to you that everything in your life is conspiring to make your unhealthy core belief ring true. More than likely, your core belief is leading you to take a prejudiced view of all your experiences. Unhealthy beliefs, such as ‘I’m unlovable’ and ‘other people are dangerous’, distort the way in which you process information. Negative information that supports your unhealthy belief is let in. Positive information that contradicts the negative stuff is either rejected, or twisted to mean something negative in keeping with your unhealthy belief.

The prejudice model in Figure 14-2 shows you how your unhealthy core beliefs can reject positive events that may Contradict Them. At the same time, your core beliefs can collect negative events that may Support Their validity. Your unhealthy core beliefs can also lead you to distort positive events into negative events so that they continue to make your beliefs seem true.

Figure 14-2:

The prejudice model illustrates howyou sometimes distort positive information to fit in with your negative core beliefs.

Negative information fits in with negative belief

Positive information ignored or dismissed

Positive information distorted to fit in with negative belief

For example, here’s how Beth’s core belief ‘I’m bad’ causes her to prejudice her experiences:

Negative experience: Beth’s boss is angry about a missed deadline, affirming her belief that ‘I’m bad’.

Positive experience: Beth’s boss is happy about the quality of her report, which Beth distorts as ‘he’s happy about this report only because all my other work is such rubbish’, further affirming her belief that ‘I’m bad’.

Beth also ignores smaller Positive Events that don’t support her belief that she’s bad, such as:

I People seem to like her at work.

I Co-workers tell her that she’s conscientious at work.

I Her friends telephone her and invite her out.

However, Beth is quick to take notice of smaller Negative Events that do seem to match up with her belief that she’s bad, for example:

I Someone pushes her rudely on a busy train.

I Her boyfriend shouts at her during an argument.

I A work colleague doesn’t smile at her when she enters the office.

Beth’s core belief of ‘I’m bad’ acts as a filter through which all her experiences are interpreted. It basically stops her from re-evaluating herself as anything other than bad; it makes her prejudiced against herself. This is why identifying negative core beliefs and targeting them for change is so important!

Making a Formulation of \lour Beliefs

When you have identified your core beliefs using the techniques outlined in the previous sections, you can use the form below (Figure 14-3) to make a formulation of your beliefs and rules. Filling out this form gives you an ‘at a glance’ reference of what your negative core beliefs are and how they lead you to act in unhelpful ways. The form is a handy reminder of the beliefs you need to target for change and why.

Follow these steps to fill out the form:

1. Relevant Early/Past Experiences. In this box, write down any significant past events that you think may have contributed to the development of your specific negative core beliefs.

FORMULATION OF MY BELIEFS AND RULES

RELEVANT EARLY/PAST EXPERIENCES

CORE UNHELPFUL BELIEFS I am…., The world is…., Other people..

RULES/ASSUMPTIONS If….then…., Demands about self, the world, others.

AVOIDANCE AND COMPENSATORY BEHAVIOURS Situations you tend to avoid or things you do excessively as a consequence of your beliefs/rules

WHAT I’VE GOT GOING FOR ME Listyour personal strengths and assets

For example, Beth records:

• Father was physically abusive and had unpredictable mood swings

• Father told me that I was bad

• I received severe and unreasonable punishment from teachers

2. Core Unhelpful Beliefs. Write your identified core beliefs about yourself, other people, and the world in this box.

Beth records her beliefs like this:

• I am bad

• Other people are unpredictable and dangerous

• The world is full of bad things

3. Rules/Assumptions. In this box write down the rules or demands you place on yourself, other people, and the world Because Of your core negative beliefs.

Beth writes:

• I must be ‘good’ at all times (demand on self).

• If I Am criticised Then It means that I am a bad person (conditional rule).

• Other people must not find fault with me or think badly of me (demand on others).

• The world must not conspire to remind me of how bad I am by throwing negative experiences my way (demand on the world).

4. Avoidance and Compensatory Behaviours. Use this box to record how you try to avoid triggering your negative core beliefs, or unhelpful things you do to try and cope with your negative core beliefs when they are triggered.

Beth records:

• Being a perfectionist at work in order to avoid any criticism

• Avoiding confrontation and thereby not asserting myself at work or with friends

• Overapologising when I do get criticised or make a small mistake

• Always assuming that other people’s opinions are ‘right’ and that my own opinions are ‘wrong’

• Being timid in social situations to avoid being noticed

• Not trusting others and assuming that they are ultimately going to hurt me somehow

5. What I’ve got going for me. Write down positive things about yourself that fly in the face of your negative core beliefs.

Beth writes:

• My work colleagues seem to like me.

• I am very conscientious at work and this has been commented on by my boss and by colleagues.

• I have some good friends who are trustworthy.

• There have been some good things that have happened to me like finishing college and getting a good job.

• I am generally hardworking and honest.

• I care about other people’s feelings and opinions.

Information you write down in this box is important because it can be used to help you develop more balanced and helpful alternative core beliefs. (We explain more about how to construct healthy core beliefs in the following sections.)

Limiting the damage: Being AvVare of Core Beliefs

To reduce the negative impact of your unhelpful core beliefs, try to get better at spotting the beliefs being activated. Step back and consider a more unbiased explanation for events rather than getting swept along by the beliefs.

One way of improving your awareness of your core beliefs is to develop a Core belief flash-card. This writt en-down statement includes the following:

What your core belief is.

How your core belief affects the way you interpret events. How you tend to act when the core belief is triggered. What a more unbiased interpretation of events is likely to be. What alternative behaviour may be more productive.

For example, Sybil wrote the following core belief flashcard:

When my core belief of ‘I’m unimportant’ is triggered, I’m probably taking something personally and wanting to withdraw. Instead, I can remember that most people don’t hold this view of me, and then lean stay engaged in the social situation.

Carry your flashcard around with you and it review it often, even several times a day. Use your flashcard, especially when you notice that your core belief has Been Triggered, or just before you enter a situation where you know that your old core belief is Likely To be triggered.

Developing Alternatives to \lour Core Beliefs

When you’ve put your finger on your core beliefs and identified those that are negative and unhealthy, you’re in a position to develop healthier alternative beliefs.

Your new core belief doesn’t need to be the extreme opposite of your old belief. Changing an extreme belief, such as ‘I’m unlovable’ to ‘I’m lovable’,may be too difficult when you’re just starting out. Instead, cut yourself some slack and realise that simply by beginning to understand that an unhealthy core belief is not 100 per cent true all the time is enough. Here are some examples:

Beth’s alternative to her unhealthy belief ‘I’m bad’ is ‘there are good things about me’.

Rashid replaces his unhealthy belief ‘I’m a failure’ with ‘I succeed at some things’.

Mahesh chooses the alternative ‘good things do happen in the world’ to replace his old belief ‘the world’s against me’.

Sybil replaces her belief ‘other people will turn against me’ with the healthier belief ‘many people can be kind’.

Milo substitutes his old core belief ‘I’m unlovable’ with the more accurate belief ‘some people do like me, and some people will love me’.

Generating alternatives for your unhealthy and absolute core beliefs is not about positive thinking or platitudes, but is about generating less absolute, more accurate, more realistic opinions about yourself, other people, and the world around you.

Shaping your world

When you start to adopt healthy core beliefs, it can feel as if you’re going against the grain because in fact that is what you are trying to do. Your old, negative core beliefs are familiar, deeply entrenched, and ‘feel’ like they must be true. New, healthy beliefs can ‘feel’ false and unnatural at first. Remind yourself that just because you’ve believed something for a long

Time doesn’t make it true. People believed the earth was flat for a long time but that old belief doesn’t change the fact that the world is round!

Some things are true, regardless of whether you believe them. Other things will never be true, no matter how fervently you believe them.

Revisiting history

Many people can look back over their lives and get a fairly clear picture of where their core beliefs have come from. Sometimes though, the source of core beliefs is not so clear.

Although most core beliefs arise from your early experiences, you can still form deep entrenched ideas about yourself, life, and other people when you’re older. For example, Mahesh develops his core beliefs about the world being against him following a string of bad luck and tragic events during his adult years.

Revisit your history with a view to come up with some reasons behind the ways that you think and behave in the present. Be compassionate with yourself, but recognise that you’re the only one who can retrain your brain into updated and healthier ways of understanding your experiences.

Replacing old meanings With new meanings

Experiences that you had earlier on in life were given a meaning by you at the time. As an adult, you’re in the fortunate position of being able to reassess the meanings you originally gave certain events and to assign more sophisticated meanings where appropriate.

For example, Beth forms the belief ‘I’m bad’ based on the information she had when her father was abusing her. She was young and worked on various assumptions, including:

I Daddy tells me that I’ve been bad, and this must be true. I You get punished when you’re bad.

I I must’ve done something bad to deserve this treatment.

Now that she’s no longer a child and recognises that she has this core belief, Beth can choose to look at her father’s abuse and assign different meanings to his treatment of her:

My father had an anger problem that had nothing to do with me.

No child should be punished so severely, no matter how disobedient they’ve been.

My father was wrong to beat me, and I didn’t deserve to be beaten.

My father did a bad thing by beating me and his bad behaviour doesn’t mean that I am bad.

Use the three-column old meaning/new meaning worksheet in Appendix B, to review past events that contributed to the development of your core beliefs and reinterpret them now as an older, wiser person.

The sheet has the three headings. Fill them in as follows:

1. In the first column, ‘Event’, record what actually happened.

2. Under ‘Old Meaning’ in the second column, record what you believe the event means about you.

This is your unhealthy core belief.

3. In the ‘New Meaning’ third column, record a healthier and more accurate meaning for the event.

This is the new belief that you want to strengthen. Table 14-1 shows an example of Beth’s worksheet.

Table 14-1 Beth’s Old Meaning-New Meaning Worksheet

Event Old Meaning Ne w Meaning

My Dad yelling, telling I must be bad for him I was much too young and afraid me I was bad when to say this so often. to be’bad’. It was my father’s I was little. angerthatwasthe problem.

Incorporating new beliefs into gour life

Constructing newer, healthier, more accurate core beliefs is one thing, but beginning to live by them is another. Before your new beliefs are really stuck in your head and heart, you need to act As (/they’re already there. For Beth,

This may mean her forcing herself to face up to criticism from her boss and making appropriate adjustments to her work without berating herself. In short, she needs to act As if she Truly believes that there are good things about herself, even in the face of negative feedback. She needs to operate under the assumption that her boss’s anger is a reasonable (or possibly an unreasonable) response to an aspect of her work, rather than proof of her intrinsic badness.

In Chapter 15, we suggest several techniques for strengthening new alternative beliefs.

Starting from scratch

We won’t tell you that changing your core beliefs is easy, because that simply isn’t true. In fact, erasing your old belief systems is so difficult that we think the best way of dealing with them is to make alternative healthy beliefs stronger so that they can do battle with your unhealthy beliefs.

*pOUr/^ Think of your old beliefs as well-trodden paths through an overgrown field. ^•/ttg^S. You can walk quickly and easily down these paths, as they’ve been worn down ( ©9 ) from years of use. Developing new alternative beliefs is like making new paths through the field. At first, the new paths are awkward and uncomfortable to walk on, because you need to break down the undergrowth.

You may be tempted to walk along the old paths because they’re easier and more well-known, but with practice, your new paths can become familiar and natural to walk along. Similarly, with regular practice, thinking and acting along the lines of your alternative beliefs can become stronger and more automatic, even when the going gets tough!

Thinking about what gou’d teach a child

When you’re challenging your negative core beliefs, try to think about what you’d tell a child. Act as your own parent by reinstructing yourself to endorse healthy ways of viewing others, yourself, and the world.

Ask yourself what types of belief you’d teach a child. Would you encourage him to grab hold of the negative core beliefs that you may hold about yourself, or would you want him to think of himself in a more positive and accepting way? Would you wish for him to think of other people as evil, mistrustful, dangerous, and more powerful than himself? Or, would you rather he had a more balanced view of people, such as variable but basically okay, generally trustworthy, and reliable? Would you want him to believe that he can stand up for himself?

Considering what gou’d Want a friend to belieVe

When challenging your core beliefs, think about having a friend like Mahesh, Beth, Rashid, Milo, or Sybil. What advice would you give them? Would you say ‘Yes, Rashid, you’re a failure’? ‘I agree, Mahesh – life’s against you’? ‘Beth, you’re bad’? ‘Sybil, no one ever thought you were important anyway’?

Or, would you be quietly horrified to spout these unhealthy and damaging beliefs? We assume the latter.

If you wouldn’t want your dear friends to believe such things, why believe them yourself? Talk to yourself like you would to your best friend when your negative core beliefs are activated.