Cognitive Processing: Advanced Focus on Conceptualizing & 

Socratic Questioning

Elizabeth Risch, Ph.D.Saba Shahid, Psy.D.

Cognitive Processing Goals

•Correct dysfunctional beliefs created by traumatic events

•Develop understanding of the trauma within the context of the child’s life

• Focus is on Changing Thoughts to improve Feelings & Behaviors

Think (Cognition)

Do (Behavior)

Feel(Affect)

CognitiveTriangle

Situation

Where do I start? Identifying Distortions

5 Areas Commonly Affected by Trauma:

Of Self Of Others/WorldTrust I make bad decisions. I can’t trust

my own judgement.People can’t be trusted. Don’t trust the system; authority.

Control/Power I don’t have control of future.Control is all or nothing. Must control what I can.

Life is unpredictable, uncontrollable. 

Esteem I am a bad kid. I am worthless. I am only valuable for…. People are bad, will hurt you.

Intimacy I shouldn’t get close to people.  Others will take advantage of me. Relationships cause pain.

Safety I am unsafe. Something bad will happen to me….

Adults won’t keep me safe. Adults are dangerous.

Belief Systems 101: Storm Clouds

CORE BELIEF

I’m worthless.

Intermediate Belief

If I didn’t put out, guys wouldn’t like me.

Automatic ThoughtHe called me 

because he heard I’m easy.

Typically, only see 

this:

May see this:

STORM CELL

STORM CLOUD

RAIN DROPS

Key to UnderstandingTherapist needs hypotheses

Lens through which world is viewed

Not visible; Not heard

Identifying Dysfunctional BeliefsThroughout treatment, listen and watch for clues on how trauma has impacted child’s beliefs about self, others, world

(Possible) Dysfunctional 

Belief

Client’s history of trauma experience & 

relationships

Client Statements during treatment

Client Behaviors/Interactions 

in Session

Client Behaviors/Interactions 

with Others

Identifying Dysfunctional Beliefs‐ “Cassie"

BeliefsI’m only valuable for sex. (worthless)

Men (People) can’t be trusted.

People will hurt you.

HistorySexual abuse by stepfather for 10 yrsLove/affection from father; poor 

relationship with  motherMother did not believe; Placed in fostercare

Previous therapist unsupportive

Statements“I wonder if man in 

waiting room abuses his daughter.”

Writing assnmnts

Interactions w/TherapistDefensive with therapist

Assumed therapist blamed her

Often disengaged

Real Life InteractionsCasual sexual encounters

Few close relationships; tumultuousDesire to recant to return home

Identifying Dysfunctional Beliefs‐ “Zach"

People can’t be trusted.

Emotions are bad.Bad things will happen even if I 

try.

HistoryEarly neglect; Severe physical abuse

Over 10 placementsFailed adoptions due to behaviors

Has “talked about it” many times before in therapy

Statements“I don’t trust many 

people.”“self‐sabotage”

Interactions w/Therapist

Uses therapy lingoEmotionally disconnected

Real Life InteractionsVerbal & physical aggression in home 

directed at fatherSabotage when going well (e.g. not do 

hmwrk = can’t play sports)

Identifying Dysfunctional Beliefs‐ “Spidey"

I’m a bad kid. I’m unlovable.Emotions are unsafe; Better to ‘lock it down.’

HistorySexual abuse by older sibling; no plans to 

reunify older sib to familyEngaged in sexual behaviors with 

younger siblingRemoved from home & last to be 

reunifiedEmotional neglect

Statements“Mom will be mad at 

me”Qs for conjoint

Interactions w/TherapistHIGHLY avoidantFear of conjoint

Insecure, tests relationship

Real Life InteractionsWell‐controlled with exception of 

extreme outburstsAttention seeking with momDesires contact with older sib

Identifying Dysfunctional Beliefs‐ Alice

It was my fault.

Mom is mad at me/blames 

me. 

HistorySexual abuse by peer for years

Involved coercion but not physical forceSome physically pleasurable 

Enjoyed attentionEnded due to being ‘caught’

StatementsHappy & Sad re: caught

Interactions w/TherapistDisengaged oftenVery concrete

Real Life InteractionsReactive towards mother

Activity: Complete for a current client

(Possible) Dysfunctional 

Beliefs

Client’s history of trauma experience & 

relationships

Client Statements during treatment

Client Behaviors/Interactions 

in Session

Client Behaviors/Interactions 

with Others

How Do Dysfunctional Beliefs Change?

• Awareness of Conflicting Information• Psychoeducation• Cognitive Processing

• Corrective Experiences• Trauma Narrative• Conjoint Sessions• Healthy Interpersonal Relationships (Parenting)

• Purposeful Change in Thinking• Cognitive Processing

Gradual, Effortful Process

Cognitive Processing: Phase Based Approach

Preparation/ Groundwork

• Validate current belief & connect to trauma experiences• Rate belief and connect to feeling• Obtain permission to evaluate

Cognitive Processing Technique

• Socratic Questioning• Best Friend Roleplay• Behavioral Experiment• Acting “As if”• Self‐disclosure

Re‐evaluate 

• Summarize new information gained• Re‐rate original belief and connected feelings• Home assignment to read and rate new & old belief daily until next session

Preparation/ Groundwork

•Validate current belief & connect to trauma experiences•Rate belief and connect to feeling•Obtain permission to evaluate

There was a sentence in your story that I wanted to go back to and talk about a bit. You wrote, “I should’ve told my mom after the first time.” Could you tell me more about that? 

If I would have told my mom or yelled, it wouldn’t have happened. I should have told.

So who would you say is responsible for you being sexually abused? Joey is, but I am too since it kept happening. 

Okay, so it was Joey’s fault, but also you feel like it was your fault. From zero (not at all) to 100% absolutely; how much do you believe it is your fault?

A lot. Maybe 75%

And when you think, “It’s my fault the sexual abuse happened,” what feelings do you have?I feel bad. Guilty that I didn’t tell. And sad, I wish I did. And I’m mad at myself.

So you feel guilty and sad and even angry at yourself. Those are some really heaving feelings to carry around. Remember we learned before about being the boss of our thoughts? Would it be ok with you if we talk about your thought “Its my fault” and see if you decide to keep it as 75% your fault or if it might change at all?

Socratic Questioning

• Help clients identify, understand, and make changes to thoughts, beliefs and behaviors contributing to their current problems. 

• Questioning that helps empower individuals to examine and determine the helpfulness or validity of their thoughts, beliefs and behaviors in a safe environment.

• Collaborative endeavor in spirit of guided discovery• Therapist has end goal

Socratic Questioning

•What is the end point/healthier thought?

•What evidence or examples of healthier thought do you want to elicit?

•What questions do you ask to get them there? 

Adapted from slide by Shannon Dorsey, Washington Department of Psychiatry and Behavioral Science

Socratic Questioning

•Preparation is key• Need multiple paths (Q’s) to healthier belief

• Stay the course• Child may shoot down first attempt; Reword

•Highlight alternative thinking• Use Pauses, Reflections, Summaries

What else could explain?

Give me an example.

What are pros and cons of...

What do we know about... How do you know 

this?Why is this the 

best...How does... affect 

....

How could you prove or disprove?

How does ... look in everyday life?

Old Thought: It’s my fault we’re in foster care. I never should have told.

Possible Endpoint: When I told, I kept my siblings safe.

What I want to tell her Turn into eliciting questions• Parents caused you to be in foster care

• Parents broke the law

• If didn’t tell, something worse could happen

• It was brave to tell

• You kept family safe

• How did you end up in fostercare?• Why do kids get put in foster care?• Did parents know it was wrong to hit?•What changed after foster care?•Why did you decide to tell?

Socratic Questioning Guide

Adapted from slide by Shannon Dorsey, Washington Department of Psychiatry and Behavioral Science

Old Thought: If I trust others, I will get hurt.

Possible Endpoint: Some people can earn my trust.

What I want to tell her Turn into eliciting questions• You are limiting self by past.

• Most parents take care of kids.

• You can trust your parents now.

• Trust isn’t all or nothing.

• Trust can be earned.

• Who have you trusted in the past?

Socratic Questioning Prep ‐ Child

Adapted from slide by Shannon Dorsey, Washington Department of Psychiatry and Behavioral Science

Old Thought: It’s my fault I was abused, I should have told.

Possible Endpoint: It’s the abuser’s fault.

What I want to tell child Turn into eliciting questions• You had reasons for not telling.

• Abuser scared you about telling.

• Most kids don’t tell.

• Abuser knew it was wrong.

Socratic Questioning Prep ‐ Child

Adapted from slide by Shannon Dorsey, Washington Department of Psychiatry and Behavioral Science

Old Thought: It’s my fault my daughter was abused, I should have known.

Possible Endpoint: I wish I would have known, but it was XXX’s fault for abusing her.

What I want to tell parent Turn into eliciting questions• You didn’t know. Abuser kept it that way.

• “Signs” could have been other things.

• No one assumes abuse.

Socratic Questioning Prep ‐ Caregiver

Adapted from slide by Shannon Dorsey, Washington Department of Psychiatry and Behavioral Science

Old Thought: Foster child’s behaviors are damage done, will have problems for life.

Possible Endpoint: Trauma has affected, but he will heal with support and stability.

What I want to tell parent Turn into eliciting questions• Some child misbehavior is normal.

• Treatment is effective. Kids heal.

• Support and stability at home are key.

• Behaviors are a reaction, way of coping.

Socratic Questioning Prep ‐ Caregiver

Adapted from slide by Shannon Dorsey, Washington Department of Psychiatry and Behavioral Science

Troubleshooting

• Client appears “lost” in discussion or Therapist feels going in circles• Be explicit in focus• Add structure or visuals• Use ratings to measure progress

• Client “arguing” for current belief or disengaged• Allow client to fully educate you on why he/she thinks this way• Validate current belief “It makes sense given your experiences of xyz…”

• Therapist struggling to find acceptable & true endpoint• Occurs when ideal isn’t reality (child may never see parent again, neighborhood is dangerous, etc)

• Belief often overgeneralized – What part isn’t true?• May seek consultation

Troubleshooting• Dysfunctional belief is vague – hard to challenge

• Turn into an “If‐then” statement.• “Emotions are bad.”  “If I am not in control of emotions, I’ll lose it.”

• Child can’t do solely verbal activity• Actively connect belief – feeling in triangle walk through• Look for evidence & paste under old & new belief

• Therapist “stuck” because of caregiver’s unsupportive stance• Find a colleague to vent to• Acknowledge your alignment with client and then attempt to understand caregiver

• Baby‐steps on change with caregiver; Gradual, effortful process