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Current Psychiatry Reviews, 2016, 12, 65-78
65
Changing Adolescent Dysfunctional Core Beliefs with Group Trial-based
Cognitive Training (G-TBCT): Proposal of a Preventative Approach in
Schools
Irismar Reis de Oliveiraa,b,c,*, Ana Cristina Matosb, Mônica Gonçalves Ribeiroc and
Michella Lopes Velasquezb
a
Department of Neurosciences and Mental Health, School of Medicine, Federal University of Bahia,
Salvador, Brazil; bPPgPIOS Postgraduate Program, Health Sciences Institute, Federal University of
Bahia, Salvador, Brazil; cClinical Research Center Nelson Pires, Salvador, Brazil
Abstract: Group trial-based cognitive training (G-TBCT) is an adaptation of trial-based cognitive
therapy (TBCT) which, in turn, is derived from standard cognitive-behavior therapy (CBT). CBT is
recognized as an effective treatment for several psychiatric disorders. Core belief (CB) change seems
to play an important role in this regard. However, little is known about methods and techniques
specifically used to change dysfunctional CBs in children and adolescents. We present here an
approach used as a preventative tool to help adolescents change their dysfunctional CBs in an
engaging fashion, by asking them to role-play Detectives of the Mind to uncover such CBs; Attorneys of the Mind to help
them evaluate if such CBs are true; Judges of the Mind to help them take distance and become metacognitively aware of
the critical voices represented by internal prosecutors and sue them; and finally Masters of the Mind to help them make
decisions that help them choose assertive and ethical behaviors. In this paper, we introduce the idea and principles of GTBCT, and, more specifically, the trial-based thought record, a method that was designed to help adolescents restructure
dysfunctional CBs about themselves.
Keywords: Adolescents, cognitive-behavior therapy, group trial-based cognitive training, school, trial-based cognitive therapy,
trial-based thought record.
1. INTRODUCTION
Recognized for its effectiveness in the treatment of
diverse adult psychiatric disorders, cognitive-behavior therapy
(CBT) is a focused, active and collaborative psychotherapy
approach, based on a comprehensive personality theory that
emphasizes the importance of cognitive processes in
mediating behaviors, emotions and physiological responses
[1]. When specifically applied to children and adolescents,
this flexible approach maintains most of the main elements
of adult-tailored CBT, such as psycho-education, selfmonitoring, behavioral interventions and skills training,
performance achievement and cognitive restructuring [2].
According to Kendall [3], CBT interventions with children
and adolescents should involve the development of emotion
regulation, problem solving skills, as well as specific strategies
targeting different aspects of information processing, such as
addressing distorted thinking. Hence, patients and therapists
play an active role in devising cognitive, emotional and
behavioral experiments to test the validity of their absolute
and idiosyncratic assumptions.
The effectiveness of CBT in the treatment of anxiety
disorders in children and adolescents is well supported in the
*Address correspondence to this author at the Rua Clementino Fraga,
198/1401, Ondina, CEP 40170-050, Salvador, Bahia, Brazil;
Tel/Fax: +55 71 32417154; E-mail: [email protected]
1875-6441/16 $58.00+.00
literature [4-7]. Over the last decades several generic
treatment manuals have been developed, such as Kendall’s
Coping Cat [3], which share the focus on psycho-education,
recognition of feelings and bodily sensations related to
anxiety, examination of cognitions in anxiety-provoking
situations, development of coping and problem solving skills
and exposure to feared stimuli [3, 4]. Solid evidence equally
supports the efficacy of CBT in the treatment of depression
in youth [8, 9], a significant mental health problem that may
have a strong impact on everyday functioning and increase
the likelihood of major depressive disorder in adulthood
[10]. Nevertheless, similarly to what happens with anxiety in
youth [7], depression is poorly diagnosed and the vast
majority of patients have no or minimal access to proper
treatment [11]. The most common features of CBT models
for depression in children and adolescents are the emphasis
on self-monitoring, the recognition of cognitive distortions
and their role in the depressed mood, along with the use of
behavioral activation and the development of problemsolving and emotion regulation skills [8, 12]. Empirical data
also supports the benefits of CBT interventions regarding the
management of childhood and adolescent obesity [13] and
substance abuse [14-16] due to the benefits in terms of
increased self-efficacy and enhanced self-regulation skills
that result from modifying dysfunctional cognitive processes,
negative core beliefs and individual behaviors [16].
However, there is still little research on CBT as a treatment
© 2016 Bentham Science Publishers
66 Current Psychiatry Reviews, 2016, Vol. 12, No. 1
option for other less prevalent but not less harmful disorders
in youth, such as Body Dysmorphic Disorder (BDD) [17, 18]
and early-onset schizophrenia [19, 20].
Belief change (BC) makes up a significant part of most
adult CBT protocols, seeing as persistent attributions that are
negative, global, and personal regarding life events, and
adverse outcomes are risk factors for the recurrence of most
psychiatric disorders. Core beliefs (CBs) are usually
developed early in life and become the foundation for later
beliefs and thoughts. These beliefs are not easily accessed
and modified, but a long-term goal in CBT with children and
adolescents often consists in changing unhealthy CBs, along
with building up and strengthening healthy ones [21].
However, as far as we know, little is understood about how
cognitive change leads to symptom reduction [22], and there
have not been studies focused on BC in children and
adolescents.
A novel approach, the Trial-Based Cognitive Therapy
(TBCT) that may be more effective at changing belief
systems than conventional thought records and logical
disputation was developed by the first author [23]. TBCT is a
three-level, three-phase, case formulation approach, whose
foundation is in cognitive therapy; however, it has a unique
approach to conceptualization and techniques that make it a
distinct intervention in modifying patients' CBs [24]. One of
its main techniques is the Trial-Based Thought Record
(TBTR), a structured strategy that is presented as an analogy
with Law, in which the therapist engages the client in a
simulation of the judicial process [25]. It is an empirically
validated method of BC, with preliminary, but promising,
results [26-28].
The first study on the effectiveness of the TBTR in
modifying negative CBs and their associated emotions was
carried out in 2008 [25] and significant reductions (p<0.001)
were observed in the intensity of CBs and related emotions
of 30 patients, supporting the hypothesis that this
intervention could, at least temporarily, contribute to the
weakening of negative CBs and the subsequent emotions
associated with them. Patients’ adherence to their negative
core beliefs and corresponding emotions after the first use of
the TBTR was assessed in a larger sample (n=166) in 2012
[26], and the results confirmed the previous findings. An
extension of this study, reaching 259 patients [27], in
addition to corroborating the earlier data, has also suggested
the greater effectiveness of the “empty chair” modality
compared to the static modality, regarding the reduction in
the intensity of the emotion associated to the negative CB.
The two modalities were again compared in a randomized
trial carried out in 2013 [28], in which the “empty chair”
modality was shown to be more effective not only in
reducing the emotional intensity, but also in the credibility
patients attributed to the negative CB. The same intervention
was compared with conventional CBT techniques in a
randomized clinical trial [26] with 36 patients diagnosed
with social anxiety disorder. The findings suggest that TBTR
was at least as effective as traditional CBT protocols in
reducing social anxiety and particularly effective in reducing
the fear of negative evaluation, reinforcing the need for
further research involving larger samples, other categories of
disorders, and different populations.
de Oliveira et al.
Affective disorders represent a heavy burden in the lives
of young people, contributing to interpersonal, academic and
physical health problems, as well as enhancing the odds of
risky behavior engagement, not to mention the direct and
indirect financial impact involved [29, 30]. Therefore,
prevention specialists worldwide reinforce the importance of
reducing the onus of adolescent mortality and morbidity
through preventative strategies [31], and recent reviews
provided modest but relevant data regarding the effectiveness
of classroom-based programs in the prevention of depression
and anxiety in youth [11, 32, 33] and general improvement
of adolescent health [31], despite the frequent methodological
limitations and heterogeneous findings. In this context,
schools may offer a very convenient setting, but future
investigation is essential [34].
The present paper introduces Group Trial-Based
Cognitive Training (G-TBCT) as a new model aiming to
modify adolescents’ CBs in a school setting as a preventative
universal approach to address dysfunctional thinking, offered
in classrooms.
2. BRIEF DESCRIPTION OF THE G-TBCT
G-TBCT is an 18-session approach, introduced by a
facilitator and a co-facilitator (mental health professionals
previously trained in TBCT) to 11-17 year-old adolescents in
class. It is presented in four phases, namely, 1. Detective of
the Mind; 2. Attorney of the Mind; 3. Judge of the Mind; and
4. Master of the Mind. Every participant receives a manual
(unpublished) containing detailed information about each
meeting as well as classroom and homework activities to
help consolidate the learning.
During the six meetings of the Detective of the Mind
phase (Phase 1), students are informed about the cognitive
model, cognitive distortions, and the thought record referred
to as the lens of the Detective of the Mind.
In the Attorney of the Mind’s phase (Phase 2), students
role-play attorneys in a court trial, evaluate and change the
negative CB (self-accusation) by means of the TBTR, in the
course of six meetings.
In phase 3, the Judge of the Mind phase, lasting
three meetings, students sue the bullying prosecutor (critical
internal voices), gaining awareness of metacognitive
processes.
Finally, in the Master of the Mind phase, during three
meetings students are introduced to a decision-making
technique, called consensual role-play [24], with which they
learn how to choose and develop assertive and ethical
behaviors.
This paper illustrates in more detail phases 1 (Detective
of the Mind) and 2 (Attorney of the Mind) because they
cover the basic components of most CBT interventions, such
as psychoeducation about the cognitive model and cognitive
distortions, as well as the presentation and practice of the
TBCT’s thought record (called detective of the mind’s lens)
and the TBTR (the most important intervention in this
approach).
Changing Adolescent Dysfunctional Core Beliefs with Group Trial-based
3. DETECTIVE OF THE MIND: FINDING AND
CHANGING
DYSFUNCTIONAL
AUTOMATIC
THOUGHTS
In the first phase of G-TBCT, trained facilitators inform
students that the Detective of the Mind investigates the mind,
which is divided into 3 levels of thought or cognitive levels.
The first cognitive level encompasses four elements:
situation, thought, emotion and behavior, giving the acronym
STEB. Fig. 1 shows how these elements are connected and
how they influence each other. In this phase, adolescents are
also introduced to the main cognitive errors (thinking traps
[21]) – assessed by means of the Cognitive Distortions
Questionnaire (CD-Quest) [23], in its adolescent’s version
(unpublished, but available under request) –, as a preparation
for using the lens of the detective of the mind (Fig. 2). This
is a simplified thought record containing the cognitive
model, and designed to help them change dysfunctional
automatic thoughts, emotions and behaviors. Students have
the opportunity to practice using this instrument in class, first
role-played by the facilitator and co-facilitator, then by the
facilitator and a student who role-plays an imaginary
Current Psychiatry Reviews, 2016, Vol. 12, No. 1
adolescent, and then they use the thought record on their own
in class and as weekly homework tasks.
Still in phase 1, they are introduced to the downward
arrow technique [35] (here called the downward ladder). As
detectives of the Mind, and by means of the volcano
metaphor (Fig. 3), they learn how to uncover the selfaccusation through key questions (“Supposing this is true,
what does it mean to me?” and “Supposing this is true, what
does it say about me?”). This accusation (hottest thought/
core belief) will be taken to court and put on trial by the
Attorneys of the Mind, the next phase in this approach.
4. ATORNEY OF THE MIND: CORE BELIEF
CHANGE
In phase 2 students are introduced to the most important
intervention in TBCT, the Trial-Based Thought Record, by
the use of role-plays, in which students volunteer to play the
role of imaginary adolescents that experience typically
activating situations in their lives. As preparation to enhance
adolescents’ adherence to the technique, they are previously
introduced to the sentence-reversal approach, a well-known
Useful Questions Asked by the Detective of the Mind
Situation
What’s happening?
Thought
What’s going through
my mind?
67
Emotion
What emotion do I
feel?
Behavior
What do I do?
Level 1
Copyright Irismar Reis de Oliveira
Fig. (1). STEB: the four elements of the cognitive model investigated by the detective of the mind.
68 Current Psychiatry Reviews, 2016, Vol. 12, No. 1
de Oliveira et al.
Fig. (2). Detective of the mind’s lens.
intervention in traditional CBT [36], through which they
become aware of how they usually disqualify the positive
pieces of information, and learn how to reverse the negative
into positive and more realistic pieces of information.
corresponding intensity of the emotion experienced by the
adolescent are recorded. At the conclusion of the role-play,
the space labeled “Final” is filled in after uncovering the
positive CB by means of the upward ladder [37].
4.1. Description of the Trial-Based Thought Record
(TBTR) Technique
The credit given by the student to the negative CB and
the intensity of the corresponding emotion are recorded in
the lower part of all the columns (with the exception of
column 5).
4.1.1. Step 1: Investigation (Table 1, Column 1)
The facilitator asks the student “what’s going through
his/her mind?” when role-playing an imaginary adolescent in
class. In the investigation step of the TBTR, the goal is to
uncover the thoughts connected to an unpleasant situation,
at first suggested by the facilitator himself/herself and
representing a common school problem, and thus help to
introduce the technique. Once students learn how to use the
TBTR, they have the opportunity to practice with their own
CBs. The thoughts are recorded in column 1 by the cofacilitator, role-playing the court recorder. To uncover
possible CBs responsible for negative thoughts and the
consequent emotional state, the therapist uses the downward
arrow technique [35]. In the lower part of column 1 of Table 1,
in the space labeled “Initial,” percentages pertaining to how
much the student believes the dysfunctional CB and the
4.1.2. Steps 2 and 3: Prosecutor and Defense Attorney’s
First Pleas (Table 1, Columns 2 and 3)
In columns 2 and 3, the student places the evidence that
supports (column 2) and also the evidence that does not
support (column 3) the negative CB. The prosecutor’s
performance, all the evidence supporting the negative CB, is
expressed and recorded in column 2. Column 3 expresses the
defense attorney’s plea; here the student is actively encouraged
to identify the evidence that does not support the negative CB.
4.1.3. Step 4: Prosecutor’s Second Plea (Table 1, Column 4)
Column 4 is the prosecutor’s reply to the defense
attorney’s allegation. The prosecutor’s reply involves the
“yes, but…” kinds of thoughts that people use to disqualify
or discount the evidence expressed by the defense attorney’s
Changing Adolescent Dysfunctional Core Beliefs with Group Trial-based
Current Psychiatry Reviews, 2016, Vol. 12, No. 1
69
The most important inves ga on conducted by the detec ve of the mind
Situa on
1. What is happening?
Thought
2a. What is going through my mind?
Feeling
3a. What is the emo on?
2b. How much do I believe it? ___%
INVESTIGATION
3b. How strong is the emo on?
____%
Behavior
4a. What do I do?
What does this
thought mean to
me?
What does it mean
about me?
I am............
ACCUSATION
Copyright Irismar Reis de Oliveira
Fig. (3). Metaphor of the volcano to hot thoughts. The hottest thought investigated by the detective of the mind produces more superficial
thoughts.
first plea (column 3). This, in turn, causes the defense
attorney’s first plea to have less credit. The sentence-reversal
technique, dealing with “yes-but...” thoughts [37], which is
accomplished in the beginning of Phase 2, must have been
exhaustively practiced in class with the student before use of
the TBTR.
4.1.4. Step 5: Defense Attorney’s Second Plea (Table 1,
Columns 5 and 6)
Columns 5 and 6 are the crucial aspects of the TBTR
technique. In column 5 (defense attorney’s response to the
prosecutor), the student is guided to invert the propositions
of the defense attorney’s first plea and the prosecutor’s
second plea (columns 3 and 4), once again connecting them
with the conjunction “but.” The facilitator reads each
sentence presented by the prosecutor’s second plea (column
4), adds the conjunction “but”, and asks the student to repeat
what was said by the defense attorney in the first plea
(column 3) after the “but.” The student is then asked to give
the new meaning of the thought in column 6, which now has
a positive tone. The facilitator stimulates the student to go
further by adding the conjunction “therefore” to complete the
meaning of the positive belief.
4.1.5. Step 6: Jurors’ Verdict (Table 1, Column 7)
This is the analytical part of the TBTR, and has the form
of a jury’s deliberation. The main question to be considered
is: “Which attorney (the prosecutor or the defense attorney)
made the least cognitive distortions?” After the student
identifies the cognitive distortions made by the prosecutor
and notice that the defense attorney made no cognitive
distortions, he/she is acquitted of the accusation that was
brought to trial.
4.1.6. Step 7: Preparation for the Appeal
Columns 6 (meaning of the defense attorney’s plea) and
7 (juror’s verdict) of Table 1 allowed the student to uncover
or to activate a positive CB, made possible by the positive
meaning brought by the defense attorney. Thus, the
facilitator used the upward arrow technique [27, 37], as
opposed to the downward arrow technique [35] used in
column 1 (investigation to uncover negative CB). For this
purpose, he asked: “Supposing that the defense attorney is
right, what does this say about you?” In the example of
Table 1, the student brings up the new positive CB “I am
intelligent.”
70 Current Psychiatry Reviews, 2016, Vol. 12, No. 1
Table 1.
de Oliveira et al.
Illustration of the trial-based thought record conducted by a facilitator and students in class.
Please, briefly describe the situation: Preparing for an exam at school.
1. Investigation to
uncover core belief
What is (was) going
through your mind?
What do (did) these
thoughts mean about
you, supposing they
are (were) true? The
answer “If these
thoughts are (were)
true, it means I am...”
is the uncovered selfaccusation.
Downward ladder:
I can’t study.
I’m a very nervous
girl
I have no patience for
Math
If the thoughts above
were true, what would
they mean about you?
I am: stupid
I feel: sad
Now, how much (%)
do you believe you are
stupid?
100%
What emotion does
this accusation make
you feel? Sadness
How strong (%) is it?
100%
2. Prosecutor’s
plea
What is the
evidence that
supports the
accusation that was
identified in
column 1?
1. She doesn’t
work hard in Math
2. She doesn’t have
patience
3. She keeps
yelling at her
colleagues in class
4. She keeps asking
others to tell her
the answers to the
exercises
Now, how much
(%) do you believe
you are stupid?
100%
How strong (%) is
your sadness now?
100%
3. Defense
attorney’s
plea
What is the
evidence that
does not
support the
accusation that
was identified
in column 1?
1. She works
hard to
understand the
subject
2. She asks
questions
about the
contents
3. She reads
and re-reads
the contents
Now, how
much (%) do
you believe
you are stupid?
80%
How strong
(%) is your
sadness now?
80%
4. Prosecutor’s
second plea
What are the
thoughts that
discount or
disqualify each
piece of
evidence in
column 3,
usually
expressed as
“yes, but...”
thoughts?
5. Defense
attorney’s second
plea
Read each thought
of column 4 first,
and then copy
each
corresponding
evidence in
column 3,
connecting them
with the
conjunction BUT.
6. Meaning of
the defense
attorney’s plea
What is the
meaning
attached to each
sentence in
column 5?
7. Juror’s verdict
Enumerate a list of cognitive
distortions, and make a succinct
report, considering who made
fewer distortions or presented true
statements.
BUT:
BUT:
Prosecutor
Defense
1. She doesn’t
understand it
2. She doesn’t
absorb
anything we
teach her
3. She doesn’t
understand
them
1. She works hard
to understand the
subject
2. She asks
questions about
the contents
3. She reads and
re-reads the
contents
It means that
(upward
ladder):
1. She’s capable,
therefore, she’s
not stupid
2. She’s a
hardworking
person,
therefore, she’s
capable of
learning
3. She tries to do
the best she can,
therefore, she
may be intelligent.
1. Discounting
positives, labeling
2. Overgeneralizing
3. Overgeneralizing
4. Discounting positives
1. True
2. True
3. True
Prosecutor
1. All-or-nothing,
2. All-or-nothing,
discounting positives
3. Discounting positives
Defense
1. True
2. True
3. True
Now, how
much (%) do
you believe you
are stupid?
95%
How strong
(%) is your
sadness now?
95%
Now, how much
(%) do you
believe you are
stupid? 45%
How strong (%)
is your sadness
now? 40%
Verdict: Not guilty
Now, how much (%) do you
believe you are stupid?
0%
How strong (%) is your sadness
now?
0%
Homework is assigned as a preparation for the appeal.
The student is encouraged to indicate on a daily basis how
much he/she finds the new positive CB to be true in
percentage, and list daily evidence supporting the new CB.
The dialogue below is an adapted transcription of the eighth
meeting of a group with which the G-TBCT manual was
used.
4.2. Changing Negative CBs with TBCT
Facilitator (F): Today I’m going to review what has been
taught so far and it’s very important that you pay attention.
After the review, Mary is going to role-play an imaginary
girl called Sarah… So, let’s do a quick review of what has
been taught, so that you all know exactly what Mary is going
to do and how she’s going to act. The first thing you’ve seen
here, if you remember, was that, in order to become
Detectives of the Mind, you’re going to ask questions to find
the “hot thought”. The hot thought is compared to a volcano,
that is, when we are hot-headed, it is as if we were erupting,
just like a volcano. Consequently, we summon the Detective
of the Mind to find the hot thought, and then put this thought
Table 1 summarizes the use of the TBTR with the
students, which is the eighth of eighteen meetings in the GTBCT manual. The facilitator actively engages the students
to participate. One of them will role-play an imaginary
student having problems related to any common school
problems (e.g., performance, bullying). Six to 12 of them
will role-play jurors and their role is to find cognitive errors
in the pleas by the prosecutor and by the defense attorney. In
order to reinforce the ideas and actively engage the other
students, the thought record is distributed to take notes and
follow along.
4.2.1. Introducing TBTR to Adolescents in Class
Changing Adolescent Dysfunctional Core Beliefs with Group Trial-based
Current Psychiatry Reviews, 2016, Vol. 12, No. 1
71
Fig. (4). Distribution of the chairs during the trial-based thought record (TBCT or Trial I).
on trial. So, I’m going to demonstrate and show you the
example of a trial… These are the positions of the chairs in a
courtroom (Fig. 4). I’m the judge, and will be sitting in this
chair. Mary, who will role-play the defendant Sarah, will sit
in this other chair. Then she’s going to switch to this chair
where she will be the prosecutor. After playing the role of
the prosecutor, she will again switch chairs and become the
defense attorney. Both the prosecutor and the defense
attorney will speak twice, and then you’re going to role-play
the jury. The jury will be composed by all the people who
are sitting here on my right, who will pay attention, take
notes, and decide if the accusation is true or not. All right?
The example I’m presenting to you is a girl who can’t study.
Mary, do you remember the question we ask ourselves
whenever we are uncomfortable or feeling sad? You have
already done this as a Detective of the Mind.
Mary (M): Yes. What is going through my mind now?
F: And to this person’s mind came the idea: “I can’t study”.
Do you remember the question from the last and most
important investigation conducted by the Detective of the
Mind? You’ll get a compliment if you remember it! When
someone says: “I can’t study”, and if he or she was trained to
be a Detective of the Mind, what question should he or she
ask?
M: What does it mean to me?
F: Exactly! The response was “It means I’m very nervous.”
And then we ask again: “And if it is true, what does it mean
to me?” The answer was: “It means I won’t be able to pass.”
And then we can ask the last question that is a little bit
different. What question is that?
found. And how about the emotion? The emotion here is
sadness and when we evaluated how much she believed the
thought, we found that Sarah believed 100% that she was
stupid. Consequently, her sadness was also very high, 100%.
So, I’d like you to role-play this imaginary person, Sarah, right?
M: Right.
F: So now I’ll call you Sarah.
M: Okay.
F: And now I’d like to invite 5 of you to be jurors with Mary
and sit in the jurors’ chairs. [Five students present to be
jurors] Mary is going to role-play a girl called Sarah, and
later she will join you as a jury member.
4.2.2. Step 1 – Inquiry (Table 1, Column 1)
F: So, Sarah, you told me about your difficulties. Can you
tell me a bit more about your problem?
M: Yes. My problem is that I can’t study.
F: You can’t study. If we consider this is true, what does it
mean to you?
M: It means that I’m a very nervous girl. I have no patience
for math.
F: And if we consider that this is true, that you’re very
nervous and that you have no patience for math, what does it
mean about you?
M: I think I’m stupid.
F: You think you’re stupid. Sarah, tell me one thing, how
much do you believe in this idea “I’m stupid”?
M: “What does it say about me?”
M: Oh, 100%.
F: Excellent! The answer was: “It means I’m stupid”. So this
is the accusation that this person, who we will call Sarah, has
F: 100%. When you believe 100% that you’re stupid, Sarah,
how do you feel?
72 Current Psychiatry Reviews, 2016, Vol. 12, No. 1
M: Sad.
F: And how sad are you now from 0 to 100%?
M: 100%.
4.2.3. Step 2 – Prosecutor’s First Plea (Table 1, Column 2)
F: Well, Mary, we’ve just role-played the detectives of the
mind to find out what we call the “hot thought”, which is the
accusation that will be brought to trial. And in this court I am
the judge and I’m very rigid and will silence you all by
saying: “Order in Court.” In this court, speaking is
prohibited, unless I ask you a question and allow you to
speak. I’ll call a court reporter who’s going to write down
everything we say. [Invites the co-facilitator to write in the
blackboard]. The jurors will copy what the court recorder
writes down. [Turning to Mary] The first thing you’re
going to do now, Sarah, is to move to that chair, as the
defendant. As in this moment you’re being accused of being
“stupid”, I’ll ask you again how much do you believe you’re
stupid?”
M: 100%
F: And you’ve said you felt sad. Can you tell me how much
you feel sad, as a percentage right now?
de Oliveira et al.
said you’re stupid because you keep asking others to give
you the answers to the exercises.” Right? When you listen to
these things, Sarah, how much do you believe you’re stupid?
M: 100%.
F: And what happens to your sadness?
M: It remains at 100%.
4.2.4. Step 3 – Defense Attorney’s First Plea (Table 1,
Column 3)
F: Now, Sarah, I’d like you to have a look at this other chair
and describe the person who’s sitting here. This is the person
who’s going to defend you from this accusation. In fact, it
seems that she’s looking at you in an understanding way,
doesn’t she?
M: Yes.
F: Right. Could you please come and sit here? Now you’re
not Sarah anymore. You’re the defense attorney, and as a
defense attorney you’re going to defend Sarah from the
accusation of being “stupid”. So, what are your pieces of
evidence to prove that she doesn’t deserve to be accused?
M: She is dedicated and she tries to do the best she can.
M: 100%.
F: She is dedicated to what?
F: You’re feeling 100% sad. Okay, Sarah, now I’d like you
to look at this chair here. [Directs attention to the
“prosecutor’s chair”] Sitting in this chair is the person who is
going to accuse you and provide evidence to prove that
you’re in fact “stupid”. Can you see this person sitting here?
Can you describe this person to me?
M: She works hard to understand the subject.
M: She is looking at me with an ugly face, disgusted, as if I
were nothing.
F: Ms. Defense Attorney, I’d like to remind you that you’re
here to defend Sarah, so you don’t need to say things that
may be used against her, right? It’s enough to say the
elements to defend her. Would you like to rephrase what
you’ve just said about Sarah?
M: Right. Can you please come and sit in this chair? Now,
Sarah, you’re this person. [Mary sits in the prosecutor’s
chair] You’re the prosecuting attorney, and now you see
Sarah sitting on the defendant’s chair and you’re accusing
her of being “stupid”. What evidence do you have that
proves Sarah is stupid?
M: She doesn’t work hard in math, and she’s nervous, and
she doesn’t have patience. Also, she stresses out everybody
in class.
F: Okay, if we could summarize your accusations, you
indicated that she doesn’t work hard in math and doesn’t
have patience. What other evidence do you have that Sarah is
stupid?
M: She keeps yelling at the other students in class.
F: She keeps yelling at the other students in class. Do you
have any other evidence?
M: She keeps asking others to give her the answers to the
exercises.
F: So, she keeps asking others to give her the answers to the
exercises. Would you please sit back there? [Mary sits on the
defendant’s chair] And now you’re Sarah. Okay, Sarah have
a look at what the prosecutor has just said about you… She
said “you don’t work hard in math, you don’t have patience,
you keep yelling at the other students in class and, lastly, she
F: You were also saying that…
F: She also talks to the teacher about the things she doesn’t
understand. And also tries to do things, but she can’t do
them.
M: She asks questions.
F: She asks questions about what?
M: About the content of the material.
F: She asks questions about the content. Do you have any
other evidence that proves Sarah doesn’t deserve to be
accused?
M: Yes, she reads and re-reads the content.
F: She reads and re-reads the contents. Okay. Now would
you please go back to that chair?
M: Yes.
F: So, Sarah, you’ve just listened to your defense attorney
say that you don’t deserve to be accused of being stupid. She
said that you work hard to understand the subject. She also
said that you ask questions about the content and that you
read and re-read the content. When you listen to all these
statements from the defense attorney, how much do you
believe you’re stupid?
M: 80%.
F: 80%. It’s still a bit high, isn’t it? And your sadness?
Changing Adolescent Dysfunctional Core Beliefs with Group Trial-based
M: 80%.
F: 80% as well.
4.2.5. Step 4 – Prosecutor’s Second Plea (Table 1, Column 4)
F: I’d like you to come and sit here once again, because
you’re going to be the prosecutor again. [Mary sits on the
prosecutor’s chair] Okay, you’re here to prosecute Sarah,
and the defense attorney has just said that Sarah works hard
to understand the subject, BUT…
M: She doesn’t understand it. People explain things to her,
but she doesn’t understand what they say.
F: She doesn’t understand what people say, right?
M: Yes.
F: The defense attorney said that she asks questions about
the content, BUT…
M: She doesn’t absorb anything people teach her.
F: So, she doesn’t absorb anything people teach her. And the
defense attorney said that she reads and re-reads the content
BUT…
M: Once again, she doesn’t understand it.
Current Psychiatry Reviews, 2016, Vol. 12, No. 1
73
F: And the prosecutor’s said that Sarah doesn’t understand
the content, BUT…
M: …she reads and re-reads the content.
F: She reads and re-reads the content. And what does it mean
about her?
M: She tries to do the best she can.
F: She tries to do the best she can, therefore...
M: …she may be intelligent.
F: Okay… Would you go back to the defendant’s chair,
please? [Waits for her to change chairs] All right, Sarah,
you’ve just listened to what the defense attorney said about
you in the attempt to defend you from the accusation of
being stupid. She said that you work hard to understand the
subject and this means you’re capable. Therefore, you’re not
stupid. The defense attorney also said that you ask questions
about the subject, meaning that you’re a hard-working
person, therefore, capable of learning. And finally, the
defense attorney also said that you read and re-read the
content, meaning that you try to do the best you can.
Therefore, you may be intelligent. When you listen to these
things, how much do you believe you’re stupid?
F: Would you go back to your seat, please? [Mary goes to
the defendant’s chair] So, Sarah, the Prosecutor insists that
you’re stupid. Insisting by saying “that you don’t understand
what people say, you don’t absorb what people teach you
and you don’t understand the content.” When you listen to
these arguments from the prosecutor, how much do you
believe you’re stupid?
M: 45%.
M: 95%.
F: So, Sarah, audience, we’re now closing this part of the
trial. We now call the jury to decide whether Sarah deserves
to be accused of being stupid. I’d like to remind you all that
Sarah is outside, waiting for the verdict. We are locked in
this room. Here is the juror’s document [Hands the cognitive
distortions list to the jurors]. We now want to find out if the
prosecutor and the defense attorney have distorted the facts.
Consequently, we’re going to read what was said by both the
prosecutor and by the defense attorney…
F: And your sadness?
M: 95% as well.
4.2.6. Step 5 – Defense Attorney’s Second Plea (Table 1,
Columns 5 and 6)
F: Okay. Now, Sarah, would you please come back and sit
here, once again as the defense attorney? [Waits for her to sit
in the defense attorney’s chair] Now you’re going to defend
Sarah, and the prosecutor has just said that “Sarah doesn’t
understand what people say”, BUT…
M: …she works hard to understand the subject.
F: And if she works hard to understand the subject, what
does it mean about Sarah?
M: It means that she’s capable.
F: She’s capable, therefore...
M: She’s not stupid.
F: The prosecutor’s said that she doesn’t absorb what people
teach, BUT…
M: …she asks questions about the content.
F: And what does it mean about Sarah?
M: It means that she’s a hard-working person.
F: And what happens to your sadness?
M: 40%.
F: It goes down to 40%.
4.2.7. Step 6 – Jury’s Verdict (Table 1, Column 7)
Caroline (C): I don’t need this paper… I know all the
cognitive distortions.
F: That’s great! You’ve been prepared for that during the
Detective of the Mind training. So, let’s start. You have no
names here, you are simply referred to as juror number 1
[Mary (M)], 2 [Caroline (C)], 3 [Paul (P)], 4 [Nick (N)], 5
[Kathleen (K)], and 6 [John (J)]. The prosecutor said that
Sarah doesn’t work hard in math. Is it true or a distortion?
What do you think, juror number 1?
M: I think it is discounting positives.
C: I think it’s discounting positives too.
F: Okay, discounting positives according to jurors number 1
and 2. Besides discounting positives, can it also be any other
distortion?
F: She’s a hard working person, therefore…
C: Yes. The prosecutor said that Sarah is stupid. So, it is also
labeling.
M: She’s capable of learning.
F: What do the other jurors think? Juror number 3?
74 Current Psychiatry Reviews, 2016, Vol. 12, No. 1
P: Discounting positives.
F: What do you think, juror number 4?
N: Discounting positives.
F: And you, juror number 5?
K: I think it’s labeling.
F: And you, juror number 6?
J: I agree with juror number 5: labeling.
F: So let’s write down the two cognitive distortions here. The
prosecutor also said that Sarah doesn’t have patience. What
do we have here? Is this a cognitive distortion or not? Can
we say someone who doesn’t have patience is stupid? What
do you think, juror number 1?
M: No. It seems to be overgeneralization.
F: What else do we have here?
C: Discounting positives.
de Oliveira et al.
F: The prosecutor came back and said that she doesn’t
understand what people say. What do you think?
K: All-or-nothing
F: I agree… What do you think, juror number 1?
M: Agree.
F: And the other jurors?
Other jurors: Agree.
F: The prosecutor also said that she doesn’t absorb what
people teach.
N: All-or-nothing.
F: Do you all agree with that?
P: I think it might be discounting positives too.
F: Okay, do you all agree with that?
Other jurors: Yes.
P: Overgeneralization.
F: On the other hand, the defense attorney’s said that she
works hard to understand the subject and this means she’s
capable. What do you think?
N: Overgeneralization.
M: It’s true.
K: Overgeneralization.
F: Does everybody think it’s true?
J: Overgeneralization.
Other jurors: Yes.
F: Overgeneralization for most of the jurors, right? It was
presented by the prosecutor that she keeps yelling at the
other students in class.
F: The defense attorney also said that she asks questions
about the subject, meaning that she’s a hard-working person
and, therefore, capable of learning. What’s your opinion?
N: It’s true.
Jurors: True.
F: Juror number 4 says it’s true. But, even if it’s true, does it
mean that she’s stupid?
F: And finally, the defense attorney said that she reads and
re-reads the content, meaning she tries to do the best she can.
Therefore, she may be intelligent. What do you think?
F: What do the other jurors think?
N: No. It’s labeling.
F: Labeling. Do you all agree with that? What else can it be?
P: Discounting positives.
F: Okay, let’s write both labeling and discounting positives.
F: The prosecutor said that she keeps asking others to give
her the answers to the exercises. As jurors, what do you
think?
M: Also discounting positives.
F: Do you all agree with that?
Other jurors: Yes.
F: Okay, so let’s take a look at what the defense attorney
said. She said Sarah works hard to understand the subject.
What do you think?
M: It’s true.
N: True.
P: True.
K: True.
F: Right. She also said that she asks questions about the
content and that she reads and re-reads the content.
Jurors: True.
Jurors: True.
F: Okay. So, let’s have a look at the results of our evaluation.
[Facilitator shows them column 7 of Table 1] What can you
see here, in the prosecutor’s column?
M: Cognitive distortions.
F: All kinds of cognitive distortions, right?
Jurors: Yes.
F: And when we look at the defense column? We see only
the truth. Now it’s up to you to decide on the verdict. Juror
number1?
M: Not guilty.
F: Juror number 2?
C: Not guilty.
F: Juror number 3?
P: Not guilty.
F: Juror number 4?
N: Not guilty.
F: Juror number 5?
K: Not guilty.
Changing Adolescent Dysfunctional Core Beliefs with Group Trial-based
Current Psychiatry Reviews, 2016, Vol. 12, No. 1
75
F: Jury number 6?
M: Yes, it is.
J: Not guilty.
F: And from now on, are you going to pay attention to what
the prosecutor has to say or to what the defense attorney has
to say to you?
F: Consequently, we’ve finished our work here and we’re
now ready to present the verdict to the judge in court.
F: Juror number 1, would you please stand here and be the
foreman? I’ll go back to the judge’s chair. [Facilitator sits on
the judge’s chair] Now I’m the judge again. Ms. foreman,
have the jurors reached a verdict about the accusation against
the defendant?
M: The defense attorney.
F: We are all going to pay attention to our own defenses as
well. All right? Thank you very much for your participation,
this play is over. Now, let’s all discuss what has happened
here.
M: Yes, Your Honor, we think Sarah is not guilty.
F: Thank you very much. [Mary sits in the defendant’s chair]
Sarah, you were accused of being stupid. Now, you’ve just
heard the jurors’ verdict, and they’ve acquitted you of this
accusation. When you listen to that, how much do you
believe that you’re stupid?
M: Zero.
F: 0%. And what happens to your sadness?
M: It goes down to zero.
4.2.8. Step 7 – Facilitator Uncovers Student’s Positive Core
Belief
F: Okay, Sarah, this accusation is not true. You can consider
yourself acquitted of the accusation of being stupid. And if it
is not true, if you’re not stupid, what does it mean about
you? What does it mean about you, considering that the
defense attorney is right?
M: That I’m innocent.
F: Right. Now, let’s leave the court and talk a little about the
trial. What do you think of this trial?
M: I think it was good and bad at the same time. I heard the
prosecutor presenting evidence about things that make me
feel “stupid.” However, I’m not stupid but rather I don’t
have patience.
F: So, what I’ve just heard you say, Sarah, is that the
Prosecutor was not fair to you.
M: That’s right, she was not fair.
F: And has falsely accused you.
M: Yes, she didn’t have patience with me either.
F: And this is why it was good and bad at the same time.
What was good about it?
M: It was good to hear that I was responsible, that I tried to
work hard but sometimes it was difficult.
F: And if the defense attorney is right, what does it say about
you?
M: That I’m innocent.
F: Right, and if you’re innocent, what does it mean about
you?
M: It means that I am an intelligent, capable person.
F: That you’re intelligent and capable, and everyday you
have new pieces of evidence that proves you that… Isn’t that
true?
5. JUDGE OF
AWARENESS
THE
MIND:
METACOGNITIVE
After several class meetings during which CBs are put on
trial, the facilitator proposes that adolescents sue the
prosecutor. This is the Judge of the Mind phase, in which
adolescents role-play a trial where the prosecutor is charged
with the accusations of incompetence (never won a case),
abuse (makes false accusations) and harassment (makes
accusations anywhere at any time). After the prosecutor is
considered guilty by the jurors, adolescents are introduced to
the concept of metacognition and how the bullying internal
voice of a disordered prosecutor sometimes paralyzes
them. Given the students’ exposure to the prosecutor’s
performance throughout the previous meetings, it becomes
less challenging for them to consider the harmful effects of
self-accusations in everyday life.
This phase is described in the TBCT clinician’s manual
[23], and is adapted to an adolescent language, as in the
transcript below:
Facilitator (F): It appears to me that, just as we do this,
you become aware that the prosecutor is inside us, right? The
defense attorney is also inside us, as well as the jurors. So,
this gives us the possibility to think: does this prosecutor
deserve credit? And even when the prosecutor is being
*
sincere and trying to do his job correctly, wasn’t he causing
harm? So then he has to rethink and modify his methods.
Now I’m going to teach you a difficult word that hardly
anyone knows. Most probably, no one you know will know
what it is. I want to teach you now a very hard word. Do you
remember what cognition means?
Student (S): Thought.
F: Now I’ll teach you an even harder word, which is
“metacognition.” You’ve never heard of this, and outside
this class you’ll probably never hear of it again. It’s a very
difficult word, but it’s important for you to learn:
“metacognition.” If cognition is thought, metacognition is
when you think about the thought. For example: can you see
a zebra thinking about what it is thinking?
S: No.
F: Can you see a dog thinking about what it is thinking?
S: No.
*
The pronouns “he” and “his” are used here because the student in this transcript was a
boy.
76 Current Psychiatry Reviews, 2016, Vol. 12, No. 1
de Oliveira et al.
F: (Speaking to the class) Can you see a cat thinking about
what it is thinking?
6. MASTER OF THE MIND: MAKING DECISIONS
TOWARDS ETHICAL AND ASSERTIVE BEHAVIORS
Class (C): No.
The final stage of G-TBCT (not shown here, but
available under request) is dedicated to prepare the student to
make decisions. A technique called consensual role-play [24]
is introduced to students after they receive information on
assertive and ethical behaviors.
F: Of course not, the cat, in fact, when the dog is down there,
the first thing it does is climb on the table and remain calm.
The zebra, while it is in the forest, it doesn’t keep thinking
about the future. It is only thinking about what it is seeing.
But, only humans have this ability to pay attention to
thoughts. And when we pay attention to our thoughts, we
reach the conclusion that such and such a thought is right or
wrong. Can you imagine a zebra saying this?
C: No.
F: Nor can the dog, or the cat, or the rat, or the lion. None at
all, therefore we have this ability to pay attention to
thoughts. Now, tell me: What is the difficult word I taught
you?
C: Metacognition.
F: Exactly. What you are doing here is paying attention to
the thought to know whether it is true or not. Most of the
time, the prosecution is a thought. And was the prosecutor
correct?
C: No.
F: And what was he making?
C: Distortions.
F: And when you hear the prosecutor saying: “Oh, I
don’t think I’ll get passing grades.” So, what did you say it
meant?
S: I said it meant I was stupid and incapable.
F: But who was saying this?
S: It was my prosecutor.
F: Does the prosecutor deserve credibility?
S: No.
F: Why doesn’t the prosecutor deserve credibility?
S: Because he makes distortions.
F: And when we held the trial, who got everything right?
S: The defense attorney.
F: And the defense was based on what?
S: On facts.
F: Consequently, who deserves more credit?
S: The defense attorney.
F: But you all have to help out your defense attorney. He or
she can’t work on his or her own. So, how are you able to
help the defense attorney?
S: Listening more to him. Trying to hear him more. When
that thought following me around comes to mind, I take a
step back and try to hear the defense attorney.
F: And by hearing the defense attorney, we can also act, take
better action, study harder because the defense attorney gives
us more courage, we’re feeling better, isn’t that right?
7. DISCUSSION AND CONCLUSION
Given the limited access offered to children and
adolescents in getting proper diagnoses and obtaining
appropriate treatment options in mental health combined
with the harmful consequences of such deficiencies in adult
life, classroom-based prevention programs can be seen as a
logical solution. However, despite the advantage of reaching
a large number of individuals at once, researchers have also
faced many context-related challenges, such as engaging
teachers and students, finding room in their busy schedules,
and dealing with diversity and psychosocial difficulties [38, 39].
Recent systematic reviews of classroom-based programs
[32, 39-41] aiming at depression and anxiety in youth
observed modest evidence in favor of prevention and early
intervention programs in schools, regardless of numerous
methodological limitations, heterogeneous results, limited
follow-up and lack of control groups. Some studies suggested
that the initial benefits of prevention programs are not
sustained over time [39, 42, 43], while others recommend
careful consideration and further investigation prior to
widespread implementation of such intervention programs
[11, 38, 40, 43-46].
In the pilot G-TBCT, the use of role-play activities
seemed to be particularly appealing to this population. By
becoming actively involved in the roles of detectives,
attorneys, judges and finally masters of the mind, students
have the opportunity to learn and put into practice valuable
skills, such as uncovering and evaluating CBs, thinking
about their own thinking (metacognitive awareness) and
decision making based on assertiveness and ethics. However,
positive results might depend on the quality of the training
offered to facilitators, who may benefit from periodic
meetings to share experiences and receive supervision
on eventual difficulties, leading to the progressive
standardization of classroom procedures. School support and
teachers’ engagement may also play a decisive role in the
outcome of this intervention.
Finally, it is important to highlight that the main
limitation of G-TBCT is the lack of empirical data
supporting its use, which we hope will be provided soon, as
it has been used in a research context in public municipal
schools in Salvador, Brazil. In this scenario, further research
on the effectiveness of G-TBCT as an alternative preventative
universal approach, with the aim to modify adolescents’ CBs
in school settings, seems promising.
CONFLICT OF INTEREST
The authors do not declare any conflicts of interest.
TBCT and G-TBCT were developed by the first author.
Changing Adolescent Dysfunctional Core Beliefs with Group Trial-based
ACKNOWLEDGEMENTS
Thanks are due to Noah Clyman, LCSW-R, and Jeremy
Rogacki, BS, who read the original version of this manuscript
and gave important suggestions. Staff and teachers at Amélia
Rodrigues and Visconde de Cairu municipal schools
in Salvador are wholeheartedly acknowledged for their
enthusiastic support to this project. Also Jones Aranha de Sá
and Juliano Matos, from Global Participações em Energia,
are to be thanked for financial support. Thanks are also due
to Municipal Secretaries of Education Jorge Khoury Hedaye
(past administration) and Guilherme Bellintani (current
administration), and their Coordinators for Educational
Inclusion Luciene Costa (past administration) and Tainã
Rodrigues (current administration) as well as psychologist
Andrea Moura. They made this project possible in municipal
schools in Salvador, Brazil.
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