Cognitive Behavior Therapy is a structured, short-term, present-oriented psychotherapy. This therapy is used to treat mental disorders like depression.

Besides this, CBT Therapy aims at solving the current problems of patients as well as modifying their dysfunctional thinking and behavior.

Thus, the CBT Treatment is based on cognitive formulation, the intermediate & core beliefs, and the behavioral strategies that characterize a specific disorder.

Besides this, the CBT Treatment is also based on a conceptualization of your patient’s specific beliefs and patterns of behavior.

Thus, as a therapist, you adopt a variety of CBT Techniques to bring about a cognitive change in your patient’s thinking and belief system. And such a cognitive change is brought about both at the intellectual level and emotional level.

Thus, the patients experience an improvement in their behavior and emotional state when they learn to evaluate their thinking in a more realistic and adaptive way.

So, as a cognitive therapist, you need to work at a deeper level of your patient’s cognition. This means you have to work on your patient’s basic beliefs about themselves, their world, and other people.

As a result, you will be able to bring about an enduring change in your patients’ mood, dysfunctional beliefs, and behavior.

Therefore, the following are the steps in CBT that will explain how does CBT work step by step.

I. Identifying Automatic Thoughts

(i) What Are Automatic Thoughts?

Automatic Thoughts are the thoughts that arise spontaneously. Such thoughts coexist with a set of more prominent thoughts. Furthermore, the Automatic Thoughts are not based on evaluation or reflection.

Besides this, automatic thoughts occur for a very brief period of time. And the patients experiencing automatic thoughts are more often aware of the associated emotion than the thoughts themselves.

(ii) Characteristics of Automatic Thoughts

Furthermore, the automatic thoughts may be in verbal form, visual form, or both. In addition to this, one can evaluate automatic thoughts according to their utility and validity.

It is important to note that automatic thoughts are common to all of us. These are not just peculiar to people with psychological distress.

Furthermore, we are hardly aware of automatic thoughts most of the time. However, we can become aware of them with a little training. Thus, we can do a reality check when we become aware of our automatic thoughts. Provided we are not suffering from any psychological dysfunction.

However, people experiencing psychological distress are unable to engage in this kind of critical examination. But, Cognitive Behavioral Therapy teaches them tools to assess their thoughts in a structured and conscious way.

As a Cognitive Behavior Therapist, you need to identify the automatic thoughts that your patient is experiencing. Well, it is fairly simple to predict your patient’s automatic thoughts once you identify his or her beliefs.

Now, you need to identify those automatic thoughts that are dysfunctional in your patient. The dysfunctional automatic thoughts are the ones that distort reality, are emotionally distressing, and get in the way of your patient’s ability to reach their goals.

So, the point is that people usually accept their automatic thoughts as true. They do not evaluate or reflect upon their automatic thoughts. However, people would experience a positive change in their thought process. Provided they identify, evaluate, and respond to their automatic thoughts in a more adaptive way.

(iii) Explaining Automatic Thoughts To Patients

As a Cognitive Behavior Therapist, you need to use the examples of your own patient to explain to him or her the negative automatic thoughts that he or she experiences. This means you need to bring to light the automatic thoughts your patient experiences pertaining to a specific problem.

Next, you need to explain to your patient the relationship between negative automatic thoughts and the associated feelings. In other words, you need to explain to your patient that his negative automatic thoughts influence his emotions in a negative way.

Then, you need to demonstrate to your patient how CBT Therapy would help him to identify his own automatic thoughts. In addition to this, you will also illustrate how your patient would be able to evaluate his automatic thoughts once he identifies such thoughts.

The first step in CBT Treatment is to teach your patient to identify the automatic thoughts when his mood is changing. You need to make sure that your patient keeps on practicing this until it’s easy for him to identify such thoughts.

Then, the next step is to teach your patient to evaluate these automatic thoughts. Thus, your patient needs to change his thinking if it is not completely right. However, both you and your patient need to work out a solution if his automatic thoughts are correct.

Finally, you can check to determine if your client has understood the above-mentioned Cognitive Model at the end of the session.

(iv) How To Elicit Automatic Thoughts?

Learning to identify automatic thoughts is the same as learning a new skill. It is quite easy for some patients and therapists to understand automatic thoughts. Whereas, others need more guidance and practice to identify automatic thoughts and images.

So, as a Cognitive Behavior Therapist, you need to ask the basic question “What Was Going Through Your Mind” to your patient. And when are you going to do it? Well, you would ask this question when your patients explain a problematic situation that they experienced. Or when you observe a shift to negative affect during the session.

Therefore, you need to vigilant to both verbal and non-verbal cues from your patient to bring out his automatic thoughts during the session.

These automatic thoughts may be associated with the patient himself, you as a therapist, or the subject in question. Such thoughts may weaken your patient’s sense of worth and may also interfere with the therapeutic relationship.

However, your patient gets an opportunity to test and respond to the automatic thoughts immediately. Provided he is able to identify his automatic thoughts.

(v) What are The Techniques To Elicit Automatic Thoughts?

You can use the following techniques in case your patient is unable to explain what was going through his mind.

• Ask them how he felt and where inside the body he experienced the emotion?
• Obtain a detailed description of the problem at hand
• Ask him to visualize the distressing situation
• Suggest him to recreate the specific interaction that he had with you through role play
• Try to obtain a mental image of what he experienced
• Supply opposite thoughts to him
• Uncover the meaning of the situation
• Phrase the question differently

(vi) Identifying Additional Automatic Thoughts

One of the other Cognitive Behavioral Therapy steps is to continue questioning your patients even when they outline an initial automatic thought. Thus, the additional questioning would bring to the front other important thoughts.

It is important to note that your patient may have other automatic thoughts. But, these thoughts are not about the same situation itself. Rather, they are about their reaction to that situation.

Thus, they may interpret their emotion, behavior, or physiological reaction in a negative way. This means that your patient may first have automatic thoughts about the specific situation. And then, he has thoughts about his anxiety and his bodily reaction.

Remember, these secondary emotional reactions can be quite distressing. Furthermore, such secondary emotions can make the situation even worse than it is for your patient.

Therefore, as a Cognitive Therapist, it is important for you to determine the points at which your patient was distressed. Furthermore, you also need to figure out what their automatic thoughts were at that point.

(vii) Identifying The Problematic Situation

As mentioned above, your patients find it difficult to identify their automatic thoughts related to a particular emotion. In addition to this, your patients may also find it challenging to recognize the issue that is upsetting them.

In such a situation, you need to propose a host of upsetting problems and help them determine the most upsetting problem.  Then, you can ask your patient to imagine how he feels where one of those upsetting problems is eliminated.

Thus, it becomes easy for your patient to identify the automatic thoughts once he is able to identify a specific situation.

(viii) Differentiating Between Automatic Thoughts and Interpretations

Remember, you look for actual words or images that go through your patient’s mind when you ask him for automatic thoughts.

So, many patients indicate interpretations instead of automatic thoughts. This is because they still have not learned to identify their automatic thoughts. As a result, these interpretations say nothing about their automatic thoughts.

Therefore, as a Cognitive Therapist, you need to on your patient’s emotions whenever he reports an interpretation instead of an automatic thought.

(ix) Mentioning Automatic Thoughts Rooted in Discussion

Your patients need to learn to mention the actual words that go through their minds. And how can they learn this?

Well, as a Cognitive Therapist, you need to smoothly lead your patients to recognize the actual words that go through their minds.

This way, you will be able to assess them effectively as a Cognitive Therapist.

(x) Changing the Form of Question Thoughts

It is common on the part of your patients to report automatic thoughts that are incomplete. Therefore, in such situations, you need to advise them to communicate the complete thought.

Besides this, you can even help them spell out the complete automatic thought. How? Just spell out an opposite thought in case your patients are unable to specify the complete automatic thought.

Then, sometimes your patients may express automatic thoughts in the form of questions. In such a case, it would become challenging for you and the patient to assess the automatic thoughts.

So, you need to guide your patient to express his thoughts in the form of a statement. You should give this guidance before helping them to assess their automatic thoughts.

(xi) Identifying Situations That Can Elicit Automatic Thoughts

Automatic Thoughts can arise both due to external stimuli and internal experiences. This means that your patients can have automatic thoughts in other areas.

For instance, your patient can have thoughts about his cognitions, emotions, behavior, physiological, or mental experiences. Therefore, any of these stimuli may give rise to an initial automatic thought t or a sequence of automatic thoughts.

Then, an initial emotional, behavioral, or psychological reaction may follow these automatic thoughts. Following this, your patient may have additional thoughts about any part of the Cognitive Model. Hence, this may further lead to additional related emotional, behavioral, and physiological reactions.

(xii) Conclusion

It is clear that people suffering from psychological disorders make predictable errors in their thinking. Thus, as a Cognitive Therapist, it is your job to teach your patients to recognize their dysfunctional thinking, to assess the same, and modify it.

Thus, this process begins with recognizing the specific automatic thoughts in particular situations. The ability to identify automatic thoughts varies from patient to patient. This means that it is easier for some patients to identify automatic thoughts. While it may take other patients some amount of practice to identify such thoughts.

Therefore, as a Cognitive Therapist, you need to ensure that your patients outline actual thoughts. So this means you would have to change your questioning in case your patients are unable to recognize their own automatic thoughts.

II. Identifying Emotions

Emotions are the primary element of Cognitive Behavioral Therapy. Furthermore, the symptom relief and abatement of the patient’s disorder are the important goals of Cognitive Therapy.

As we already know, excessive negative emotion is painful and may be dysfunctional. This happens when negative emotions interfere with your patient’s capability to think clearly, solve problems, act effectively, or gain satisfaction.

So, patients suffering from a psychiatric disorder often experience intense emotions. And the intensity of these emotions may be inappropriate to the situation.

However, the intensity of your patient’s emotions matters when you identify the strength of his automatic thoughts and beliefs. This is because such automatic thoughts and beliefs of your patient are highly activated.

Hence, the following are the things you need to do as a Cognitive Therapist to help your distressed patient identify his emotions.

(i) Things CBT Therapists Need To Do In Identifying Emotions

As a therapist, it is important for you to acknowledge as well as empathize with the way your patient feels. Besides this, you should not challenge or dispute your patient’s emotions.

This means, you just need to assess the thoughts and beliefs underlying your patient’s distress to reduce his depression. And you have to restrain yourself from evaluating his emotions.

Besides this, you do not have to discuss all the situations or events where your patient feels depressed or unhappy. Rather, you have to determine your patient’s important problematic issues based on your Conceptualization of your patient.

Typically, the problems with the highest levels of distress are the most important problems of your patient. And the problems in which the patients have a normal level of distress are usually less important.

Thus, the aim of CBT is not to get rid of all the distress. Remember, negative emotions are equally an important part of our lives as positive emotions. This is because negative emotions serve an important function just like physical pain.

In addition to this, you need to strive towards increasing your patient’s positive emotions. How? Well, you need to discuss your patient’s interests, positive events occurring in the previous week, and positive memories.

Besides this, you need to assign homework to your patient. Such assignments must involve activities that give pleasure to your patient.

(ii) Differentiate Automatic Thoughts From Emotions

Many patients do not understand the difference between thoughts and emotions. Thus, as a therapist, you need to help your patient understand what he is going through. In addition to this, you also need to share your understanding of the experience with him.

In other words, as a Cognitive Therapist, you need to consistently help your patients understand their experiences through the Cognitive Model.

How To Distinguish Between Thoughts and Emotions?

So to achieve this, you first need to organize your patient’s data into the Cognitive Model categories. These include Situation, Automatic Thought, and Reaction. The Reaction includes emotion, specific behavior, and physiological response.

Besides this, you need to be vigilant enough in situations when your patient confuses his thoughts and emotions. In such situations, you can either ignore the confusion, address it at that time, or address it later.

The action you choose would depend upon the flow of the session, your patient’s goals, and the strength of your alliance with the patient.

So, you should clearly state the difference between emotion and thought to your patient if you choose to address the confusion. You need to let your patient know that feelings are what you experience or feel emotional. Typically, emotions are represented in one word like anger, anxiety, fear, and so on.

However, thoughts are the ideas that your patient has. Your patient thinks about the ideas either in words or in images.

(iii) Why It’s Important To Distinguish Among Emotions?

As a therapist, you constantly conceptualize your patient’s problems. This is so because you want to understand his experiences, viewpoints, beliefs, automatic thoughts, emotions, and behavior.

So, the connection among your patient’s thoughts, emotions, and behavior should make sense. This means you need to investigate further when your patient’s emotions do not match with the content of his automatic thoughts.

(iv) Difficulty in Labeling Emotions

Many patients label their emotions quite easily and correctly. However, there are some patients who have a very poor vocabulary for emotions. Besides this, there are still others who face difficulty labeling their own specific emotions.

Thus, it is important in such situations to help your patient to link his emotional reactions in particular situations to his labels.

So, how can your patient learn to label his emotions more effectively? The answer is using an ‘Emotion Chart’. In the Emotion Chart, your patient can write down the current and previous situations in which he felt a specific emotion. This way he can even refer back to the chart whenever he faces challenges naming how he felt.

In addition to this, as a Cognitive Therapist, you need to make sure that the content of the automatic thoughts must match with the stated emotion.

(v) Rating Degrees Of Emotion

At times, it is important for your patients to not only identify their emotions. But, it is equally important for them to quantify the degree of emotions they are experiencing.

For instance, your patient may have flawed beliefs about experiencing an emotion. He may believe that his distress will increase and become intolerant if he feels even a small amount of distress.

Thus, in such a situation, you must ensure as a therapist that your patient learns to rate the intensity of his emotions. This is because it will help him in testing his own beliefs.

Besides this, you also need to evaluate whether questioning and adaptively responding to a thought or belief have been effective. This way you can judge whether your patient’s cognition requires further intervention.

However, if you fail to do so, you may end up reaching the wrong conclusions. For instance, you may either conclude that CBT interventions have succeeded. Or you may continue discussing an automatic thought or belief that no longer significantly distresses your patient.

Conclusion

Evaluating the intensity of emotion in a given situation helps both you and the patient determine whether the situation demands close scrutiny.

This means that a relatively less emotionally laden situation may be less valuable to discuss as compared to the one that is more distressing to your patient.

(vi) Using Emotional Intensity To Direct Therapy

Your patients may not have an understanding regarding the situations that they should bring up for discussion. In such a situation, you can always ask your patients to rate the degree of distress they are still experiencing.

Such a rating would help your patients to decide whether discussion regarding a specific situation would be of any help to them.

Therefore, as a Therapist, you need to get a clear picture of the events or situations that distress your patients. Furthermore, you need to help your patients differentiate between their thoughts and emotions. In addition to this, you also need to help your patients to evaluate their flawed thinking that is responsible for their distressed mood.

III. Evaluating Automatic Thoughts

Your patients have innumerable thoughts a day. Some thoughts are flawed whereas some are functional. However, as a Cognitive Therapist, you need to evaluate only a few ones in a given CBT session.

The following is the manner in which you can evaluate the automatic thoughts of your patients.

(i) Select Key Automatic Thoughts

Say, your patient makes an instantaneous revelation during the session. Then, he associated an automatic thought from the previous week with such a revelation. Or, your patient narrated an automatic thought that he anticipates would occur in the future.

So, you as a Cognitive Therapist, identify your patient’s automatic thoughts. Now, the next thing that you need to do is to conceptualize whether your patient’s automatic thought is important or not. In other words, you need to determine whether the automatic thought is currently distressing or likely to repeat in the future for your client.

How? Well, you need to ask questions to your client from the previous week in case the automatic thoughts occurred in the previous week. Besides this, you will also ask yourself whether your patient is likely to have this kind of thought again in the future and feel depressed.

You can change the questions a bit in case you believe there is a chance of recurrence of the automatic thoughts in the near future. In addition to this, you also need to ask additional questions to your patient to determine whether there are certain additional automatic thoughts that are important.

(ii) Use Socratic Questioning To Evaluate Automatic Thoughts

So, you have identified your patient’s automatic thoughts and determined that it’s important and distressing for your client. Besides this, you have also recognized the associated reactions to such automatic thoughts.

Now, the next step is that you need to collaborate with your patient and evaluate his automatic thoughts. You need not challenge your patient’s thoughts directly. This is because:

• You are unaware of the intensity of your patient’s automatic thoughts beforehand.
• Challenging your patient’s thoughts directly can make him feel invalidated.
• Lastly, directly challenging the thought process of your patient would go against the CBT principle of collaborative empiricism.

Besides this, you should also keep in mind that automatic thoughts cannot be entirely inaccurate. These thoughts do have some amount of truth in them.

How To Evaluate Automatic Thoughts?

Typically, you need to use Socratic Questioning to help your patients evaluate their thinking. It is important to note that the patients need a structured methodology to evaluate their thought processes.

In the absence of a structured method, your patients would respond to their automatic thoughts superficially or unconvincingly. As a result, your patients would not be able to enhance their mood or functioning.

Furthermore, the evaluation should be fair. For instance, you do not want your patient to overlook the evidence by:

1. supporting his automatic thoughts
2. creating another explanation that is not appropriate, or
3. accepting an unjustified positive view of what might happen?

So, what are the questions that you need to ask your patient? Well, the following table lists those questions.

Questions For Evaluating Automatic Thoughts

S.No	Aspect	Question
1.	Analyze the validity of the automatic thought.	What is the evidence that supports this idea? What is the evidence that works against this idea?
2.	Survey the likelihood of alternative interpretations or viewpoints	Is there any other explanation or viewpoint?
3.	Decatastrophize the problematic situation.	What is the worst that could happen? If it happened, how could I cope? What is the best that could happen? What is the most realistic outcome?
4.	Identify the impact of believing the automatic thought.	What is the effect of my believing the automatic thought? What could be the effect of changing my thinking?
5.	Gain distance from the thought.	What would I tell_____________________ [a specific friend or family member] if he or she were in the same situation?
6.	Take steps to resolve the problem.	What should I do?

Conclusion

However, you need to keep in mind that not all questions are appropriate to ask your patient. Furthermore, asking all the questions may overwhelm your patient and may be very time-consuming.

Remember, that your patients would end up not evaluating their thoughts at all if they consider the entire process to be overwhelming. So, make sure that you ask one or a few questions at a time.

Besides this, you may use Socratic Questioning from the first CBT session itself. This is because it will help you to evaluate a specific automatic thought of your patient.

Then, in the following session, you can explain the entire process of Socratic Questioning more specifically to your patients. This way, your patients can learn to evaluate their thinking between the sessions.

(iii) Assess The Outcome of the Evaluation Process

As a Cognitive Therapist, you would evaluate to what extent your patient believes in the automatic thought that came to his mind originally? Additionally, you will determine how your patient feels emotionally once he has evaluated his thoughts.

This will help you as a therapist to determine what you should do next in the CBT Session. Remember, you might not use all Socratic Questions mentioned in the above table to evaluate your patient’s automatic thoughts.

Sometimes, you might not even use a single question and may adopt a different path altogether to assess the automatic thoughts of your patient.

(iv) Conceptualize

Say, your patient still believes his original automatic thought to a great extent and feels inferior emotionally. In such a case, you need to conceptualize why your attempt at cognitively restructuring your patient was not sufficiently effective.

There can be a number of reasons for such ineffectiveness or failure. Some of the common reasons are given in the table below.

Conceptualization Example

Let’s consider the example of Stephanie – a University student. She reports the thought “If I participate in the Community Dance Competition, I Will Never Be Able to Make It.”

1. Other Automatic Thoughts Are Unevaluated

So, when Stephanie evaluates this automatic thought in case of the first situation, she does not get distressed. This is because she has other important automatic thoughts running in her mind.

Now, what can the alternative automatic thoughts be? These may include thoughts like: “What if the audience thinks I am not a good dancer?” or “What if I forget the dance steps?”

Remember, Stephanie does have an image of her Dance Teacher and other competitors watching her with mocking, scornful faces.

2. Implausibility in Evaluating an Automatic Thought

Now, in the second situation, Stephanie responds to an Automatic Thought superficially.

For instance, Stephanie thinks that she will not be able to perform dance this time around as she has her exams.

However, despite having this belief, she tells her teacher that she will probably perform.

In this case, Stephanie did not evaluate her automatic thought before responding. Therefore, her response is insufficient and her anxiety did not decrease.

3. Insufficient Evidence

Let’s take up the third case. Say, as a therapist, you do not investigate thoroughly. As a result, Stephanie does not communicate the evidence fully that her automatic thought is true. This leads to Stephanie giving an ineffective adaptive response.

4. When Automatic Thought Is The Fundamental Belief

Now, let’s consider the fourth situation. Stephnie identifies an automatic thought that also happens to be her core belief. Like, Stephanie always thinks that she is inept.

She believes this belief so strongly that a single evaluation does not change her perception and the associated effect. Thus, as a therapist, you need to use a number of techniques over a period of time to change Stephanie’s beliefs.

5. Inability To See Distortion at Emotional Level

Finally, there can be a situation when Stephanie indicates that she believes an adaptive response “intellectually” in her mind. However, she does not believe it “emotionally” in her heart or soul. Thus, she disregards the adaptive response. So, in this case, you and Stephanie need to discover the unexpressed belief that lies behind Stephanie’s automatic thought.

(v) Use Alternative Methods

As a Cognitive Therapist, you can use alternative strategies in addition to using Socratic Questioning to evaluate the automatic thoughts of your patients.

These strategies include:

• Using alternative questions

  As a therapist, you need to vary questions in case you believe that the standard questions as mentioned in the previous section are not working. These alternative questions would help your patient to adopt a more functional perspective.

  You can begin by questioning the validity of the automatic thought of your patient. Then, you can shift your focus to the implicit underlying belief.

  In the end, you can ask your patient an open-ended question to understand whether your patient needs further help in responding to her thoughts.

• Recognizing Cognitive Distortion

  Patients tend to make errors in their thought process consistently. As per Aron Beck, people suffering from a psychiatric disorder have a systematic negative bias in their cognitive processing.

  The following table showcases the most common cognitive errors.

  Common Cognitive Errors

  S.No.	Error in Automatic Thought	Description
  1.	All-or-nothing thinking	In this kind of thinking, your patient views a situation in only two categories.
  2.	Catastrophizing	It is the type of thinking in which your patient predicts the future negatively without considering other outcomes.
  3.	Disqualifying	In this, your patient tells himself unreasonably that positive experiences, deeds, or qualities do not count.
  4.	Emotional Reasoning	This makes your patient think that something must be true because he “feels” it so strongly. Thus, your patient ignores the evidence.
  5.	Labeling	Your patient puts a label on himself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion.
  6.	Magnification or Minimization	Your patient unreasonably magnifies the negative or minimizes the positive whenever he evaluates himself, another person, or a situation.
  7.	Mental Filter	It happens when your patient pays undue attention to one negative detail instead of seeing the whole picture.
  8.	Mind Reading	This is a situation when your patient believes you know what others are thinking, failing to consider other, more likely possibilities.
  9.	Overgeneralization	Overgeneralization is a cognitive error that occurs when you make a sweeping negative conclusion that goes far beyond the current situation.
  10.	Personalization	Personalization occurs when your patient believes that others are behaving negatively because of him, without considering more plausible explanations for their behavior.
  11.	“Should” and “Must” Statements	In this, your patient has a precise, fixed idea of how he or others should behave. Also, he overestimates how bad it is that these expectations are not met.
  12.	Tunnel Vision	Tunnel Vision is a Cognitive Error that occurs when your patient only views the negative aspects of a situation.

• Using Self-Disclosure

  As a therapist, you might use well-thought-out self-disclosure in place of or in addition to Socratic Questioning or other methods.

  You do this because you want to showcase as a therapist that even you have automatic thoughts and how you were able to change similar thoughts.

(vi) Respond When Automatic Thoughts Are True

At times, the automatic thoughts of your patients turn out to be true. So, you may choose to undertake one or more of the following:

• Emphasize on Solving Problems

  You already know that all problems cannot be solved. However, you would like to investigate whether your patient’s problem can be resolved when his perception of a situation is likely to be valid.

• Investigate Invalid Conclusions

  There can be a possibility that your patient’s automatic thought turns out to be true. However, the meaning of such a thought may be invalid or may not be completely valid. So, you need to ask your patient further questions in order to investigate the invalid or dysfunctional conclusions that he might have drawn.

• Work Toward Acceptance

  Some problems can’t be solved. And they can never be solved. However, your patients need help in accepting this. They may continue to feel depressed if they have unreasonable expectations about an unresolvable problem.

  In other words, your patients will remain miserable if they believe that the problem at hand can be resolved somehow.

  So, you need to assist your clients in learning to focus on their core values when they continue to have unrealistic expectations. Besides this, you also need to emphasize the more rewarding aspects of their lives and enhance their experience in new ways.

(vii) Teach Patients To Evaluate Automatic Thoughts

Some patients learn to evaluate automatic thoughts quickly. However, others need repeated guided practice. Say, for instance, one of your patients is able to better evaluate his automatic thoughts with a variation in the Evidence Question.

Whereas, another patient who catastrophizes events may do better with a variation of the “Decatastrophizing” Question.

Still another patient may find it useful to answer the “Distancing” Question. Therefore, as a therapist, you need to select one of your patient’s automatic thoughts for which most of the questions are valid. You may do this when your patient is ready to learn the skill of evaluating his automatic thoughts.

Then, you can either give a copy of those questions to your patient following a part of a CBT session. Or else, you can wait until a later time. Provided your questioning is ineffective, you do not have time to review, or you think the patient will become overwhelmed.

So, while handing out the copy of questions to your patient, you can intimate your patient to seek help in case he finds difficulty. This would prevent your patient from self-criticism and defeatism.

However, you need to continue discussing how answering questions would make things better for your patient. Provided he judges his capability to complete the assignment.

(viii) Do Not Use Questions At All

You may simply ask your patients to devise an adaptive response when they have progressed in therapy. That is, they are ready to evaluate their automatic thoughts.

IV. Responding To Automatic Thoughts

Your patient experiences certain automatic thoughts in between the sessions or outside the sessions. There are two types of thoughts that your patient experiences during such a time period.

The first kind of automatic thought is the one that he has already recognized and evaluated during the CBT session. And the second type of automatic thought is Novel Cognition.

So, for the first type of automatic thoughts, you would ensure that your patient has made a note of the robust responses either in writing or in audio format.

Whereas, for the novel cognitions in between the sessions, you need to teach your patient to either use:

• The list of questions mentioned in the above section, or
• Use a Worksheet such as the Thought Record, or
• Utilize “Testing Your Thoughts”

Besides this, there are other ways to respond to automatic thoughts. For instance, your patients can resort to problem-solving, undertake certain relaxation techniques, or accept their thoughts without evaluation.

The following section explains the process that could help your patients to respond to their automatic thoughts.

How To Respond To Automatic Thoughts?

• Reviewing Therapy Notes

  As mentioned, you would evaluate your patient’s automatic thoughts usually through Socratic Questioning. Then, you need to ask your patient to summarize the discussion.

  You can ask questions like:

  • Can you summarize the discussion?
  • What do you think is important for you to remember this week?
  • What would you tell yourself if you face this situation again?

  Furthermore, you can ask your patient to record a brief summary of the discussion that he gives. This would help your patient to remember the response when similar automatic thoughts arise in the near future.

  However, you need to guide your patient if his summary is too superficial, confusing, or wordy. You can give suggestions to your patient which they can record for future use.

  In addition to this, you need to ensure that your patient reads his therapy notes. He can read them every morning or any time during the day whenever he feels the need.

  This is important as patients consolidate responses into their thinking process when they rehearse those responses repeatedly.

  Furthermore, it is important to note that reading therapy notes regularly is more effective. This is because the regular reading of therapy notes prepares your patient for challenging situations constantly.

  However, Reading Therapy Notes only when your patients face challenging situations is less effective in preparing them for such situations.

  What Do Therapy Notes Include?

  Now, what do these therapy notes have that prepare your patients for unwanted situations. These notes include:

  • Responses to distorted thinking
  • Behavioral Assignments, or
  • A combination of the above two

  It is important to note that as a therapist, you must have a photocopy of your patient’s therapy notes. These copies would help you in reviewing your patient’s assignments.

  Moreover, it will help your patient as well in case he misplaced the original copy of the therapy notes.

  Audio-Recorded Therapy Notes

  Though, writing the Therapy Notes is the ideal way of recording the things discussed during the CBT sessions. However, there are some patients who do not like or cannot read. Or they find listening to notes to be more effective.

  In any case, you need to either turn on your audio recorder. Or else, you can ask your patient to record the responses to automatic thoughts discussed during the therapy session.

  You need to ensure that your patient reads or listens to the therapy notes during the week post the therapy session. And for this, you need to consistently motivate your patient to do so.

  Remember, motivating your patient to read or listen to the therapy notes is the same as facilitating him to do any kind of assignment.

• Evaluating and Responding to Novel Cognitions

  In the above section, we emphasized that your patients must use Socratic Questions to evaluate their thinking.

  However, you need to make sure of the following things before suggesting your patients to use such questions at home whenever they feel upset.

  • Your patients must understand that evaluating their thinking would help them feel better.
  • The Patients need to believe that they will be able to use Socratic Questions effectively at home.
  • Your patients have an understanding that not all Socratic Questions apply to all the automatic thoughts.
  • You have created a short list of questions for your patients as they find too many questions overwhelming.

  Besides this, you also need to guide your patients as to when and how to use the questions.

  CBT Thought Record

  The CBT Thought Record (TR) is also called Daily Record. It is a worksheet that induces your clients to evaluate their automatic thoughts whenever they feel depressed.

  It generates more insights than just responding to the Socratic Questions. Now, it is not mandatory for your patients to use a CBT Thought Record if the Socratic Questions are useful to them.

  However, many patients prefer using an automatic Thought Record over Socratic Questions. This is because a CBT Thought Record Worksheet helps them to organize their thoughts and responses in a much better way.

  But remember, a TR is not specifically useful for those patients who are low functioning, do not like writing, and are unmotivated.

  Further, a CBT Thought Log is also not useful for patients who are not qualified or prepared intellectually to benefit from it.

  So, the best that you can do as a therapist is to first use the list of Socratic Questions with your patients. Then, you can demonstrate to them how to write the answers and other details on a Thought Record Template.

  The following section provides a Thought Record Template for you to download and use with your patients.

  CBT Thought Record Template

  Directions: When you notice your mood getting worse, ask yourself, “What’s going through my mind right now?” and as soon as possible jot down the thought or mental image in the Automatic Thought(s) column.
  Date/Time	Situation	Automatic Thoughts	Emotions	Adaptive Response	Outcome
  	What actual events or stream of thoughts led to the unpleasant emotion? Then, what distressing physical sensations did you have?	What thoughts and/or images went through your mind? . How much did you believe each one at the time?	What emotion (sad/anxious/angry/etc.) did you feel at the time? How intense (0–100%) was the emotion?	(optional) What cognitive distortion did you make? Use questions at the bottom to compose a response to the automatic thoughts. How much do you believe in each response?	How much do you now believe each automatic thought? What emotion do you feel now? How intense (0–100%) is the emotion? What will you do (or did you do)?

  Questions to help compose an alternative response

  • What is the evidence that the automatic thought is true? Not true?
  • Is there an alternative explanation?
  • What’s the worst that could happen?
  • How could I cope?
  • What’s the best that could happen?
  • What is the most realistic outcome?
  • What’s the effect of my believing the automatic thought?
  • What could be the effect of my changing my thinking?
  • What should I do about it?
  • If [friend’s name] was in the situation and had this thought, what would I tell him/her?

  Download CBT Thought Record PDF Template

  The above table showcases a sample thought record worksheet from the Cognitive behavior therapy worksheet packet by Judith S. Beck. Bala Cynwyd, PA: Beck Institute for Cognitive Behavior Therapy.

  To download the CBT Thought Record PDF template, click the link below:
  Download CBT Thought Record PDF

  Testing Your Thoughts Worksheet

  You can use a simplified version of a CBT Thought Record in case your patients find it too overwhelming. The simplified version of a CBT Thought Log is the “Testing Your Thoughts” Worksheet.

  Testing Your Thoughts Worksheet is similar to an automatic Thought Record. It consists of similar questions, is written in the readable language, and is more structured. Thus, patients find it easy to complete a Testing Your Thoughts Worksheet.

  CBT Testing Your Thoughts Worksheet

  The following table showcases the “Testing Your Thoughts” Worksheet. This Worksheet is taken from the Cognitive behavior therapy worksheet packet by Judith S. Beck. Bala Cynwyd, PA: Beck Institute for Cognitive Behavior Therapy.

  What’s the situation?______________________________________________________________________________________________________________

  What am I thinking or imagining?______________________________________________________________________________________________________________

  Different things that makesme think the thought is true?______________________________________________________________________________________________________________

  What makes me think the thought is not true or not completely true?______________________________________________________________________________________________________________

  What’s another way to look at this?______________________________________________________________________________________________________________

  What’s the worst that could happen? What could I do then?______________________________________________________________________________________________________________

  Wha is the best that could happen?______________________________________________________________________________________________________________

  What will probably happen?______________________________________________________________________________________________________________

  What’ll happen if I keep telling myself the same thought?______________________________________________________________________________________________________________

  What could happen if I changed my thinking?______________________________________________________________________________________________________________

  What would I tell my friend [think of a specific person] happened to him or her?______________________________________________________________________________________________________________

When a CBT Thought Record Worksheet Is Not Enough

As a therapist, you should not overstate the importance of a particular Cognitive Behavioral Therapy Technique. The same goes for the CBT Thought Record Worksheets as well.

Usually, patients find it overwhelming to complete a worksheet at some point in time. Or, they may realize that completing a worksheet did not give them the much-required relief.

So, you should always point out the general functionalities of a CBT Thought Record Worksheet. Plus, you should also demonstrate the learning opportunities from such Worksheets.

This will help your patients to avoid automatic thoughts that are disapproving of themselves, the therapy, the worksheets, and much more.

Responding To Automatic Thoughts in Other Ways

There may be times when you will have to use other CBT techniques to help your patients respond to their automatic thoughts.

One of such CBT techniques is called “AWARE”. This technique is used to help your patients evaluate their anxious thoughts.

As a therapist, you can use certain relaxation or distraction CBT techniques. You can use these techniques when your patient’s emotions are too strong. And, hence, it is ineffective to use your patients’ cognitive function to evaluate their automatic thoughts.

V. Identifying and Modifying Intermediate Beliefs

This section deals with the deeper understandings that the patients have about themselves, others, and their personal lives. These understandings lead to the development of specific automatic thoughts.

However, these ideas are often unarticulated before CBT Therapy.  But, as a therapist, you can easily bring out these ideas.

It is important to note that such beliefs or ideas are often of two types: Intermediate Beliefs and Core Beliefs.

Intermediate Beliefs are the ideas composed of rules, attitudes, and assumptions. Whereas, the Core Beliefs are the rigid and global ideas that your patients have about themselves, others, and the world.

Furthermore, the Intermediate Beliefs are still modifiable relative to the Core Beliefs of a patient.

Now, as a therapist, you first need to develop a Cognitive Conceptualization of your patient before planning CBT Therapy for him. Furthermore, Cognitive Conceptualization would help you to chose suitable CBT interventions.

In addition to this, it also helps you to use other CBT techniques in case the standard CBT interventions fail.

(i) Cognitive Conceptualization

Typically, as a therapist, you would guide your patients to work on their automatic thoughts. You would not directly engage in modifying the intermediate beliefs of your patients.

Thus, you would develop a Cognitive Conceptualization about your patient from the very beginning of CBT Therapy. This is because Cognitive Conceptualisation about your patient helps you to associate automatic thoughts with deeper-level thoughts.

Therefore, you are less likely to direct CBT Therapy effectively and efficiently if you fail to see the bigger picture.

So, you need to develop a Cognitive Conceptualization Diagram. Then, you need to start filling it out with your patient after the first CBT session.

But, you can do this only if you have your patient’s data collected in the form of a cognitive model. In other words, you must have your patient’s data about his automatic thoughts, emotions, behavior, and beliefs to develop Conceptualization.

Remember, that a Cognitive Conceptualization Diagram showcases the relationship between your patient’s core beliefs, intermediate beliefs, and the present automatic thoughts.

In other words, it provides you with a cognitive map of your patient’s psychopathology. Furthermore, it also helps you to organize a wide range of data your patient presents.

Therefore, a Cognitive Conceptualization Diagram consists of the questions you need to ask yourself to complete the same.

Cognitive Conceptualization Diagram

As a therapist, you should consider filling in this diagram after the first CBT session as your initial, tentative effort. This is because you do not have sufficient cognitive data of your patient just after the first CBT session itself.

Thus, the insufficient data would not help you to determine the degree of your patient’s automatic thoughts. Furthermore, the incomplete diagram would mislead you. Provided, you chose situations in which the themes of your patients’ automatic thoughts do not form part of an overall pattern.

Thus, it is important to complete the Cognitive Conceptualization Diagram with your patient. And, you will be able to develop a complete diagram after three or four CBT sessions. This is because you will get your patient’s complete pattern after completing these sessions.

Also, you can verbally share the partial Conceptualization Diagram with your patient. And you can do so when you summarize every session in the form of a cognitive model.

However, you may not be able to share an incomplete worksheet with your patients. This is because, unlike the Diagram, the incomplete worksheets can be quite overwhelming or confusing for your patients.

CBT Cognitive Conceptualization Diagram Template

How To Fill A Cognitive Conceptualization Diagram?

• Create A Tentative CBT Conceptualization Diagram

  In the beginning, you might just have some data to complete a part of the diagram. So, you can either leave the other boxes blank. Or, you can fill the items that you have worked out with a question mark. This would indicate that the information in such boxes is tentative.

  In addition to this, you will confirm the details of all the boxes with a question mark with your patient in future sessions.

• Review The Tentative Cognitive Conceptualization Diagram

  Well, at some point during the CBT Treatment, you will have to share both the top and the bottom parts of the Conceptualization Diagram. This happens when you want your patient to take a much broader view of the challenges.

  It is at this time that you will verbally review the Conceptualization of your patient’s automatic thoughts. Besides this, you will also share with your patient a simplified version of the Conceptualization on a blank paper.

• Share A Blank Cognitive Conceptualization Diagram

  But, you can also give your patient a blank Cognitive Conceptualization Diagram so that you can fill it together. Provided you believe that your patient would benefit from such an exercise.

  Remember, you will always present tentative explanations with your patient. Furthermore, you would label such explanations as Hypotheses. Then, you would ask your patients whether they believe the explanations are true or not.

  Typically, it is ideal to start with the bottom half of the Conceptualization Diagram. Then, as a therapist, you make a note of three typical situations in which your patient became upset.

  Following this, you will have to make a note of the primary automatic thought of your patient, its meaning, and the following emotions and behavior of your patient.

  However, there might be a case that you do not directly ask your patient the meaning of his automatic thoughts. In such a situation, you need to either hypothesize or adopt the downward arrow technique.

  You can use this technique in the next CBT session to uncover the meaning of each of your patient’s automatic thoughts.

  Remember, you need to logically connect the meaning of each of your patient’s automatic thoughts with the Core Belief Box.

• Complete The Top Box of the Cognitive Conceptualization Diagram

  The following are the questions you need to ask yourself to complete the top box of the diagram:

  • How did the core belief arise and become maintained?
  • What life events did your patient experience, specifically in childhood, that might relate to the maintenance of the belief?

  Typically, the childhood data may include certain key events. These may include:

  • A rift between parents or family members,
  • Parental divorce,
  • Negative conversations with parents, siblings, teachers, or peers, or others where your patient felt blamed or devalued,
  • Serious illness
  • Death of important people in your patient’s life,
  • Physical or sexual abuse,
  • Financial distress,
  • Experiencing trauma, or
  • Other adverse conditions

  However, there can be a possibility that your patient’s childhood data is more subtle in nature. For instance your patient:

  • Did not meet his parent’s expectations, teachers, or others,
  • Was demeaned by his peers
  • Felt that his parents favored his sibling

  Next, you need to ask yourself that did your patient cope with this core belief? Further, you also need to think about the intermediate beliefs that your patient developed during childhood.

• Complete The Assumptions Box of the Cognitive Conceptualization Diagram

  The next step is to list the key assumptions that your patient made about his core beliefs in the Conditional Assumptions/Beliefs/Rules Box.

  You need to list the assumptions once you have determined the core as well as the intermediate beliefs of your patient. Remember, that you can categorize your patient’s beliefs into attitudes or rules, as the case may be.

  It is important to note that your patient forms assumptions because these assumptions help him to cope with his core or intermediate beliefs.

  But, you must also know that your patient may also develop a negative assumption of the same positive assumption he formed in the first place to cope with his beliefs.

  Typically patients with anxiety disorders tend to function using the assumption phrased in a positive manner. However, they tend to rely on the negative assumption if they become psychologically distressed.

• Fill The Coping Strategies Box of the Cognitive Conceptualization Diagram

  To complete this box, you need to determine the behavioral strategies your patient developed to cope with his core belief.

  Now, the nature of the strategies that your patient developed to cope with his core belief would depend upon his cognitive and behavioral style.

  This behavioral style is the result of his intermediate beliefs. These beliefs developed as a consequence of his interactions with the environment around him.

  Furthermore, these beliefs reinforced his cognitive and behavioral strategies.

  Now, you need to understand that adopting coping strategies is normal behavior. This is because everyone makes use of these strategies to cope with challenging situations.

  However, it turns out abnormal when psychologically distressed people overuse these strategies at the cost of more functional strategies.

Summary of Cognitive Conceptualization Diagram

Cognitive Conceptualization Diagram includes only the data your patient presents. Secondly, you must consider your hypotheses as tentative till the time your patient confirms them.

Next, you will keep on reevaluating and refining your diagram as and when you collect more data. Remember, your conceptualization stands incomplete till the time your patient terminates the CBT treatment.

As mentioned above, you may not share the actual diagram with your patients. However, you will verbally communicate the conceptualization about your patient’s experience right from the first CBT session.

This will help your patient to get a sense of their current reactions to various situations. Then, at some point, you would present the larger picture to your patient.

Remember that some patients may not be ready both intellectually and emotionally to see the larger picture. In such a case, you need to wait until your patient is ready.

(ii) Identifying Intermediate and Core Beliefs

The following are the strategies that you can adopt to identify the intermediate and core beliefs of your patient.

(iii)Deciding Whether To Modify A Belief

Once you have successfully determined a belief, the next step is to determine whether the intermediate belief is important or not.

It is important to note that to conduct CBT Therapy efficiently, you need to focus on the most intermediate beliefs.

Moreover, it’s a waste of time and effort to focus on the dysfunctional beliefs that are not important to your patient.

Then, you need to decide whether to explicitly present the belief to your patient or not. Besides this, you also need to determine whether you will just identify the belief and work on it in the future. Or, whether you would prefer to work on it at the present time.

And, you need to do all this once you have figured out your patient’s important intermediate belief. S, you can ask yourself the following questions:

• What is the Belief?
• How Strongly Does My Patient Believe in It?
• How Strongly Does It Impact His Life In Case He Believes in it Strongly?
• Should I Work On His Belief Now in Case He Believes in It Strongly?
• Will My Patient Be Able To Evaluate His Beliefs With Reasonability?

So, you need to start modifying your patient’s beliefs as early as possible. It is important to note that your patient will be able to interpret his experiences in a more reasonable and functional way. Provided, he no longer strongly endorses his beliefs.

However, some beliefs are deeply embedded in your patient’s mind. So, it is ideal to teach your patient to first evaluate his automatic thoughts. This is because your patient will come to know that it is not mandatory that whatever he thinks or believes is not necessarily true.

Remember, it is easy to modify beliefs in some patients. However, it is much more difficult with others. Also, you need to ensure that you modify the intermediate beliefs of your patients before their core beliefs.

This is because the core beliefs are rigid and it is challenging to modify them.

(iv) Educating Patients About Beliefs

You may decide to educate your patient about the nature of his beliefs using a particular belief as an example. However, you should do this once you have identified an important belief your patient strongly believes in.

So, you can explain to your patient that he could have adopted a range of beliefs. Furthermore, you also need to explain that beliefs are learned, are not innate, and hence can be modified.

(v) Altering Rules and Attitudes Into Assumption

It is important to note that it is easy for your patients to identify the distortion and evaluate an intermediate belief. Provided, such a belief is in the form of an assumption.

However, it will be quite challenging for your patient to observe and assess an intermediate belief if it is in the form of a rule or an attitude.

Therefore, as a therapist, you need first identify the rule or the attitude. Then, you need to use the Downward Arrow Technique to determine the meaning of such a belief.

(vi) Determining Advantages and Disadvantages of Beliefs

It is quite helpful for your patients to determine the advantages and disadvantages of holding a certain belief.

Therefore, as a therapist, you need to try to minimize the advantages and reinforce the disadvantages of holding such a belief.

(vii) Developing A New Belief

As mentioned above, you certainly need to decide the strategies in order to modify your patient’s belief. While doing so, you also need to formulate a more adaptive or functional belief for your patient.

Although, formulating a new belief is a collaborative procedure. But still, you need to formulate a range of more functional beliefs in your mind. This is because you can use such beliefs while choosing strategies to change the old belief of your patient.

(ii) Modifying Beliefs

There are a number of strategies that you can adopt as a therapist to modify the intermediate or core beliefs.

However, you must understand that some beliefs may change easily. But, many other beliefs may take a constant effort on your part over a period of time.

Now, you can keep asking your patients the degree to which they believe a specific belief. And, you can do this at both intellectual and emotional levels.

This will help you to determine the amount of work needed to be done to modify a given belief.

You must understand that it is impossible to reduce the level of belief to 0%. This means you need to make a judgment call to decide when to stop working on a belief.

Typically, your patient stops believing in a given belief if he affirms to it less than 30%.

Furthermore, a belief tends to minimize when your patient is more likely to continue modifying his dysfunctional behavior. Although, your patient continues to believe just a small part of the belief.

Also, you need to ensure that your patient keeps a track of the beliefs he evaluates in his therapy notes.

He needs to do this in a structured format. For instance, he can use the following format:

• Dysfunctional Belief – Strength of the Belief (in percentage)
• New Belief – Strength of the Belief (in percentage)

Furthermore, you also need to ensure that your patient reads and reevaluates the degree to which he believes in both old and new beliefs daily.

Now, there are certain CBT techniques that you can practice to modify your patient’s beliefs. These include:

• Socratic Questioning

  You need to use the same types of questions to evaluate your patient’s belief that you used in evaluating his automatic thoughts.

  Through these questions, you try to help your patient evaluate his beliefs with regard to specific situations. This specificity makes the evaluation process more meaningful and less abstract.

• Behavioral Experiments

  Just like automatic thoughts, you can help your patient in developing behavioral tests to evaluate the validity of a belief.

  Remember, the behavioral experiments can modify your patient’s beliefs more effectively as compared to the verbal techniques. Provides, such experiments are designed and carried out properly.

• Cognitive Continuum

  This technique is useful to modify both your patient’s automatic thoughts and beliefs reflecting contradictory thinking.

  Furthermore, building a Cognitive Continuum for the concept in question facilitates your patient to recognize the middle ground.

  Also, this technique is useful when your patient showcases dual thinking. So, like other CBT techniques, you can directly teach your patient the manner in which he can employ this technique himself.

• Role Plays

  This CBT Technique is also called Point-Counterpoint Technique. It is typically used after you have tried other CBT techniques with your patient.

  You can use this technique when your patient believes intellectually that a given belief is dysfunctional. However, emotionally, your patient still believes that the given belief is true.

  Therefore, in the first round of the role play, you play the “intellectual” part of your patient’s brain. Whereas, you ask your patient to play the “emotional” part of his brain – the one that strongly believes in the dysfunctional belief.

  Then, in the second segment of the role play, you switch roles. It is important to note that in both the segments, both you and your patient speak as the patient. In other words, you both use the word “I”.

  Thus, when you switch roles, it provides an opportunity for your patient to speak the intellectual voice that you just modeled. Likewise, you make use of the same reasoning and emotional words that your patient used.

  Therefore, using their own words helps your patients to respond more precisely to the specific concerns.

  Now, there can be a possibility that your patient is unable to formulate a response while he is playing the intellectual part.

  In such a case, you can either switch roles temporarily or else you can come out of the role and discuss the issue with your patient.

  Furthermore, you will also evaluate the effectiveness as well as the degree to which your patient needs to work on a given belief.

  And how can you do this? You can do this by asking your patient to rate the degree to which they believe in the belief even after cognitive interventions.

  Note that many patients find this role play useful. While others feel uncomfortable doing it. Therefore, both you and your patient need to mutually decide whether to use this CBT technique or not.

• Using Other People As a Reference Point

  Your patient is at a distance from his own beliefs when he considers the beliefs of other people. In such a situation, your patient observes an inconsistency between what they believe about themselves and what they more strongly believe is true about others.

  This is one way to modify an intermediate or core belief of your patient. Another way to do this is to make your patients recognize someone else who has the same dysfunctional belief as them.

  Sometimes, your patients may be able to see the distortion in someone else’s thinking and apply the night to themselves.

  Besides this, you can even do a role play with your patients. While doing this, you can instruct them to convince another person that the belief they both hold is invalid for the other person.

  Finally, many patients can distance themselves from a belief by using their own or other children as a reference point.

• Acting “As If”

  Changes in belief lead to corresponding changes in behavior. And changes in behavior lead to corresponding changes in belief.

  Say, for instance, your patient has a fairly weak belief. In such a case, your patient may be able to change target behavior quite easily, without much cognitive intervention.

  But, there are many beliefs that require some modification before your patient is willing to change behaviorally. However, only some and not complete belief modification is required.

  And once your patient begins to change his behavior, the belief itself gets weakened.

• Self-Disclosure

  You can help some of your patients view their beliefs differently using appropriate and judicious Self-Disclosure. Remember, the Self-Disclosure should be genuine and relevant.

VI. Identifying and Modifying Core Beliefs

Note that your patients may have negative core beliefs about other people and their environment. For instance, “Other People are Not Trustworthy”, “This World is a Bad Place to Live In”, “Guys Can Never Stay Committed in a Marriage“, etc.

These are fixed overgeneralized ideas. Hence, these need to be evaluated and modified in addition to the core beliefs that your patient has about himself.

Remember, the positive schema of your patient turns into a negative schema as and when he becomes depressed.

As a result, your patient begins to overemphasize and overgeneralize negative data.

Furthermore, such overgeneralization of the negative data reinforces your patient’s beliefs.

At the same time, your patient fails to identify a significant amount of positive data related to his schema. As a result, the positive data fails to get incorporated into his cognitive schema.

Thus, when this happens, your patient does not voluntarily process information in a dysfunctional manner. This kind of information processing happens automatically and is a symptom of depression.

Therefore, it is important as a therapist to work on modifying the negative core belief of your patient. This will result in not only relieving him from depression. But, it will also reduce the severity of future episodes.

So, you will have to directly start working on modifying the beliefs of your patient as soon as possible in the CBT treatment. This is because it is less likely for your patients to process thoughts in a dysfunctional manner once they change their beliefs.

In some situations, your patients may have more functional and realistic automatic thoughts. However, there may be times when they may be holding quite rigid beliefs.

Therefore, the following are the reasons why you may not be able to succeed in modifying your patient’s beliefs.

Thus, in all such cases, you will teach your patient certain tools. These include tools of recognizing, evaluating, and adaptively responding to automatic thoughts and intermediate beliefs. You should teach these tools for modifying intermediate beliefs before modifying your patient/s core beliefs.

It’s quite unconscious a practice to evaluate your patient’s core belief early in the treatment. This is because your patient expresses the core belief as an automatic thought. Furthermore, such an evaluation may not turn out to be effective.

Besides, there may be another possibility. You might intentionally test the modifiability of a core belief. And you may do this even before working on your patient’s automatic thoughts and intermediate beliefs.

Note that the degree of complexity in recognizing and modifying core beliefs varies from patient to patient.

Thus, patients under significant emotional distress easily express their core beliefs relative to others.

Also, it is much easier to modify the negative core beliefs of the patients suffering from anxiety disorders. This is because they have been counterbalancing positive core beliefs throughout much of their lives.

However, it is much more challenging to modify the core beliefs of the patients suffering from personality disorders. This is because they have less positive core beliefs and their positive core beliefs are weak. Plus, they develop numerous strongly held negative core beliefs that connect with each other like a network.

Steps in Modifying Core Beliefs

The following are the steps that you need to follow as a therapist in identifying and modifying the core beliefs of your patients.

I. Categorize Core Beliefs

The first thing that you need to do as a therapist is to categorize your patient’s core beliefs. You can categorize these beliefs into:

• Helplessness Realm
• Unlovability Realm
• Worthlessness Realm

Thus, you try to seek the category of your patient’s core belief whenever he presents his problems, automatic thoughts, behavior, etc. The following table showcases some of the examples of different categories of core beliefs.

Helplessness Core Beliefs	“That I am incompetent.”	“I am ineffective.”	“That I can’t do anything right.”	“I am helpless.”	“That I am weak.”
Unlovable Core Beliefs	“I am unlovable.”	“That I am different.”	“I am undesirable.”	“That I am unattractive.”	“I am unwanted.”
Worthless Core Beliefs	“That I am worthless.”	“I am immoral.”	“That I am a waste.”	“I don’t deserve to live.”	“That I am evil.”

So, sometimes it is quite clear the category in which a specific core belief falls into. However, at other times, you may not know initially which category the core belief belongs to.

Therefore, in such situations, you need to formulate a hypothesis about your patient’s core beliefs in your mind. You need to do this when your patient presents the data in the form of their automatic thoughts and reactions.

Therefore, you first need to bifurcate your patient’s cognitions that seem to fall into helpless, unlovable, or worthless categories.

II. Identify Core Beliefs

To identify your patient’s core beliefs, you need to use the same CBT techniques that you used to identify his intermediate beliefs.

Besides using the downward arrow technique, you can look for central themes in your patients’ automatic thoughts. In addition to this, you can also look for core beliefs expressed as automatic thoughts. And, you can also directly bring forth the core belief.

Hence, it is important for you as a therapist to identify your patient’s core belief early in CBT therapy. This is because you can conceptualize your patient and plan his treatment only if you recognize his core belief.

In addition to this, you need to collect data about your patient and help him evaluate his core belief early on.

Remember, sometimes your patient’s early evaluation of core belief is ineffective. But it certainly helps you test the strength and modifiability of such a core belief.

III. Present Core Beliefs

As mentioned above, you need to collect sufficient data to hypothesize about your patient’s core belief. Also, you need to ensure that your patient is receptive enough to listen to your conceptualization about your patient.

Once all of this is done, you need to tentatively present your conceptualization about your patient to him.

Or else, you can review different related automatic thoughts your patient had in different situations. Then, you can ask them to draw a conclusion as to an underlying pattern.

You can also use a simplified version of the Cognitive Conceptualization Diagram with some of your patients early in the CBT treatment. Furthermore, you can even explore your patient’s childhood.

Remember, you need to use your patient’s historical data when you present your hypothesis to him. This hypothesis is about how your patient came to believe a core belief in the first place. At that time, you also need to explain to your patient how his core belief could be untrue. Although, he currently believes it so strongly.

IV. Educate Patients About Their Core Beliefs

It is important for your patient to understand the following things about his core belief that:

• It is just an idea and not mandatorily a truth.
• He can believe it strongly and feel that it’s true. Yet it might be entirely untrue.
• It can be tested as it is an idea.
• It can arise from childhood events. So it may or may not be true at the time he first came to
  believe it.
• It continues to be maintained through the operation of his schemas. In that, he readily recognizes the data that supports his core belief. However, he ignores the data that goes against the core belief.
• You and your patient can use different strategies to modify his core belief over time. This is done to help him view himself in a more realistic way.

V. Develop A New Core Belief

Many depressed patients had a different core belief before the onset of anxiety disorder. At that time, this core belief was a much more positive, reality-based, and functional idea.

Therefore, they may easily identify this belief.

However, when your patient is unable to communicate his former idea, you mentally devise a new, more realistic, and functional belief for him. Furthermore, you guide your patient towards it.

Remember, that a relatively positive belief is usually easier for your patient to adopt than an extreme belief.

Therefore, you need to start working on weakening the negative core belief and strengthening the positive core belief. You can start doing this once you have identified a negative core belief and devised a positive belief.

VI. Strengthen New Core Beliefs

There are two ways in which you can strengthen the new core beliefs.

1. Obtain Positive Data

The first way is to intentionally obtain positive data from your patient. This you can do by questioning your patient.

Furthermore, you need to point out the positive data to your patient. And you need to do this especially when the data contradicts the old, negative core belief but supports a new, more reality-based belief.

Now, what are the ways in which you can point out the positive data about your patient?

Well, you can ask your patient about his strengths, his positive experiences, and keeping a credit list.

Besides this, you can provide him with feedback and ask your patient to give positive evidence regarding his cognitions not being true.

2. Ask Patients To Evaluate Experiences In A New Way

The second way is to ask your patient to evaluate his experiences in a new way specifically when you are working on strengthening his new core belief.

This would facilitate your patient’s capability to recognize the positive data himself.

You need to help your patient adopt a different view of his experiences when you try to strengthen his new core belief.

In this, your patient asks himself what he is doing or what is happening that could provide support to his new core belief.

3. Adopt Other Ways To Strengthen New Beliefs

However, there might be a possibility that your patient may face a challenge in carrying out this work. In such a case, you need to modify it.

You need to remember that many patients need either a visual or an audio cue to remind themselves to look for positive data throughout the day.

Therefore, you need to ensure that you encourage your patients to record the data in some way.

4. Track Your Patient’s New Core Beliefs

Also, it is important for you as a therapist to track how strongly your patients believe in their new core beliefs over time. And you need to track this both at an intellectual and an emotional level.

Besides this, you need to get an account of instances in which their degree of belief was relatively higher. Then, you need to reinforce their interpretation. This way you will help your patients reframe the meaning of the experiences in which their belief was relatively lower.

VII. Modify Negative Core Beliefs

You will have to adopt many techniques to hep your patients changes their core beliefs. Some of these CBT techniques are as follows.

Remember, that the core beliefs typically change at the intellectual level first specifically when you apply intellectual-level techniques.

This means you need to apply emotional-level techniques to change the core beliefs of your patients at the emotional level.

VIII. The Core Belief Worksheet

You may make use of The Core Belief Worksheet once you have identified the old core belief and developed a new one.

Your patients can fill out this worksheet during the session as well as for homework. This would help them monitor the manner in which their beliefs operate.

Furthermore, it will help them in reframing the evidence that seemed to support their old beliefs.

IX. Use Various Other Techniques To Modify Core Beliefs

You can also make use of some other CBT Techniques to modify the core beliefs of your patients. These include:

• Use Extreme Contrasts
• Use Stories, Metaphors, and Movies
• Historical Tests of Core Beliefs
• Restructuring Early Memories

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