cbt homework first session

How to Design Homework in CBT That Will Engage Your Clients

Take-home assignments provide the opportunity to transfer different skills and lessons learned in the therapeutic context to situations in which problems arise.

These opportunities to translate learned principles into everyday practice are fundamental for ensuring that therapeutic interventions have their intended effects.

In this article, we’ll explore why homework is so essential to CBT interventions and show you how to design CBT homework using modern technologies that will keep your clients engaged and on track to achieving their therapeutic goals.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with a detailed insight into positive CBT and give you the tools to apply it in your therapy or coaching.

This Article Contains:

Why is homework important in cbt, how to deliver engaging cbt homework, using quenza for cbt: 3 homework examples, 3 assignment ideas & worksheets in quenza, a take-home message.

Many psychotherapists and researchers agree that homework is the chief process by which clients experience behavioral and cognitive improvements from CBT (Beutler et al., 2004; Kazantzis, Deane, & Ronan, 2000).

We can find explanations as to why CBT homework is so crucial in both behaviorist and social learning/cognitive theories of psychology.

Behaviorist theory

Behaviorist models of psychology, such as classical and operant conditioning , would argue that CBT homework delivers therapeutic outcomes by helping clients to unlearn (or relearn) associations between stimuli and particular behavioral responses (Huppert, Roth Ledley, & Foa, 2006).

For instance, imagine a woman who reacts with severe fright upon hearing a car’s wheels skidding on the road because of her experience being in a car accident. This woman’s therapist might work with her to learn a new, more adaptive response to this stimulus, such as training her to apply new relaxation or breathing techniques in response to the sound of a skidding car.

Another example, drawn from the principles of operant conditioning theory (Staddon & Cerutti, 2003), would be a therapist’s invitation to a client to ‘test’ the utility of different behaviors as avenues for attaining reward or pleasure.

For instance, imagine a client who displays resistance to drawing on their support networks due to a false belief that they should handle everything independently. As homework, this client’s therapist might encourage them to ‘test’ what happens when they ask their partner to help them with a small task around the house.

In sum, CBT homework provides opportunities for clients to experiment with stimuli and responses and the utility of different behaviors in their everyday lives.

Social learning and cognitive theories

Scholars have also drawn on social learning and cognitive theories to understand how clients form expectations about the likely difficulty or discomfort involved in completing CBT homework assignments (Kazantzis & L’Abate, 2005).

A client’s expectations can be based on a range of factors, including past experience, modeling by others, present physiological and emotional states, and encouragement expressed by others (Bandura, 1989). This means it’s important for practitioners to design homework activities that clients perceive as having clear advantages by evidencing these benefits of CBT in advance.

For instance, imagine a client whose therapist tells them about another client’s myriad psychological improvements following their completion of a daily thought record . Identifying with this person, who is of similar age and presents similar psychological challenges, the focal client may subsequently exhibit an increased commitment to completing their own daily thought record as a consequence of vicarious modeling.

This is just one example of how social learning and cognitive theories may explain a client’s commitment to completing CBT homework.

Let’s now consider how we might apply these theoretical principles to design homework that is especially motivating for your clients.

In particular, we’ll be highlighting the advantages of using modern digital technologies to deliver engaging CBT homework.

Designing and delivering CBT homework in Quenza

Gone are the days of grainy printouts and crumpled paper tests.

Even before the global pandemic, new technologies have been making designing and assigning homework increasingly simple and intuitive.

In what follows, we will explore the applications of the blended care platform Quenza (pictured here) as a new and emerging way to engage your CBT clients.

Its users have noted the tool is a “game-changer” that allows practitioners to automate and scale their practice while encouraging full-fledged client engagement using the technologies already in their pocket.

To summarize its functions, Quenza serves as an all-in-one platform that allows psychology practitioners to design and administer a range of ‘activities’ relevant to their clients. Besides homework exercises, this can include self-paced psychoeducational work, assessments, and dynamic visual feedback in the form of charts.

Practitioners who sign onto the platform can enjoy the flexibility of either designing their own activities from scratch or drawing from an ever-growing library of preprogrammed activities commonly used by CBT practitioners worldwide.

Any activity drawn from the library is 100% customizable, allowing the practitioner to tailor it to clients’ specific needs and goals. Likewise, practitioners have complete flexibility to decide the sequencing and scheduling of activities by combining them into psychoeducational pathways that span several days, weeks, or even months.

Importantly, reviews of the platform show that users have seen a marked increase in client engagement since digitizing homework delivery using the platform. If we look to our aforementioned drivers of engagement with CBT homework, we might speculate several reasons why.

Implicit awareness that others are completing the same or similar activities using the platform (and have benefitted from doing so) increases clients’ belief in the efficacy of homework.
Practitioners and clients can track responses to sequences of activities and visually evidence progress and improvements using charts and reporting features.
Using their own familiar devices to engage with homework increases clients’ self-belief that they can successfully complete assigned activities.
Therapists can initiate message conversations with clients in the Quenza app to provide encouragement and positive reinforcement as needed.

The rest of this article will explore examples of engaging homework, assignments, and worksheets designed in Quenza that you might assign to your CBT clients.

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Let’s now look at three examples of predesigned homework activities available through Quenza’s Expansion Library.

Urge Surfing

Many of the problems CBT seeks to address involve changing associations between stimulus and response (Bouton, 1988). In this sense, stimuli in the environment can drive us to experience urges that we have learned to automatically act upon, even when doing so may be undesirable.

For example, a client may have developed the tendency to reach for a glass of wine or engage in risky behaviors, hoping to distract themselves from negative emotions following stressful events.

Using the Urge Surfing homework activity, you can help your clients unlearn this tendency to automatically act upon their urges. Instead, they will discover how to recognize their urges as mere physical sensations in their body that they can ‘ride out’ using a six-minute guided meditation, visual diagram, and reflection exercise.

Moving From Cognitive Fusion to Defusion

Central to CBT is the understanding that how we choose to think stands to improve or worsen our present emotional states. When we get entangled with our negative thoughts about a situation, they can seem like the absolute truth and make coping and problem solving more challenging.

The Moving From Cognitive Fusion to Defusion homework activity invites your client to recognize when they experience a negative thought and explore it in a sequence of steps that help them gain psychological distance from the thought.

Finding Silver Linings

Many clients commencing CBT admit feeling confused or regretful about past events or struggle with self-criticism and blame. In these situations, the focus of CBT may be to work with the client to reappraise an event and have them look at themselves through a kinder lens.

The Finding Silver Linings homework activity is designed to help your clients find the bright side of an otherwise grim situation. It does so by helping the user to step into a positive mindset and reflect on things they feel positively about in their life. Consequently, the activity can help your client build newfound optimism and resilience .

As noted, when you’re preparing homework activities in Quenza, you are not limited to those in the platform’s library.

Instead, you can design your own or adapt existing assignments or worksheets to meet your clients’ needs.

You can also be strategic in how you sequence and schedule activities when combining them into psychoeducational pathways.

Next, we’ll look at three examples of how a practitioner might design or adapt assignments and worksheets in Quenza to help keep them engaged and progressing toward their therapy goals.

In doing so, we’ll look at Quenza’s applications for treating three common foci of treatment: anxiety, depression, and obsessions/compulsions.

When clients present with symptoms of generalized anxiety, panic, or other anxiety-related disorders, a range of useful CBT homework assignments can help.

These activities can include the practice of anxiety management techniques , such as deep breathing, muscle relaxation, and mindfulness training. They can also involve regular monitoring of anxiety levels, challenging automatic thoughts about arousal and panic, and modifying beliefs about the control they have over their symptoms (Leahy, 2005).

Practitioners looking to support these clients using homework might start by sending their clients one or two audio meditations via Quenza, such as the Body Scan Meditation or S.O.B.E.R. Stress Interruption Mediation . That way, the client will have tools on hand to help manage their anxiety in stressful situations.

As a focal assignment, the practitioner might also design and assign the client daily reflection exercises to be completed each evening. These can invite the client to reflect on their anxiety levels during the day by responding to a series of rating scales and open-ended response questions. Patterns in these responses can then be graphed, reviewed, and used to facilitate discussion during the client’s next in-person session.

As with anxiety, there is a range of practical CBT homework activities that aid in treating depression.

It should be noted that it is common for clients experiencing symptoms of depression to report concentration and memory deficits as reasons for not completing homework assignments (Garland & Scott, 2005). It is, therefore, essential to keep this in mind when designing engaging assignments.

CBT assignments targeted at the treatment of depressive symptoms typically center around breaking cycles of negative events, thinking, emotions, and behaviors, such as through the practice of reappraisal (Garland & Scott, 2005).

Examples of assignments that facilitate this may include thought diaries , reflections that prompt cognitive reappraisal, and meditations to create distance between the individual and their negative thoughts and emotions.

To this end, a practitioner looking to support their client might design a sequence of activities that invite clients to explore their negative cognitions once per day. This exploration can center on responses to negative feedback, faced challenges, or general low mood.

A good template to base this on is the Personal Coping Mantra worksheet in Quenza’s Expansion Library, which guides clients through the process of replacing automatic negative thoughts with more adaptive coping thoughts.

The practitioner can also schedule automatic push notification reminders to pop up on the client’s device if an activity in the sequence is not completed by a particular time each day. This function of Quenza may be particularly useful for supporting clients with concentration and memory deficits, helping keep them engaged with CBT homework.

Obsessions/compulsions

Homework assignments pertaining to the treatment of obsessive-compulsive disorder typically differ depending on the stage of the therapy.

In the early stages of therapy, practitioners assigning homework will often invite clients to self-monitor their experience of compulsions, rituals, or responses (Franklin, Huppert, & Roth Ledley, 2005).

This serves two purposes. First, the information gathered through self-monitoring, such as by completing a journal entry each time compulsive thoughts arise, will help the practitioner get clearer about the nature of the client’s problem.

Second, self-monitoring allows clients to become more aware of the thoughts that drive their ritualized responses, which is important if rituals have become mostly automatic for the client (Franklin et al., 2005).

Therefore, as a focal assignment, the practitioner might assign a digital worksheet via Quenza that helps the client explore phenomena throughout their day that prompt ritualized responses. The client might then rate the intensity of their arousal in these different situations on a series of Likert scales and enter the specific thoughts that arise following exposure to their fear.

The therapist can then invite the client to complete this worksheet each day for one week by assigning it as part of a pathway of activities. A good starting point for users of Quenza may be to adapt the platform’s pre-designed Stress Diary for this purpose.

At the end of the week, the therapist and client can then reflect on the client’s responses together and begin constructing an exposure hierarchy.

This leads us to the second type of assignment, which involves exposure and response prevention. In this phase, the client will begin exploring strategies to reduce the frequency with which they practice ritualized responses (Franklin et al., 2005).

To this end, practitioners may collaboratively set a goal with their client to take a ‘first step’ toward unlearning the ritualized response. This can then be built into a customized activity in Quenza that invites the client to complete a reflection.

For instance, a client who compulsively hoards may be invited to clear one box of old belongings from their bedroom and resist the temptation to engage in ritualized responses while doing so.

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Developing and administering engaging CBT homework that caters to your client’s specific needs or concerns is becoming so much easier with online apps.

Further, best practice is becoming more accessible to more practitioners thanks to the emergence of new digital technologies.

We hope this article has inspired you to consider how you might leverage the digital tools at your disposal to create better homework that your clients want to engage with.

Likewise, let us know if you’ve found success using any of the activities we’ve explored with your own clients – we’d love to hear from you.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

Bandura, A. (1989). Human agency in social cognitive theory. American Psychologist , 44 (9), 1175–1184.
Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., & Wong, E. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed.) (pp. 227–306). Wiley.
Bouton, M. E. (1988). Context and ambiguity in the extinction of emotional learning: Implications for exposure therapy. Behaviour Research and Therapy , 26 (2), 137–149.
Franklin, M. E., Huppert, J. D., & Roth Ledley, D. (2005). Obsessions and compulsions. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 219–236). Routledge.
Garland, A., & Scott, J. (2005). Depression. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 237–261). Routledge.
Huppert, J. D., Roth Ledley, D., & Foa, E. B. (2006). The use of homework in behavior therapy for anxiety disorders. Journal of Psychotherapy Integration , 16 (2), 128–139.
Kazantzis, N. (2005). Introduction and overview. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 1–6). Routledge.
Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta‐analysis. Clinical Psychology: Science and Practice , 7 (2), 189–202.
Kazantzis, N., & L’Abate, L. (2005). Theoretical foundations. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 9–34). Routledge.
Leahy, R. L. (2005). Panic, agoraphobia, and generalized anxiety. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 193–218). Routledge.
Staddon, J. E., & Cerutti, D. T. (2003). Operant conditioning. Annual Review of Psychology , 54 (1), 115–144.

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CBT Session Structure Outlines: A Therapist’s Guide

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What is a typical CBT session structure? How does having a clear structure help your patient?

Having a regular CBT session structure ensures that the patient and therapist are on the same page and both know what to expect. Each session should follow a clear structure made up of tasks such as identifying problems, setting goals, and assigning homework.

Keep reading to find outlines of exemplary CBT session structures.

CBT Session Structure: Types of Sessions

In Cognitive Behavior Therapy: Basics and Beyond, psychologist Judith Beck outlines ideal CBT session structures.

Each CBT session structure consists of regular activities. Here we’ll go over the CBT session structure for three types of sessions:

The evaluation session, which aims to build a cognitive conceptualization of the patient
The first therapy session, where treatment and problem-solving will begin
Each therapy session afterward, where treatment continues and the patient progresses toward self-sufficiency

The CBT session structures will refer to tasks such as problem-solving, identifying beliefs, and assigning homework.

The Evaluation Session

The goal in the evaluation session is to start building a cognitive conceptualization of the patient. Treatment and problem-solving should NOT be done until the first therapy session.

Prepare by gathering all the notes available, including previous psychiatry work.

Check that the patient has had a recent medical check-up—an organic issue like hypothyroidism may be misdiagnosed as depression.

Invite a family member or friend to attend, but start the meeting alone with the patient and discuss when to bring the other person in on the session.

Set the agenda and convey expectations for the session.

“This is an evaluation session. I’ll ask a lot of questions to determine the diagnosis. A number of questions may not be relevant. Is that OK?”
“I’d like to find out about symptoms you’ve been experiencing and how you’ve been functioning lately. I’ll ask you to tell me anything else you think I should know. Then we’ll set broad goals, I’ll share initial impressions, and what we should focus on in treatment. At the end I’ll see whether you have other questions. Does that sound OK?”
“Is there anything else you want to cover today?”

Conduct the assessment.

Get a full medical and social history.
Ask patients to describe their typical day. Look for variations in mood; how they interact with other people; how they function at home and work; how they spend free time.
Pinpoint difficulties in their daily life to address (for example, difficulty sleeping, social isolation, limited opportunities for mastery, or falling behind in schoolwork).
Ask about positive experiences (“what are the better parts of the day?”)
Ask about coping strategies (“even though you were tired, how did you get yourself to go to class?”)
Structure the questions to get what you need: “For these next questions, I just need a yes or no.”
End with: “Is there anything you’re reluctant to tell me? You don’t have to tell me what it is. I just need to know if there’s more to tell.”

Discuss bringing the guest into the session , and ask if there’s anything the patient wants to guard from the guest.

Ask the guest what is most important for you to know.
If the guest focuses on the negative, ask about the patients’ positive qualities and strengths.

Relate your impressions.

“I’ll need time to review my notes to establish the diagnosis. But my impressions so far are [these].”

Set initial broad goals.

“We’ll set more specific goals, but broadly should we say our goals are: reduce depression, do better at school, get back to socializing?”
“In the future we’ll find problems to solve and engage in problem solving, examine your depressed thinking and the evidence, and come up with solutions.” Elaborate on what this means.
“We’ll plan to meet every X weeks, then with less frequency later. My guess for how many sessions we need is between 8 to 14. We’ll decide together what’s best.”

Elicit feedback from the patient.

How does that sound? Does this sound OK? Do you want to come back next week?

Look for indications the patient is unsure about committing to treatment.

Positively reinforce their expression of skepticism. “It’s perfectly understandable that you think this won’t work. Thanks for sharing that.”
Ask, “what makes you think I can’t help, or that this treatment won’t work?”
“I can’t give you a 100% guarantee. But there’s nothing you’ve told me that makes me think it won’t work.”
If the patient says it hasn’t worked in the past: “ did your last therapist set agendas; write down what to remember; ask for feedback?” and so on, covering your usual procedure. If not, then “ It sounds like our treatment here will be different . If it were exactly the same as your past experiences, I’d be less hopeful.”
If yes, then you will need to find out precisely what occurred in the past and how the treatment failed.

After the session, develop your hypothesis of the cognitive model and treatment plan .

Focus first on fixing immediate short-term problems, then working more on core beliefs in the middle.
You may not be sure yet whether to focus on historic antecedents, or about other dysfunctional beliefs that were not mentioned.

Create goals other than what the patient has articulated.

Investigate dysfunctional beliefs about X.
Identify and respond to automatic thoughts.

Initial Therapy Session

The first therapy session is when you can begin problem-solving and treating the patient.

As always, describe the agenda, ask if that sounds OK, and ask if the patient would like to add anything.

Rationale: “We’ll do this at the beginning of every session so we make sure we have time to cover what’s most important to you.”
Language: “in a few minutes, we’ll discuss your diagnosis and how that affects your thoughts.” This signals that the agenda setting is not yet complete.
Chronic problems (such as arguments with family) can usually be postponed to a future session.

Do a mood check.

“Tell me in a sentence or two how you felt for most of the week?”
Ideally the patient fills out a questionnaire beforehand.
If this is difficult for the patient, simplify the question—”what was your mood, on a scale of 0 to 10?”

Get an update.

Ask if anything significant has happened since the evaluation session.
For a reported problem, ask how upsetting or significant it was, then prioritize according to the severity.

Discuss the patient’s diagnosis.

Use human language: “The evaluation shows that you have a moderate depression. I want you to know that it’s a real illness. It’s not the same as people saying, ‘oh, I’m so depressed.’” Avoid using the label of a personality disorder diagnosis.
Make it real: “I know that because you have the symptoms in this diagnostic manual (DSM). The manual lists the symptoms for each mental health disorder, just like a neurology manual would list the symptoms of a migraine.”
Normalize the situation: “It’s very common for people with depression to feel this way.” “Most depressed people start criticizing themselves for not being the same.” “Sometimes it’s hard to figure out these thoughts.”
Connect the patient’s reactions to the condition : “The thoughts you’ve been having are a result of your depression. There isn’t anything wrong with you.“
Give optimism to avoid a crushing feeling of diagnosis: “Fortunately, cognitive behavior therapy is effective in helping people overcome depression. I’ve seen a lot of patients improve through the course of therapy.”
Analogy: “For everyone with depression, it’s as though they’re seeing themselves and the world through eyeglasses covered with black paint (pantomime this). These make everything look dark and hopeless. What we’ll do in therapy is to scrape off the black paint (pantomime) so you see things more realistically. Is that clear?”

Identify problems and set goals.

“Let’s review the problems you’ve been having.” “It sounds like you have these major problems right now: [list the problems]. Are there any others?”
“Would you like to write them down, or should I?”
Problem: “I don’t feel like I hang out with friends anymore.”
Goal: “Have an active social life.”
Homework: “Call Jessica this week to have lunch.”
Elicit a response instead of dictating: “Would it help if you answered back the thought? What could you remind yourself?”
Patient: “I’d like to be happier.”
Therapist: “If you were happier, what would you be doing?”
Less control: “I’d like my boss to stop pressuring me.”
More control: “Learn new ways of talking to my boss.”
For depressed patients, try to discuss the problem of inactivity. Overcoming passivity and experiencing pleasure and master is essential. (Shortform note: More generally, find the common problem that, if fixed, will yield short-term results. )

Educate the patient on the cognitive model.

“Can we talk about how your thinking affects your mood? Can you think of a time when you noticed your mood change? What were you thinking?”
“So you had the thought “X.” How did those thoughts make you feel emotionally?”
“You just gave a good example of how your thoughts influence your emotion.” (Show a diagram of Situation → Automatic Thoughts → Reaction.)
Make sure the patient can verbalize an understanding of the model. “Can you tell me in your own words about the connection between thoughts and feelings?”
“We’ll start evaluating your thoughts to see if they’re 100% true, 0% true, or somewhere in between. For example, you may find that instead of (this automatic thought), the reality is (an alternative explanation).”
If the patient balks that she has real problems, not just bad thoughts, respond “I do believe you have real problems—I didn’t mean to imply you don’t. We’re going to solve those problems together.”

Start working on a problem with the patient (see next chapter for details). The goal is to discuss a situation in which the patient struggled or felt dysphoric, and to create a solution together.

Set homework.

Write the homework tasks on a paper.
Remind yourself of the disorder and positive thoughts. “If I start thinking I’m lazy and no good, remind myself that I have a real illness, called depression, that makes it harder for me to do things. As my treatment starts to work, my depression will lift, and things will get easier.”
Identify automatic thoughts.
Review the goals list.
Patients in dysphoria overestimate the work it takes. With the patient, estimate the time needed for each item with the patient.
Collaborate to find a way to review the homework regularly at multiple touchpoints per day. An alarm helps.
If the patient balks at a task, suggest making it optional or crossing it off altogether, and ask the patient what she’d like to do.

Summarize at the end of a session.

“Can you tell me what you think is most important for you to remember this week?”

Elicit feedback.

Give two chances for feedback—once live at the end of the session, and after the session in a written Therapy Report.
“What did you think of today’s session?”
“Was there anything about this session that bothered you? Anything I got wrong?”
“Is there anything you’d like us to do differently next session?”
What did we cover today that’s important to you to remember?
How much did you feel you could trust your therapist today?
Was there anything that bothered you about therapy today? If so, what was it?
How much homework had you done for therapy today? How likely are you to do the new homework?
What do you want to make sure to cover at the next session?

Each Session Thereafter

Each session after the initial therapy session is similar in structure, save for these gradual changes:

Over time the problem solving will extend beyond automatic thoughts to underlying beliefs.
As the patient feels better, start work on preventing relapses and anticipating setbacks, as the patient feels better.
Over time the patient will play a more active role in setting the agenda.

Prepare for the session yourself.

What is your conceptualization of the patient’s difficulties?
What progress have we made so far? In mood? Behavioral changes? Deepening of the cognitive level?
How strong is our therapeutic alliance? What do I need to do today to strengthen it?
Have any dysfunctional ideas hindered therapy?

The patient precedes the session by filling out a Preparing for Therapy Worksheet. Questions include:

What did we talk about last session that was important? What do my therapy notes say?
What has my mood been like, compared to other weeks?
What happened (positive and negative) this week that my therapist should know?
What problems do I want help in solving? What is a short name for each of these problems?
What homework did I do? What did I learn? If I didn’t do it, what got in the way?

Check on mood and medication.

“How are you feeling? Were you thinking about the whole week, or just today?”
“Why do you think you’re a little less depressed?”
“Can you see how your thinking and what you did affected how you felt, in a positive way?”
If the patient points to an external source, like medication, say, “I’m sure that helped, but did you also find yourself thinking differently or doing anything different?”
Things that make me feel better
Things that make me feel worse
When asking about medication, ask not a binary question of whether they took medicine, but more, “ how many times this week did you take your medication?”

Set the agenda.

Reduce the patient’s suggested problems to clear, simple names, like “applying for a job.” Interrupt if they get too long.
Ask for when in the past week they felt the worst.
Think about which problem is most important; which is most solvable; and which is most likely to bring about symptom relief.

Get an update on the week.

“Did anything else happen this week?”
For each problem mentioned by the patient, ask if it’s a problem we need to talk about today.
This helps patients realize they didn’t feel distressed the entire week .

Review homework. This is critical for the patient to continue doing homework.

The patient reads aloud the assignment from the previous week.
Rate how much they believe the adaptive statements and beliefs they’ve written down as part of homework.
Ask, “Did you do the assignment? What did you learn from it?”
“Which of these assignments are helpful to continue in the coming week?”
Consider: how much did the patient agree with each statement in the therapy notes from last week?

Prioritize the agenda.

List the named problems. Ask if there’s any other problem that is even more important than those you named.
If this tactic is effective, teach the patient to do this herself.
“If we run out of time, are there things we can put off until next week?”
Alternatively, ask, “what 1 or 2 problems are most important to talk about?”
Avoid any problems the patient can resolve alone or at another session.

Problem-solving.

List the important problems and ask which one to work on first . This gives them active responsibility in their treatment.
Collect data to understand the situation clearly
Investigate other situations the problem arose, and which one the patient felt most upset in.
Evaluate the patient’s automatic thoughts (evidence for and against)
For example, if you were anxious about an upcoming interview and felt unprepared, how would you try to become more prepared or feel less anxious?
Reduce patient distress and create symptom relief in the moment.
Suggest behavioral changes to apply in the future.
Teach the patient new skills and reinforce the cognitive model.
Set new homework.
Assess new patient mood after problem solving.
If the patient is fuzzy on details of the problem, paint a vivid picture of the scenario and ask the patient to imagine it.
If you can’t solve a problem, ask the patient to name a person who could have the same problem, and what advice she would give him.
Ask, “Do I need to do anything to reestablish rapport?”

Summarize often.

Summarize the content of a problem. Use the patients’ words as much as possible , because paraphrasing lessens the intensity of the automatic thought.
Summarize the session at the end. “Do you think that about covers it?”
As the patient makes progress, ask the patient to summarize. “What do you think is most important for you to remember this week?

Obtain feedback from the patient.

“What did you think about the session?”
“Is there anything I got wrong?”
“Is there anything we should talk about next time, or do differently?”

Take notes after the session.

Therapist objectives
Problems discussed
Dysfunctional thoughts and beliefs, written verbatim
Interventions made in session
Newly restructured thoughts and beliefs
Assigned homework
Agenda items for future sessions
Refinements to conceptualization of patient

The above CBT session structures can help you build a regular and clear structure for your future sessions.

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Elizabeth Shaw

Elizabeth graduated from Newcastle University with a degree in English Literature. Growing up, she enjoyed reading fairy tales, Beatrix Potter stories, and The Wind in the Willows. As of today, her all-time favorite book is Wuthering Heights, with Jane Eyre as a close second. Elizabeth has branched out to non-fiction since graduating and particularly enjoys books relating to mindfulness, self-improvement, history, and philosophy.

Why You Seek Validation From Others & How to Stop

What Is Fallibilism? Nothing Can Be Proven True

The Four Agreements Exercises: 21 Discussion Questions

The Things They Carried: Questions for Thoughtful Discussion

What Are the Benefits of Social Prescribing?

The 5 Mental Errors That Cause Inaccurate Predictions

Helping you live the life you want

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The first CBT session

Assessment and formulation of the presenting problems.

Several of my CBT textbooks dedicate up to 40 pages on how to do the CBT assessment. Fair enough – they provide a comprehensive overview of what to do and details of how to do it. But having entered the chapter and explored its furthest reaches, it’s easy to lose sight of the wood for the sheer number and type of trees around!

I have therefore found it helpful to structure the assessment in the first session around the following two themes:

Is CBT with me the right treatment for this client, at this particular point in their life?
Using the assessment process itself to model the CBT model (I guess you could call this meta-modelling!) and to make an individualised formulation of the client’s current problems

I usually start the session with a script that highlights these themes. Of course, you will have your own form of words but I’m offering up mine, in case this is helpful.

'Today, I’m interested in establishing your suitability for this kind of treatment – is CBT right for you at this point in time and if so, and how will it actually help you with your problems? If it isn’t, then we’ll consider what else might be available. That’s what I’d like to get out of this session. Is there anything else specifically that you’d like to get out of our time together today?’

This sets the agenda up nicely for the session. It also models a collaborative spirit to the otherwise largely therapist–directed agenda in this first session. In practice, clients rarely add anything substantially different to the agenda in answer to the last question.

I then begin the assessment by saying:

‘It would be very helpful if you can cast your mind back to a situation in the last seven days in which you felt very distressed. Can you start by describing the situation please? Then we’ll dive into the detail of what was going on for you in the moment when you were at your most distressed in that situation.’

Note that the focus of this session is squarely on the client’s current problems.

I then use a funnel style of questioning to structure my assessment of their presenting problems.

Figure: funnel style of questionning

I write the cross sectional 'hot cross bun' formulation up on the whiteboard during the session. Most clients will see that their own feelings, thoughts and behaviours were linked in the specific situation described. Time usually allows for us to look at a second specific situation in some detail too.

I then generalise back from their own examples to explain how CBT works, using the following script:

‘ CBT is based on the observation that the way that we think and the way that we behave and the way that we feel emotionally and physically, are all closely connected. Furthermore they also work together in a single system, with each component keeping every other component going. And we have shown this on the board using the specific situation you just told me about. Naturally the situation doesn’t occur in a void, it occurs in the context of your environment. This means your current environment, like your job or family or society in general and your past environment, including your developmental experiences.’

Figure: the cross sectional, ‘hot cross bun’ formulation of the client’s problems

‘These double- headed arrows show the inter-relationships between all the components, so that the whole thing works as a system. CBT works like any system - the great thing is that you only have to change one component of it for the impact to be felt across all of it, so that in fact the whole system shifts. So if metaphorically, the arrows linking the boxes were made of elastic bands, and we picked up the box labeled ‘behaviour’ and pulled it to the left, it would increase tension on the other boxes too. All the arrows would stretch a bit and at first, the other boxes would resist and try to pull the behaviour box back. This means that in the early stages of CBT, a person sometimes get an upsurge in the other symptoms initially. But if you stick with holding the behaviour box in its new position over here on the left, and be persistent, quite soon, the whole system shifts over. Metaphorically that’s what I’m helping clients do in CBT – I’m helping them to identify more helpful tweaks to their behaviours and thoughts, so that they start to feel better physically and emotionally. This means that clients are learning lots of new skills and techniques, starting with identifying and monitoring feelings and thoughts, then moving onto to generating more realistic and helpful thoughts and behaviours and putting them into practice between sessions as homework assignments. CBT is a practical therapy in which you will learn new skills to take away with you into real life – does this sound like the kind of treatment you’d be willing to invest your time and energy into currently?’

This approach has been successful for me in selecting out the occasional client who either wants the therapeutic work to be in the act of talking and being listened to (i.e. counselling) or who cannot make a logistical or psychological commitment to regular attendance and practice between sessions.

It’s also important in the first session assessment to find out if the client is at particularly high risk of self-harm or suicidality – if so, discussion with your supervisor may suggest a more urgent intervention is needed, or that the client is less suitable for a trainee caseload.

Finally, I reinforce the CBT model of active skills-acquisition by giving them a Mood Diary to complete for homework. It’s important to talk through the rationale for using it and how to use it in as much detail as necessary. And that’s it.

Summary points

Is CBT right for this patient right now?
Use the assessment process to model and explain the CBT model itself
Use a funnel style of questioning to elicit information about the current problems
Generate a hot-cross bun formulation of the current problems
Assess risk and manage appropriately
Set the first homework, usually a Mood Diary

Reference: Padesky 5 Aspects, 1986, available from https://www.getselfhelp.co.uk/docs/5aspects.pdf

With thanks to Tanya Woolf at Efficacy for introducing me to the elastic band metaphor.

https://www.efficacy.org.uk/therapy/

Dr Anita Goraya

Press and Interviews

Nov 2021 - BBC Radio Five Live interview on CBT and the legacy of its founder, Dr Aaron Beck, who died on 1st November 2021, aged 100.

https://www.bbc.co.uk/sounds/play/m00113kg

The interview starts at minute 4:40

Adrian Chiles - Guardian Article 30 Sep 2020

read the article here...

https://www.theguardian.com/society/2020/sep/30/my-treatment-for-add-changed-my-life-so-why-cant-i-stop-worrying-about-it

Websites for therapists by : YouCan Consulting

Cognitive Behavioural Therapy (CBT) Exercises and Techniques

Life can be challenging sometimes. We’re constantly faced with problems, big and small. As we experience these challenges, it’s normal to become fearful or default to negative thinking. Sometimes patterns of negative thinking are learned in childhood, when we’re first developing our cognitive skills.

Without good problem-solving skills, a strong belief system in ourselves, and tools to keep a clear perspective on what’s happening around us, we can quickly become our own worst critics. Without knowing how to give ourselves a reality check, we might assume the worst of our abilities and let our negative internal dialogue guide our future decision-making.

This can have a real impact on our mental health and weaken our coping skills for future challenges—from handling the ebbs and flows of friend and family relationships, to work stress, to navigating grief.

It’s not that our challenges are not real or bad (sometimes they are!), it’s more that we have greater control of our reactions to them than we might realize.

What is cognitive behavioural therapy (CBT)?

Cognitive behavioural therapy (CBT) is a form of psychotherapy or counselling therapy that centres on our thought patterns and how they affect our attitudes, our emotions and our behaviours.

CBT was first developed over 60 years ago by Dr. Aaron T. Beck at the University of Pennsylvania when he observed his patients seeing him for depression would have consistent streams of negative thoughts that were rather spontaneous. By helping them re-evaluate those thoughts about themselves, the world or their future, they became more resilient to everyday life.

While we might address your personal history working with a therapist (your past might inform why you have certain thought patterns now), CBT is really about the present moment—the here and now. It’s about understanding what’s going on around us, how we’re making sense of those events, and how they make us feel.

According to the Centre for Addiction and Mental Health (CAMH) in Toronto, CBT comes down to the relationship between thoughts and behaviours. They’re intertwined and influence one another. They outline three levels of cognition that are helpful when understanding how our thoughts are formed:

Automatic thoughts: like what Dr. Beck observed, these flow without full awareness, without that check for accuracy or relevance to the present situation
Schemas: Shaped by our childhoods and life experiences, these are pervasive beliefs we’ve decided are true about ourselves, which can be dysfunctional
Conscious thoughts: these are rational and made with the ability to see a situation clearly

CAMH and the American Psychological Association (APA) outline a few ways CBT helps to reduce emotional distress with strategies to change thinking and behaviours, such as:

Identifying if certain thoughts or thinking patterns are distorted
Understanding that our thoughts are just our ideas, not facts
Taking a step back to see our situation from different viewpoints
Gaining a greater understanding of the behaviour and motivations of others
Facing fears, or using role playing to learn how to anticipate and prepare for potentially problematic interactions
Building confidence in our actual abilities
Learning to calm our minds and bodies

Examples of thought distortions

“My friend didn’t text me back. She hates me!”

“My boss gave me a lot of feedback on my work. I’m terrible at this job.”

“Bad things always happen to me.”

It’s very human and normal to have negative thoughts—we’re ultimately trying to protect ourselves from dangerous situations or to cope with stress. If we expect the worst, we’ll be prepared for it. The problem is, it doesn’t always help us live a full and happy life.

Distorted thinking becomes a problem when it’s habitual—our default—and it shapes how we operate in our lives and how we feel about ourselves. Eventually, it can increase anxiety, symptoms of depression, or negatively impact our relationships.

Some themes of cognitive distortions include:

Catastophizing: We consistently think that the very worst scenario is the only possible reality. It can come from experiencing real negative situations—we start to be fearful. If you’ve lived in financial strain before and you have a small work hiccup today, it might lead to thinking you’ll lose your job and won’t be able to pay rent. With some guidance, you can work through the facts of the current situation, how you handled something similar before, and how you can handle it now.
Fortune-telling: Similar to catastrophizing, we predict a negative future without considering the likelihood of that outcome. Usually, these beliefs about the future lean negative. If we think that’s set in stone, we’ll make decisions based on that assumed outcome. This can actually create a self-fulfilling prophecy—we take steps that make the negative assumption true, instead of steps to make a positive assumption true.
Mind reading: As we gain experiences in life, we tend to take mental shortcuts to simplify and understand a situation that is similar to one we went through before. Sometimes, this can distort our thinking. Mind reading happens when we assume we know what others are thinking and feeling without any real information to back it up. This can cause anxiety and stress, particularly deepening social anxieties.
Labelling: Negative experiences do happen, but one stumble doesn’t define us. Labelling occurs when we generalize one characteristic or one event to define a whole person—including ourselves. If you fail one test, you’re not “a failure.” We might then unfairly misunderstand or underestimate ourselves or others.
“Should”ing: Making a lot of “should” statements might be a clue that we’re engaging in unfairly negative views about your life. This could arise from deep cultural, family, or work expectations (that may be toxic) that chip away at our sense of self worth with our real accomplishments, our real goals, and increase anxiety.

How does CBT work?

CBT is usually time based and takes place over a set number of sessions, with “homework” exercises in between. Over the course of these sessions and exercises, you’ll learn to identify problems clearly, examine your automatic thought patterns and challenge underlying assumptions about yourself that motivate those thoughts, become more aware of your emotions in different situations, establish some goals, and focus more on how things are instead of how they should be —which is a much more manageable reality to live in.

Here are three commonly used exercises and techniques for CBT:

Challenging cognitive distortions: Distorted thinking develops over time as a reaction to life’s challenges. We start to form thinking habits that are inaccurate and negatively biased. Once you start to learn and identify these distortions, you can start to challenge them. Over time, they become less automatic.
Journaling : Related to cognitive distortions, journaling is a common exercise used in CBT to help track thought patterns. You’ll keep a record of negative thoughts, when and why they occurred, and eventually you’ll include jotting down new thoughts to challenge old ones.
Activity scheduling: Putting off activities we enjoy is a common outcome of anxiety or depression. Part of CBT may include putting a new event in your calendar and sticking to it. This also helps break negative cycles, helps establish new habits and provides a positive sense of accomplishment.

According to the American Psychological Association , there is an emphasis on helping people “become their own therapists” with CBT. With new tools in your toolbox, you can continue to challenge your own thought patterns on your own and control your own behaviour to maintain more balanced emotions.

You’ll likely come across CBT on many of First Session’s partner therapist profiles under their modalities. It’s so commonly used by counsellors, in part, because it’s one of the most well-researched techniques out there—meaning there is a lot of scientific evidence that proves it’s effective , with good funding behind it, and therefore a lot of training available to help counsellors offer CBT.

There is even evidence that CBT can help with physical ailments like back pain !

While CBT is very common and is proven to help relieve symptoms associated with anxiety and depression, it’s not always the right choice for everyone. If you need help working through trauma or more support working on past issues, this might not be for you (or, not the only thing for you).

There are other models like dialectical behavioural therapy (DBT) , mindfulness therapy, or body-focused therapy (somatic therapies) that can be effective for working through mental health issues as well.

Book an appointment or free therapy consultation today with Canadian therapists and counsellors who specialize in CBT .

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Nicole Laoutaris

Nicole Laoutaris is a freelance writer and adult learning professional based in the Greater Toronto Area. She specializes in educational content for brands and companies in industries such as mental health, pet health, lifestyle and wellness, cannabis, and personal finance. Nicole holds a double undergraduate degree in Communications and Film studies from Wilfrid Laurier University, and post-graduate certificate in Corporate Communications from Seneca College. She currently lives in Hamilton Ontario with her spouse and her cat.

Discover More About therapy techniques (modalities)

Learning about mindfulness in therapy, exercises and techniques, somatic therapy exercises and techniques, dialectical behaviour therapy (dbt) exercises and techniques.

The CBT Working Alliance

The therapeutic relationship in CBT is often referred to as the ‘CBT working alliance’; this term in itself reflects the fact that it is different in this modality from others.

The word ‘working’ shows the action-oriented nature of CBT work, with the client as well as the therapist having to put in active work.

The word ‘alliance’ recognises that this is a collaborative effort between client and therapist, in which they are working together – as allies – to help the client affect the changes they wish to make.

CBT Working Alliance - icon showing two persons and arrows pointing from each person to the other

Three Key Strands

In a 1979 paper published in Psychotherapy: Theory, Research & Practice (252–260), Edward Bordin asserted that the working alliance has three key strands:

agreement on goals
assignment of tasks
development of bonds

This reflects the fact that as well as the quality of the relationship (i.e. development of bonds), both goal-setting (often using SMART methodology) and assigning tasks (in the form of exercises during the session and also as homework) are similarly important.

Implicit versus Explicit Strands

In the therapeutic relationship, some aspects may be implicit, while others are explicit.

Explicit aspects are those that are clearly out in the open through being expressed; they may even be directly discussed in contracting.

For example, explicit aspects may include specific statements by the therapist during the initial session that clients cannot receive therapy if under the influence of drugs or alcohol (e.g. in an addiction charity, in order to ensure psychological contact) – and that the client will be expected to be actively involved in the therapy, to undertake homework and to accept personality responsibility for change.

In order to detect implicit aspects of the therapeutic relationship, the therapist must be sensitive to how the client relates to them and the joint work, for example picking up on subtle signs of unduly positive or negative reactions.

These warning signs could indicate the presence of transference/countertransference and/or parallel process.

Transference involves the client unconsciously transferring feelings and attitudes relating to a person from their past onto the therapist in the present, e.g. if the therapist reminds them of, say, a teacher or parent.

Countertransference describes the response to this in the therapist, or when the therapist unconsciously sees a figure from their own past in the client.

Parallel process, meanwhile, occurs when the therapist sees themselves and their own experiences mirrored in the client’s process.

Transference and Countertransference

Transference/countertransference and parallel process should ideally be quickly picked up on by the therapist, helped by their self-awareness and personal-development work during counselling training.

However, these are not always immediately obvious to the therapist (though they may be aware of some emotions and/or thoughts that feel somehow out of place in the counselling room).

This is a key purpose of clinical supervision, where a specially trained and experienced third-party practitioner can help the therapist explore what is going on and identify any such problems.

CBT Working Alliance - Transference and Countertransference

These can then be addressed ether by undertaking personal-development work (e.g. through journaling or other reflection) or (if appropriate – i.e. of likely value to the client) bringing this into the counselling room using immediacy and congruence, in order to deepen the therapeutic relationship and help the client’s process.

As Simmons & Griffiths (2014: 46) note, ‘the relationship history of both therapist and client also has an effect on the therapeutic relationship’.

Relational Factors

In modern times, Mick Cooper has investigated the extent to which four categories of factors – client factors, therapist factors, relational factors, and technique and practice factors – relate to the effectiveness of therapy outcomes.

In his book Essential Research Findings in Counselling and Psychotherapy: The Facts Are Friendly (Sage, 2008), Cooper describes the relational factors that have been demonstrated in research, drawing on the work of several key researchers including Ahn & Wampold (whose meta-analysis ‘Where oh where are the specific ingredients?’ was published in 2001), and Asay & Lambert (authors of ‘The empirical case for the common factors in therapy: quantitative findings’ in 1999).

Cooper concludes that ‘demonstrably effective’ elements of the relationship are goal consensus and collaboration (in line with Bordin’s elements of goals and tasks), therapeutic alliance and empathy (the last two relating to Bordin’s bonds).

He adds that ‘promising and probably effective’ elements are the management of countertransference, feedback, positive regard, congruence, appropriate self-disclosure, relational interpretations, and repair of alliance ruptures.

Because of the complexities of human-to-human relationships and the diversity among people, ruptures can occur in the working alliance. These inevitably have an adverse effect on the therapy itself.

Ruptures may be triggered by therapist factors – e.g. if they are intrusive, defensive or negative, self-disclose inappropriately (i.e. in a way that is not purely in the client’s service) or challenge/push the client too much before relational depth has been established.

Ruptures may also be due to client factors , such as resistance, hostility, challenge, withdrawal and misunderstanding of in relation to certain topics.

Cultural differences can also make it more difficult to build a good working alliance between the two parties. With the right skills, the therapist can address these issues, allowing therapy to progress effectively.

Measuring the Working Alliance

In CBT, there are two important questionnaires that measure the integrity of the working alliance.

First, certain questions in Safran and Segal’s Suitability for Short-Term Cognitive Therapy Rating Scale relate directly to the therapeutic alliance (e.g. questions 5 and 6, on the client’s alliance potential – i.e. ability to form effective relationships – within and outside sessions).

Some of the other questions are indirectly related to – and can be influenced by – the working alliance too, since a strong alliance (and thus client–counsellor communication) will, for example, improve the chance of good motivation and of effective socialisation to the CBT model.

This questionnaire can be used by the therapist after the initial session to rate the client’s suitability for CBT.

Second, the Working Alliance Inventory (Short Revised) was developed by Adam Horvath to measure agreement on goals, assignment of tasks, and the development of bonds, in line with Bordin’s (1979) work, with four items in the scale relating to each of these three key strands.

Applying Theory to Practice

Ways in which it is possible to practically encourage the development of a strong working alliance, promoting collaboration and acceptance of personal responsibility, include:

during contracting, inviting clients to ask any questions
gaining explicit agreement to the contract by asking the client to sign this
providing clients with their own copies of all paperwork
setting homework tasks for the client from the first session together (e.g. an initial task of spotting and correcting irrational thinking in fictional scenarios, as practice in applying the CBT model)
encouraging clients to take their own notes during sessions (so long as they are comfortable with writing)
asking clients to complete the Working Alliance Inventory (perhaps as homework) after a few sessions
eliciting feedback from clients at the end of each session.

Free Handout Download

Ahn H & Wampold B (2001) ‘Where oh where are the specific ingredients? A meta-analysis of component studies in counseling and psychotherapy’, Journal of Counseling Psychology, 48 (3), 251–257

Asay T & Lambert M (1999) ‘The empirical case for the common factors in therapy: Quantitative findings’, In Hubble M, Duncan B & Miller S (Eds.) The heart and soul of change: What works in therapy, 23–55), American Psychological Associatio

Bordin E (1979) ‘The generalizability of the psychoanalytic concept of the working alliance’, Psychotherapy: Theory, Research and Practice , 16, 252–260.

Cooper M (2008) Essential Research Findings in Counselling & Psychotherapy: The Facts Are Friendly , Sage

Simmons J and Griffiths R (2014) CBT for Beginners , Sage

Finding a Therapist Who Can Help You Heal

Therapy for anxiety disorders.

Cognitive Distortions: Put an End to Distorted Thinking

The Psych Ward: What is a Psychiatric Hospital Really Like?

What to expect when calling a helpline, emdr therapy for trauma, ptsd, anxiety, and panic, support groups: types, benefits, and what to expect.

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What is cognitive behavioral therapy (CBT)?

How cbt works, benefits of cbt, types of cbt, what to expect from cbt, how to know if cbt is working, getting the most from cbt, cognitive behavioral therapy (cbt): what it is, how it helps.

Treatment for anxiety, depression, PTSD, substance abuse, eating disorders, and other mental health issues often involves breaking free of negative thought patterns. Here’s how CBT or “talk psychotherapy” can help.

Reviewed by Jenna Nielsen, MSW, LCSW , a clinical social worker/therapist at ADHD Advisor, with specializations in anxiety, depression, ADHD, PTSD, and relationships

Are you worried and anxious much of the time? Do you feel overwhelmed, hopeless, or unable to control intrusive thoughts? Cognitive behavioral therapy (CBT) or “talk therapy” examines how your thoughts, emotions, and behavior are connected. The main principle of CBT is to increase awareness of your negative thinking so you can respond to challenges in a more effective way.

CBT is conducted through a series of structured sessions in collaboration with a mental health professional. The goal is to provide tools that can be applied to manage unhealthy thinking and behavioral patterns in order to reduce distress.

Cognitive behavioral therapy can be useful for treating many different issues, including depression, anxiety, PTSD, substance abuse, and eating disorders. It can also help with emotional trauma, dealing with grief and loss, managing physical symptoms of a chronic illness, or coping with the stressful circumstances of daily life. CBT alone may be recommended if medication isn’t the best option, or it may be used in combination with other treatments and lifestyle changes.

Taking the first step towards change is often the hardest part. If you’re hesitant about trying CBT, keep in mind that it is a short-term technique which involves minimal risk or side effects. CBT can be delivered in person, either individually or in a group setting with family members or other people with similar concerns. Online therapy sessions have become increasingly popular, particularly during the pandemic, and can be a great option if you don’t have access to local mental health resources or feel more comfortable talking from home.

As the name implies, cognitive behavioral therapy is formulated on two different components: thoughts (cognition) and behaviors.

The cognitive aspect of CBT

The cognitive aspect is applied to what we think about and how this is processed. This is composed of core beliefs, dysfunctional assumptions, and negative automatic thoughts.

Negative core beliefs are learned early in life, primarily based on childhood experiences. For example, you may have formed negative views about yourself, the world around you, or how you see the future. You may also have negative core beliefs about other people, assuming they can’t be trusted or always have ulterior motives.

Dysfunctional of false assumptions about yourself could include the belief that you’re somehow inadequate or “My worth is connected with what others think of me.”

One of the primary cognitive components of CBT is to increase awareness of these types of views and how your thinking is based on long standing, negative assumptions. To accomplish this, your therapist may suggest:

Keeping thought records to help you recognize negative thinking patterns that may not actually be true. For example, you may think “Nobody cares about me,” or “If I don’t do well, it means I’m a failure.” As you become more aware of these negative thoughts, you can learn to reframe or replace them with more positive views, such as “Nobody is perfect. We all make mistakes, but that doesn’t mean I’m a failure.” Reframing your thoughts can also help you learn to view problems as challenges, rather than dwelling on them and feeling overwhelmed.

[Read: How to Stop Worrying]

Role-playing . Your therapist may take on the role of another person in order to re-enact an anxiety-provoking situation. For example, if you’re fearful about going to the doctor for a check-up, the therapist will assume the role of the doctor and act out the scenario with you. Over time, this can help you build your confidence and find the best way to handle this type of situation in the future. The next time you see your doctor, you’ll have a less stressful experience because you’ve already worked out the issues that were making you feel worried or afraid.

The behavioral aspect of CBT

The behavioral component of CBT is most often used for anxiety-related disorders. This usually involves:

Activity scheduling . Planning each day in advance can make it seem more manageable, improve your decision-making, and reduce worry. Activity scheduling also helps you look forward to activities you enjoy to boost your mood and outlook—whether it’s taking a leisurely walk, getting involved in a community group, going out with friends, or visiting a museum.

Graded task assignments are manageable steps to decrease apathy and procrastination and overcome anxiety-provoking situations. If you’re depressed or anxious, for example, but want to plan an outing with a friend to go to a movie, the first step might be deciding which friend to go with. The next steps could involve calling your friend and choosing which movie to see. The final step would be following through and actually going to the movie theatre with your friend.

Testing out anxiety-producing predictions . These types of tasks are introduced gradually so that you learn to tolerate anxiety over time. For example, if you’re fearful about leaving the house, you may be asked to walk down the street and see if something bad actually happens. This technique can also help address avoidance behaviors that prevent you from facing your fears .

Learning relaxation and breathing techniques can be extremely useful for minimizing anxiety or alleviating a panic attack. Deep breathing exercises and mindfulness meditation are effective ways to relieve stress, focus on the present moment, and disconnect yourself from obsessive or negative thoughts. Your therapist may recommend listening to a guided meditation or practicing relaxation techniques whenever you’re feeling anxious.

CBT has been referred to as the “gold standard” of treatment because it is considered to be a highly effective approach for numerous problems. Research studies have shown that CBT can greatly improve quality of life and overall functioning.

With CBT, you can achieve more self-awareness and take control of negative self-talk. At the completion of your CBT treatment, you should be able to reframe negative thinking patterns and change your behavior. Since you will no longer be stuck in an unproductive mindset, you will feel less anxious and depressed. This will enable you to find more enjoyment in your daily life and feel motivated to make healthier lifestyle choices such as exercising regularly , eating more nutritious foods , and making sleep a priority .

Along with improving coping skills, CBT can also be effective for building self-esteem and self-confidence. The problem-solving abilities you’ll gain can be applied to all areas of your life. This also facilitates better decision-making and less procrastination when faced with challenges. CBT can also teach you how to communicate more effectively and manage your emotions to improve your relationships.

While the benefits are numerous, CBT is not suitable for everyone, so it’s important to consider both the pros and cons of talk therapy.

Advantages of CBT

CBT can be tailored to the individual in order to target specific goals or problems.
It can provide everyday skills and coping strategies that are easy to use.
It offers support and accountability as you work in conjunction with a therapist or other mental health professional.
Can be just as effective as medication in treating many mental health issues in the long-term.
The treatment can be completed in a relatively short period of time, as compared to other types of therapy.
Various tools can be incorporated to enhance the process, such as books, videos, apps, and computerized programs.

Disadvantages

As with any type of therapy, finding the right therapist that you trust and feel comfortable with may take some work.
CBT may bring up issues that make you feel uncomfortable. This may initially create additional anxiety or worsen existing behavioral problems.
The focus of CBT is on addressing the issues you are currently facing, not causes or symptoms stemming from the past.

There are various types of CBT that may be recommended by your therapist, depending on the specific issues you are dealing with. The goals remain the same for all types—to modify your negative ways of thinking and develop more effective coping skills.

Some of the main types of CBT include:

Dialectical behavior therapy (DBT) was developed mainly to treat people with borderline personality disorder (BPD) , but is now used for a variety of mental health issues, including ADHD, eating disorders , substance abuse, and PTSD . DBT is similar to CBT, but is more focused on coming to terms with uncomfortable feelings, emotions, and behaviors. This can improve coping skills and problem-solving abilities to cultivate more resilience .

Mindfulness-based cognitive therapy (MBCT) combines CBT with meditation to treat anxiety, depression, and bipolar disorder . You may be familiar with mindfulness techniques for stress reduction or as part of a yoga practice. The goal of MBCT is to help you become less-judgmental and concentrate more on a present-moment mindset.

Acceptance and commitment therapy (ACT) utilizes strategies related to acceptance and mindfulness to increase the ability to concentrate on a present-oriented state of being. With ACT, you will be working towards behavior change by dealing with thoughts, feelings, and memories that you have been avoiding.

Rational emotive behavior therapy (REBT) was the foundation for CBT and is based on how our thoughts influence our behavior. The three principles are activating events, beliefs, and consequences. We often have irrational thoughts and beliefs that shape our behavior on a daily basis, even though we may not be consciously aware of these thoughts. This therapy promotes the development of more rational thinking to foster healthier behaviors and responses to situations.

Exposure therapy is a type of CBT used for obsessive-compulsive disorder (OCD) , post-traumatic stress disorder (PTSD), and various phobias and irrational fears . The triggers for your anxiety are identified and specific techniques are applied to reduce these sensations. One method of exposure therapy targets these triggers all at once time (flooding). The other strategy is a more gradual process of dealing with different triggers over a period of time (desensitization).

[Read: Therapy for Anxiety Disorders]

Interpersonal therapy (IPT) is most often used to treat depression , but is also effective for other mental health conditions. In these sessions, a therapist will help you examine your relationships with other people and work on developing better social skills to improve interactions with others.

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During CBT sessions with a therapist, you will work together to identify problems and find workable solutions to manage these problems. The goals you will focus on the ‘SMART’ model: Specific, Measurable, Achievable, Realistic, and Time-limited.

Your therapist will help you prioritize these goals and set up incremental steps to achieve them. If you’re feeling depressed, for instance, you may have a hard time setting goals or believing that you can attain them. Having the support of a mental health professional can enable you to develop more realistic goals and maintain your motivation throughout the course of treatment.

You may also be given “homework” assignments to guide you during therapy, such as journaling to record your disturbing thoughts or practicing breathing exercises when you’re feeling anxious. All of these components will be important steps in the healing process.

Your first CBT sessions

CBT is a time-limited treatment that is usually completed in 5-20 sessions. You will generally meet with a therapist once-a-week or once every two weeks. Each session lasts about 30-60 minutes.

The first session is primarily an assessment of your current situation. The therapist will ask questions about the challenges you’re facing and how any feelings of anxiety or depression are interfering with your family life, work, or personal relationships. They may also go over a treatment plan that will benefit you.

This is also a time to begin evaluating whether there is a good rapport between you and the therapist.

[Read: Finding a Therapist Who Can Help You Heal]

During your early sessions, the therapist will outline the expectations related to the course of treatment. You will work as a team with the therapist to break down problems into more manageable parts.

Your thoughts, feelings, and behaviors will be addressed through various tasks and exercises. While the aim will be to change specific thoughts and behaviors that are not serving you well in your life, rest assured that you will not be expected to do anything you don’t feel comfortable with.

In subsequent sessions, you will focus on applying these desired modifications to your daily life. By practicing coping techniques and other helpful skills, you will be better able to function independently once the CBT sessions have been completed. This will increase the likelihood that your anxiety, depression, and other symptoms will not resurface.

During the course of treatment, you will be able to assess whether CBT is having a positive impact. Here are a few indications:

You are developing new skills that are modifying negative thinking and behaviors in your life.
You are making headway towards achieving long-term goals by breaking them down into smaller steps.
Your therapist is able to measure results and provide evidence of your progress with specific tests and exercises.
You are feeling more optimistic and connected to friends and family members.
Others have observed and commented on the progress you’re making and are supportive of your efforts.
You look forward to your CBT sessions and feel motivated to continue with the work.

Your mental health provider should give you an estimated time frame for when you will begin to see results. Some conditions will improve after only about 12 sessions, but others may take a few months.

If you are uncertain about whether the treatment is working, be sure to share your concerns with your therapist. There’s no shame in asking for additional help. Your therapist may recommend combining CBT with medication or trying another type of talk therapy or counseling. The most important thing is to make sure you’re receiving the help you need.

CBT is a commitment that takes work on your part for a successful outcome. You will be entering into a partnership with a therapist, and how you incorporate their guidance to your advantage is up to you. Whether you opt for in-person or online therapy , you will reap the most benefit if you:

Follow through with all the sessions as outlined by your therapist and complete any homework, graded task assignments, or activity scheduling exercises.

Openly share your feelings with your therapist . This includes letting your therapist know if you feel the therapy is not working or is not the right fit for you. You should feel comfortable and have a good rapport with your therapist in order to move forward. There are many therapists to choose from and various types of therapies that can be tailored to your individual needs.

Are ready and willing to change . CBT can be highly effective if you are willing to devote the necessary time and effort it takes to apply these skills to your daily life.

One of the most significant outcomes of CBT is understanding that you have the ability to make changes in your life. CBT can help you realize that other people and outside situations are not responsible for your problems—but rather, it’s often your own thoughts and reactions that create these negative perspectives.

When you change your thoughts, you also change the way you feel and behave. By eliminating “black and white” (all-or-nothing) thinking, you can expand your horizons and embrace a more holistic view of the world. These changes can support the effort you put forth in therapy and offer greater fulfillment in your life.

More Information

How it works – Cognitive behavioural therapy (CBT) - Guide to CBT. (NHS)
Evaluating Outcomes: 5 Signs Cognitive Therapy Is Working for Someone with Schizophrenia or Other Mental Illness - Tips on assessing how well therapy is working for you. (RtoR.org)
Fenn, Kristina, and Majella Byrne. “The Key Principles of Cognitive Behavioural Therapy.” InnovAiT 6, no. 9 (September 1, 2013): 579–85. Link
David, Daniel, Ioana Cristea, and Stefan G. Hofmann. “Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy.” Frontiers in Psychiatry 9 (January 29, 2018): 4. Link
https://www.apa.org. “What Is Cognitive Behavioral Therapy?” Accessed April 11, 2022. Link
“Psychotherapy | NAMI: National Alliance on Mental Illness.” Accessed April 11, 2022. Link
Twohig, Michael P., Michelle R. Woidneck, and Jesse M. Crosby. “Newer Generations of CBT for Anxiety Disorders.” In CBT for Anxiety Disorders: A Practitioner Book , 225–50. Wiley Blackwell, 2013. Link
Turner, Martin J. “Rational Emotive Behavior Therapy (REBT), Irrational and Rational Beliefs, and the Mental Health of Athletes.” Frontiers in Psychology 7 (September 20, 2016): 1423. Link
“Overview of IPT | International Society of Interpersonal Psychotherapy – ISIPT.” Accessed April 11, 2022. Link
“ACT | Association for Contextual Behavioral Science.” Accessed April 11, 2022. Link
Lopez, Molly A., and Monica A. Basco. “Effectiveness of Cognitive Behavioral Therapy in Public Mental Health: Comparison to Treatment as Usual for Treatment -Resistant Depression.” Administration and Policy in Mental Health 42, no. 1 (January 2015): 87–98. Link
Hofmann, Stefan G., Anu Asnaani, Imke J.J. Vonk, Alice T. Sawyer, and Angela Fang. “The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-Analyses.” Cognitive Therapy and Research 36, no. 5 (October 1, 2012): 427–40. Link

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How Much Does Homework Matter in Therapy?

What research reveals about the work you do outside of therapy sessions..

Posted April 16, 2017 | Reviewed by Ekua Hagan

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Homework is an important component of cognitive behavior therapy (CBT) and other evidence-based treatments for psychological symptoms. Developed collaboratively during therapy sessions, homework assignments may be used by clients to rehearse new skills, practice coping strategies, and restructure destructive beliefs.

Although some clients believe that the effectiveness of psychotherapy depends on the quality of in-session work, consistent homework during the rest of the week may be even more important. Without homework, the insights, plans, and good intentions that emerge during a therapy session are at risk of being buried by patterns of negative thinking and behavior that have been strengthened through years of inadvertent rehearsal. Is an hour (or less) of therapeutic work enough to create change during the other 167 hours in a week?

Research on homework in therapy

Research on homework in therapy has revealed some meaningful results that can be understood collectively through a procedure called meta-analysis. A meta-analysis is a statistical summary of a body of research. It can be used to identify the average impact of psychotherapy homework on treatment outcomes across numerous studies. The results of four meta-analyses listed below highlight the value of homework in therapy:

Kazantzis and colleagues (2010) examined 14 controlled studies that directly compared treatment outcomes for clients assigned to psychotherapy with or without homework. The data favored the homework conditions, with the average client in the homework group reporting better outcomes than about 70% of those in the no-homework conditions.
Results from 16 studies (Kazantzis et al., 2000) and an updated analysis of 23 studies (Mausbach et al., 2010) found that, among those who received homework assignments during therapy, greater compliance led to better treatment outcomes. The effect sizes were small to medium, depending on the method used to measure compliance.
Kazantzis et al. (2016) examined the relations of both quantity (15 studies) and quality (3 studies) of homework to treatment outcome. The effect sizes were medium to large, and these effects remained relatively stable when follow-up data were collected 1-12 months later.

Taken together, the research suggests that the addition of homework to psychotherapy enhances its effectiveness and that clients who consistently complete homework assignments tend to have better mental health outcomes. Finally, although there is less research on this issue, the quality of homework may matter as much as the amount of homework completed.

To enhance the quality of homework, homework assignments should relate directly to a specific goal, the process should be explained with clarity by the therapist, its method should be rehearsed in session, and opportunities for thoughtful out-of-session practice should be scheduled with ideas about how to eliminate obstacles to completion.

To find a therapist, please visit the Psychology Today Therapy Directory .

Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in Cognitive and Behavioral Therapy: A meta‐analysis. Clinical Psychology: Science and Practice, 7(2), 189-202.

Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta‐analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17(2), 144-156.

Kazantzis, N., Whittington, C., Zelencich, L., Kyrios, M., Norton, P. J., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: a meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47(5), 755-772.

Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research, 34(5), 429-438.

Joel Minden, Ph.D., is a clinical psychologist, author of Show Your Anxiety Who’s Boss , director of the Chico Center for Cognitive Behavior Therapy, and lecturer in the Department of Psychology at California State University, Chico.

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What to Expect in Your First CBT Session
Types of Homework in CBT
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CBT and 6 Stages of Homework
CBT session structure
Self Practice Record Form (CBT Homework Worksheet)

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PART 2: Everything You Need to Know About a CBT Therapy Session
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COMMENTS

How to Design Homework in CBT That Will Engage Your Clients
Practitioners looking to support these clients using homework might start by sending their clients one or two audio meditations via Quenza, such as the Body Scan Meditation or S.O.B.E.R. Stress Interruption Mediation. That way, the client will have tools on hand to help manage their anxiety in stressful situations.
CBT Session Structure and Use of Homework
A common feature of CBT is that the therapist sets the client 'homework', which is then reviewed in the next session; this aims to help clients generalise and apply their learning. Homework in CBT refers essentially to tasks set to be completed by the client between sessions. For some clients, 'homework' is a word that triggers ...
CBT Session Structure Outlines: A Therapist's Guide
Here we'll go over the CBT session structure for three types of sessions: The evaluation session, which aims to build a cognitive conceptualization of the patient. The first therapy session, where treatment and problem-solving will begin. Each therapy session afterward, where treatment continues and the patient progresses toward self-sufficiency.
The First CBT session
Use the assessment process to model and explain the CBT model itself. Use a funnel style of questioning to elicit information about the current problems. Generate a hot-cross bun formulation of the current problems. Assess risk and manage appropriately. Set the first homework, usually a Mood Diary.
Assigning Homework in Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is known to be a highly effective approach to mental health treatment. One factor underlying its success is the homework component of treatment. It's certainly ...
CBT WORKSHEET PACKET
Beck Institute for Cognitive Behavior Therapy • One Belmont Ave, Suite 700 • Bala Cynwyd, PA 19004 • beckinstitute.org 6 The Strength-Based Cognitive Conceptualization Diagram (SB-CCD) helps organize clients' patterns of
Homework in CBT
Explore as a team, in a non-judgmental way, to explore why the homework was not done. Here are some ways to increase adherence to homework: Tailor the assignments to the individual. Provide a rationale for how and why the assignment might help. Determine the homework collaboratively. Try to start the homework during the session.
The New "Homework" in Cognitive Behavior Therapy
A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits?. Behaviour Research and Therapy, 72, 56-62. Kazantzis, N., & L'Abate, L. (2006). Handbook of homework assignments in psychotherapy: Research, practice, and prevention. New York, NY: Springer.
Cognitive Behavioural Therapy (CBT) Exercises and Techniques
How does CBT work? CBT is usually time based and takes place over a set number of sessions, with "homework" exercises in between. Over the course of these sessions and exercises, you'll learn to identify problems clearly, examine your automatic thought patterns and challenge underlying assumptions about yourself that motivate those thoughts, become more aware of your emotions in ...
CBT Practice Exercises
This CBT worksheet will help you teach your clients about the relationship between thoughts, emotions, and behaviors through the use of several examples and practice exercises. Discuss the examples, complete the practice exercises, and then help your client generate experiences from their own life that they can fit into the model.
CBT Worksheets
The Cognitive Triangle. worksheet. The cognitive triangle illustrates how thoughts, emotions, and behaviors affect one another. This idea forms the basis of cognitive behavior therapy (CBT). Perhaps most important to CBT, when a person changes their thoughts, they will also change their emotions and behaviors.
The CBT Working Alliance • Counselling Tutor
setting homework tasks for the client from the first session together (e.g. an initial task of spotting and correcting irrational thinking in fictional scenarios, as practice in applying the CBT model) encouraging clients to take their own notes during sessions (so long as they are comfortable with writing)
A Session-to-Session Examination of Homework Engagement in Cognitive
Cognitive Therapy (CT) has been established as an efficacious treatment for depression (DeRubeis, Webb, Tang, & Beck, 2010).The use of homework is an integral component of CT, with homework assignments serving as a critical way of encouraging patients to practice integrating the skills they learn in therapy into their everyday lives (Beck, Rush, Shaw, & Emery, 1979; Kazantzis & Lampropoulos ...
Demystifying Therapy: What Should I Expect for my first CBT Session
As you prepare for your first CBT session, it's natural to have questions and feel a mix of anticipation and uncertainty. This comprehensive guide is designed to demystify the process, providing you with a clear understanding of what to expect and how these sessions can pave the way for meaningful change.
What is the Status of "Homework" in Cognitive Behavior Therapy, 50
Fortunately, the research underpinning CBT homework is moving towards more clinically meaningful studies. Therapist skill in using homework has been shown to predict outcomes 9-10, and recently a study found that greater consistency of homework with the therapy session resulted in more adherence. 11 Our Cognitive Behavior Therapy Research Lab (currently based at the Turner Institute for Brain ...
CBT: Cognitive Behavioral Therapy: What it is, How it Helps
Your first CBT sessions. CBT is a time-limited treatment that is usually completed in 5-20 sessions. You will generally meet with a therapist once-a-week or once every two weeks. Each session lasts about 30-60 minutes. The first session is primarily an assessment of your current situation.
Homework in Cognitive Behavioral Supervision: Theoretical Background
Homework in Therapy. While specific recommendations for the practical usage of homework have been clearly articulated since the early days of CBT, 11, 12 practitioners state that they do not follow these recommendations. 13-15 For example, many physicians admit that they forget homework or do not focus on standard specifications when, where, how often, and how long the task should last.
How Much Does Homework Matter in Therapy?
Homework is an important component of cognitive behavior therapy (CBT) and other evidence-based treatments for psychological symptoms. Developed collaboratively during therapy sessions, homework ...
Supporting Homework Compliance in Cognitive Behavioural Therapy
Homework Non-Compliance in CBT. Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [1,2].It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [3-6].
What is Cognitive Behavioural Therapy and what will happen in my first
During your first session, the agenda will be set by the therapist, but in future therapy sessions you'll both set it. Your first session agenda will look something like this: About CBT: An explanation from your therapist about the CBT Model and you'll be able to ask lots of questions. About you: A chance for you to describe your problem.
What to Expect in CBT
CBT helps you to build confidence in both your decision making skills and your abilities to face challenges that may arise during your day to day life after you finish treatment. Learn about what to expect in cognitive behavioral therapy. Information about the first sessions, later session and homework is provided.