In all forms of CBT that are derived from Beck’s model, clinicians base treatment on a cognitive formulation: the maladaptive beliefs, behavioral strategies, and maintaining factors that characterize a specific disorder (Alford & Beck, 1997). You will also base treatment on your conceptualization, or understanding, of individual clients and their specific underlying beliefs and patterns of behavior.

In a nutshell, the cognitive model proposes that dysfunctional thinking (which influences the client’s mood and behavior) is common to all psychological disturbances. When people learn to evaluate their thinking in a more realistic and adaptive way, they experience a decrease in negative emotion and maladaptive behavior.

Cognitions (both adaptive and maladaptive) occur at three levels. Automatic thoughts (e.g., “I’m too tired to do anything”) are at the most superficial level. You also have intermediate beliefs, such as underlying assumptions (e.g., “If I try to initiate relationships, I’ll get rejected”). At the deepest level are your core beliefs about yourself, others, and the world (e.g., “I’m helpless”; “Other people will hurt me”; “The world is dangerous”). For lasting improvement in clients’ mood and behavior, you will work at all three levels. Modifying both automatic thoughts and underlying dysfunctional beliefs produces enduring change.

I hope you have an aspiration to become an excellent therapist and help hundreds or thousands of individuals in your career. Keeping this aspiration in mind can help you persevere if you become anxious while reading this book.

To the untrained observer, CBT sometimes appears deceptively simple. The cognitive model, the proposition that one’s thoughts influence one’s emotions and behavior (and sometimes physiology), is quite straightforward. Experienced CBT therapists, however, seamlessly accomplish many tasks at once: building rapport, socializing and educating the client, collecting data, conceptualizing the case, working toward clients’ goals and overcoming obstacles, teaching skills, summarizing, and eliciting feedback. As they’re accomplishing these tasks, they sound almost conversational.

As of right now, start noticing when your mood has changed or intensified in a negative direction, you are having bodily sensations associated with negative emotion (such as your heart beating fast when you become anxious), and/or you are engaging in unhelpful behavior or avoiding engaging in helpful behavior. Ask yourself what emotion you are experiencing, as well as the cardinal question of cognitive therapy: “What was just going through my mind?”

Some clients, particularly those with personality disorders, do require a far greater emphasis on the therapeutic relationship and advanced strategies to forge a good working alliance (J. S. Beck, 2005; Beck et al., 2015; Young, 1999).

Cognitive Therapy of Depression (Beck et al., 1979), advised therapists to use weekly symptom checklists and to elicit both verbal and written feedback from clients at the end of sessions. Various studies have since demonstrated that routine monitoring improves outcomes (Boswell et al., 2015; Lambert et al., 2001, 2002; Weck et al., 2017). Client outcomes are enhanced when both clients and therapists receive feedback on how clients are progressing.

CBT has traditionally reflected the values of the dominant culture in the United States. Clients with different ethnic and cultural backgrounds, though, have better outcomes when their therapists appreciate the significance of cultural and ethnic differences, preferences, and practices (Beck, 2016; Smith et al., 2011; Sue et al., 2009). CBT tends to emphasize rationality, the scientific method, and individualism. Clients from other cultures may hold different values and preferences: for example, emotional reasoning, varying degrees of emotional expression, and collectivism or interdependence.

Recent research demonstrates the importance of emphasizing positive emotion and cognition in treating depression (see, e.g., Chaves et al., 2019). You help clients actively work toward cultivating positive moods and thinking. It is also very important to inspire hope.

As Abe becomes less depressed and more socialized to treatment, I encourage him to become increasingly active in the session: deciding which steps to take toward his goals, problem solving potential obstacles, evaluating his dysfunctional cognitions, summarizing important points, and devising Action Plans.

CBT is aspirational, values based, and goal oriented. In your initial session with clients, you should ask them about their values (what is really important to them in life), their aspirations (how they want to be, how they want their life to be), and their specific goals for treatment (what they want to accomplish as a result of therapy).

When Abe viewed distressing situations more realistically, solved problems, and worked toward his goals, he felt less depressed. His mood became more positive as he focused his attention on what was going well in his life and what admirable qualities those experiences indicated about him as a person.

CBT uses guided discovery and teaches clients to respond to their dysfunctional cognitions. In the context of discussing a problem or goal, you ask clients questions to help them identify their dysfunctional thinking (by asking what was going through their mind), evaluate the validity and utility of their thoughts (using a number of techniques), and devise a plan of action.

Action Plans usually consist of identifying and evaluating automatic thoughts that are obstacles to clients’ goals, implementing solutions to problems and obstacles that could arise in the coming week, and/or practicing behavioral skills learned in session.

Clients tend to forget much of what occurs in therapy sessions, and when they do, they tend to have poorer outcomes (Lee et al., 2020). So here’s our rule of thumb: Anything we want clients to remember is recorded.

You share your conceptualization and ask the client whether it “rings true” or “seems right.” If your conceptualization is accurate, the client invariably says something like “Yes, I think that’s right.” If you’re wrong, the client usually says, “No, it’s not exactly like that. It’s more like ___________.” Eliciting the client’s feedback strengthens the alliance and allows you to more accurately conceptualize and conduct effective treatment. In fact, sharing your conceptualization can itself be therapeutic (Ezzamel et al., 2015; Johnstone et al., 2011).

CBT is based on the cognitive model, which hypothesizes that people’s emotions, behaviors, and physiology are influenced by their perception of events (both external, such as failing a test, and internal, such as distressing physical symptoms).

The way people feel emotionally and the way they behave are associated with how they interpret and think about a situation. The situation itself does not directly determine how they feel or what they do.

PEOPLE’S REACTIONS ALWAYS MAKE SENSE ONCE WE KNOW WHAT THEY’RE THINKING.

You can learn, however, to identify your automatic thoughts by attending to your shifts in affect, behavior, and/or physiology. Ask yourself, “What was just going through my mind?” when you begin to feel dysphoric, you feel inclined to behave in a dysfunctional way (or to avoid behaving in an adaptive way), and/or you notice changes in your body or mind that distress you (e.g., shortness of breath or racing thoughts). Having identified your automatic thoughts, you can, and probably already do to some extent, evaluate the validity of your thinking. For example, when I have a lot do, I sometimes have the automatic thought “I’ll never get it all finished.” But I do an automatic reality check, recalling past experiences and reminding myself, “It’s okay. You know you always get done what you need to.”

THE THEMES IN PEOPLE’S AUTOMATIC THOUGHTS ALWAYS MAKE SENSE ONCE WE UNDERSTAND THEIR BELIEFS.

Beginning in childhood, people develop certain ideas about themselves, other people, and their world. Their most central or core beliefs are enduring understandings so fundamental and deep that they often do not articulate them, even to themselves. Individuals regard these ideas as absolute truths—just the way things “are” (Beck, 1987). Well-adjusted individuals primarily hold realistically positive beliefs much of the time. But we all have latent negative beliefs that can become partially or fully activated in the presence of thematically related vulnerabilities or stressors.

The latent negative counterparts to these beliefs might temporarily surface when these clients negatively interpret a setback related to their effectiveness, an interpersonal problem, or an action they took that was contrary to their moral code. But they probably reverted back to their more reality-based core beliefs after a short period of time—that is, unless they developed an acute disorder. When this happens, they may need treatment to help them reestablish their primarily adaptive beliefs.

Reader E tends to selectively focus on information that confirms her core belief, disregarding or discounting information to the contrary. For example, Reader E did not consider that other intelligent, competent people might not fully understand the material in their first reading.

She seems to have the core belief “I’m incompetent.” This belief may operate only when she is in a depressed state; it may be active some or much of the time; or it may be fairly dormant. When this core belief is active, Reader E interprets situations through the lens of this belief, even though the interpretation may, on a rational basis, be patently invalid. Reader E tends to selectively focus on information that confirms her core belief, disregarding or discounting information to the contrary. For example, Reader E did not consider that other intelligent, competent people might not fully understand the material in their first reading. Nor did she entertain the possibility that the author had not presented the material well.

When Reader E is exposed to a relevant experience, this schema becomes active, and the data, contained in negative rectangles, are immediately processed as confirming her core belief—which makes the belief stronger.

Reader E, who thought she was too unintelligent to master this text, frequently has a similar concern when she has to engage in a new task (e.g., renting a car, figuring out how to put together a bookcase, or applying for a bank loan). She seems to have the core belief “I’m incompetent.” This belief may operate only when she is in a depressed state; it may be active some or much of the time; or it may be fairly dormant. When this core belief is active, Reader E interprets situations through the lens of this belief, even though the interpretation may, on a rational basis, be patently invalid. Reader E tends to selectively focus on information that confirms her core belief, disregarding or discounting information to the contrary. For example, Reader E did not consider that other intelligent, competent people might not fully understand the material in their first reading. Nor did she entertain the possibility that the author had not presented the material well.

Within this schema is Reader E’s core belief: “I’m incompetent.” When Reader E is exposed to a relevant experience, this schema becomes active, and the data, contained in negative rectangles, are immediately processed as confirming her core belief—which makes the belief stronger.

Core beliefs are the most fundamental level of belief; when clients are depressed, these beliefs tend to be negative, extreme, global, rigid, and overgeneralized. Automatic thoughts, the actual words or images that go through a person’s mind, are situation specific and may be considered the most superficial level of cognition. Intermediate beliefs exist between the two. Core beliefs influence the development of this intermediate class of beliefs, which consists of (often unarticulated) attitudes, rules, and assumptions

How do core beliefs and intermediate beliefs arise? People try to make sense of their environment from their early developmental stages. They need to organize their experience in a coherent way to function adaptively (Rosen, 1988). Their interactions with the world and other people, influenced by their genetic predisposition, lead to certain understandings: their beliefs, which may vary in their accuracy and functionality. Of particular significance to the CBT therapist is that dysfunctional beliefs can be unlearned, and more reality-based and functional new beliefs can be developed and strengthened through treatment.

The quickest way to help clients feel better and behave more adaptively is to help them identify and strengthen their more positive adaptive beliefs and to modify their inaccurate beliefs.

The hierarchy of cognition, as it has been explained to this point, can be illustrated as follows: Core beliefs ↓ Intermediate beliefs (rules, attitudes, assumptions) ↓ Situation ↓ Automatic thoughts ↓ Reaction (emotional, behavioral, physiological)

This sequence of events illustrates the diathesis–stress model. Abe had certain vulnerabilities: very strong and rigid values of productivity and responsibility, biased information processing, a tendency to see himself as incompetent, and genetic risk factors. When these vulnerabilities were exposed to relevant stressors (loss of job and marriage), he became depressed.

Treat every client at every session the way I’d like to be treated if I were a client.   Be a nice human being in the room and help the client feel safe.   Remember, clients are supposed to pose challenges; that’s why they need treatment.   Keep expectations for my client and myself reasonable.

You will need to focus more heavily on the relationship when you treat clients with strong, dysfunctional personality traits or serious mental health conditions. They tend to bring the same extreme negative beliefs about themselves and others to treatment—and may assume, until strongly demonstrated otherwise, that you will view them negatively (J. S. Beck, 2005; Beck et al., 2015; Young, 1999). A good case conceptualization can help you avoid problems.

You will continuously demonstrate your commitment to and understanding of clients through your empathic statements, choice of words, tone of voice, facial expressions, and body language. You will try to impart the following implicit (and sometimes explicit) messages, when you genuinely endorse them: “I care about you and value you.” “I want to understand what you are experiencing and help you.” “I’m confident we can work well together and that CBT will help.” “I’m not overwhelmed by your problems, even though you might be.” “I’ve helped other clients with issues like yours.” If you cannot honestly endorse these messages, you may need help from a supervisor or colleague to respond to your automatic thoughts about the client, about CBT, or about yourself. And you may need additional training and supervision to increase your competence.

When you recognize or infer that clients are experiencing increased distress, you will often address the issue right at the moment—for example: “You’re looking a little upset. [or ‘How are you feeling right now?’] What was just going through your mind?” Clients often express negative thoughts about themselves, the process of therapy, or you. When they do, make sure to positively reinforce them. “It’s good you told me that.”

Even when you discern that your alliance with clients is strong, elicit feedback from them at the end of sessions. For the first few sessions, you might ask, “What did you think about the session? Was there anything that bothered you, or you thought I misunderstood? Is there anything you want to do differently next time?” After several sessions, when you believe clients will give you honest feedback, you can just ask, “What did you think of the session?”

It’s important to recognize that your own background and culture exert an influence on your beliefs and values and on how you perceive, speak to, and behave toward your clients. Understanding the impact of your cultural biases helps you respond to clients in a culturally sensitive way

You want clients to accurately perceive you as a warm, authentic person who wants, and is capable, of helping them. Judicious self-disclosure can go a long way in fortifying this perception. Of course, self-disclosure should have a definite purpose, for example, strengthening the therapeutic relationship, normalizing the clients’ difficulties, demonstrating how CBT techniques can help, modeling a skill, or serving as a role model.

When clients have an incorrect view of you, they may very well have a similarly incorrect view of other people. If so, you can help them draw a conclusion about your relationship and then test it in the context of other relationships.

JUDITH: Looking at it now, what do you think is most likely? Does she have a history of cancelling on you and not caring? MARIA: (Thinks.) No, I guess not. JUDITH: It’s so important that you recognized that! I wonder if you have a certain vulnerability to assuming that people don’t care when they actually do. (pause) Do you think that’s possible? MARIA: I’m not sure. JUDITH: Well, let’s keep it in mind. I’m going to put it in my notes in case it comes up again.

“Which clients do I wish would not come in today?” Then use CBT techniques on yourself if any client comes to mind. Identify your cognitions about this client and do one or more of the following: Evaluate and respond to your cognitions about the client; create a coping card to read. Check on your expectations for your clients. Work on accepting them and their values as they are. Check on your expectations for yourself. Make sure they’re realistic. Specify your concern and conceptualize: What might the client do or say (or not do or not say) in session (or between sessions) that could be a problem? Which beliefs might underlie this behavior? Cultivate nondefensiveness and curiosity. Problem-solve by yourself or with a colleague/supervisor. Set appropriate limits with clients. Work on accepting your own emotional discomfort. Do good self-care throughout the day (e.g., deep breathing, taking a walk, calling a friend, doing a short mindfulness practice, eating in a healthy way).

In any case, I was alert that my own belief of incompetency could get activated and so I prepared myself to react in a nondefensive way. Making these mental preparations allowed me to approach our sessions with curiosity (“I wonder what she’ll do today to feel safe?”) instead of with dread.

It’s important to observe your negative reactions, accept your emotional reactions nonjudgmentally, and then figure out what to do. Once clients feel safe with you, you can address the maladaptive coping strategies they use with you—and likely with others as well. Monitor your level of empathy, and be on the alert for your own unhelpful reactions. Assess your skill deficits, engage in continual self-reflection and self-improvement (Bennett-Levy & Thwaites, 2007), get additional training, and regularly consult with others or seek supervision to increase your competence.

Another important part of the evaluation (or the first treatment session) is asking clients how they spend their time. This description gives you additional insight into their daily experience, facilitates goal setting, and helps pinpoint positive activities that you can encourage them to engage in more frequently.

Throughout the evaluation, you’ll be alert for indications that the client is unsure about committing to treatment. As Abe describes his current symptoms, he expresses hopeless thinking. I use his automatic thoughts to subtly relate the cognitive model, indicate how thoughts like these would be a target of treatment, and ensure that our tentative alliance hadn’t suffered.

When clients express concern because previous treatment hasn’t worked, positively reinforce them (“It’s good you told me that”) for expressing their skepticism or misgivings. Ask whether they felt they had a good relationship with their previous therapists and whether, at every session, their therapists set agendas, figured out with them what they could do to have a better week, made sure the most important points of the session were recorded for them to review daily at home, taught them how to evaluate and respond to their thinking themselves, successfully motivated them to change their behavior, and asked for feedback to make sure therapy was on the right track.

Toward the end of the assessment, it’s useful to ask clients two questions: “Is there anything else that’s important for me to know?” and “Is there anything you’re reluctant to tell me? You don’t have to tell me what it is. I just need to know whether there’s more to tell, maybe some time in the future.”

Setting goals often stimulates hope (Snyder et al., 1999), as does describing a treatment plan that makes sense to clients. It’s important for them to get a concrete idea of how it is that they will recover from their condition. When you relate the treatment plan, make sure to elicit feedback.

JUDITH: So that’s going to be our general treatment plan: set goals, start working toward them one by one, and learn skills. In fact, that’s how people get better, by making small changes in their thinking and behavior every day.

People’s values shape their choices and behavior. But when they perceive they’re not living up to their values, they often become distressed. In a conversational tone, you can ask clients, “What’s really important to you in life? Or what used to be really important to you?”

In addition to the elements listed below, you may interweave psychoeducation, eliciting and responding to automatic thoughts, devising Action Plan items, and identifying goals throughout the session. Initial Part of Session 1 Do a mood (and, when relevant, a medication or other treatment) check. Set the agenda. Ask for an update (since the evaluation) and review the Action Plan. Discuss the client’s diagnosis and provide psychoeducation. Middle Part of Session 1 Identify aspirations, values, and goals. Do activity scheduling or work on an issue. Collaboratively set a new Action Plan; check on likelihood of completion. End of Session 1 Provide a summary. Check how likely it is that the client will complete the new Action Plan. Elicit feedback.

To elicit clients’ aspirations, ask one or more questions such as the following (Beck et al., in press): “What do you want for your life?” “What are your hopes for the future?” “What do you want your future to look like?” “When you were growing up, what did you want your life to be like? What did you hope for?”

Help clients draw conclusions about having achieved their goals and aspirations, especially in terms of improving their life, self-image, sense of purpose and control, and connectedness to others. Ask questions such as these (Beck et al., in press): “What would be especially good about [achieving your aspirations and goals]?” “How would you feel about yourself? What would it say about you? How might other people view you or how might they treat you differently?” “What would it suggest about your future?” “How would you feel [emotionally] if all this came true? Can you get that feeling right now?”

JUDITH: Would it show that you were a good worker, a good father, a good grandfather, a good friend? ABE: Yes. JUDITH: And how would other people view you? ABE: I would hope the way they did before. That I’m reliable, I’m hardworking, friendly. JUDITH: And if all these things happen, what do you think your future would be like? ABE: Pretty good, I think. JUDITH: And how would you feel about yourself? ABE: Much better.

Using imagery can make aspirations more concrete and lead to clients’ experiencing positive emotion in the session. JUDITH: Abe, I wonder if you could imagine a day in the future when you’ve completely recovered from depression, when all these good things have come true? Let’s say it’s a year from now. Where do you think you’ll wake up?

When clients say, “I don’t know” to your goal setting questions, you can try a “miracle” question instead. Solution-focused brief therapy (de Shazer, 1988) suggests you ask a question such as the following: “If a miracle happened and you weren’t depressed when you woke up tomorrow, what would be different? How would someone know you weren’t depressed?”

Sometimes clients express goals that are too broad (e.g., “I don’t want to be depressed anymore” or “I want to be happier” or “I just want everything to be better”). To help them become more specific, you can ask, “If [you weren’t depressed anymore/if you were happier/if everything was better], what would you be doing differently?”

“It’s important to act according to your values, what’s really important to you, instead of what you feel like doing—because depression makes you tired and then you’ll feel like avoiding. But avoidance just makes depression worse. Don’t wait until you feel energetic or motivated to start an activity or task. Do it first. You’ll probably find that you get more energized and motivated some time after you start.

Clients often believe they can’t change how they feel emotionally. Helping them become more active and giving themselves credit for their efforts are essential parts of treatment.

research show that an essential part of getting over depression is becoming more active.

When people are as depressed as you are, trying to solve really big problems becomes overwhelming. That’s why it’s better to start with small things and build up your confidence by showing you that you can take control of parts of your life and that you can be effective.

We discuss unhelpful thoughts she might have before, during, and after the activities. We review the importance of giving herself credit and set up a reminder system. We also discuss how she would feel when she accomplished these tasks and what that would signify about herself and her future. Finally, we make this a no-lose proposition: Either she would do the activities or she would keep track of the thoughts or practical problems that got in the way.

Remember what we tell clients in the evaluation or first session: The way people get better is to make small changes in their behavior and thinking every day.

Using Socratic questioning first is often useful, but actually disconfirming predictions out in the world through personal experience usually results in significantly greater cognitive and emotional change (Bennett-Levy et al., 2004).

You’ll ask clients about their goals for each session and collaboratively decide what steps the client wants to take in the coming week. You’ll also identify obstacles to taking these steps and do cognitive restructuring for potentially interfering cognitions and/or problem solving, and/or skills training.

A good rationale for the task is that it helps people regain confidence in themselves and see themselves more realistically. If you give yourself credit throughout the day (as I do), you can use self-disclosure to motivate clients to do the same.

The single most important question to ask clients to assess the probability that they’ll complete their Action Plan is this: “How likely are you to do this, 0–100%?”

When clients say they are less than 90% sure that they’ll do their Action Plan, you’ll need to find out what could get in the way. On one occasion, Maria was only 75% sure. I asked her: “What’s the 25% part of you that thinks you won’t do it?” I could also ask: “Why are you 75% sure and not 50% sure?” “What could we do to get you from 75% to 95%?” “What are the advantages and disadvantages of doing the Action Plan?”

“What will you lose if it doesn’t work?” “What could be the potential gain in the long run if it does work?”

When clients have successfully completed an activity or task on their Action Plan, there are several questions you can ask to help them derive positive meanings and strengthen positive beliefs about themselves (Beck et al., in press): “Were you able to give yourself credit for doing that?” “What was good about the experience [e.g., ‘I helped other people’; ‘My family is happy’; ‘I got the job finished’]?” “What emotions did you experience [e.g., ‘I felt good’; ‘I was pleased’; ‘I felt proud’]?” (You can give them a list of positive emotions (p. 229) to help them identify additional positive emotions they may have experienced.) “What did the experience mean to you [e.g., ‘This shows ___________’; ‘It’s worth putting in the effort’; ‘People seem to like me’]?” “What did the experience show about you [e.g., ‘I can do hard things’; ‘I can take control’; ‘I’m stronger than I thought I was’; ‘I’m a good person’; ‘I’m likeable’; ‘I’m effective/competent/capable’; ‘I’m able to protect myself’; ‘I’m able to make good decisions’]?”

JUDITH: Is going to the park connected to something important?

In a different situation, Maria has correctly recalled the Action Plan but again she has overestimated the energy it would require. I first help specify the problem by doing a modified, short version of covert rehearsal, and I ask her a question to link the Action Plan to one of her important values. MARIA: I wasn’t sure I’d have the energy to take Caleb to the park. JUDITH: Was the problem mostly getting out of the house, going to the park, or what you’d have to do at the park? MARIA: Getting out of the house. I have to get so much stuff together—his diaper bag, the stroller, a snack, his coat and boots … JUDITH: Is going to the park connected to something important?

THERAPIST: Okay, you couldn’t do the Action Plan because you didn’t have time. Let’s pretend for a moment that this problem magically disappears. Let’s say you have a whole day free. Now how likely are you do to the Action Plan? Would anything else interfere? Would any thoughts get in the way?

When planning a session, remember that the way people get better is by making small changes in their thinking and behavior every day.

Sometimes clients recognize they are distressed but can’t identify a particular situation or issue that is associated with their distress (or which part of a situation is the most upsetting). When this happens, you can help them pinpoint the most problematic situation by proposing several potentially upsetting problems, asking them to hypothetically fix one problem, and determining how much relief the client feels. Once a specific situation has been identified, the automatic thoughts are more easily uncovered.

JUDITH: [summarizing] So, it sounds as if you’ve been very upset for the past few days and you’re not sure why, and you’re having trouble identifying your thoughts—you just feel upset most of the time. Is that right? MARIA: Yes. I just don’t know why I feel so bad. JUDITH: What kinds of things have you been thinking about? MARIA: Well, I’m still fighting with my mom. And my sister is mad at me too. I still can’t find a job, my apartment is a mess, and, I don’t know, everything. JUDITH: Anything else? MARIA: I haven’t been feeling too well. I’m afraid I might be getting sick. JUDITH: Which of these situations bother you the most? Your mom, your sister, not having a job, your apartment, or feeling sick? MARIA: Oh, I don’t know. They’re all pretty bad. JUDITH: Let’s say hypothetically we could completely eliminate the feeling sick problem. Let’s say you now feel physically fine, how upset are you now? MARIA: About the same. JUDITH: Okay. Say, hypothetically, your mom and your sister call and apologize and say they want to have a better relationship with you. How do you feel now? MARIA: Somewhat better. JUDITH: Okay. Let’s say you find out you got the job you interviewed for after all. Now how do you feel? MARIA: Much better. That would be a great relief.

The overarching goals of treatment are to facilitate remission of clients’ disorders; to increase their sense of purpose, meaning, connectedness, and well-being and to build resiliency and prevent relapse. To achieve these objectives, you need to have a solid understanding of clients’ current symptoms and functioning; aspirations, goals, and values; and presenting problems, precipitating events, history, and diagnosis. The treatment plan should be based on your ongoing conceptualization, and you should share your treatment plan with clients and elicit feedback. It’s important to plan treatment both for individual sessions and across the course of treatment.

It’s important to get clients’ attribution for an improved mood. We want to help them see that positive changes in their thinking and behavior are associated with feeling better.

[subtly reinforcing the cognitive model] So you thought, “Maybe therapy is helping,” and that thought made you feel slightly more hopeful, less depressed?

JUDITH: [subtly reinforcing the cognitive model] So you thought, “Maybe therapy is helping,” and that thought made you feel slightly more hopeful, less depressed?

Next, I help Abe draw some positive conclusions about his behavior. JUDITH: What does it mean that you were able to do these things? You weren’t able to a few weeks ago. ABE: I guess that I’m taking more control. JUDITH: [providing positive reinforcement] Absolutely.

Sometimes clients are unsure as to why they’re feeling better. If so, ask, “Have you noticed any changes in your thinking or in what you’ve been doing?”

Emphasizing the positive helps clients see reality more clearly, as the depression has undoubtedly led them to focus almost exclusively on the negative.

His automatic thought is “I won’t have enough stamina for a full workday.” I teach him two questions to evaluate his thinking: “What makes me think this thought is true? What makes me think it isn’t true, or not completely true?”

“Why do you think you’re feeling worse this week? Could it have anything to do with your thinking, or with the things you did or didn’t do?” In this way, you subtly reinforce the cognitive model and imply that clients can take some control over how they feel.

You could have clients who say, “Nothing can improve my mood.” It might be helpful to create a chart such as the one in Chapter 7, page 130. Recognizing that there are things that make them feel better or worse can help reinforce the notion that clients can affect their mood. Through guided discovery, you can help them see that avoidance, isolation, and inactivity generally increase their dysphoria (or at least do not improve it), while engagement in certain activities (usually that involve interpersonal interaction or that have the potential for pleasure or mastery) can lead to an improvement in their mood, even if initially the change is small.

socialized. If they’re not sure what should go on

If they’re not sure what should go on the agenda, you can ask them one or more of the following questions: (taking out a copy of the client’s goals) “Is there something on this list you’d like to talk about?” “How would you like the next few days to be better?” “How do you want to feel next week when you come in? What will you need to do this week to feel that way?” “Do you want to talk about ___________ [a goal] or ___________ [a specific issue]?” “When was the past week most difficult for you?”

Also seek clients’ attributions when their mood has become worse: “Why do you think you’re feeling worse this week? Could it have anything to do with your thinking, or with the things you did or didn’t do?” In this way, you subtly reinforce the cognitive model and imply that clients can take some control over how they feel.

Recognizing that there are things that make them feel better or worse can help reinforce the notion that clients can affect their mood. Through guided discovery, you can help them see that avoidance, isolation, and inactivity generally increase their dysphoria (or at least do not improve it), while engagement in certain activities (usually that involve interpersonal interaction or that have the potential for pleasure or mastery) can lead to an improvement in their mood, even if initially the change is small.

You may encounter situations in which you don’t know how to help a client solve a problem or resolve an obstacle. There are several things you can do: Find out what the client already tried to do and conceptualize why it didn’t work. You may be able to modify the solution or modify thoughts that got in the way. Use yourself as a model. Ask yourself, “If I had this problem or goal, what would I do?” Ask the client to name another person (usually a friend or family member) who could conceivably have the same kind of problem or goal. What advice would the client give him or her? See whether that advice could apply to the client. Ask the client if he or she knows someone who could help with the problem or goal.

To review, the cognitive model suggests that the interpretation of a situation (rather than the situation itself), expressed in automatic thoughts or images, influences one’s emotion, behavior, and physiological response. It’s important to help clients respond to their unhelpful or inaccurate thoughts.

The basic questions you ask clients are: “What [is/was/will be] going through your mind?” “What [are you/were you/will you be] thinking?” You’ll ask one of these questions when clients describe a problematic situation, emotion, behavior, or physiological reaction they had (often in the past week) or expect to have (often in the coming week); and/or when clients experience a negative shift in affect or exhibit an unhelpful behavior in the therapy session itself.

Interestingly, clients sometimes have greater access to their thoughts when you supply them with a thought that you believe is opposite to their actual thoughts.

In later sessions, you might also explicitly teach the client other techniques if the basic question (“What’s going through your mind right now?”) isn’t effective. The handout in Figure 12.2 can be useful. What’s going through my mind? or What am I thinking? What am I definitely NOT thinking? (Identifying an opposite thought can help prompt you to identify the actual thought.) What does the situation mean to me? Am I making a prediction? Or remembering something? REMEMBER: JUST BECAUSE I THINK SOMETHING DOESN’T NECESSARILY MEAN IT’S TRUE.

Automatic thoughts are associated with specific emotions, depending on their content and meaning. They are often brief and fleeting and may occur in verbal and/or imaginal form. People usually accept their automatic thoughts as true, without reflection or evaluation. Identifying, evaluating, and responding to automatic thoughts (in a more adaptive way) usually produces an adaptive shift in affect and/or behavior.

Recalling positive memories of how they have coped with difficulties in the past allows clients to cope better in the present (Tugade et al., 2004).

You will actively work to elicit and increase clients’ positive emotions in the session and throughout the week by discussing their interests, positive events that occurred during the week, and positive memories; creating Action Plans aimed at increasing positive emotions by, for example, becoming engaged in social, pleasurable, meaningful and productive activities and giving themselves credit; and helping clients draw adaptive conclusions about their experiences, for example, by asking: “What does this experience show you?” “What does it say about you that you [did ___________]?” “How do you think ___________ views you [as a result of this positive experience]?” “I think this [experience] points out ___________ about you. Do you think I’m right?”

It’s also helpful to have clients specify their positive emotions by asking: “How did you feel when you did ___________ [or when ___________ happened]?” “How did you feel afterward?”

Like Maria, some clients believe that negative emotions are unsafe: “If I get upset, ___________,” for example, “it will get worse and worse until I can’t stand it, I’ll lose control, it will never go away, or I’ll end up in the hospital.” These kinds of beliefs can interfere with working to achieve their goals. Clients may avoid situations in which they predict they will become upset.

Emotional reactions always make sense, given what the individual is thinking.

Instead of challenging or disputing automatic thoughts, we often use a gentle process of Socratic questioning.

See Overholser (2018) for an extensive discussion of the Socratic method of psychotherapy. What is the evidence that the automatic thought is true? Not true? Is there an alternative explanation? What’s the worst that could happen, and how could I cope? What’s the best that could happen? What’s the most realistic outcome? What’s the effect of my believing the automatic thought? What could be the effect of changing my thinking? If _____________ [friend’s name] was in the situation and had this thought, what would I tell him/her? What should I do about it?

Questions to evaluate automatic thoughts 1 (from the Thought Record). What is the situation? What am I thinking or imagining? What makes me think the thought is true? What makes me think the thought is not true or not completely true? What’s another way to look at this? What’s the worst that could happen? What could I do then? What’s the best that could happen? What will probably happen? What will happen if I keep telling myself the same thought? What could happen if I changed my thinking? What would I tell my friend [think of a specific person] if this happened to them? What should I do now?

Many clients predict a worst-case scenario. Ask them how they could cope if the worst does happen.

Clients’ worst fears are often unrealistic.

When clients’ worst fears are that they’ll die, you obviously won’t ask the “How would you cope?” question. Instead, you might ask for the best and most realistic outcomes. You might also decide to ask what the worst part of dying would be: fears of the process of dying, fears of what they imagine an afterlife might be like, or fears of what would happen to loved ones after the client’s death.

Clients tend to make consistent errors in their thinking. Often there is a systematic negative bias in the cognitive processing of clients who suffer from a psychiatric disorder (Beck, 1976).

Cognitive Distortions All-or-nothing thinking Example: “If I’m not a total success, I’m a failure.” Catastrophizing (fortune-telling) Example: “I’ll be so upset, I won’t be able to function at all.” Disqualifying or discounting the positive Example: “I did that project well, but that doesn’t mean I’m competent; I just got lucky.” Emotional reasoning Example: “I know I do a lot of things okay at work, but I still feel like I’m a failure.” Labeling Examples: “I’m a loser”; “He’s no good.” Magnification/minimization Example: “Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn’t mean I’m smart.” Mental filter Example: “Because I got one low rating on my evaluation [which also contained several high ratings], it means I’m doing a lousy job.” Mind reading Example: “He’s thinking that I don’t know the first thing about this project.” Overgeneralization Example: “Because I felt uncomfortable at the meeting, I don’t have what it takes to make friends.” Personalization Example: “The repairman was curt to me because I did something wrong.” “Should” and “must” statements Example: “It’s terrible that I made a mistake. I should always do my best.” Tunnel vision Example: “My son’s teacher can’t do anything right. He’s critical and insensitive and lousy at teaching.”

(1) What is the evidence that the automatic thought is true? Not true? (2) Is there an alternative explanation? (3) If the worst happened, how could I cope? What’s the best that could happen? What’s the most realistic outcome? (4) What’s the effect of my believing the automatic thought? What could be the effect of my changing my thinking? (5) If __________ [person’s name] was in this situation and had this thought, what would I tell him/her? (6) What would be good to do?

“What did you make of that experience?” or “What did you learn?” or “What do you conclude?” “What does this experience mean about you [or about other people or about how other people view you]?” “What does this experience probably mean about the future?”

One definition of mindfulness, reached through consensus by experts, is maintaining attention on immediate experience while taking an orientation of openness, acceptance, and curiosity (Bishop et al., 2004). It teaches you to focus on what’s currently happening, either externally (such as talking to someone) or internally (such as your thoughts, emotions, or bodily or mental sensations), and you practice being willing to experience whatever is happening in a nonjudgmental way. Mindfulness is particularly useful when clients are engaged in a maladaptive thought process, such as obsessing, ruminating, worry, or self-criticism.

JUDITH: (Pauses for 5 seconds.) I’d like you to start thinking about your life and your future again, either to yourself or out loud, just like you did when you were sitting on the couch this weekend: how you should be looking for a job, how you’re wasting your life, what a failure you are, how you used to have a good life but everything has turned bad, and how there’s no hope and you’ll never feel better. (Pauses for 30 seconds.) How are you feeling? ABE: Pretty sad. JUDITH: On a 1 to 10 scale? ABE: About an 8. Next, I turn on the audio recording app on his phone. JUDITH: Now, keep your eyes closed. I want you to focus on your breathing, on the sensations you feel as you breathe. (Pauses for 10 seconds.) Notice how the air feels going in and out of your nostrils; how your lungs, chest, and abdomen feel as they expand and contract. (Pauses for 15 seconds.) You can notice the sensations as a whole (pause) or focus on a specific sensation like the air going in and out of your nostrils, whichever is most comfortable to you. (Pauses for 30 seconds.) As you do this, you’ll notice that your mind is going to wander, various thoughts will show up, or you’ll get caught up in rumination from a minute ago. As you become aware of this, gently bring your focus back to the breath. (Pauses for 45 seconds.) No matter how many times your mind wanders, every time, just become aware that it’s happened, and gently bring that focus back to the breath. (Pauses for 30 seconds.) There’s no need to criticize yourself or get frustrated when your mind wanders because that’s what our minds do; all you have to do is notice it’s happened and gently bring that focus back to the breath. (Pauses for 40 seconds.) It’s okay if you notice thoughts in the back of your mind. You don’t need to force them away or make them any different. Just notice they’re there and let them fade on their own, as your main focus is on those breathing sensations (60-second pause).

beliefs may be classified in two categories: intermediate beliefs (composed of rules, attitudes, and assumptions) and core beliefs (global ideas about oneself, others, and/or the world)

Core beliefs are one’s most central ideas about the self, others, and the world. Adaptive beliefs are realistic and functional and not at an extreme. Dysfunctional core beliefs are rigid and absolute, maintained through maladaptive information processing. Some authors refer to these beliefs as schemas.

Once a schema is activated, three things generally happen: The client interprets this new experience in accordance with the core belief. The activation of the schema strengthens the core belief. Other kinds of schemas become activated too.

Clusters of interrelated and co-occurring schemas are termed “modes.” At every session, we seek to deactivate the depressive (or “client/patient”) mode and activate the adaptive mode (Beck et al., 2020).

Likewise, when clients say, “I’m worthless,” they may mean that they don’t achieve highly enough (helpless category) or that they won’t be able to gain or maintain love and intimacy with others because of something within themselves (unlovable category). The cognition “I’m worthless” falls in the worthlessness category when clients are concerned with their immorality or toxicity, not their effectiveness or lovability.

Fixed, overgeneralized negative ideas often need to be evaluated and modified, in addition to negative core beliefs about the self. Ideas that are more reality based often need to be strengthened by, for example, asking clients to draw conclusions about their neutral and positive experiences (“What does this experience show about you? About others? About the world? What does it say about what your future could be like?”).

JUDITH: Okay, to summarize, you were looking around your apartment and you thought, “It’s so messy. I should never have let it get this way?” ABE: Yes. JUDITH: We haven’t looked at the evidence to see if these thoughts are true. But I’d like to see if we can figure out why you had those thoughts. Let’s assume for a moment that your apartment is too messy and you shouldn’t have let it get like that. What would that mean about you? ABE: I don’t know. I just feel so incompetent. You can phrase the downward arrow question in different ways: “If that’s true, so what?” “What’s so bad about …?” “What’s the worst part about …?”

Evaluation of conditional assumptions through questioning or other methods often creates greater cognitive dissonance than does evaluation of the rule or attitude. It is easier for Abe to recognize the distortion and/or dysfunctionality in the assumption “If I please other people, they won’t hurt me” than the related rule (“I should please others all the time”) or attitude (“It’s bad to displease others”).

It is important for clients to understand the following: Beliefs, like automatic thoughts, are ideas, not necessarily truths, and can be tested and changed. Beliefs are learned, not innate, and can be revised. There is a range of beliefs that the client could adopt. Beliefs can be quite rigid and “feel” as if they’re true—but be mostly or entirely untrue. Beliefs originated through the meaning clients put to their experiences as youth and/or later in life. These meanings may or may not have been accurate at the time. When relevant schemas are activated, clients readily recognize data that seem to support their core beliefs, while discounting data to the contrary or failing to process the data as relevant to the belief in the first place.

Even suggesting that a dysfunctional belief may not be true, or not completely true, can be anxiety provoking for some clients

When clients need additional motivation, you can ask them to visualize a day in their life several years from now, first having maintained their negative core belief as is, and then believing their new core belief for quite a long time. You can say something like this: “I’d like you to imagine a day in your life ___________ years from now; so it’s the year ___________. You haven’t changed your core belief that you are ___________. So you’ve believed it day in and day out for ___________ more years. It’s gotten stronger and stronger with each passing day, and week, and month, and year. (pause) Now I’d like to ask you some questions. (pause) See how well you can picture yourself and your experience in your mind’s eye. “How do you feel about yourself?” “How far along are you in achieving [each of your aspirations and goals]?” “To what degree are you living in accordance with your values?” Next, tell clients: “I’d like you to imagine how your belief has affected various parts of your life. Remember, your core belief is so much stronger than it is today. Really try to picture each part of your life, as I ask you about it. And think about how much enjoyment or satisfaction you’ll likely be experiencing … Where do you see yourself waking up? In the same place as today? Or someplace different? … What does it look like? … How much enjoyment or satisfaction do you get from where you live?”

Now repeat the same questions for a second scenario, but start out by saying: “Now I’d like you to imagine that you’ve believed your new core belief, that you are ___________. You’ve believed it more and more strongly day after day, week after week, month after month, and year after year for ___________ years. See how well you can picture yourself and your experience in your mind’s eye. Tell me about these same areas, and how much enjoyment and satisfaction you get from each.”

You begin to formulate a hypothesis about clients’ core beliefs whenever they provide data in the form of their automatic thoughts (and associated meanings) and reactions (emotions and behaviors). You hypothesize whether cognitions seem to fall in the helpless, unlovable, or worthless categories. You identify both intermediate and core beliefs in many ways. You can look for the expression of a belief in an automatic thought, provide the conditional clause (“If …”) of an assumption and ask the client to complete it, directly elicit a rule, use the downward arrow technique, recognize a common theme among automatic thoughts, ask clients what they think their belief is, or review the client’s belief questionnaire.

The downward arrow technique helps you identify clients’ negative core beliefs. It involves asking clients to assume their automatic thoughts (ones with recurrent themes) are true and then questioning them about the meaning of their automatic thoughts.

It’s important to reinforce these more positive beliefs (Ingram & Hollon, 1986; Padesky, 1994; Pugh, 2019) throughout treatment by helping clients engage in activities that could bring them a sense of mastery, pleasure, connection, and empowerment. Other important strategies include eliciting positive data and drawing helpful conclusions about their experiences, eliciting the advantages of believing adaptive beliefs, pointing out the meaning of positive data, referencing other people, using a chart to collect evidence, inducing images of current and historical experiences, and acting “as if.”

At the beginning of each session, I asked Abe, “What positive things happened since I saw you last? What positive things did you do? [or “When this week did you feel even a little better?”] Then I asked, “What do you conclude about [these experiences]? What do these experiences say about you?” I asked Abe to keep a credit list of everything he did each day that was even a little difficult but that he did anyway. Once we identified an important adaptive belief (“I’m competent, with strengths and weaknesses like everyone else”), I added a question at the beginning of each session: “How strongly do you believe today that you’re competent? When did you believe that most strongly this week? What was going on?”

also helped Abe examine the advantages of seeing himself as competent.

I also helped Abe examine the advantages of seeing himself as competent. We identified several advantages: It would be more reality based, increase his self-confidence, make him feel better about himself, improve his mood, motivate him to try things that seemed difficult, and help him accomplish tasks.

As therapy progressed, I elicited the meanings from Abe. “What does it say about you that you were so helpful at the homeless shelter?” “What does it say about you that Charlie wants you to keep working for him?”

Ask clients about people who historically viewed them in a favorable light: “Who in your life believed most strongly that you were competent? Why? Could this person have been right?”

“Abe, can you imagine what it would be like if you completely believed you were competent when you went for your job interview?

Cognitions change in the presence of affect, so the best time to work on negative beliefs is when their schemas are activated in session.

It’s very important that clients change their behavior by decreasing their avoidance and entering into situations they’ve been avoiding. Otherwise, they won’t have the actual experience of having their beliefs disconfirmed. For an extensive description and discussion of behavioral experiments, see Bennett-Levy and colleagues (2004).

You can help clients develop a different idea about themselves by encouraging them to reflect on their view of characters or people who share the same negative core belief that they themselves have. When clients experience vivid examples of how others’ very strong beliefs are invalid, or mostly invalid, they begin to understand how they too could have a powerful core belief that isn’t accurate.

For additional common metaphors used in CBT, see Stott and colleagues (2010) and De Oliveira (2018).

Acceptance of negative emotion (instead of avoidance) is key for some clients (Linehan, 2015; Segal et al., 2018). Acceptance and commitment therapy (Hayes et al., 1999) describes useful metaphors for accepting negative emotion and turning one’s attention to valued action.

If examining my thinking doesn’t help, I change my focus. I tell myself, “Thinking about this right now isn’t helpful. It’s okay that I’m feeling ___________ (nervous, irritated, etc.). I should just refocus on what I’m doing (or engage in a valued action).”

You can also ask clients how they’ve solved similar problems in the past, or how they might advise a close friend or family member to solve the same kind of problem

Many clients, especially those who are depressed, have difficulty making decisions. When clients want your help in this area, ask them to list the advantages and disadvantages of each option and then help them devise a system for weighing each item and drawing a conclusion about which option seems best

Imaginal exposure is often helpful. You can ask clients to imagine entering a situation or engaging in an activity, especially in two conditions: When clients are too fearful to do even mild exposures. When it’s impractical to do regular exposures.

It’s often helpful to clients to see their ideas in graphic form. A pie chart can be used in many ways, for instance, helping clients set goals.

Clients tend to become overwhelmed when they focus on how far they are from a goal, instead of focusing on their current step. A graphic depiction of the steps is often reassuring (Figure 19.2

Clients often have automatic thoughts in the form of unhelpful comparisons. They compare themselves at present with how they were before the onset of their disorder, or with how they would like to be, or they compare themselves with others who don’t have a psychiatric disorder. Doing so helps to maintain or increase their dysphoria, as it does with Maria. I help her see that her comparisons are unhelpful. I then teach her to make more functional comparisons (with herself at her worst point).

Many clients experience automatic thoughts not only as unspoken words in their minds but also in the form of mental pictures or images (Beck & Emery, 1985).

Imagery affects how we feel (influencing both positive and negative emotions) more than verbal processes (Hackmann et al., 2011). I’ve found that many CBT therapists, even very experienced ones, don’t use techniques to induce positive images in their clients and/or fail to identify and address their clients’ important distressing images.

Creating vivid positive imagery can increase clients’ positive emotions, motivation, and self-confidence. You can have clients recall memories, relevant to a current or upcoming situation, in which they solved problems, coped well with difficult situations, or experienced success (Hackmann et al., 2011).

Helping Abe visualize a day in the future when his mood and functioning have improved creates hope and motivation.

Substituting a more pleasant image has been extensively described elsewhere (e.g., Beck & Emery, 1985).

Another type of induced image is designed to allow clients to view a situation more positively. One client, who feared undergoing a Cesarean section, envisioned the excited face of her partner, holding her hand; the kind and caring faces of the nurses and doctor; and then the wonderful image of holding her newborn child.

Following an image to the end can be ineffective when clients keep imagining more and more obstacles or distressing events with no end in sight. At this point, you might suggest that clients imagine themselves at some point in the near future, when they’re feeling somewhat better.

Another technique is to teach clients to treat images as verbal automatic thoughts, using standard Socratic questioning. I teach Maria to compare a spontaneous image with what is really happening.

Imagery can be used in various ways to heighten positive emotion, increase confidence, rehearse the use of coping techniques, and change cognition.

Be alert at every session for opportunities to reinforce clients for their progress. When they experience an improvement in mood, find out why they think they are feeling better. Emphasize the idea, whenever possible, that they themselves have brought about changes in their mood by making changes in their thinking and behavior. Point out or ask clients to state what these positive changes mean about them. Doing these things helps build their sense of self-efficacy.

Early warning signs—Sad mood, anxiety, rumination, spending too much time on the couch, desire to avoid socializing, letting apartment get messy, procrastinating (e.g., not paying bills), trouble sleeping, self-criticism. What to remember—I have a choice. I can catastrophize about the setback, think things are hopeless, and probably feel worse. Or I can look back over my therapy notes, remember that setbacks are a normal part of recovery, and see what I can learn. Doing these things will probably make me feel better and make the setback less severe. What to do—If some of these things happen, have a self-therapy session. Set new goals, evaluate automatic thoughts, schedule activities, do mindfulness if I’m ruminating, see what problems need solving, and especially—reach out for help—to kids and to Charlie. If this isn’t enough, call Judith so we can decide together whether I should return to treatment, probably briefly.

Next, we collaboratively decide not to focus on this current situation at the moment. Instead, I take advantage of Abe’s negative mood state to identify an important early experience, in which the same core belief had been activated. I ask him to imagine the scene. Then we discuss the memory on the intellectual level, and I help Abe see an alternative explanation for his mother’s outburst in which she blamed and criticized him. JUDITH: When is the first time you remember feeling this way, as a kid?

Identify a specific situation that is currently quite distressing to a client and is associated with an important dysfunctional belief. Heighten the clients’ affect by focusing on her automatic thoughts, emotions, and somatic sensations. 2. Help the client identify a relevant early experience by asking, “When do you remember feeling like this when you were growing up?” or “When is the earliest time you remember believing this about yourself? [or ‘When did your belief get much stronger?’]” Elicit a description of a specific situation and the meaning the client put to it. Use Socratic questioning to help her reframe the dysfunctional belief that had been activated.