CBT Overview Training

COGNITIVE BEHAVIORAL THERAPY: OVERVIEW,
STRATEGIES, AND INTERVENTIONS FOR COMMON

CLINICAL PRESENTATIONS AND PROBLEMS
About the author: Scott H Waltman, PsyD, ABPP, is a clinician, international trainer, and
practice-based researcher. His interests include evidence-based psychotherapy practice, training,
and implementation in systems that provide care to underserved populations. He is certified as a
qualified Cognitive Therapist and Trainer/Consultant by the Academy of Cognitive & Behavioral
Therapies. He also is board certified in Behavioral and Cognitive Psychology from the American
Board of Professional Psychology. He is a board member for the International Association of
Cognitive Psychotherapy. More recently, Dr. Waltman, worked as a CBT trainer for one of Dr.
Aaron Beck’s CBT implementation teams in the Philadelphia public mental health system. He is
the first author of the book Socratic Questioning for Therapists and Counselors: Learn How to
Think and Intervene like a Cognitive Behavior Therapist.
Course Syllabus
Introduction
The Generic Cognitive Model of CBT
Levels of Cognition
Core Beliefs
Compensatory Strategies
Rules and Assumptions
Cognitive Filters
Connecting the CBT Case Conceptualization and the Treatment Plan
Creating A CBT Case Conceptualization
Drawing out the Cycle
Drawing out the Cycle Form
Self-Monitoring
Demonstrating the CBT Model with Self-Monitoring
Increasing Self-Awareness of Thoughts
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

Increasing Self-Awareness of Emotions
Increasing Self-Awareness of Behaviors
Example with a Behavior: Behavioral Activation
Session Structure
Core Interventions
Socratic Questioning
Thought records
Behavioral Experiments
Hypothesis A/Hypothesis B
Problem Solving
Behavior Modification
Exposure
Acceptance-Based Approaches
Cultural Considerations
CBT for specific presentations
Depression
Generalized Anxiety Disorder
Social Phobia
Panic Disorder
PTSD
Summary
References
Learning Objectives:
Upon completion of the learning material, the reader will be able to:
1. Explain the theoretical underpinnings of CBT, including how to create a cognitive
behavioral case conceptualization.
2. Identify where the strategic intervention point is in that conceptualization.
3. Describe the self-monitoring phase of CBT and the core CBT interventions.
4. Recognize CBT strategies to treat different clinical presentations including
depression, anxiety, social phobia, panic disorder, and posttraumatic stress disorder.

INTRODUCTION
Cognitive Behavioral Therapy (CBT) is commonly regarded as the gold standard of
psychotherapy (David et al., 2018); this assertion is based on the vast and thorough research base
supporting CBT including evidence that it has been widely and successfully implemented.
Although this does not mean that CBT is the only effective form of talk therapy, it does mean that
CBT is a reliable therapy found to work well in real-world settings for a host of problems and
presentations. Participants of this course likely have some interest in and experience with CBT.
Probable motivations for clinicians taking this course are either (1) to improve their CBT practice
to be more effective with their difficult to treat clients, or (2) to learn new interventions to add to
their toolbox. This learning material is designed with these goals in mind. Although CBT does
have a host of potent interventions which are examined in this course, it is more important for
participants to learn to think like a CBT therapist. The true power of a CBT therapist is in knowing
how and where to intervene. Learning to form individualized case conceptualizations and being
familiar with diagnosis-specific models helps clinicians be more strategic with their interventions.
In practice, CBT is a way of thinking that is driven by hypothesis testing and case formulation.
CBT is among the most studied form of psychotherapy, with hundreds of outcome trials
demonstrating the clinical efficacy and effectiveness (Clark & Taylor, 2009; David et al., 2018;
Hoffman et al., 2012). Although CBT may sometimes be inaccurately conceptualized as a
collection of interventions and strategies, the model is better characterized as a way of thinking,
or a theory-driven philosophy (Beck & Dozois, 2011), which can be used to guide the selection of
interventions (Rosenbaum & Ronen, 1998). This working formulation (i.e., the cognitive
behavioral case conceptualization) evolves over the course of treatment, serving as a guide for
treatment and a lens for understanding the client (Beck, 2011). This learning material first reviews
the basic components of the model and then applies those principles to real world cases to illustrate
how to use it with clients.
THE GENERIC COGNITIVE MODEL OF CBT

The Generic Cognitive Model refers to the overarching CBT model as developed and
conceived by Aaron T Beck. The basic tenet of the Generic Cognitive Model is that the perception
of a situation directly influences emotion, physiology, and behavior (Beck, 1963, 1964). This idea
is not unique to cognitive behavior therapy (CBT), Ellis was quick to point out that the Stoic

philosopher Epictetus wrote, “People are disturbed not by things, but by the views which they take
of them (Epictetus, 125, as cited in Ellis & Harper, 1961).” This is supported by basic science and
clinical outcomes research (see Lorenzo-Luaces, German, & DeRubeis, 2015).
The Generic Cognitive Model holds that, typically, a person has situation-specific thoughts
or automatic thoughts that arise spontaneously (i.e., automatically), are often brief and fleeting,
and take the form of a thought or image. The automaticity of these thoughts can lead a person to
hold these thoughts as truths without reflection or evaluation. Automatic thoughts stem from an
underlying belief system and influence how individuals feel and what they do (i.e., behave).
Cognitive behavior therapy has a robust tradition of research and scientific inquiry (David
et al., 2018); and, the Generic Cognitive Model of CBT has been revised and refined over the years
(Beck & Haigh, 2014). A more recent advance in the cognitive model is the inclusion of modes
(Beck & Haigh, 2014). Modes are conceptualized as a constellation of activated schema (a pattern
of thought) and the associated coping/compensatory strategies. A person’s current emotional-
cognitive-behavioral state is termed modal activation (Fassbinder et al., 2016).
The concept of modes was first introduced in the schema therapy literature to account for
rapid changes in the presentation of clients with borderline personality disorder. This is a useful
concept when a client has large variations in presentation. Schema therapists noted that when these
patients would get dysregulated, they would have extreme thinking patterns, high emotional
activation, and engage in impulsive behaviors (see Fassbinder et al., 2016). Alternatively, when
these patients were regulated, their thinking would not be extreme, their emotions were not
elevated, and their behavior was not impulsive; these different presentations represent different
modal states (Fassbinder et al., 2016). As the Generic Cognitive Model has been revised over the
years, other modes have been identified (e.g., depressive mode; Beck & Haigh, 2014). Clinically,
this concept is quite useful when clients have large variability in their presentations. When a
clinical presentation includes modes at relative extremes (e.g., over-control and under-control), the
goal of treatment might be to foster a more balanced mode—this might be counter to a client’s
initial hope that the therapist teach them how to permanently stay in an over-control/unsustainable
mode of functioning.
Another advance in the Generic Cognitive Model is the recognition that people do not have
only negative or maladaptive core beliefs, they also have positive and adaptive beliefs. Therefore,
therapy strives not only to target the beliefs that are associated with distress and dysfunction, but

also wants to build up previously existing (possibly dormant) healthy beliefs. This practice is well
demonstrated through strengths-based CBT, where there is both an assessment and targeting of the
traditional treatment targets (i.e., maladaptive beliefs and behaviors) and a fostering of strengths
and adaptive beliefs (Geschwind et al., 2019; Padesky & Mooney, 2012).
LEVELS OF COGNITION
Core Beliefs
At its core, CBT is a learning theory, and core beliefs are the ideas individuals develop
about others, the world, and themselves over the course of time, through their experiences (and
their perceptions of their experiences). These ideas can be positive and/or negative and typically
are accepted as absolute truths. Often negative core beliefs are overgeneralizations of partial truths.
While automatic thoughts reflect the view of a given situation, core beliefs are more global ideas
that exist independent of any given situation; these are the themes of a person’s thought processes
across situations.
There is an abundance of human diversity and individuals typically have very
individualized core beliefs that are reflective of their background and experiences. A person can
have core beliefs about themself, others, the world, and the future. Negative core beliefs about
one’s self often fall into two major themes: competency or desirability (Dozois & Beck, 2008).
Later in the course, the common cognitive presentations of people with various diagnoses (e.g.,
posttraumatic stress disorder) is explored.
Examples of core beliefs reflective of incompetence are: I am incompetent; I am a failure;
I am weak; I am not good enough; I am inferior; and, I am dumb. Examples of core beliefs
reflective of undesirability are: I am undesirable; I am unattractive; I am unlovable; I am unlikable;
I am bad; and, I am worthless. A person can have multiple core beliefs. These core beliefs may be
universal, or they may be situation-specific. The Generic Cognitive Model accounts for this, by
holding that certain beliefs or schema may at times be inactive but can be triggered or “energized”
under certain stressors (Beck & Haigh, 2014); for example, the sudden end of a romantic
relationship could activate previously dormant beliefs of being unlovable or defective.

Compensatory Strategies
Behaviors are another important component of CBT conceptualization. In keeping with the
construct of a self-fulfilling prophecy (Rosenthal & Jacobson, 1968), behaviors associated with
core beliefs can lead to outcomes that reinforce the beliefs. For example, consider a woman who
was parentified at an early age and developed assumptions that she needs to take of other people
and that her needs are not as important as what other people want. Over the years, she would likely
accumulate a number of people in her life who are overly dependent and take advantage of her
caretaking behaviors. This behavior would cause her to have a lot of people in her life who need
help and, likely, not a lot of people who are able to reciprocate her caretaking. This
behavioral/relational pattern would only reinforce her assumptions about herself, the world, and
other people. Compensatory strategies can either be belief consistent (i.e., acting as if the belief is
true), over-compensatory (i.e., heavy-handed attempts to prove the belief wrong), or belief
avoidant (i.e., attempting avoid the belief by avoiding situations where the belief might be
activated; Young, 1999). For example, a person with beliefs about incompetence might be wary
of taking risks for fear that failing proves they are incompetent. They likely learn to avoid trying
difficult things at which they might fail or quit at the first sign of failure—because quitting is less
painful than failing for individuals who hold such beliefs. Such a person would likely develop the
conditional assumption (described below) that, “If I try, then I’ll fail; but, if I don’t try, then I can’t
fail.”
Alternatively, a person with a similar core belief but an overcompensating behavioral
response, might have the idea that they must accomplish big things and take risks otherwise
people will see them as incompetent. This person might develop the conditional assumption, “If I
don’t achieve, then people will see how incompetent I am; but, if I try extra hard, and push as
hard I can, then maybe I can keep people from noticing that I am completely incompetent.”
Rules and Assumptions

In between situation-specific automatic thoughts and more pervasive core beliefs are what
is referred to as rules or assumptions. Rules are universal ideas that individuals believe about
themselves, others, or the world; examples include: things will never work out for me; everyone
else is more capable than I am; and, the world is a dangerous place. Assumptions are conditional
statements that link behavioral strategies with core beliefs. These are framed in an ‘if-behavior,

then-outcome’ format, and are typically a way of connecting what a person is afraid of happening
and what they are doing to avoid that perceived injury.
Other examples, of conditional assumptions include:
• “If I tell other people what I want, then I’ll be vulnerable to injury; but, if I keep it
to myself, then maybe I’ll be OK.”
• “If I let myself feel sad, then I’m weak; but, if I avoid my feelings, then I won’t
have to feel weak.”
• “If I let people really get to know me, then they’ll see how terrible I am and leave
me; but, if I keep my relationships really superficial/ focus on taking care of other
people then maybe no one will notice how bad I am.”
• “If I say no, they won’t like me; but, if I always acquiesce and say yes, then
people will like me.”
Conditional assumptions are a strategic intervention point because they demonstrate how
beliefs and behaviors fit together. Targeting both the belief and corresponding behavior can be
especially important when the behavior is an avoidance strategy. Take the example of the person
who is afraid of failing and so they do not take risks or try difficult things. If the clinician were to
weigh the evidence of the perceived incompetence with them, there would not be a lot of useful
experiences to draw from to demonstrate their competence. Similarly, take the example of the
person who is afraid people will not like her if she declines their requests. If she never says no,
then there is a limited pool of experience from which to draw.
Cognitive Filters
The updated Generic Cognitive Model places an emphasis on the role of attentional
processes and mental filters in maintaining a belief set (Beck & Haigh, 2014), seminal texts on the
topic often address this as well (Beck, 2011). Judy Beck (2011) refers to this mental process as the
information-processing model where people selectively attend to negative information that
confirms their core beliefs and either ignore or misconstrue positive information that disconfirm
their belief set. Consider the example of a man with a belief that he is a bad person, who at the
start of the session shares about how terrible he feels for having the veterinarian put down his dog
earlier that day. For this man, that is further evidence of how wretched of a man he is; though,

there is a lot of context he is missing. In discussing the situation with him, the therapist learns that
this dog was a rescue dog and that this client has a penchant for taking in rescue dogs, typically
focusing on dogs that no one else is willing to take in. This dog had a degenerative neurological
condition that made it violent and unpredictable. This man had exhausted all medical options and
is no longer able to safely house the dog at his home. He contacted various dog rescues to see if
anyone would take this dog and was unsuccessful. The decision to have the dog euthanized is his
last option and one that the veterinarian strongly recommends. To the objective observer, this is
not an example of the client being a completely bad person, so why does he think this situation is
simply more evidence that he is bad? Because he is selectively attending only to the elements of
the story that are consistent with his previous belief, and he is twisting information to fit his
assumption.
There is a popular euphemism about seeing the world through rose-colored glasses,
meaning that one has an overly positive view of the situation. From the perspective of CBT, people
view the world through a schematic lens that filters information in a way that confirms their biases.
If therapists can learn to understand clients’ filtering process, they can help clients see what they
are missing.
CONNECTING THE CBT CASE CONCEPTUALIZATION AND

THE TREATMENT PLAN
A number of different methods to form case conceptualizations have been developed. Judy
Beck’s Cognitive Conceptualization Diagram (CCD) is among the most popular (see Beck, 2011).
Other commonly used methods include one developed by Persons (2012) that is similar to the
CCD. Padesky and Mooney (2012) modified the collaborative case conceptualization form to
incorporate strength and resiliency factors, and Moorey (2011) developed a “vicious flower”
conceptualization format that is used to draw out the cycle of thoughts, beliefs, behavior, and
compounding factors involved in maintaining a client’s difficulties. Notably, even the best
conceptualizations are hypotheses (informed guesses), and therapists are prone to all the same
judgement and perceptual errors as everyone else. Therefore, it is important for therapists to treat
case conceptualization as a working hypothesis where they are looking for confirmatory and
disconfirmatory information to help refine their formulation over time.

Regardless of the specific format used to construct a cognitive case conceptualization, there
are a number of common elements which comprise the individual’s current problematic situations,
their corresponding thoughts, feelings, and behaviors, and the underlying beliefs that are driving
these current thoughts, feelings, and behaviors. The CBT therapist employs a strategic approach
and is most interested in what is maintaining these belief sets; therefore, a main objective of the
case conceptualization is to draw out how the underlying beliefs are affecting current thoughts and
behaviors and how current cognitive styles and behaviors strengthen and reaffirm strongly held
core beliefs and underlying assumptions. For example, consider the assumption listed above, “If I
try then I’ll fail, but if I don’t try then I can’t fail.” This type of assumption likely corresponds to
core beliefs of incompetence and behavioral strategies of avoiding difficult tasks and bailing out
at the first sign of failure. This type of pattern tends to get stronger and stronger over time. This
individual likely feels shame and sadness when having thoughts about their inadequacy. “I’m such
a failure.” “I can’t do anything right.” “I have nothing to show for my life.” Consequently, they do
not take a lot of risks in their life—why try if failure is certain? Therefore, they have a low level
of accomplishment in their life, which they construe as evidence that they are incompetent. “Of
course, I’m a failure; I have accomplished nothing with my life.” This leads to more thoughts about
their inadequacy and further behavioral avoidance.
Thus, it is a cycle and a cognitive therapist seeks to break up this pattern using cognitive
strategies and behavioral experiments. Correspondingly, there are a number of potential
intervention targets and opportunities for CBT strategies.
CREATING A CBT CASE CONCEPTUALIZATION

Therapists organize the information about clients to form their CBT case
conceptualizations. The steps are as follows:
1. First, start with the relevant childhood data/background data. Commonly, peoples’ views
are based on formative experiences in their lives. The therapist starts out by reviewing the
context of the client’s life, including cultural background and sociodemographic factors.
Formative experiences often happen in childhood, but major events in adulthood can also
shape one’s thinking and sense of self.

2. Next, therapists take a look at the client’s current functioning to get some clues about how
their thought processes affect their day-to-day life. A therapist should gather information
about current situations that typify the client’s current difficulties. A therapist will get
useful data by focusing upon the situations that most typify the client’s difficulties. Next,
the therapist breaks these situations down into the cognitive-behavioral-affective
components. This sounds complicated, but really, the therapist is simply looking to parse
out the situations that illustrate the client’s difficulties: what the client is typically thinking,
feeling, and doing. Here the therapist is able to see the common thought, behavior, and
emotional patterns of the client.
3. Now that the therapist has examples of the client’s current difficulties, the therapist can use
these examples to hypothesize what the client’s potential core beliefs might be. First,
identify the meaning of the automatic thoughts, or rather the emotional meaning of the
automatic thoughts. This can be done by employing the downward arrow. The emotional
meaning (see Beck, 2011), or hidden meaning (see Beck, 1979), of the thought is typically
connected to the core belief or schema system. Targeting the emotional meaning of the hot
thought allows work to be done on a deeper level.
This strategy is rather straight forward and involves following a thought to the underlying
vulnerability. Once a thought that seems to be central to the current distress is identified,
the therapist should simply ask the client what it would mean if the thought were true.
There are few variations to this process. Some therapists try to anchor it back to the client,
by asking the client, “If this thought was true, what would it mean about you?” Other
therapists, might turn it into a sideways arrow of sorts to find the feared outcome when
evaluating anxious thinking, “So, if that event happened, what are you worried would
happen next?” or “If that happened, why would that be so bad?”
Typically, there is a brief series of items worked through till the therapist and client get to
the underlying meaning, which is probably a core belief, or closely connected to a core
belief. Therapists often ask, “How far down do I need to go or how many times do I need

to ask the question before I find the core belief?” The answer is, there is no set amount -
keep going until there is a noticeable change in a client’s affect, or a re-occurring theme
(like a circular loop) is identified.
4. The theme across the emotional meaning is likely a core belief. This is something that will
be a target cognition worked on over the course of treatment with the client. These beliefs
developed over time and the work is to incrementally decrease how much the client
believes a maladaptive core belief, while building up a healthier alternative.
5. Now that there is an identified belief to target, the therapist wants to know what behaviors
might get in the way of modifying it. So, by looking at what the client typically does when
this belief is active, what the behaviors are that might need to change can be better
understood. Commonly, these behaviors are likely compensatory strategies (attempts at
coping that often lead to short-term relief and long-term problems).
6. The final, hardest, and most important step, identifying the conditional assumptions, is
next. The goal here is to connect the client’s core beliefs and compensatory strategies
together into an if-behavior, then-outcome framework. Therapists want to know the
situations that are triggering for clients - what are clients afraid might happen and what are
they doing to prevent that perceived harm? These are framed in an ‘if-behavior, then-
outcome’ format, and are typically a way of connecting what a person is afraid of
happening and what they are doing to avoid that perceived injury. If I do _____ then this
bad thing will happen; but if I do _____ then maybe this bad thing won’t happen or maybe
it won’t be as bad.
Drawing out the Cycle

The specific purpose of the case conceptualization is to draw out the pattern that leads to
the reinforcement of the pre-existing belief. The case conceptualization answers the question,
what’s maintaining the problem? The section above reviews how a person’s beliefs influence
how they think, what they do, and in turn what happens, and how they perceive what happens.
All of these factors can create a feedback loop that ultimately strengthens the pre-existing belief.

Drawing out this cycle can help the clinician understand how the belief is being maintained and
identify strategic intervention points. If this cycle is completed collaboratively (and flexibly), it
can also serve as in-session intervention that helps the client mentally take a step back, see this
cycle they have been stuck on, and build motivation for doing something new. Consider the
following template and examples.
Template:
[underlying belief] → [situation specific prediction] → [emotional response] →
[behavioral response] → [outcome from situation] → [schematic filtering that reinforces
underlying belief]
Examples:
1) [I am a failure and incompetent] → [“I’m too stupid to understand this subject, I’m not
going to waste my time studying or asking for help”] → [sadness] → [avoidance] → [fails class]
→ [interprets failing class as further evidence of what a failure they are instead of how their fear
of being a failure is keeping them from really trying]
2) [I am unlovable, and no one will like the real me] → [“she’ll leave me if she sees how I
really am”] → [fear] → [remains superficially in the relationship but stays overly guarded] →
[client’s girlfriend ends the relationship because she thinks the client is aloof and uninterested] →
[client interprets being dumped as further evidence that they are intrinsically unlovable and not
that they sabotage relationships by not fully committing]
3) [the world is a hostile place] → [“they will take advantage of me if I don’t show my
strength first”] → [anger] → [being aggressive and hostile in neutral situations] → [people
respond with anger] → [interpretating how people respond to hostility as evidence that everyone
is hostile and aggressive to begin with]
Drawing out the Cycle:

The diagram below can be printed out and used with clients to write out the various specific
elements of a feedback loop that maintain the problem. For example, if the underlying belief is I
am a failure this can be written onto the form, and so on. This helps clients integrate conceptually
and specifically their cycle, its function in maintain their problem/s, and points of intervention.
(Note: all forms presented in this course may be printed out and used with clients).

Underlying
Prediction
Belief
Schematic
Emotion
Filtering
Behavioral
Outcome
Response
Once the vicious cycle has been drawn out, the treatment plan can be set - targeting each
element of the formulation. Start by making changes to the behavioral responses the client has the
most control over, this can be aided by using Socratic strategies to evaluate the corresponding
predictions/cognitions. If changes can be made to the predictions and behaviors, this will lead to
new experiences (outcomes). Therapists then have the very important job of helping clients see
that what they typically would have expected to happen did not happen this time. Therapists can
help clients interpret events in a more balanced way, potentially leading to steady and incremental
changes in the core belief.

SELF-MONITORING
Beck (1979) noted early on that people needed to be trained to focus on certain types of
thoughts. His initial strategy was to use shifts to unpleasant emotion as a signal, and would teach
individuals to look at what they were thinking about just prior to that shift. This initial phase of
treatment is called self-monitoring. This teaches clients the value of and pathways to greater self-
awareness, and facilitates their noticing and labeling their thoughts and feelings. Those skills are
then employed to gather data that can be used to inform the case conceptualization and, later, in
the selection of interventions. The initial phase is a time of tracking the frequency, intensity, and
duration of the self-monitoring target. During this time the therapist also learns about the context
in which the thought, behavior, or emotion occurs. What is the function of the behavior? What are
the antecedents? What are the consequences? This clarifies why the behavior is occurring and if
there is a short-term payoff.
Demonstrating the CBT Model with Self-Monitoring

Orienting clients to the CBT model is a multistep process. Therapists first explain the
model and then, once engaged in the therapeutic process, need to demonstrate the model with the
content from the clients’ own lives. There are varied ways to explain the CBT model; the most
common are with an ambiguous hypothetical situation to emphasize that different individuals can
have different reactions to the same situation. The other method is to use a triangle (or rhombus;
see Greenberger & Padesky, 2015).
Example 1. Imagine that you post a picture that you are proud of to your social media and
no one responds to it. You can see that your friends are online and posting, but no one likes or
comments on your post. How does this make you feel? Do you think everyone would react the same
way you did? Do you know anyone who would react differently? Why do you think different people
would have different reactions to similar situations? What we find is that it is not only what
happens to people that guided their reaction, but it is also how they interpret or make meaning of
what happens. So, this type of therapy I use helps people learn to slow down, mentally take a step
back, and look at their thought processes to see if any adjustments can be made to help you in your
efforts to live the kind of life you want to live.
Example 2. Now, let me draw something to help illustrate how this works. The basic idea
behind this therapy is this, that how we think affects how we feel and what we do. So, I am going

to draw a triangle and at the corners I am going to write thinking, feeling, and doing. This is a
way to break down situations to understand your response and how we can work to change your
response. For example, it is hard to change your feelings directly, but because how we think and
how we behave are connected to how you feel, we can indirectly work to improve your mood by
making changes to your thought and behavior patterns.
The next step is to talk with the client about their concerns and recent upsetting situations
and then fold those situations into the model to test out whether CBT will be a good fit for them.
After this has been done a few times, therapists should ask questions to help clients begin to see
the connection between thoughts, feelings, and behaviors. Once they are aware of this connection
it is easier to advance cognitive and behavior change strategies.
Therapist: Okay, so we have reviewed the idea of this therapy, but before we get into it, I
want to spend some time making sure this is going to be a good fit for you. So, can we spend some
time reviewing some situations that have been difficult for you to see if your thoughts, feelings,
and behaviors are connected?
The basic flow of this process is straightforward layering. First, we teach the client how to
notice their thoughts and feelings. As they learn how to do this, we build on that by drawing a
connection between their thoughts and feelings. As they come to see a connection between how
they are thinking and feeling, we use that to build a rationale for learning cognitive change
strategies.
Increasing Self-Awareness of Thoughts
An automatic thought by definition is a rapid evaluative thought that occurs just outside of
a person’s awareness (Beck, 1963, 1964). Individuals need to be taught to notice and recognize
their thoughts, especially the ones that are affecting their mood (Beck, 1979). Some clients will
take to this more naturally than others. People typically accept and state their thoughts as facts.
The therapist’s job is to help clients take the first step of pausing and catching their thoughts. When
initially teaching the client to notice their automatic thoughts, therapists often use a strong
emotional reaction as the clue.
• “What was going through your mind right before you got really upset?”
• “What were you telling yourself?”
• “What were you thinking was going to happen?”
• “How were you making sense of what happening?”

Some clients are easily able to articulate what they were thinking, others need some help.
Commonly, they might share a thought that is really a situation or emotion, and the therapist helps
them to identify the actual thought. Consider the following example: a client reports having a
terrible day at work after finding out they were passed over for a promotion. The therapist might
ask the client what it means to them that this happened. This helps the therapist understand the
client’s current thoughts on the matter. Alternatively, the therapist might ask to walk through the
client’s mental process of finding out the news, track changes in their affect, and target the moment
right before the largest change in affect occurred. Helping the client identify what was going
through their mind in that moment gives the therapist a better example of the client’s reactionary
automatic thoughts. Step one is listening for thoughts and labeling thoughts as thoughts. In fact,
labeling situations as situations, thoughts as thoughts, emotions as emotions, and behaviors as
behaviors gets clients pretty far in this practice. Some clients have more difficulty with this and,
for therapists, it may be tempting to skip this step – but that would be a mistake.
This self-awareness and self-monitoring skill is foundational and it is really hard to
implement the later steps if the client is not able to mentally take a step back and notice what they
are thinking. Imagery strategies such as having the person slow down and mentally walk through
the event can be helpful. Drawing out a timeline can be helpful. Asking for an interpretation of the
situation gives therapists an approximation of the client’s automatic thought which can then be
targeted.
Ideally, therapists do not provide the client with guesses or speculations about what they
are thinking. Judy Beck (2011) presents the brilliant strategy of therapists guessing the opposite of
what they think clients might be thinking. This is actually quite useful. While therapists want to
avoid telling clients what therapists think clients are thinking, therapists can label clients’ thoughts
as thoughts when they hear them. The earliest phases of treatment are often focused on rapport
building, and labeling thoughts as thoughts can be folded into a therapist’s reflective listening.
Increasing Self-Awareness of Emotions
Clients present to treatment with a broad variability in their emotional awareness,
emotional tolerance, and beliefs about emotions (Leahy, 2018). Therefore, the amount of work
that needs to be done on this item depends on a client’s presentation. In some cases, basic
emotional education is an important part of treatment, and perhaps a pretreatment of sorts. In other
cases, it can be folded in as the therapy progresses. At the very least a client should be able to name

a few of the basic emotions (anger, disgust, fear, happiness, sadness, and surprise; see Ekman,
1992). See Persons (1992) for a more thorough review of theories of emotion as they relate to CBT
and Leahy (2018) for a more thorough guide of working with emotions in CBT.
As the client becomes more able to identify their emotions, the therapy moves into self-
monitoring strategies like the CBT triangle or three-column thought record which is explained
later in this learning material. If a client has continued trouble identifying their feelings, the
therapist might have them track upsetting situations, then help them unpack the situations, and,
then, label their emotions later in session.
Increasing Self-Awareness of Behaviors
Self-monitoring can be used to target behaviors clients are trying to increase or decrease
(Korotitsch & Nelson-Gray, 1999). The first step is determining whether the client is aware of the
behavior when they are doing it. If not, tracking may need to focus first on the occurrence of the
consequences of the behavior. When they begin tracking a behavior there can be a reactive effect,
where a decrease in an undesired effect takes place as a byproduct of them being more aware that
they are doing the behavior (see Korotitsch & Nelson-Gray, 1999). If there are specific behaviors
that are identified, therapists should guide clients to track what is happening before and after the
behavior to help clarify potential treatment targets. Tracking an individual’s overall behaviors in
a day can be a helpful way to better understand their situation and functioning. Typically, by
tracking daily behaviors, rather than relying on simple retrospective remembering in a weekly
therapy session, therapists find something unexpected or that might otherwise be missed
(Brittlebank et al., 1993; Williams & Scott, 1988). Behaviors can be logged daily in a number of
ways (Cohen et al., 2013). Typical elements are behavior or occurrence logs that track when a
behavior happened, the context, and the co-occurring mood and thoughts.
Example with a Behavior: Behavioral Activation
This beginning phase is called self-monitoring in the literature, and it accomplishes two
objectives: 1) further orienting the client to the model, and 2) uncovering strategic targets. There
can be a big pull to jump right into trying to change thoughts or change behaviors. These attempts
can fall flat if it is still unknown where to intervene or if the client does not see the connection
between how they think and act and how they feel. Take for example behavioral activation (Martell
et al., 2013). It is commonly understood that the goal of behavioral activation is to get the client
more active to help them feel less depressed. The commonsense approach is to just tell a client

directly to get more active and that it will help them feel better. The problem is that when
individuals have clinical depression, they have very low energy, and often have the following
thoughts: I will not enjoy anything, I will not have the energy to do it, and I’m too depressed to do
anything. So, when a therapist tells them to get more active, they say to themself, “Yeah, but I’m
depressed. I don’t have the energy. I can’t do it.” They might even say to themself, “When I start
feeling better, then I’ll do more.” This is of course a trap, because it is likely they will not feel
better before they start changing their behavior.
So, what is a therapist to do? The early goal is to resist the pull of telling the client advice
that they likely will not follow and, instead, align with them and help them see for themselves that
what they are doing is affecting how they are feeling. Ideally, this is a joint discovery that is called
activity monitoring. The idea is simple, use details from the client’s life to prove the cognitive
behavioral model and look for strategic points to intervene. Activity monitoring involves looking
at the client’s week as it is, and framing this as a way to learn more about them.
Consider the following example:
Chad is a young man stuck in a job he does not like, struggling to pay for a child he and
his wife had not planned for. He has been depressed for a number of months and presents in session
as emotionally flat and exceedingly apathetic.
Often when symptoms are severe, behavior change is the first target and as symptoms
improve, cognitive strategies are used to further gains (Beck et al., 1979).
The therapist explains to Chad the model of how his feelings and behaviors are connected.
The therapist has some initial ideas about things he might do differently to feel better, but resists
the pull to tell him thoughts about the answers to his problems and instead suggests they study his
depression together. The therapist asks him to track his depression for a week. This entails tracking
what he was doing and how he was feeling. The therapist asks him to look for subtle variance in
his depression—times he felt more depressed and times he felt slightly less depressed. The
following week they review his log together. He is quite unhappy at work and notes a high
frequency of “depression naps” that often leave him feeling worse. The therapist notices Chad has
a slight improvement in his mood in the early evening and so the therapist focuses their curiosity
on this. Chad explains that he actually sort of enjoys himself when he is cooking dinner. “Great!”
the therapist exclaims internally. The therapist shows more curiosity about this, what is it about
cooking dinner that is enjoyable to him? While thinking about this question, Chad realizes that he

feels like he is not really good at his job, or at being a dad, or at a lot of things, but that he sort of
knows how to cook. And, when he is cooking, he feels (thinks) he is finally doing something right.
This is huge. They have identified an activity that helps to alleviate his depressive
symptoms. From looking at overall log, the therapist asks him if he sees any connections between
what he was doing and how he was feeling. Chad can see the connection. The therapist asks him
what he wants to do about this connection, and he says that he thinks he may want to make some
changes to his schedule to see if it helps him feel better (this will be reviewed later in the section
about behavioral activation). They talk about other ways to feel a greater sense of mastery, and
as they increase his mastery experiences his depression lifts. He becomes a more engaged father
and spouse, and he finds a more fulfilling career.
In the above example, the takeaway for therapists is clear. If the therapist just told Chad
to do the first thing that they thought of, then the therapist would have completely missed this
more potent intervention and by guiding Chad to discover this for himself, it increased both his
buy-in and motivation for the activity.
SESSION STRUCTURE
Therapists are commonly attracted to CBT interventions; whereas, the structural aspects
seem less exciting. Readers may have even thought about skipping this section when they saw its
heading. The value of the session’s structure is that it helps facilitate interventions. What follows
is a brief overview and practical guide for CBT session structure. At the start of the session, a CBT
therapist collaboratively plans with the client how to spend their time together and at the end of
the session there is a debrief on how it went and whether modifications are needed to help
personalize treatment. Typically, the session follows a structure of starting with a mood rating,
bridge, action plan (homework) review, agenda setting, and agenda finalizing. Then the dyad
works the agenda. They later summarize the session, seek feedback, and make a new action plan
(homework).
There is some variation in how this goes, but the common steps are:

At Start of Session Mood Check
Bridge
Action Plan Review
Generating Agenda Items
Finalizing Agenda Plan
Bulk of Session Time Working the Agenda Plan
At the End of the Session Summarizing the Session
Seeking Feedback
Setting New Action Plan
The mood check is a quick check on how the client is feeling. It is not intended to be a
lengthy update, where the therapist hears about everything that happened in the week. Instead, it
is intended to be a quick way to gauge how the client is doing and informs the focus of the session.
Typically, a therapist has the client rate their overall mood on a scale of 1 to 10 or 1 to 100.
Sometimes therapists track specific moods (e.g., depression 1 to 10) and other times they track a
client’s mood in general, where a higher number might be a more positive mood and a lower
number is a more negative mood. Therapists are free to choose how they want to do it; however,
it is recommended that they are consistent with the scale because they are also teaching the client
how to monitor mood through this process.
The bridge is a figurative bridge between sessions, to help pick up where the previous
session left off. The bridge is similar to watching a television show - before the age of streaming.
The television viewer had to wait a week to see what happens, and if there is something important
to the plotline, there would be a quick recap that reviews what happened in the previous episode
so the show could pick up where it left off a week earlier. The bridge is not intended to be a
memory test. Clients can be asked to provide the bridge or therapists can provide it; both are
acceptable. A review of the previous session summary can be a good bridge.
The action plan (homework) is ideally an extension of what happened in session.
Reviewing the main points from the previous session is a nice way to transition into reviewing the
previous action plan or homework from the previous week. Notably, the term homework can have
negative connotations or be paired with previous negative experiences; therefore, alternate terms
like ‘action plan,’ ‘commitment,’ ‘skill practice,’ or ‘goal’ may be used instead. Therapists can

ask questions to review the previous session’s action plan: How did it go? What did they learn? If
a client had a success or new type of experience, they might want to put that on the agenda and
spend more time unpacking and synthesizing the new information. If a client ran into trouble, the
therapist should reinforce the client’s efforts and engage in problem solving to see what went
wrong and how they might adjust the practice for next time. If the client did not complete the
homework, then it is important to nonjudgmentally assess what happened, “What got in the way?”
In this assessment, it is important to identify if this was a problem related to the assignment being
too difficult, unclear, or not being perceived as helpful. Together, they want to try to problem solve
the barrier so the client is more likely to succeed in the future; for example, if the client “forgot”
and still thinks it would be useful to do this practice, then troubleshooting ways to remember future
homework is indicated. They might also choose to do the task together in session.
It can help to think about setting the agenda as two distinct tasks: 1) generating possible
agenda items, and 2) finalizing the plan. When setting an agenda, it is important to be realistic (try
to keep it to 1-2 items) and collaborative (balancing the client’s suggestions and the treatment
goals). Before a client is fully oriented to CBT, is it quite common for them to just start talking
about whatever is on their mind before the agenda has been set or finalized. In these cases, it is
important to gently interrupt the client to set and finalize the agenda before starting the session
(Beck, 2011) - just because something interesting or relevant comes up during the check-in, does
not mean it is the most pressing/distressing issue. The session then transitions toward putting
specific questions or problems on the agenda. General items (or topics) like “my mother is visiting”
tend to lend themselves to a less-focused session of updates and stories, while more explicit
statements like “handling stress related to my mother’s upcoming visit” or “planning for a
successful visit with my mother” lend themselves to a more active session. In setting the agenda,
therapists should ask if there is a clear objective for the session, “What are our goals for today’s
session?” Another strategy for making an agenda more exact is to ask for specific examples of
when the problem occurred. For example, if when setting an agenda, the client states that they
want to talk about their emotional eating, the therapist might ask, “Was there a time this week that
was particularly bad?” “Should we put talking about that on the agenda?” Once there are some
ideas of how the session time might be spent, then the agenda is finalized and agenda items
prioritized. A good routine is for therapists to read back the plan they have written down ensuring
there is agreement and mutual understanding of the plan.

Once the agenda is finalized, the therapist and client work the established plan. The ideal
flow for the session depends on the agenda, treatment plan, and case conceptualization. Typically,
a CBT practitioner spends a few minutes gathering information about the problem on the agenda.
Once the therapist has a hypothesis about what the problem might be (or what the way forward
might be), they present that to the client as a hypothesis. If the client agrees the therapist suggests
an intervention or strategy to be used and if the client is okay with the plan that is what the bulk of
the session time is spent on.
Ideally therapists should save 5-10 minutes at the end of the session for the close out. A
nice way to start transitioning to a close is to start summarizing the session. Broadly, therapists are
interested in feedback related to the client’s reaction/satisfaction with the session and their
learning/understanding of what the therapy dyad are doing and why they are doing it. This
information can help therapists tailor the treatment to their clients. The question, “How was the
session?” can be followed-up with inquiring about specific areas of strengths and areas to change
“What did you like about the session?” “What would you change next time?” Also, it is important
to elicit encapsulating summaries, such as: “What did you learn today?” “What’s the takeaway
message from today’s session?” These questions can be informative even if the client does not
exactly know how to answer them; this can be a good indicator when a client is not quite grasping
what the therapist is saying in the session. The therapist can then use that information to modify
the approach, perhaps slowing down, maybe drawing things out on a white board, perhaps asking
for the client to restate ideas in their own words throughout the session.
Finally, it is now time to design a new action plan. Ideally, this is a collaborative process;
although, collaborating is not the same thing as going with whatever the client suggests. Often,
especially early in treatment, therapists need to shape client suggestions and provide their own
suggestions. If a therapist happens to get a good take-away message when seeking feedback, they
may use that as an anchor for the action plan, “How can you apply that to your coming week?” or
“I like that idea. Can I suggest a small modification that I think will make it stronger?” or “That
sounds like general good self-care that I would be in support of, can I suggest something else you
might do that would help you practice the skills you’re learning here, to help you get the most out
of therapy?” It is wise to avoid assigning something therapists would not do themselves. Regarding
the amount and difficulty of assignments, too easy is much better than too hard, especially when
momentum is still building. Therapists should meet clients where they are at, so introducing new

skills/worksheets as homework is not optimal. The idea of homework is for clients to practice
applying skills in their lives. Ideally, practice the assigned skills together in session first and if a
client finds a skill helpful - assign it as homework. Commonly clients, with the best of intentions,
let the week get away from them and forget to do the homework. So, plan out with them when
they will do it and how they will remember to do it. Also, address and troubleshoot other
anticipatable barriers that might arise.
Problems with Session Structure
When clients are reluctant to join in the structural aspects of a session (e.g., hesitancy to
set or follow a session agenda) one possibility is to encourage them to treat it as an experiment
(Beck, 2011). Such a proposal might sound like, “So, I gather you’re not sold on this idea of
structuring our sessions. You seem unsure about picking a specific goal to work towards each
session and then focusing solely on that objective with the hope that it will help us make as much
progress as possible in our sessions. Can I suggest that we might treat this as an experiment?
What if we were to set aside our next four sessions to use this structure, and then we’ll see if it
actually makes a difference. What are your thoughts on that?”
Similarly, if the therapist is not sure about this whole structure thing, they might consider
using it as an experiment. Some of the most common feedback CBT trainers get is how surprised
therapists are by how much they like the session structure. Often therapists report using it across
the board, even with their clients who are not receiving CBT. Think about the agenda as being a
time budget. If therapists meet with clients for 1 hour weekly, then they are spending less than 1%
of their time in session, and so that clinical hour needs to go as far as it can. Budgeting time to
prioritize the most important therapy items is similar to not have a lot of money and prioritizing
what needs to be paid.
Another strategy to address clients who are harder to contain or who are less willing to
follow a set agenda, is to propose splitting the agenda between time for support and time for the
more active work (Beck, 2011). Such an arrangement might be suggested by saying: “I can see
there is a lot going on for you, and I know you don’t have a lot of places to talk about this. So, I
want to find a way to make sure you’re getting the support you need, and at the same time, I don’t
want to just talk about how bad things are, I want to work to make things better. I’d suggest that
we try splitting our session time. Let’s set aside and protect 10 minutes every session, just for
support and stories, and then we’ll use the remainder of the time to work on problem solving, skills

training, and working on some of these very painful beliefs that you have. How would you feel
about that?
In essence, this treat-it-as-an-experiment approach is a way to side-step potential power
struggles and demonstrate the principles of collaborative empiricism. If the structure makes
sessions more productive, then it will be easy to talk about continuing to use it. If it seems to not
actually make a difference, then therapists might not need to worry about the structure so much—
though, first they might want to reassess their diagnosis, formulation, and treatment plan as a
general course correction might be indicated.
CORE CBT INTERVENTIONS

CBT is an umbrella term that describes a range of therapies that target cognitive and
behavioral change. This section reviews the core CBT strategies. A defining characteristic of CBT
interventions is the use of collaborative empiricism; this term refers to the process of using
strategies to join with the client in applying scientific curiosity to their thought and behavior
processes (Tee & Kazantzis, 2011).
Socratic Questioning
Socratic questioning typifies collaborative empiricism. While Socratic questioning is a
transtheoretical psychotherapeutic process, there is some evidence that employing Socratic
strategies artfully and competently in session is among the hardest skills for a psychotherapist to
learn (Waltman et al., 2017). A common pitfall to Socratic questioning is termed provided
discovery (as opposed to guided discovery), which is when therapists tell clients the conclusions
they should be reaching. Many thought records and attempts at cognitive restructuring focus on
trying to show the client why their thinking is distorted (see Waltman, Frankel, Hall, Williston,
Jager-Hyman, 2019)—this can be counter to collaboration.
Additionally, many therapists fall into the trap of trying to convince the client to see things
from the therapist’s point of view or to guide the client to what they think is the right answer. This
often results in noncollaborative encounters with therapists telling clients how things “really are.”
As anyone who has been providing therapy for a while might say, “that if you simply give your
client the answer, you will be giving them the same answer week after week after week, because it
won’t really sink in.”

A Framework for Socratic Questioning
It can be helpful for clinicians to have a framework for thinking about collaborative
empiricism and Socratic strategies. In conjunction with the largest public mental health CBT
training initiative in the United States, the method for teaching Socratic questioning to therapists
has been refined (Waltman et al., 2020). This framework is a reversal of these mentioned pitfalls,
instead of trying to get the client to see it from the therapist’s perspective, therapists should instead
focus on trying to see it from the client’s perspective and then focus on expanding that perspective
together.
Step 1: Focusing. The first step in applying Socratic strategies is to identify the targets for
these strategies. In a practical sense, there is simply not enough time to address every thought that
might be distorted. The aim is to target the thoughts that are central to the problems and related to
the core difficulties and underlying beliefs. Often some delving and sifting is required to find the
optimal cognition to focus on. This skill requires a therapist’s patience and conceptual skills. A
therapist needs to help a client break a situation down to its components, identifying the various
thoughts and feelings about the most upsetting part of the situation, identifying the hot thought
(i.e., most distressing thought) from among those thoughts, and delving to find the emotional
meaning of the hot thought using the downward arrow (discussed earlier). Two strategies make
this an easier practice: 1) collaboratively defining the target and, 2) creating a shared definition.
Collaboratively defining the target. This is a crucial step that is often skipped. When a
therapist feels like they are chasing a client in session and trying to evaluate something, but the
client keeps moving on, a good question to ask themself is whether the client understands what the
therapist is trying to do. This can be done as an overt act; it will make the rest of the process a lot
easier. Once a preferred cognitive target is identified, the therapist should talk about it, so the client
understands that the focus of the session is on this one cognition rather than looking for others or
hearing more stories. This can be done fairly quickly, and it typically pays off with easier sessions.
It is also a crucial step if a skills-training approach to treatment is being employed. “Okay, John,
we’ve been talking about the situation with your boss and how you have thoughts that he doesn’t
care about you and the meaning that you’re being treated unfairly, and this idea that you can’t
stand being treated unfairly. I want to shift focus and really take a look at this last idea. Would it
be alright with you if we were to spend some time focusing on evaluating this idea that you can’t
stand being treated unfairly?”

Creating a shared definition. Often, the cognitive target initially can be vague. What does
it mean to be a good person? How do we define being a loser? What is a good mother? What does
it mean to be successful? Typically, clients’ definitions are skewed in a way that is consistent with
their underlying beliefs. Evaluating a thought using a skewed definition is working harder than
necessary. Once the thought that will be evaluated is identified, it can be helpful to create a shared
or universal definition (see Overholser, 2018). It is important to note that creating a universal
definition is not a discovery task. The goal is not to get their definition and see how well they
measure up against their definition, because their definition is skewed. The goal is to jointly create
a fair definition (that both therapist and client agree on) so the thought can have a fair evaluation.
Often, when creating a shared definition, the client starts by listing out why they think they
do or do not fit their own criteria. It is necessary to interrupt them, highlight what they are doing,
and redirect them into making a universal definition. The shared definition can draw from
dictionaries, encyclopedias, or other established sources to help create a fair description. As
illustrated above, when setting the definition, the therapist can construct it in a way that makes it
easier to evaluate the target cognition and influences the types of generalizations that are made.
There are a number of questions therapists can ask themselves to guide this process including:
• What are the different components of the story that could be upsetting to my client?
• What’s the most upsetting part? Where’s the heat?
• How do they feel about the situation?
• What are the client’s different thoughts about the situation?
• Do their thoughts and feelings line up?
• Am I missing anything?
• How does what I hear fit with my case conceptualization of the client?
• Am I hearing any cognitive distortions or irrational beliefs?
• Which thought do I want to target?
• Which thought is most connected to the behaviors that are keeping them stuck?
• Which thought is most distressing?
• What’s the emotional meaning of this thought?
• Does the client appear to have a fair definition of this term, or should we create a shared
definition?
• Is the client on board to evaluate the thought?

Step 2: Phenomenological Understanding. Phenomenology refers to understanding something
in both subjective and objective terms. The task of this step is to understand the client and the
target cognition. The guiding principle is that individuals come by their beliefs honestly and
therapists want to understand how it makes complete sense that their clients think that way. This
early emphasis on validation is also strategic in that it is relationship enhancing and can be
regulating for the client. Individuals tend to be more willing to have an open mind to alternatives
when they feel like they have truly and sincerely been listened to.
There are several questions therapists can ask themselves to guide this process:
• What experiences are this thought based on?
• What are the facts that support this?
• If this was true, what do you think would be the strongest evidence to support it?
• Is this something people have directly said to them in the past?
• What is it like to believe this thought?
• How long have they believed this?
• When do they tend to believe this more and less?
• What do they typically do when thoughts like this come up for them?
Step 3: Collaborative Curiosity. Although this is functionally the disconfirming evidence step,
curiosity is key to this process. Now that the therapist sees it from the client’s point of view, they
can work to expand that view together. Therapists can ask themselves: “What is the client
missing?” Functionally, there are two kinds of blind spots: 1) things the person doesn’t see and, 2)
things the person doesn’t know. Therapists need to figure out what clients are not attending to due
to attentional filters as well as the gaps in experiences that developed because of avoidance
patterns. Many great questions and lines of inquiry can often be found from evaluating elements
from the previous steps. People tend to twist information to fit into their pre-existing assumptions
and beliefs. So, therapists want to help clients to mentally take a step back and look at both context
and the big picture. It is often easier to expand the client’s point of view, by first focusing upon
coming to see things the way they do. Together, the point of view can be expanded by: (1)
evaluating the previously presented evidence to see if anything has been skewed, twisted or
overstated; (2) attending to disconfirming evidence; and, (3) seeking out new evidence with
behavioral experiments.

There are a number of questions therapists can ask themselves to guide this collaborative
curiosity process including:
• Can we add context to the supporting evidence to mitigate its effect or that would lead to
a new conclusion?
• If we had been in that situation what would we have expected to happen?
• Are there exceptions or discrepancies that we can help them remember?
• What are the facts?
• What would they tell a friend?
• What might a friend tell them?
• Has it always been this way?
• How has believing this thought affected their behavior and the available evidence to
draw from?
• Can we go and gather new evidence?
Step 4: Summary and Synthesis. There can also be a pull for the therapist to try and pick a
purely positive thought because those thoughts might feel better. The trouble with purely positive
thoughts or thoughts that are only based on the disconfirming evidence is that they can be brittle
if they do not fit the reality of the client’s life. Therefore, the aim is for clients to develop new
thoughts that are balanced and adaptive. This process involves summarizing both sides of the story,
and helping the client develop a new more balanced thought that captures both sides. The question
to ask is whether the new thought is believable. Once a summary statement is established,
synthesize it with the previous statements and assumptions. How does the new conclusion compare
to the initial assumption? And their underlying beliefs? How do they reconcile their previous
assumptions and this new evidence? Help solidify these gains by helping the client translate the
cognitive shift into behavior change. Ask how they want to put the new thought into practice or
test it out in the coming week.
There are a number of questions therapists can ask themselves to help with this question
• So how does this all fit together?
• Can we summarize all the facts?
• What’s a summary statement that captures both sides?
• How much do they believe that?

• Do we need to shape this to make it more believable?
• How do they reconcile our new statement with the thought we were evaluating? With the
core belief we’re targeting?
• How should we apply our new statement to their upcoming week? How can we test this
out?
• If this was true, what would that mean about (the client, the world, the future, the target
core belief, target problem, goals, etc.)?
• What did we learn about their thought processes from this exercise?
Thought Records
Thought records (Beck et al., 1979) are a central intervention strategy in CBT. Thought
records primarily teach the cognitive model and facilitate cognitive change. The format,
components and complexity of thought records have evolved substantially since their inception,
resulting in numerous published and unpublished versions. For example, Waltman, Frankel, Hall,
Williston, and Jager-Hyman (2019) identify 110 non-identical thought records which they coded
into 55 unique component combinations. The basic categories for their thought record coding
system relates to the basic function of the thought record and how that function is accomplished.
A thought record can be used early in treatment to demonstrate and teach the cognitive model
using the three-column thought record and later cognitive change can be brought about by using
other versions of the thought records such as the five-column thought record, the seven-column
thought record, or the ABC worksheet (see Waltman et al., 2019); this is elaborated upon later in
the learning material.
Thought records are useful because they externalize the cognitive restructuring process.
That is, they provide a written road map that includes prompts for each step in the sequence and a
mechanism for future review of key points of learning. Padesky argued that using thought records
helps the patient learn how to engage in Socratic processes (see Kazantzis, Fairburn, Padesky,
Reinecke, & Teesson, 2014). This is aided by the use of a framework to help patients learn the
main steps of cognitive restructuring. Over time thought records can become more flexible, but
following a general routine helps patients initially learn the skill. Having an identified skill on a
worksheet that they take with them to practice helps transport the skill from the session to their
“real lives.” Thought records provide a physicalized distancing from thoughts and requires actions

in order to practice the skill (e.g., writing rather than doing it “in their head”). In this way, the
client is taught to be their own therapist (see Beck, 2011).
Thought Records: Teaching the Cognitive Model
A core use of thought records is to teach patients the cognitive model. If the therapy is not
bringing about cognitive change, therapists might first wonder how well the patient understands
and accepts the cognitive model. The first thing to keep in mind is that patients are more engaged
in Socratic strategies when they see how their beliefs are affecting what they do and how they
think. So, therapists should first explain the cognitive model and then demonstrate it for patients
using the three-column thought record, or a similar thought record. A three-column thought record
can be created very easily by taking a paper and breaking it into three sections with two lines. The
therapist writes what happened in one section, how the client felt in another and, in the last section,
what the client thought. Below is the Focusing Worksheet which was created to accomplish the
tasks of the three-column thought record and is also compatible with the 4-step framework for
Socratic questioning discussed above.
Different versions of the three-column thought record exist, typically the columns are
labeled “Situation,” “Automatic Thoughts,” and “Emotions” respectively—the order differs
sometimes. However, columns dedicated to physiological and behavioral responding may also be
included, if one of the goals is to help patients discover the relationships between their automatic
thoughts and either of these two variables.
The situation, simply put, is the context that gave rise to the distress. Using imagery or
acting out the situation can help increase the salience of the important elements of the situation
which can lead to a richer memory related to thoughts and emotions later on. Questions for
assessing the situation are:
• What event seemed to trigger your distress?
• What was occurring around the time you noticed a shift in your distress?
The context isn’t always exclusively external to the person. It may include internal variables
that are antecedent to distressing automatic thoughts. In these cases, it can be useful to ask: Did
you experience anything internally that seem to prompt your distress (e.g., physical sensations,
thoughts, images)?
Depending on the form, automatic thoughts might be next in the sequence; however, it can be
helpful to skip to the emotion column next because this can heighten the saliency of emotion which

can, in turn, serve as a retrieval cue for important thoughts. Following this strategy, it can be
helpful to say, “We’re going to skip the automatic thought column for just a moment and instead
focus on the emotion column next. We’ll discuss why shortly.” Useful questions for assessing
emotion include:
• What distressing emotion(s) were you experiencing?
• What emotional label(s) best captures how you were feeling in this situation?
• How were you feeling emotionally?
• From 0 to 100, how [Depressed/Anxious/Angry/etc.] were you feeling?
After assessing and noting emotional responses, return to the automatic thought column to
assess and record the client’s stream of consciousness. Example questions are:
• What were you saying to yourself right before you noticed that change in
[depression/anxiety/anger/etc.]?
• What was running through your mind then?
• Did any pictures or images occur to you?
• What other thoughts or images did you experience?
• If I could observe thought bubbles above your head in that situation, what would I see in
those bubbles?
• What ideas were occurring to you at that moment?
After these three elements have been disentangled (i.e., the situation, automatic thoughts,
emotions) and recorded on a thought record the next step is to assist the patient with understanding
their relationship. Key questions are:
• How do these (pointing to the writing on the thought record) seem to go together?
• When you look at what we’ve pulled apart here, what do you make of this?
• Is there anything for you to learn from this exercise?
• I wonder if there’s any sort of relationship between your thoughts and emotions.
• What is the difference between [situations and thoughts; thoughts and emotions]?
• Do you typically experience situations, thoughts, and emotions separately or all at once?
How might separating them be useful?
• Do you think it was useful to write this out? How do you think it would’ve gone if we just
did this in our heads?

• Are you typically aware of your thoughts in these situations or are you more are of your
distressing emotions? Any idea how increasing your awareness of your thoughts might be
helpful?
Focusing Worksheet
Situation Description:
What are the different upsetting things that happened?
1.
2.
3.
4.
What was the most upsetting part?
What thoughts were going through your mind? What was the
corresponding feeling?
Which thought was the most upsetting?
What’s the emotional meaning of that thought?

Thought Records: Facilitating Cognitive Change
Based on the analysis of extant thought records the coding system developed by Waltman
and colleagues (2019) there are three different ways a thought record might go about promoting
cognitive change. The first method is something called rational responding (Beck et al., 1979).
This involves straightaway asking the patient to pick an alternate thought that seems more rational.
The first five-column thought record was this style of thought record (Beck et al., 1979). The
second way a thought record might promote cognitive change is by focusing on identifying why
the original thought is distorted such as by identifying cogntive distortions. Burns (1989) was the
first to target cognitive distortions with thought records. Padesky developed and pioneered the
third method, typified by her seven-column thought record (Greenberger, & Padesky, 2015). The
seven-column thought record was developed when she found that her patients were able to use
thought records well with her in session, but that they struggled to complete it on their own; she
examined what they were doing in session together that the patients weren’t doing on their own
and found the missing piece was examining the evidence (see Waltman et al., 2019). So, she
developed the seven-column thought record which dedicated space to evaluating the evidence of
the thought in question to help her patients do on their own what she was doing with them in
session.
The Socratic Thought Record (shown below) helps facilitate the four step framework for
Socratic dialogue. Clinicians are free to use whatever thought records they prefer. It is currently
unknown if there are differences in clinical outcomes for the different thought records; very few
studies have made head to head comparisons of the various thought records (Waltman et al., 2019),
although there are some early indications to suggest it might matter, or that certain populations
might have varied and diverse responses to each type of thought record (see Waltman et al., 2019).
Functionally, there is a difference between asking a patient to look at a situation differently, asking
them if their views are distorted, and asking them to evaluate the situation to come up with a more
balanced and accurate thought. The latter strategy is more consistent with collaboratived
empiricism and is a more Socratic strategy.
The ultimate goal when using thought records is cognitive change resulting in behavior
change and improved emotional responding. An important pre-requisite to the client successfully
using the remaining elements of thought records is an adequate understanding of the cognitive
model (the first three columns of the thought record just described). Some clients grasp the model

quickly, whereas others require many practice trials before they develop this prerequisite skill.
Importantly, intellectual understanding of the model is insufficient. Clients must be able to
discriminate when they experience affective shifts and use them as cues to search for important
cognitive content. Furthermore, they must be able to successfully identify their automatic thoughts.
If using a five- or seven-column thought record, once the first three columns are completed,
the clinician must collaborate with the patient to develop a focus for the Socratic dialogue.
Successful and effective cognitive intervention is dependent on successful focusing strategies.
Picking a thought just because it sounds like a distortion or sounds painful is a gamble that might
not pay off, taking the time to understand the situation and weigh the options can help in
collaboratively choosing the optimal target for the thought record. Also, engaging the client in this
process helps them learn how to focus on the key thoughts as well. Some questions facilitative of
this task are:
• What are the different parts of the problem?
• Which part is most upsetting?
• What meaning are you attributing to this situation?
• What are you telling yourself?
• If we made a change in just one thought today that would make all the difference
in the world for you, which one would it be?
• Which thought upsets you the most?
The next step in this process depends on which thought record is being employed. Ideally,
the steps followed in-session are consistent with the flow or prompts from the thought record so
the patient can learn these steps for themselves. If the Socratic Thought Record is included, the
therapy first seeks to gain a better understanding of the thought. Here are some questions that are
consistent with the prompts on the Socratic Thought Record.
• What experiences are this thought based on?
• What are the facts that support this?
• If this was true, what do you think would be the strongest evidence to support it?
• Is this something people have directly said to you in the past?
• What is it like to believe this thought?
• How long have you believed this?

• When do you tend to believe this thought more and less?
• What do you typically do when thoughts like this come up for you?
After a good understanding of the targeted thought is determined, the therapy seeks to
expand that understanding with collaborative (joint) curiosity. Here are some questions for the
client that are consistent with the prompts on the Socratic Thought Record.
• Is there important context missing from the above statements?
• Did your previous behaviors influence your experiences?
• What do we not know?
• What are the facts that tell you this might not be true?
• Are there any exceptions we're forgetting about?
• What would you tell a friend?
• What might a friend tell you?
• Has it always been this way?
• How has believing this thought affected your behavior and the available evidence
to draw from?
• Can we go and gather new evidence?
The classic steps of Socratic questioning are analysis and synthesis—breaking it apart and
putting it back together. A Socratic dialogue using a thought record as a tool is incomplete without
summary and synthesis steps. Here is where therapists help patients fit it all together in a way that
produces a durable and balanced belief that can be used to bring about lasting and meaningful
change. Summarizing can be characterized as fitting together the different elements covered in the
evaluation portion of the thought record. The synthesis part is where the summary is fit together
with the bigger picture. Here is where the new learning is made explicit. Some helpful questions
that are consistent with the prompts from the Socratic Thought Record are:
• So how does this all fit together?
• Can you summarize all the facts for me?
• What’s a summary statement that captures both sides?
• How do you reconcile our new statement with the thought we were evaluating? (or
with the core belief we’re targeting?)

A final step is to assess the impact of the inquiry. Did the examination reduce believability
in the targeted thoughts? Did emotional distress become more proportional to the event? Finally,
connect the new perspective to a planned change in behavior. “How can you apply this new
perspective to the coming week?” This sets the stage nicely for a behavioral experiment which can
reinforce the new perspective either by directly testing it out or gathering new evidence to inform
a future thought record.
Socratic Thought Record
Focusing: What thought are we targeting?
Understanding: How does it make sense that I think this?
Curiosity: What are we missing?
Summary: How can we summarize the whole story?
Synthesis: How does this summary fit with my original statement?

Take-Away Message: What’s a more balanced and believable statement?
How can I apply that statement to my upcoming week?

Behavioral Experiments
Behavioral experiments are a potent cognitive change strategy that are commonly used in
CBT (Greenberger & Padesky, 2015). Behavioral experiments have roots in behavioral therapy
and (after being modified) are now widely used in a broad range of cognitive and behavioral
therapies (see Bennett-Levy et al., 2004; Greenberger & Padesky, 2015; Waltman et al., 2020). A
core component of CBT is creating cognitive change, and behavioral experiments allow for using
behavioral means to bring about cognitive change (i.e., changing thoughts through changing
behaviors; see Beck et al., 1979). Additionally, there are traditional cognitive strategies that can
be used to enhance behavioral experiments, all of which are examined later in the learning material.
In Beck’s (1979) seminal text on the theoretical aspects of cognitive therapy, he describes
applying the scientific method to experiment on a patient’s belief. This is essentially, what a
behavioral experiment is, the application of scientific inquiry and curiosity to a prediction. Beck
went on to explain that an individual’s perception of a situation is limited by their perception of
reality, and that their engagement with reality is limited by their world view. Conceptually, this
fits together to understand that a person has a belief based on their experience of reality. That belief
can shape their reality and create a feedback loop that strengthens the belief. For example, the
person’s predictions and behaviors are typically predicated on their belief system, thus limiting the
experiences they can draw from to shape their worldviews – then avoidance prevents the
opportunity for corrective learning (Beck, 1979).
It is thought, though not empirically proven, that behavioral experiments have greater
effect than thought records. It was been suggested that, “Generating an alternative interpretation
(insight) is usually not sufficient to generate a large emotional shift. A crucial, but sometimes
neglected, step in therapy is therefore to test the patient’s appraisals in behavioral experiments,
which create experiential new evidence against the patient’s threatening interpretation (Ehlers &
Wild, 2015, p. 166).”
Behavioral experiments (Bennet-Levy et al., 2004) are a commonly used approach to
cognitive restructuring that teach patients to use the scientific process to systematically test their
beliefs. Like thought records, different versions of behavioral experiments have been developed
over the years, though with considerably less variability. Broadly, the three categories of
behavioral experiments are distinguished as follows:

• Testing a specific prediction: Testing a specific prediction is the most common type of
behavioral experiment. This can be used to test out whether an alternative thought that
was developed using a thought record or rational responding is actually true. A thought
record does not have to be completed to find a prediction to test out, though it is a good
way reinforce and build momentum on a successful thought record. The general idea is
to target the predictions (i.e., automatic thoughts) that are preventing skillful behavior
and to foster more adaptive and more accurate predictions.
• Gathering new evidence: Gathering new evidence falls under the umbrella of a
behavioral experiment, though it is perhaps not a true experiment. This can be an ideal
strategy if there is a lack of disconfirmatory evidence due to avoidance or lack of
exposure. These can be done in session or out of session.
• Doing something different: This is not actually a behavioral experiment. Sometimes a
therapist might say, “Why don’t we try this and see what happens?” or perhaps assign
the patient the task of not engaging in the problem behavior. These can at times be
helpful suggestions, but they are underpowered interventions that could be better if
turned into a true behavioral experiment. Therapists are interested in more than getting
the client to do something different in their lives; therapists should be clever and set
clients up for success.
The following list of steps and accompanying descriptions explain how to design and use a
behavioral experiment to test a specific prediction.
Step 1. Identify a prediction that is getting in the way.
Step 2. Identify alternative predictions.
Step 3. Define the behavioral experiment question.
Step 4. Design the experiment.
Step 5. List any obstacles to a successful execution of the experiment or anything that
might go wrong and note strategies for overcoming obstacles.
Step 6. Conduct the experiment.
Step 7. Analyze the results of experiment.
Step 8. Note what can be concluded from the experiment.
Step 9. Re-rate degree of belief in targeted and alternative beliefs.
Step 10. Define action plan based on the study’s conclusions.

Step 1. Identify a prediction that is getting in the way.
Similar to other Socratic strategies, therapists want to be strategic as to what they target
with behavioral experiments. Keep in mind that the goal of behavioral experiments is to change
thoughts by changing behaviors. So, therapists should test predictions that are facilitative of the
desired new behaviors or determine the negative predictions which prevent more skillful behavior
(i.e., what prediction would help them be more skillful? or what prediction is keeping them stuck?).
The questions patients are taught to ask themselves are, “What is a fear or negative prediction that
I have which prevents me from having the life I want to have?” and “What specifically does that
fear make me predict will happen? How strongly do I believe this will happen (1-100%)?”
There are some key considerations specific to each step in the process. With respect to the first
step, identifying cognitions to test, it’s important to specify the cognition in falsifiable form (i.e.,
it is not possible to prove a negative). Some people illustrate this with the Santa Clause principle,
if Santa Claus exists it can be proven, but if he does not exist, one could not prove it. One could
only prove that they have yet to find him or find evidence of him in certain places or with certain
methods. Specifying a cognition in the falsifiable form can be accomplished by asking what
predictions can be derived from the stated belief? There may be one or several implications to any
particular belief.
Step 2. Identify alternative predictions.
The questions clients are taught to ask themselves are, “Is there a plausible alternative
prediction of what could happen? How strongly do I believe this will happen (1-100%)?” The
second component in which a possible alternative view is specified involves at least two
considerations. First, it’s important to identify what the client needs to learn in order to solve their
problem. The answer to this question points to the type of belief that would be helpful to formulate
and test via the experiment. Second, given the biasing effects of the client’s core beliefs, it is useful
to identify aspects of the experimental situation they might have trouble attending to. Specifying
an alternative belief helps navigate their attention to features of the situation they might not have
otherwise paid attention to, therefore interfering with important learning.
Step 3. Define the behavioral experiment question.
The questions patients are taught to ask themselves are, “Specifically, what am I testing?”
and “Can it be proven?” The therapist wants to make sure that everyone is on the same page and
to talk through the feasibility of testing the idea out. In cases where everyone is on the same page,

this step might seem redundant, but it is a failsafe and a place to flesh-out the target prediction and
plan for success. It is easier and better to spend a few moments in session making sure everyone
is on the same page, then debriefing a behavioral experiment that went awry and unnecessarily
discouraged the patient.
Step 4. Design the experiment.
The questions patients are taught to ask themselves are, “What’s the plan? Who, what,
when, where, and how will I test my prediction?” and “How will I know if it comes true?”
Designing an experiment is the next component. In addition to ensuring the exercise has the
potential to produce new learning in relation to the tested cognition(s), it’s very important to
describe the experiment in specific detail. For example, how long will the experiment last? How
will outcomes be measured? What, specifically, will the client say or do? How many times will
they implement the procedure over the duration of the experiment?
Therapists should help clearly define what is being testing, because clients may twist what
happens to fit their expectations otherwise. For example, someone with anxiety might complete a
difficult task and then erroneously conclude it was a failure because they became anxious during
the task. This is why it is important to clearly define the success criteria. In this anxiety example,
therapists can clearly discuss how clients will likely be anxious because they are doing something
that they are afraid of doing, but that the therapy is testing whether they can feel anxious and do it
anyway. Notably, this will likely need to be reviewed again during the debrief.
Step 5. List any obstacles to a successful execution of the experiment or anything that might
go wrong and note strategies for overcoming obstacles.
The questions patients are taught to ask themselves is, “What problems might come up and
what can I do to plan for success?” Next is an important and commonly overlooked component:
anticipating obstacles and problems that might arise. This is a crucial step because typically the
first time a person does something it does not go as smoothly as one would hope. Clinicians should
ask themselves whether the client has the necessary skills to conduct the experiment. If they don’t
have the existing skillset, then the clinician should either come up with a different experiment or
train the skill before they run the experiment. It is also important to identify what might go wrong
or what problems might arise to the degree that these can be anticipated. For example, if there is
an out of session exposure type experiment other people might notice the client’s behavior. Is this
likely? If so, will it present a problem? If a clinician is accompanying them out of the office might

someone approach the patient and clinician to ask what they are doing? What would the clinician
say that would not violate the patient’s confidentiality?
This troubleshooting step is related to the implementation of the actual experiment and can
also target treatment compliance here. Are there barriers that might come up and get in the way of
the client completing the experiment? Are they prone to forgetting? Have we scheduled when they
will do it? Do we need to make reminders? Do we need to make coping cards about why it is worth
it? Have we planned an optimal time to do the experiment?
Step 6. Conduct the experiment.
The questions patients are taught to ask themselves are “Did I conduct the experiment as
planned?” and “Do I need to rework the plan?” This step is straightforward – clients simply track
if they did the experiment as planned. There is also a question about whether the plan needs to be
reworked. This is because sometimes unanticipated barriers come up. The therapist should focus
on retooling the plan and guard against it being a failure experience for the patient. All data is
valuable. If, for example, a new unanticipated barrier is discovered, the session should be used to
rethink the experiment.
Step 7. Analyze the results of experiment.
The question patients are taught to ask themselves is, “What actually happened?” After
conducting the experiment it’s important for the patient to record all the relevant data. The most
accurate data is gathered if they track what happens the same day instead of filling the form out in
the waiting room before the session. The most important consideration with this step is for the
patient to just list the facts and not their interpretation of those facts. Interpretation occurs in the
next step.
Step 8. Note what can be concluded from the experiment.
The questions patients are taught to ask themselves are, “What does the outcome of the
experiment mean about my prediction and my alternate prediction?” and “Am I missing anything?”
The goal of this step is to draw out a clear conclusion from the experiment. Early in treatment this
is something the therapist and client will shape together. Remember their conclusions will be
filtered through their expectations and so this is a chance to help detangle their perceptions and
help draw out a more constructive conclusion. The question about whether they are missing
anything is a place to address any negative events that happened in the experiment. There might
be important context that is missing that helps mitigate negative findings. For example, if the client

became intensely anxious during the experiment, they might consider it a failure (because they’ve
learned to ascribe a meaning of failure to anxiety); however, the lesson they might be missing is
that they became incredibly anxious and were still able to do what they set out to do. The lesson
that the presence of anxiety does not have to prevent them from choosing how they behave is an
important finding to highlight.
Step 9. Re-rate degree of belief in targeted and alternative beliefs.
The questions patients are taught to ask themselves are, “How has my belief in my
predictions changed?” and “On a scale of 1-100%, what would I rate each of the beliefs?” An
important behavioral experiment component is to assess and note the impact of the experiment by
re-rating degrees of belief in the two tested ideas (i.e., the target cognition and the alternative).
Step 10. Define action plan based on the study’s conclusions.
The questions patients are taught to ask themselves are, “What did I learn?” and “How can
I build on this new learning in the coming week?” A central tenet of a CBT approach is
interweaving cognitive and behavioral strategies to make change. This demonstrates how, after a
behavioral experiment, cognitive strategies are used to draw out a new conclusion. Next, building
on the new conclusion, the therapy makes plans to do something behaviorally which continues to
foster new experiences, providing a broader base of experiences for the cognitive strategies.
Behavioral Experiment Form
Behavioral Experiment Plan

What is a fear or negative prediction that I have which prevents me from having the life I want
to have?
What specifically does that fear make me predict will happen? How strongly do I believe this
will happen (1-100%)?
Is there a plausible alternative prediction of what could happen? How strongly do I believe this
will happen (1-100%)?

Specifically, what am I testing?
Can it be proven?
What’s the plan? Who, what, when, where, and how will I test my prediction?
How will I know if it comes true?

What problems might come up and what can I do to plan for success?
Did I conduct the experiment as planned? Do I need to rework the plan?
What actually happened?
What does the outcome of the experiment mean about my prediction and my alternate
prediction?
Am I missing anything?
How has my belief in my predictions changed? How would I rate each (1-100%)?
What did I learn?
How can I build on this new learning in the coming week?

Hypothesis A/Hypothesis B
A popular method for treating health anxiety is called Hypothesis A/Hypothesis B
(Salkovskis, & Bass, 1997); this strategy may be applied to a host of other problems as well.
Essentially it is a comparison of two conclusions to see which is most plausible. Typically, the
client has some assumption which has some plausibility and then that is compared to an alternate
conclusion that is thought to be more plausible. For therapists who commonly want to provide a
reframe or alternate conclusion of their own, this can be a way to make that process more
compatible with CBT by increasing the collaborative empiricism. The flow of this intervention is
similar to a thought record, the only difference is the facts of a situation can be sorted into
supporting one or both hypotheses. The purpose of the intervention is to teach people that just
because something is possible does not necessarily mean it is likely to be true. Therefore, it is a
good intervention for people who have a tendency to jump to the worst-case scenario.
For example, consider a client with health anxiety and constant fear that they are having a
heart attack whenever their heart rate speeds up. They have been cleared by a cardiologist who,
after extensive testing, concludes it is “just” anxiety. Hypothesis A/Hypothesis B evaluates their
anxious intrusive thoughts that they are having a heart attack. The therapist and the client can do
a side-by-side comparison of the evidence that supports the heart rate being signs of a heart
problems and signs of the heart rate being signs of anxiety. A key thing to keep in mind is that
sometimes there is a third explanation that fits the facts best. For example, the heart rate might be
elevated due to exercise.
Hypothesis A/Hypothesis B Thought Record
Hypothesis A Hypothesis B
Which conclusion are we evaluating? What alternative conclusion are we
considering?
Evidence that supports Hypothesis A Evidence that supports Hypothesis B

Summary of Hypothesis A Evidence Summary of Hypothesis B Evidence
Which Hypothesis Better Fits the Facts Best?
Problem Solving
Problem solving is not unique to CBT, but it remains an important intervention because
not all problems are addressed with cognitive restructuring. Many clients have deficits in problem
solving (often fueled by avoidance patterns tied to their core beliefs). A wealth of frameworks for
teaching problem solving have been developed and Problem-Solving Therapy is an iteration of
CBT that is an evidence-based therapy for treating depression (Cuijpers et al., 2018). A key step
in using problem solving in CBT is teaching the client a framework so they can learn to do this on
their own as well. Therapists may already have preferred and suitable frameworks for employing
problem solving as an intervention. The common elements of problem-solving frameworks are:
1. Define the problem.
2. Formulate a hypothesis that integrates thoughts about why the problem is happening or
what it would take to solve the problem.
3. Brainstorm possible solutions.
4. Evaluate workability and pros/cons of possible solutions to select a solution.
5. Create a plan to put the solution into practice.
6. Work the solution.
7. Evaluate whether the solution worked to inform future problem solving.
Problem Solving Worksheet
Define the problem:
What would it take to solve the problem?

What are our options?
Which option is most likely to work? And have the best outcome?
What is the plan to put that option into action?

(who, what, when, where, why, how)
Are there potential barriers that might come up that need to be accounted for?
Go and do the plan.

Debrief: How did it go?
What did we learn?
Behavior Modification
Goal-directed behavior/value-directed behavior is an important component of the cognitive
and behavioral therapies. This is especially emphasized in the so called “third wave” CBTs. Often
clients come into therapy really focused on wanting a specific unpleasant emotional state to go
away, but as commonsense dictates, the absence of bad is not the presence of good. While
symptom reduction might be one of the treatment goals, there is also a focus on enlarging and
enriching clients’ lives. For many clients improving their task completion and follow through
improves their situation greatly.
The behavioral part of CBT is potent and pragmatic. There are two main principles of using
behaviorism to understand and modify behavior patterns are: 1) classical conditioning and, 2)
operant conditioning.

Classical conditioning (or Pavlovian conditioning) works through pairing and association.
A neutral stimulus can create a conditioned response when it is paired with something that would
naturally elicit that response. This is seen in the acquisition of fear and is reviewed later in the
section on using exposure therapy to treat anxiety disorders. Operant conditioning (see table
below) is the modification of behavior by manipulation of contingencies. A behavioral response
can be strengthened by the use of reinforcement or weakened by the use of punishment. Generally,
punishment does not lead to long term behavior changes and so the clinical emphasis is typically
on blocking reinforcement for undesirable behaviors and then reinforcing desired behaviors. A
common pet peeve of behaviorists is the misuse of the term negative reinforcement to mean getting
attention for doing something negative, this is not what the term means. Negative reinforcement
means a behavior is strengthened when something aversive goes away. Your car makes an
annoying beeping noise until you buckle your seat belt. Removing the annoying sound is a negative
reinforcement of buckling your seat belt.
Positive Negative
(adding something) (taking something away)
Increased Likelihood of the Positive Reinforcement Negative Reinforcement

Behavior
Decreased Likelihood of Positive Punishment Negative Punishment

the Behavior
There are a number of behavioral strategies to change targeted behaviors including: the
ABC model, graded task assignment, the Premack principle, and behavioral shaping & chaining.
The ABC Model
The ABC model of behavior modification is a way to map out the contingencies of a
behavior. This was initially conceived as stimulus-response-outcome (SRO) but has changed into
antecedent-behavior-consequence (ABC) over the years. This is similar to the ABC acronym used
in rational emotive behavior therapy of activating event-belief-consequence.

Antecedent Behavior Consequence
The first step in using the ABC model to change a behavior is using it to understand a
behavior. So, first the therapist and client need to map out what happened before the behavior.
Sometimes people call this the “trigger.” It is also necessary to map out how the behavior is being
reinforced—what is the client getting out of it? Sometimes a behavior results from a sequence of
events and then a series of overlapping ABCs might need to be completed. In these strategies the
C from one behavior is the A for the next chain. This process, referred to functional analysis and
sometimes called behavioral analysis or chain analysis, is a tool for understanding a behavior; it is
also the principal skills used in individual Dialectical Behavior Therapy sessions. The goals of
chain analysis are to identify what stimuli are prompting a behavior and what contingencies are
reinforcing that behavior (Skinner, 1957, 1969). Functional analysis is typically considered to be
an assessment tool; however, it can also be used as a clinical intervention. In other words, chain
analysis is used to hypothesize the function of a behavior. The results of a functional analysis
produce a “functional diagnosis,” which informs the treatment targets—clinicians strategically
target the mechanisms that are thought to be maintaining the problem.
Graded Task Assignment
It is common for clients get overwhelmed and discouraged by everything that needs to be
done. Graded task assignment is a practical strategy for dealing with this. It is illustrated in a
quotation by Desmond Tutu, “There is only one way to eat an elephant: a bite at a time.” A popular
1991 movie starring Bill Murray and Richard Dreyfuss called this strategy “baby steps,” and many
clients can easily recognize the concept when it is discussed in session. The idea of graded task
assignment is simple, help the client break down tasks that are large and unwieldy into to smaller
chunks that are more manageable and doable.
The Premack Principle
Sometimes called “grandma’s rule,” the Premack principle is a straightforward and
commonsense strategy. Grandma’s rule is: if you want to have dessert you have to first eat your
veggies. The larger principle is using high frequency occurring behaviors as reinforcement for low

frequency occurring behaviors. Or rather, using the things the client already does (and enjoys
doing) as reinforcement for what the client has trouble doing. Behaviorists joke that there is no
such thing as a “pre-reward.” According to the ABC model, the reinforcement has to follow a
behavior to increase the frequency of the behavior. The framework of “first-work then-play” can
be illustrated with a number of examples. An example from this writer’s life is: I woke up this
morning to a new cookie recipe in my email inbox. I wanted to make them and try them, but I
knew that would derail my typing plans for the morning. So, I used the Premack principle on
myself, I told myself that if I meet my typing goal, I can make the cookies that I want. Other
common examples are homework first then video games or do your chores on Saturday morning
then enjoy your weekend.
Shaping and Chaining
Sometimes the therapy is trying to build up a behavior that is complicated or difficult. In
these instances, employing such behavioral modification strategies as shaping and chaining may
be useful. Shaping means rewarding successive approximations of the target behavior—rewarding
progress and not demanding perfection. Behavioral chaining is applying the strategy of graded
task assignment to behavior change where a sequence of skills it built up. For example, if there is
a client who has a very impulsive automatic response the therapist might first teach them to pause
when they notice themselves getting worked up, then to breath, then to consider the situation, then
to respond in a more skilled manner. This complex skill is actually a number of micro-skills that
need to be taught one by one.
Exposure
In order to effectively use exposure strategies a therapist must understand negative
reinforcement; this refers to the increased likelihood of repeating a behavioral response when an
aversive stimulus is removed. For example, a man who experiences social anxiety may notice
temporary relief in social situations when distracting himself on his Smartphone. As a result, he
will be more likely to engage in the same escape or avoidance behavior in the future. Mower’s
Two Factor Theory holds that avoidance of the feared situation, which is fueled by negative
reinforcement, is what maintains an anxiety disorder (Mowrer, 1951). Thus, the rationale for
exposure-based therapies is that they block avoidance. Recent research suggests that cognitive
change may be a mechanism of change in exposure therapy (see Craske, Treanor, Conway,

Zbozinek, & Vervliet, 2014), and that perhaps exposure therapy facilitates this change in cognition
by allowing for new learning that was counter to the client’s expectations (Craske et al., 2014).
Currently there are three approaches to using exposure therapy: habituation, inhibitory
learning, and acceptance-based strategies. Habituation has been the main model for decades and
strategies like fear hierarchies are rooted in this model. The idea is that clients’ fear response
becomes less reactive (or habituated) with successive and prolonged exposure to what they are
afraid of. In other words, if a person has a fear of riding in elevators, the best treatment is riding in
elevators. Habituation is less popular among academic researchers now that it has been found to
not predict who has a sustained reduction in anxiety. A sustained reduction in anxiety is predicted
by a cognitive process referred to as expectation violation learning, or simply put learning that the
thing a person is afraid of happening did not actually happen; this is a main component of the
inhibitory learning model. Acceptance- and mindfulness-based models of exposure therapy are
also becoming increasingly popular.
Habituation
When working from a habituation model there are a few key things the therapist needs to
do: psychoeducation about the fight or flight response and the habituation model, and create and
refine a fear hierarchy.
Psychoeducation - Exposure has to be done willingly and so a client must understand
anxiety and why anxiety is treated with exposure. Therapists might already have an introduction
to these concepts that they use and like. Here are some examples of what might be said to clients.
“When we have sudden and intense anxiety this is what we call the fight-or-flight response.
It is hardwired into us. It is how our body responds when our mind perceives danger. Our body
does a lot of things that would make sense if we were running or fighting for our lives. Our mind
speeds up and starts to race because we need to be able to think quickly. Our heart speeds up
because we need our blood pumping. Our vision might narrow because we need to be able to scan
the horizon for threats. Our breathing becomes rapid and shallow as if we were sprinting. We
might have gastrointestinal distress because we need our blood for muscle movement and not
digesting. A lot of things can physically happen that can feel unpleasant and make us want to run
or fight. This is why we call this the fight-or-flight response.”
“Now many people experience this fight-or-flight response as being unpleasant and have
a corresponding urge to avoid and escape from situations that bring up this response. There can

be a prediction that the longer I am in this situation the worse it is going to get and so I need to
get out of here. While in actuality this fight-or-flight response is a short-term survival mechanism.
Our bodies physically cannot maintain that level of activation forever. People typically avoid and
escape the situations they fear and so they don’t notice that the fear naturally comes down on its
own. We call this process habituation when the fight-or-flight response naturally subsides, and a
goal of treatment to help people learn to face their fears and stay with these feared situations long
enough for their fear response to habituate. Repeated habituations lead to a reduction of overall
fear. Simply stated, we are going to start small and start facing your fears together, then as we
keep doing it, it will get easier, and we’ll gradually do harder and harder things, and we’ll conquer
your fear.”
Creating a fear hierarchy -Therapists should not stress too much about getting the hierarchy
perfect. The main point is that the hierarchy helps with building momentum, blocking avoidance,
and increasingly aims to do a little bit more. The first step is to generate a list of possible exposure
ideas. This can be approached from two different directions, or in combination. Identify what the
feared objects and situations are and incorporate elements that include these, or assess what
activities the client has stopped doing and what places they have stopped going to because of their
anxiety and focus on those. Individuals are often more motivated to do the naturally occurring
exposures in their lives. Below is a cost of avoidance form used to generate possible exposure
items. After listing items that a client is avoiding, they can sort these items from least difficult to
most difficult. If generating a good list is difficult, brainstorm (or do an internet search) for
exposure ideas for what they are afraid of. Then as the list of ideas is made, work through the list,
trying to find a pace that is a stretch but not an over stretch. Notably, exposure therapy is the
willing exposure to things that are anxiety inducing but not actually dangerous, clients should not
put themselves into actual physical danger. People should be afraid of things that are actually
dangerous.
There are a few main ideas to understand when doing exposure: catastrophizing, safety
behaviors, and a subjective units of distress scale (SUDS). Catastrophizing is the main cognitive
distortion in anxiety disorders and is reviewed in the section on the inhibitory learning model of
exposure. Safety behaviors (also call False Safety Behaviors) are things that clients do to try and
alleviate/escape anxiety, but actually end up worsening the problem. Examples include people with
social anxiety wearing sunglasses indoors, people with panic disorder carrying water with them

everywhere they go, or people with generalized anxiety constantly seeking reassurances. Ask the
client what they do to try to reduce their anxiety when they are engaged with the elements that will
be targeted during exposures. There are absolutely things that they do, which seem very creative.
If these behaviors are geared towards reducing anxiety, they are the target behaviors that the
therapy seeks to reduce, and ideally get the patient to stop. Doing the exposure tasks without the
safety behaviors can be added to the fear hierarchy as a way to honor that it will be more difficult
(and more effective).
Subjective Units of Distress - Finally, SUDS is an important concept. Habituation refers to
the point where the distress has reduced by half. To track this, teach the client to rate their distress
on a scale of 1-100 (or 1-10) then the exposure is conducted until the high point reduces by half.
So, if they elevate to a 90, they stay with the exposure until they come down to a 45. Typically, 70
is a target difficulty for exposures and items that previously would have been a 90+ become easier
over the course of treatment. This process can take a while, and the first habituations take the
longest because the client has such a well-developed pattern of avoidance and escape. Treatment
developers would initially have 90 minute or two-hour sessions for the first two exposures to allow
habituation to occur in session. Notably, the client does not have to habituate in session, it is just
clinically useful to be able to demonstrate that habituation occurs and that therefore they do not
need to avoid or escape.
Cost of Avoidance
What has my avoidance and anxiety cost me?

What have I stopped doing because of my anxiety?
What am I currently not doing (types of situations, people, places, and events do I avoid)?
What will I miss out on if I don’t change?

What are the themes
What types of types of situations, people, places, and events create the most anxiety?
What parts of my life do I miss out on the most because of my avoidance?
Plan to Overcome my Fear

Consider the example of strength training. You start with something that is strenuous and keep
at it. As, you keep working, you build muscle, and you will find that you are able to do things
you previously thought you couldn’t.
What fear do I want to work on?
Why is it worth it for me to face this fear?
List places to go, things to do, and ways to face my fears: SUDS 1-100

The Inhibitory Learning Model
The inhibitory learning model of exposure is different from the habituation model (see
Craske et al., 2014). There is less focus on a clear hierarchy as the treatment developers found that
a more random/naturalistic exposure schedule works best. The model also focuses on fostering
expectation violation learning to counter the catastrophic predictions. Catastrophizing occurs
along three pathways - over-estimating the likelihood that something negative is going to happen
and how bad it will be, and then also under-estimating their ability to cope with it. This leads to
anxiety responses that are disproportionate to the situation. The person predicts catastrophes and
their body prepares as if it will be a catastrophe. Catastrophizing can be targeted on all three
pathways. “Did what you were afraid would happen actually happen?” “Was it as bad as you
thought it would be?” “Were you able to cope with it?”
Therapists working from the perspective of the inhibitory learning model, are less focused
on creating a strict hierarchy and do not focus on habituation. Instead, they focus on drawing out
what the catastrophic prediction is and then getting the client to face their fear in the exposure task.
Afterwards, the therapist debriefs and contrasts what actually happened compared to what the
client was afraid would happen with the aim of demonstrating the expectations did not meet reality.
Acceptance-Based Approaches
Therapists working from an acceptance- or mindfulness-based approach to exposure such
as Acceptance and Commitment Therapy or Acceptance-Based Behavior Therapy, focus on how
clients’ avoidance prevents them from living the type of life they want to live. The therapist focuses
on helping clients recognize that they can feel fear and still live the kind of life they want to live.
Acceptance-based approaches employ strategies like mindfulness-training to increase acceptance
of anxious sensations and exposures focus on fully engaging in the life they have been avoiding,
to live a life consistent with their values (as opposed to being guided by fear).
It is important to note that CBT therapists do a lot of skills training in their sessions. The
goal is to teach the client to be their own therapist. All of the strategies described are taught as
skills, but this is not an exhaustive list. Clients are taught skills related to assertiveness, relaxation,
mindfulness, communication, organization, distress tolerance, emotion regulation, and so on. A
CBT therapist can pull a skill from any other type of therapy (or beyond) and pull it into the
treatment plan if it is in keeping with the case conceptualization of the client’s problems. Ideally,

these skills help the client make changes in their life. So, the goal is more than just coping, the
goal is thriving and engaging in life.
CULTURAL CONSIDERATIONS
CBT has been found to be effective with people across a wide range of cultural
backgrounds and identities (David et al., 2018). Still a question is raised as to whether treatment
can (or should) be culturally modified to meet the unique needs of culturally diverse clients. To
date 11 meta-analyses on culturally adapted interventions have been conducted with varied
findings. To reconcile the differences of the previous meta-analyses, a new meta-analysis was
conducted that included 13,998 participants, 95% of whom were non–European American, in 78
studies evaluating culturally adapted interventions with psychopathology outcomes. Using a
random effects multilevel regression model, the overall effect size (g = 0.67, p < .001) favored the
effectiveness of culturally adapted interventions over other conditions (e.g., no intervention, other
interventions). There was a medium effect size favoring the effectiveness of culturally adapted
interventions over unadapted versions of the same intervention (g = .52). Culturally adapted
interventions had 4.68 times greater odds than other conditions (including no treatment) to produce
remission from psychopathology (p < .001) in 16 studies that reported remission (Hall et al., 2016).
However, culturally adapting a psychotherapeutic intervention can also weaken the
therapy’s effect. This is well illustrated in a seminal review article by Huey et al. (2014). They
reviewed a broader base of individual studies where treatment was tailored to meet the cultural
needs of a client population. They concluded,
A cursory review of the literature suggests hundreds of potential strategies when
working with ethnically diverse populations. Unfortunately, the dearth of well-designed
studies precludes efforts to separate the wheat from the chaff with regard to cultural
competence. If our ultimate goal is to promote effective mental health care for ethnic
minorities while discouraging inert or harmful practices, then rigorous evaluation of
cultural competence models and strategies is needed to truly assess their worth. …Given
the ambiguous findings concerning the role of cultural competence in evidence-based care
and the possibility that tailoring could inadvertently weaken existing treatments, how
should clinicians proceed? Our overarching recommendation is to use EBTs [evidence-
based therapies] as first-line treatments. (p. 327, 330)

That is to say, they would recommend using the standard intervention first because that is
what the evidence-base is. If the standard treatment does not seem to be working, then further
assessment and possible modification of the treatment is indicated.
CBT FOR SPECIFIC PRESENTATIONS

Readers have thus far been provided with an overview of CBT and the core techniques;
ways this might be applied to specific situations is now illustrated. The format for the following
section with be a real-life case example, an overview of the CBT model of that specific diagnosis,
a description of what treatment typically consists of for that presentation, and finally an illustration
of how to treat the diagnosis using the case example.
Depression
Jennifer is a young mother who struggles with postpartum depression. Prior to giving birth
to her child, she had a semi-successful career and a very active social life. She had always looked
forward to motherhood, but found it was not exactly what she thought it would be. Her energy is
low. She feels guilty for not wanting to be around her baby all the time. She finds herself feeling
like she has made a terrible mistake. This is compounded with shame and guilt she feels from
everyone else telling her how excited they are for her and how beautiful they think her child is.
She thinks something is very wrong with her, and like a dirty secret, these feelings fester for a few
months. She comes in for CBT at the request of her physician after she screens positive for
depression on a symptoms inventory.
The following is a discussion on how to treat a case like Jennifer's with CBT:
The cognitive model of depression describes a cognitive negative triad (Beck &
Bredemeier, 2016); negative beliefs about the self (e.g., “I am bad”), the world (e.g., “no one loves
me”), and the future (e.g., “things will never get better”). The behavioral model of depression is
that individuals are not engaged in their environment in a meaningful way; that is to say, they have
too many aversive experiences and not enough positive experiences in their life. The cognitive and
behavioral models fit together. Typically, treatment will first consist of using behavioral strategies
to decrease symptoms of depression and then building on that momentum with cognitive strategies
to target that negative triad.

While some therapists might have heard about something called depressive realism in an
undergraduate psychology course (see Ackerman & DeRubeis, 1991), much of that research was
done on nonclinical samples and the idea that folks with clinical levels of depression have a more
realistic view of the world, is not exactly accurate (Ackerman & DeRubeis, 1991). They are
perhaps less prone to error of over-confidence or errors of making overly optimistic predictions,
but their view of the past is often distorted (Ackerman & DeRubeis, 1991). People with depression
are often over-generalizers. That is to say, they have a harder time remembering specifically what
happened, and tend to remember what they think happened based on overgeneralized ruminative
processes (Brittlebank et al., 1993; Kuyken & Dalgleigh, 1995). Further, there might be particular
difficulty in remembering positive experiences or memories (Brittlebank et al., 1993; Williams &
Scott, 1988); again, this is likely due to ruminative thought processes (Watkins & Teasdale, 2001),
as individuals with depression churn through their memories of the past, there is a re-storying and
consolidating of memories in a way that produces over-generalized memories—that tend to fit
with their depressive core beliefs and assumptions (Watkins & Teasdale, 2001). To account for
this CBT clinicians focus cognitive interventions on specific situations not global ideas. It is easy
for someone with depression to overgeneralize or over globalize negative attributions that paint
things as being worse than they actually are. So, in turn, the therapy looks for specific things that
happened because in specific experiences the discrepancies and exceptions are found.
Considering Jennifer’s treatment, a CBT therapist would first start with psychoeducation
about the cognitive model and about depression in general. As the therapist builds rapport and gets
up to speed, an early intervention would be to use activity monitoring as described earlier in this
learning material. The idea is to first gather information about what the client’s week looks like
before making any changes. From there ideas can be generated about where to make some small
changes that might have the largest probability of paying off. In this case example, one of the early
barriers is how tired Jennifer is—it is not unusual for a young parent to be exhausted and
depression itself can make a person pretty tired. Commonly, therapists will find that clients with
depression will report that they are too tired to do anything, and they have things that they want to
do, but they're waiting until they're less tired to do them. And they will wait for years till they have
the energy and the energy never comes. Because the less one does, the less energy they have (their
inactivity takes away from their energy levels). So, Jennifer has this idea, “I'm too tired to do
anything and I just need to rest and then I'll have more energy.” So, while building rapport the

therapist uses some simple Socratic questioning to evaluate this with Jennifer. Together they look
at the question, “will waiting and resting help me get more energy?” They look to see how long
she has been doing this and find that the more she rests, the more she oversleeps, the more she
pulls the covers over her face, and the more she avoids the world, she actually feels worse. So, as
they map this out Jennifer is able to see, “Oh I'm constantly resting because I think that's a way to
help me feel better, but actually the less I do, the worse I feel.” This paved the way for some
behavioral strategies like behavioral activation.
When first using behavioral activation with clients, therapists cannot just tell them, “Hey
get more active and then you will feel better.” If a therapist tries this, the client will likely look at
them like they're crazy and say “I'm too tired to do anything.” It is better to present clients with
this conundrum:
“Jennifer, on the one hand, your current activity level is connected with you having no
energy, feeling terrible, and being depressed; while on the other hand you don't have a lot of
energy and it's hard to get going and hard to do things. So, what we want to do is first gather some
data about what your week looks like so we can try to understand where we might be able to make
some small changes that will have the most likelihood of paying off. So, what I want you to do
between now and next week is to track hour by hour what are you doing and how are you feeling.
Some of the changes in how you're feeling might be kind of subtle so would be helpful if you could
rate your mood on a scale of 1 to 10 where 10 would be a wonderful not at all depressed mood
and then a 1 would be severe depression. How does that sound? Does that sound doable to you?
Can we get started by mapping out what you did this morning before we met?”
With Jennifer, her week is a lot of low numbers. When she is taking care of her child, her
numbers are low. When she is lying in bed sleeping and oversleeping, her numbers are low, which
are discouraging for her to look at.
Thematically, there are two main things therapists want to focus on when reviewing an
activity log - the high points and the low points of the week. And the thing they want to figure out
is why were the good points good and why were the bad points bad. Questions to ask are:
• What about this was enjoyable?
• What about this was unpleasant?
Jennifer does have a few points where she isn't quite happy, but she is perhaps less
depressed than the rest of the week. These are when she is cooking a meal for herself and she also

gets a video phone call from an old friend. (Notably, the intervention is not “then cook more meals
for yourself and video call someone every day”, the therapist should look a little deeper than that.)
After asking Jennifer what she gets out of cooking a meal for herself, she is able to recognize that
this was a time where she was doing something for herself and she felt more like her old self. This
wasn't a meal for a child, it was a meal that she would actually want to eat. It was a time where
she felt like she was more than just a caretaker, but also a person. Which helps them understand
what she might be missing in her life and what she needs more of. A similar theme was found with
the video call. The problem is not that she does not talk to people, she actually has a lot of phone
calls during the week. The question is what makes this call different? And the difference is that
this friend didn't spend the whole time talking about the baby. This friend spent some time
reminiscing talking about the glory days, bringing up old jokes, and treating Jennifer like a person,
not only a parent. This inquiry helps illuminate more of what Jennifer needs to be less depressed
in her daily life. Being treated like a person and not just a parent was antidepressant to her. Moving
towards behavioral activation, they look for ways to build more opportunities into the week where
she can feel like she is a human being and not only a parent. Interestingly, as they increase these
behaviors, she resents being a parent less, and finds more joy in taking care of her child.
Now that some symptom relief has been achieved, they move to fold in some cognitive
strategies to build on the gains she has made. They use thought records to evaluate thoughts she
has about herself, about how she is changing, and about her future. She previously had a lot of
thoughts about how her life was over and she would never be the kind of person that she was
before. There is a kernel of truth to this idea that things are different for her. But she is
overgeneralizing, as people with depression commonly do. Through the use of thought records,
she is able to evaluate these thoughts and come to a more balanced conclusion that while her life
is different, she is still herself, and she can still live a meaningful and enjoyable life. She even
finds that she can still have fun.
Generalized Anxiety Disorder

Rob recently lost his job and has a host of worries, related both to finding a new job and
life in general. Although Rob's history of problems with worry predates his job situation, they are
exacerbated by his current situation. Rob spends hours and hours thinking about things that might

happen and how he would respond if they were to happen. He does not sleep much at night because
he is always thinking and always worrying. For him, the worst part is the not knowing.
In this section how to treat generalized anxiety disorder and what a treatment plan for Rob
could be is explored. Generalized anxiety disorder is characterized by chronic worry. A core
component of anxiety disorders is that avoidance is what drives and keeps them going. In
generalized anxiety disorder the chronic worry is actually avoidance of uncertainty. By attempting
to think through every possible scenario, the sufferer is trying to avoid being caught off guard.
They are trying to create control in a situation that they do not have control over and exhausting
themselves over a problem that they cannot solve (Hebert & Dugas, 2019).
Worry can be conceptualized as ineffective problem solving. The trouble is that people
who worry tend to worry about the wrong things. They tend to worry about things that are out of
their control and things that they cannot do anything about. A CBT plan for generalized anxiety is
designed to teach people how to be more productive or more efficient worriers.
There are some CBT interventions that are unique to treating generalized anxiety disorder.
These include the use of worry time and worry logs. The sequence for this treatment will be
discussed with an example of Rob. A first intervention employed with someone who has
generalized anxiety disorder is to teach them to use worry time. Worry time can be a counter
intuitive idea, but it's a practical strategy that therapists can build on. The idea of worry time to
help people constrict the amount of time they spend worrying and increase the time they spend
being productive.
Worry time might be explained to Rob like this: Rob, the first thing I want you to do is to
start doing something called worry time. Let me explain what that means. What we know is that
worrying all the time is exhausting. We also know that just simply not worrying at all is probably
unrealistic. So, the strategy then is to try and constrict or reduce the amount of time you spend
worrying. My goal is to teach you to be a better worrier so we can try and shift some of this
worrying to productive problem solving. So, the first step is to set aside 30 minutes to an hour
every day to sit down and worry, or rather think about all the things you've been worrying about.
Then after worry time is over, any worries that come up I want you just to write them down, and
you'll get to them tomorrow during the next worry time. So, really, I'm asking you to do two things,
start keeping track of the different worries that come up for you and constricting the time you

spend worrying to this specific hour. What people typically find, is that this helps them focus on
the things that they can do something about, the things that are in their control, and it helps us
spend less time worrying about the things that they can't do anything about. This might also be a
helpful strategy to help with your insomnia, at night when you're overthinking you can roll over
and write on a notepad the problem that you thought of and during the daytime you can deal with
it. Because generally we don't do great problem solving in the middle of the night.
The process of working with worry then becomes a layering process. First, start with worry
time and worry logs. This is an early symptom management strategy. This also gives a good
foundation for building more advanced strategies. Clients bring the worry logs to sessions, so they
can review them with their therapist. Here the therapist can see what the client is focusing on and
where they are spending their time. Is how they are spending their time worrying proportionate to
the stressors in their life? Typically, individuals are spending a lot of time worrying about things
they cannot do anything about - which is a great way to be anxious and miserable. To address this,
the next step is creating categories to sort the worries that are identified. Common categories will
be things I can do something about, things I can't do anything about, and so on. Clients are then
directed to sort their worries into the different categories. This activity is how the therapy increases
the focus on that which is going to be most productive.
In the case of Rob, he is spending hours and hours worrying about things that are
completely out of his control. He reads the news on how the job market is doing. He worries about
international trade deals. He second guesses his job training. He spends hours and hours looking
at other people's social media, looking at how nice their lives are and worrying if he will ever be
as happy as they are. All of this is unproductive and eats away the energy he needs to be spend on
job seeking. Once worry time and worry logging are instituted, he is able to track his various
worries. These worries are sorted into things he can and cannot control; he is able to see how
unproductive his worry is. This leads to a deliberate focus on shifting his attention to things he can
do something about. As he becomes more productive, he finds relief in the sense of
accomplishment he derives from working towards his goals. This example illustrates the ways the
treatment shifts unproductive worry to productive and proactive problem solving, leading to an
overall reduction in his anxiety and greater engagement in his life.

Social Phobia
Kim is a young early career professional who has always been shy and introverted. She
has dealt with social anxieties for years through avoidance. She has recently been recommended
for a promotion at work, but the new position requires some public speaking which causes her
great anxiety. Rather than turn down the promotion, she finally seeks treatment.
There are a few different models for treating social anxiety or social phobia from a CBT
perspective. Common elements across the models include fear of being judged, a fear of being
evaluated, fear of being embarrassed, and a negative schematic bias (filter). One thing to be aware
of in treating social phobia or social anxiety is the effect that safety behaviors can have on
maintaining the problem (Wells et al., 1995). For example, people with social anxiety typically
have a fear of coming across as weird in a social situation. One of the ways that they will deal with
that, is to prepare and rehearse comments they're going to make before they make them. So, these
individuals will be in a conversation, but they will not be listening to what is being said, instead
they will be focusing on preparing their comments. After they say what they planned to say, they
will mentally review what they said, to make sure nothing unusual came out of their mouth. Now
there is an unintended consequence that accompanies this strategy. If someone is afraid of coming
across as weird, and therefore preparing what to say instead of listening to what the other person
is saying, they are going to come across as a little weird. What is said will not line up with the flow
of the conversation. However, those with social phobia do not attribute the weirdness to their safety
behaviors, they attribute it to their own social ineptness. Although, there are a number of social
skills training protocols, the first strategy is usually just teaching people to drop the safety
behaviors. Typically, if people can get lost in the conversation, instead of being lost in their head,
this will greatly improve the situation overall.
Another target is the catastrophic predictions made about their social competence. For
example, Kim has a mental image of herself giving a presentation, and in her mind, she does a
terrible job. To test this out Kim records herself giving one of her presentations. She is afraid to
watch it because she thinks it will be the worst job anyone has ever done. However, as her therapist
and she watch it together, she sees that it was not perfect, but it also was not terrible. This helps
her to form more balanced ideas about her abilities. Now that her self-image has been de-
catastrophized, they complete behavioral rehearsals in session to increase her confidence. She

specifically fears the sensation of being breathless and if she gets nervous while giving a
presentation, she becomes more nervous because she notices her nervousness. They target this by
having her practice giving her presentations while jogging. This helps her improve her breath
control and helps her learn to not be afraid of these body sensations. Cognitive work uses some
thought records to target some expectations she has of herself. It all comes together for her and she
ends up doing quite well and enjoying her new job.
Panic Disorder
Felipe has his first panic attack when he hears about the death of his grandfather. The
panic attack induces excessive anxiety for him and he goes to the emergency room because he
thinks he is having a heart attack. The ER staff tells him that it is just anxiety and to go home. He
is embarrassed that he had a panic attack and afraid that it will happen again. Overtime his life
becomes smaller and smaller because he avoids things and activities that make him feel like he
might have another panic attack.
The experience of panic attacks is different from having actual panic disorder. Panic
disorder is characterized by a fear of having panic attacks; a fear of fear. What commonly happens
when individuals have a fear of having panic attacks is, they developed a heightened body
sensitivity. They have a hypervigilance for any physical symptom of a panic attack. So, they
develop an intolerance of normal body sensations. For example, if their heart is beating a little
faster than usual (because they take the stairs) or if it's sunny outside and they're sweating, they
will interpret this physical sensation as a sign that they are going to panic. This causes them to feel
anxious. This results in increase physical symptoms of anxiety, which they interpret as more
evidence that they are going to have a panic attack. Cycling up, they fear their body sensations and
when they notice body sensations it causes them to experience anxiety, which only causes more
body sensations. This continues to cycle and escalate until a panic attack occurs. Panic disorder is
therefore characterized by an intolerance of body sensations and catastrophic misinterpretation of
body sensations. This is treated using a combination of cognitive strategies to target these
catastrophic interpretations and a special type of exposure called interoceptive exposure (i.e.,
exposure to body sensations). Breath retraining is another common element in the treatment of
panic disorder. Though the benefits of it seem only to be an increase in the client's willingness to

engage in treatment. The main active ingredients for the treatment of panic disorder are cognitive
restructuring and exposure (Pompoli et al., 2018).
To treat Felipe’s panic disorder, the therapist first conducts psychoeducation about the
cognitive model and about the cognitive model of panic disorder. Felipe is shown how his fear of
his body sensations and his catastrophic misinterpretation of body sensations is driving his panic
disorder. This is the rationale for using exposure therapy to treat his panic disorder. They start by
having him track whether or not the cognitive model of panic disorder holds true for him. He keeps
track of when he has panic attacks and then, in session, walk through moment by moment how it
starts, builds, and ends. This helps him see it is his fear of his body sensations that is causing an
increase in anxiety and a panic attack. After they do this, he is willing to engage in exposure
therapy.
With the interoceptive exposure, they focus on the symptoms that are most distressing to
Felipe. What is most distressing to him is his accelerated heart rate. He had previously gone to the
ER because he believed he was having a heart attack. Whenever his heart speeds up he gets
anxious. The goal of interoceptive exposure is to expose the client to the body sensation that they
are afraid of and avoiding. After receiving clearance from his physician, they employ physical
exercise to increase his heart rate. The first time using this strategy is together in session. The
therapist and the client together complete the exposure task by doing jumping jacks together. The
idea of this frightens Felipe, he is afraid he will have a panic attack in therapist’s office. He does
not. If a client does have a panic attack during an exposure, it's useful to keep in mind that a panic
attack is not dangerous. The worst thing anxiety can do is make a person feel anxious. So, if a
client has a panic attack during a session, the therapist should calmly sit with them and breathe
with them through it.
It is worth noting that breath retraining for panic disorder is different than it is for anger
management. When individuals get anxious their breathing becomes rapid and shallow. To counter
this, the focus is on slowed breathing. If they focus on deep breathing, there is a risk of them taking
rapid deep breaths, which would lead to over breathing (hyperventilating)—this would only make
them feel dizzier.
Felipe makes continued progress as he does his exposure tasks on his own. Identifying of
his heart rate increasing is targeted through exercise. In therapy the ideal exposure tasks can be
done by assessing both what a client is afraid of and what they are no longer doing. His fear

hierarchy lists of all the places and activities he avoid, and his therapy goals are for him to go to
those places and do those activities. His panic attacks remit with treatment.
Posttraumatic Stress Disorder

Maria develops posttraumatic stress disorder after being sexually assaulted. She blames
herself for the attack and avoids interactions with people she does not know out of fear of being
attacked again. She becomes increasingly isolative and emotionally numb. She has intense and
frequent flashbacks of the attack that she sometimes copes with by using non-suicidal self-injury
such as cutting.
Cognitive behavioral treatment of posttraumatic stress disorder (PTSD) is informed by the

two most popular manualized treatments: Prolonged Exposure (PE; Foa, 2007) and Cognitive
Processing Therapy (CPT; Resick, 1992). Cognitive behavioral treatments target the mechanisms
that are thought to be maintaining a problem. In the case of PTSD, it is theorized that symptoms
are maintained by avoidance of cues and memories related to the trauma and maladaptive beliefs
about what happened (Foa; 2007; Resick, 1992). Exposure strategies are used to block avoidance,
and Socratic questioning is used to address maladaptive beliefs. Prolonged exposure tends to
emphasize the exposure piece, whereas CPT tends to emphasize the cognitive piece.
The main focus of cognitive strategies for treating PTSD is modifying beliefs about the
meaning and implications of the traumatic event. This involves understanding how the event
impacted a person’s set of beliefs. Resick (1992) discusses the different ways that a person can
respond to a traumatic event. If the person interprets the event as being consistent with their
previous assumptions, then the individual will assimilate the event into their existing schemas. In
contrast, if the occurrence is counter to their previous learning, then a person will adjust their
beliefs to accommodate this new occurrence. Sometimes when an event is traumatic, the new
learning is so poignant and unexpected that a person may over-correct or over-accommodate their
belief set. Over-accommodation often involves a person over-generalizing trauma-based learning
and developing beliefs such as, “The world is dangerous,” or, “Other people are not to be trusted.”
The goal of treatment is typically to foster accommodation. This involves coming to terms with
what happened and integrating this new learning into the person’s belief set.

A common fallacy that is addressed in CBT is the notion that good things happen to good
people and bad things happen to bad people (i.e., just world belief). People who live their lives
subscribing to this belief as a tacit contract with the universe experience significant distress when
they are involved in a traumatic event, because they then blame themselves for the event. “This
either happened because of something I did that I shouldn’t have or something I didn’t do that I
should have.”
Another useful protocol is the Ehlers and Clark (2000) model (CT-PTSD) out of the United
Kingdom. The initial phases of treatment include psychoeducation, case formulation, and
treatment planning. This includes exploring the trauma(s), learning about the most upsetting
elements, and exploring the personal meaning of the traumas (identifying posttraumatic
cognitions). When there are multiple traumas, the therapist tends to focus on the ones being re-
experienced. The therapist uses psychoeducation and behavioral experiments to explore the
effectiveness of avoidance at managing the PTSD symptoms. Treatment planning can be flexible
depending on the sequela of co-morbid symptoms. Other components of treatment include:
• Clients reclaiming/rebuilding their lives where therapists encourage clients to re-engage in
previously enjoyed and meaningful behaviors and relationships. This is different from the
in-vivo exposure component of PE as the emphasis is on approaching what matters in the
client’s life as opposed to approaching what is feared (though in practice there might be
overlap in the task).
• Stimulus discrimination: this step is focused on helping the client distinguish between 'then'
and 'now,' to target trauma cues and re-experiencing symptoms. This is done in a gradual
process and involves introduction of trauma cues in-session and eventually outside of
session, to help the client learn that the trauma is not happening over and over again.
• Updating trauma memories which involves going over the trauma narrative either
imaginally (as in PE) or in written form (as in traditional CPT or Written Exposure
Therapy). Either method is acceptable in CT-PTSD. Imaginal methods can be more intense
and quicker, and written methods can be recommended when the narrative is substantially
long, disorganized, or has a number of gaps due to memory impairing factors of the trauma.
CT-PTSD clinicians also tend to use written narratives when the client is prone to
disassociate. In this protocol, the goal is not habituation, but rather to identify "hot spots,"

their corresponding meaning, and context to help "update"/correct/modify/contextualize
these memories.
• If re-experiencing persists, then the trauma narrative or image will be shifted in a manner
to signify that the trauma is now over. Revisiting the scene of the trauma (either in real-life
or online, such as through Google Street View) is also an important part of this process,
that typically happens towards the end of treatment. It allows for the gathering of more
memory retrieval cues that be used to further update the trauma memory and to help with
stimulus discrimination.
• Addressing unhelpful behaviors and dissociation: Standard skills such as grounding are
taught and then the therapist will move into stimulus discrimination as described above.
Maria’s course of treatment is similar in flow found across the trauma focused therapies.
Typically, treatment starts with psychoeducation and therapeutic relationship building. Next, the
therapist focuses on skills training. There are a number of skills to draw from including grounding,
breathing retraining, relaxation training, progressive muscle relaxation, yoga and movement-based
relaxation, and spiritual coping. Treating trauma is analogous to cleaning out an infected wound
and clients need some skills to weather the process. Maria responds well to paced breathing and
grounding. The next step in therapy moves her into the cognitive work. The therapist notes early
on that Maria carries a lot of guilt and shame about what happened. The therapist hypothesizes
that Maria blames herself for the attack and this the first thing the therapist focuses upon. The
therapist directly asks Maria if she ever thinks or wonders if there are things she could have done
to prevent the attack from happening. Maria emphatically answers, “Yes!” The therapist asks her
to describe what it is she thinks she should have done. The therapist takes good notes on this, and
then they evaluate these ideas together. The idea is that people second guess what they think they
should have done but they don't think it through all the way. So, for example, Maria often says to
herself that she should have fought back, but she doesn't stop to consider how the attacker would
have responded to her fighting back. When the therapist explores this with her, she remembers that
the attacker told her that if she fought back, he would kill her. This helps Maria to understand why
she hadn't fought back. It is important to hold on to the idea that people are generally doing the
best they can with what they have, and that their behavior makes sense in the moment.

After reducing some of the self-blame that Maria carries, the therapist focuses on Maria's
isolating behaviors. These seem to connect to the idea that the world is imminently dangerous. The
therapist explores Maria’s historical view of the world prior to the trauma and finds that it is
different from how Maria feels currently. This appears to be an over-correction or over-
accommodation. The therapist uses Socratic strategies to help the client reconcile the discrepancy
between thinking the world was safe to her new view that the world was imminently dangerous.
Through a series of ongoing conversations, thought records, and Socratic dialogues Maria arrives
at a more balanced view that the world is more dangerous than she initially thought but that it is
not imminently dangerous. This helps to reduce her hypervigilance and start reengaging in the
world. Clients who have a propensity for dissociation tend to also need a narrative element where,
together with their therapist, they review through the trauma over and over again, to help make
sense of what happened.
SUMMARY
Cognitive behavioral therapy is among the most researched psychotherapy. It has been
shown to be effective across a range of populations and presentations. This course provided an
overview of the theory and the core interventions and described how to apply the theory to specific
case examples. The next step is to put this into practice. Self-practice is recommended. If readers
use the skills and strategies on themself, they will come to understand the skills in a way that
extends beyond the reading. Seeking out supervision or peer consultation is also recommended.
There is still much to do and much to learn, as is the theme with on-going continuing education.

REFERENCES
Ackermann, R., & DeRubeis, R. J. (1991). Is depressive realism real? Clinical Psychology
Review, 11(5), 565-584.
Beck, A. T. (1963). Thinking and depression I. Idiosyncratic content and cognitive distortions.
Archives of General Psychiatry, 9, 324-333.
Beck, A. T. (1964). Thinking and depression II. Theory and therapy. Archives of General
Psychiatry, 10(6), 561-571.
Beck, A. T. (1979). Cognitive therapy and the emotional disorders. New York: Meridian.
Beck, A. T., & Bredemeier, K. (2016). A unified model of depression: Integrating clinical,
cognitive, biological, and evolutionary perspectives. Clinical Psychological Science,
4(4), 596-619.
Beck, A. T., & Dozois, D. J. A. (2011). Cognitive Therapy: Current status and future directions.
Annual Review of Medicine, 62, 397-409.
Beck, A. T., & Haigh, E. A. P. (2014). Advances in cognitive theory and therapy: The Generic
Cognitive Model. Annual Review of Clinical Psychology, 10, 1-24.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy of Depression.
New York, NY: Guilford.
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd Ed.). New York, NY:
The Guilford Press.
Bennett-Levy, J. E., Butler, G. E., Fennell, M. E., Hackman, A. E., Mueller, M. E., &
Westbrook, D. E. (2004). Oxford guide to behavioural experiments in cognitive therapy.
New York: Oxford University Press.
Brittlebank, A. D., Scott, J., Mark, J., Williams, G., & Ferrier, I. N. (1993). Autobiographical
memory in depression: State or trait marker? The British Journal of Psychiatry, 162(1),
118-121.
Burns, D. D. (1989). The feeling good handbook. New York: William Morrow and Company.
Clark, D. A., & Taylor, S. (2009). The transdiagnostic perspective on cognitive-behavioral
therapy for anxiety and depression: New wine for old wineskins? Journal of Cognitive
Psychotherapy, 23(1), 60-66.

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing
exposure therapy: an inhibitory learning approach. Behaviour Research and Therapy, 58,
10–23. doi:10.1016/j.brat.2014.04.006
Cuijpers, P., de Wit, L., Kleiboer, A., Karyotaki, E., & Ebert, D. D. (2018). Problem-solving
therapy for adult depression: an updated meta-analysis. European Psychiatry, 48(1), 27-
37.
David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current
gold standard of psychotherapy. Frontiers in Psychiatry, 9(4), 1-3.
Dozois, D. J., & Beck, A. T. (2008). Cognitive schema, beliefs, and assumptions. In K. S.
Dobson & D. J. Dozois (Eds.), Risk factors in depression (pp. 122-144). Amsterdam:
Elsevier/Academic.
Ekman, P. (1992). An argument for basic emotions. Cognition & Emotion, 6(3-4), 169-200.
Ellis, A., & Harper, R. A. (1961). A guide to rational living. North Hollywood, California:
Wilshire.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour
Research and Therapy, 38(4), 319-345.
Ehlers, A., & Wild, J. (2015). Cognitive Therapy for PTSD: Updating Memories and Meanings
of Trauma. In: U. Schnyder, M. Cloitre (Eds.), Evidence Based Treatments for Trauma-
Related Psychological Disorders (pp. 161-187). Springer: Cham, Switzerland.
Fassbinder, E., Schweiger, U., Martius, D., Brand-de Wilde, O., & Arntz, A. (2016). Emotion
regulation in schema therapy and dialectical behavior therapy. Frontiers in Psychology,
7, 1-19.
Foa, B. E., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure for PTSD:
Emotional processing of traumatic experiences. New York: Oxford.
Geschwind, N., Arntz, A., Bannink, F., & Peeters, F. (2019). Positive cognitive behavior therapy
in the treatment of depression: A randomized order within-subject comparison with
traditional cognitive behavior therapy. Behaviour Research and Therapy, 116, 119-130.
Greenberger, D., & Padesky, C. A. (2015). Mind over mood: Change how you feel by changing
the way you think. Guilford Publications.
Hall, G. C. N., Ibaraki, A. Y., Huang, E. R., Marti, C. N., & Stice, E. (2016). A meta-analysis of
cultural adaptations of psychological interventions. Behavior Therapy, 47(6), 993-1014.

Hebert, E. A., & Dugas, M. J. (2019). Behavioral experiments for intolerance of uncertainty:
Challenging the unknown in the treatment of generalized anxiety disorder. Cognitive and
Behavioral Practice, 26(2), 421-436.
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of
Cognitive Behavioral Therapy: A review of meta-analyses. Cognitive Therapy and
Research, 36(5), 427-440.
Huey Jr, S. J., Tilley, J. L., Jones, E. O., & Smith, C. A. (2014). The contribution of cultural
competence to evidence-based care for ethnically diverse populations. Annual Review of
Clinical Psychology, 10, 305-338.
Kazantzis, N., Fairburn, C. G., Padesky, C. A., Reinecke, M., & Teesson, M. (2014). Unresolved
Issues Regarding the Research and Practice of Cognitive Behavior Therapy: The Case of
Guided Discovery Using Socratic Questioning. Behaviour Change, 31(01), 1-17.
doi:10.1017/bec.2013.29
Korotitsch, W. J., & Nelson-Gray, R. O. (1999). An overview of self-monitoring research in
assessment and treatment. Psychological Assessment, 11(4), 415.
Kuyken, W., & Dalgleish, T. (1995). Autobiographical memory and depression. British Journal
of Clinical Psychology, 34(1), 89-92.
Leahy, R. L. (2018). Emotional schema therapy: distinctive features. New York: Routledge.
Lorenzo-Luaces, L., German, R. E., & Derubeis, R. J. (2015). It's complicated: The relation
between cognitive change procedures, cognitive change, and symptom change in
cognitive therapy for depression. Clinical Psychology Review, 41, 3-15.
Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2013). Behavioral activation for depression:
A clinician's guide. New York: Guilford.
Moorey, S. (2010). The six cycles maintenance model: Growing a “vicious flower” for
depression. Behavioural and Cognitive Psychotherapy, 38(2), 173-184.
Mowrer, M. O. (1951). Two-factor learning theory: Summary and comment. Psychological
Review, 58, 350-354.
Overholser, J. C. (2018). The Socratic Method of Psychotherapy. New York: Columbia
University Press.

Padesky, C. A., & Mooney, K. A. (2012). Strengths-Based Cognitive-Behavioural Therapy: A
four-step model to build resilience. Clinical Psychology & Psychotherapy, 19(4), 283-
290.
Persons, J. B. (2012). The case formulation approach to cognitive-behavior therapy. New York:
Guilford.
Pompoli, A., Furukawa, T. A., Efthimiou, O., Imai, H., Tajika, A., & Salanti, G. (2018).
Dismantling cognitive-behavior therapy for panic disorder: a systematic review and
component network meta-analysis. Psychological Medicine, 1, 1-9.
https://doi.org/10.1017/S0033291717003919
Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault
victims. Journal of Consulting and Clinical Psychology, 60(5), 748–756.
Rosenbaum, M., & Ronen, T. (1998). Clinical supervision from the standpoint of cognitive-
behavior therapy. Psychotherapy: Theory, Research, Practice, Training, 35(2), 220-230.
Salkovskis, P. M., & Bass, C. (1997). Hypochondria-sis. In D. M. Clark & C. G. Fairburn (Eds.),
Science and practice of cognitive behaviour therapy (pp. 313-340). Oxford: Oxford
University Press
Skinner, B. F. (1957). Verbal behavior. New York: Appleton Century-Crofts.
Skinner, B. F. (1969). Contingencies of reinforcement: A theoretical analysis. Englewood Cliffs,
NJ: Prentice-Hall.
Tee, J., & Kazantzis, N. (2011). Collaborative empiricism in cognitive therapy: A definition and
theory for the relationship construct. Clinical Psychology: Science and Practice, 18(1),
47-61.
Waltman, S. H., Codd III, R. T., McFarr, L. M., & Moore, B. A. (2020). Socratic Questioning for
Therapists and Counselors: Learn How to Think and Intervene Like a Cognitive Behavior
Therapist. New York: Routledge.
Waltman, S. H., Frankel, S. A., Hall, B. C., Williston, M. A., Jager-Hyman, S. (2019). Review
and analysis of thought records: Creating a coding system. Current Psychiatry Research
and Reviews, 15, 11-19.
Waltman, S. H., Hall, B. C., McFarr, L. M., Beck, A. T., & Creed, T. A. (2017). In-session stuck
points and pitfalls of community clinicians learning CBT: Qualitative investigation.
Cognitive and Behavioral Practice, 24, 256-267. doi:10.1016/j.cbpra.2016.04.002

Watkins, E. D., & Teasdale, J. D. (2001). Rumination and overgeneral memory in depression:
effects of self-focus and analytic thinking. Journal of Abnormal Psychology, 110(2), 353
Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social
phobia: The role of in-situation safety behaviors in maintaining anxiety and negative
beliefs. Behavior Therapy, 26(1), 153-161.
Williams, J. M. G., & Scott, J. (1988). Autobiographical memory in depression. Psychological
Medicine, 18(3), 689-695.
20 B

CBT Overview Training

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CBT Overview Training

Uploaded by

Copyright:

Available Formats

COGNITIVE BEHAVIORAL THERAPY: OVERVIEW,

STRATEGIES, AND INTERVENTIONS FOR COMMON

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

THE GENERIC COGNITIVE MODEL OF CBT

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

Rules and Assumptions

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

CONNECTING THE CBT CASE CONCEPTUALIZATION AND

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

CREATING A CBT CASE CONCEPTUALIZATION

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

Drawing out the Cycle

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

Drawing out the Cycle:

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

Demonstrating the CBT Model with Self-Monitoring

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

CORE CBT INTERVENTIONS

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

What are the different upsetting things that happened?

What was the most upsetting part?

Which thought was the most upsetting?

What’s the emotional meaning of that thought?

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

Socratic Thought Record

Focusing: What thought are we targeting?

Understanding: How does it make sense that I think this?

Curiosity: What are we missing?

Summary: How can we summarize the whole story?

Synthesis: How does this summary fit with my original statement?

How can I apply that statement to my upcoming week?

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

Behavioral Experiment Form