Windy Dryden - How To Get The Most Out of CBT - A Client's Guide-Routledge (2015)

How to Get the Most
Out of CBT
How to Get the Most Out of Cognitive Behaviour Therapy (CBT):

A client’s guide is aimed at those who are either considering
consulting a cognitive behaviour therapist or who are actually
consulting such a therapist. Written by one of the world’s lead-
ing CBT practitioners, it will steer you through the CBT process.
The guide will help you to decide whether CBT is right for you,
give you advice about how to make a therapeutic agreement
with a therapist, show you how to prepare for CBT sessions and
how to apply what you have learned from CBT after therapy
has ended.
How to Get the Most Out of Cognitive Behaviour Therapy (CBT)

is a concise and practical guide that will help you to understand
the CBT process and how to make the most of your therapy, no
matter which CBT approach your therapist practises, so that
you continue to benefit from it once therapy has ended and can
learn to be your own therapist.
Windy Dryden is in full-time clinical and consultative prac-

tice and is an international authority on Cognitive Behaviour
Therapy. He is Emeritus Professor of Psychotherapeutic Stud-
ies at Goldsmiths, University of London. He has worked in
psychotherapy for more than 40 years and is the author and
editor of over 200 books.
“World renowned psychologist, Windy Dryden, has provided
clients with an outstanding guide: How to Get the Most Out of
CBT: A Client’s Guide. This practical, concise and very help-
ful roadmap to your experience in CBT will be an invaluable
tool for the many people who can benefit from this powerful
approach. This is the kind of book that will help you ask the
right questions and help you understand how you can best
participate in this active and engaging therapy. Excellent!”
—Robert L. Leahy, Ph.D., Director, American
Institute for Cognitive Therapy, Clinical Professor
of Psychology, Department of Psychiatry, Weill-
Cornell University Medical College, New York
Presbyterian Hospital, USA
“Dryden’s book How to Get the Most Out of CBT: A Client’s

Guide fills a unique and much neglected niche. There are
nowadays many quality, evidence-based book on self-help,
written for the clients, but there has been little for the person
who after perhaps reading one or several self-help books,
decides they need, after all, to seek a professional therapist.
At this point they will usually have a host of questions and
worries: what kind of therapist, what kind of therapy, what
can I expect, what will be expected of me. Dryden address all
these concerns in an accessible and engaging writing style,
covering comprehensively most if not all the points a poten-
tial client might have in mind, plus many others he or she
would be advised to think about. I would personally recom-
mend this book for the majority of people who have reached
that stage of seeking therapy within the Cognitive Behaviour
Therapy family of therapies.”
—Peter Trower, Honorary Professor of
Clinical Psychology, Founder of the Centre
for REBT, University of Birmingham
“Informed by a leading expert’s forty years of experience

in practice, writing and teaching, this is not merely a collec-
tion of techniques, but genuinely useful guidance on how to
gain greater benefit from the journey of problem solving and
personal growth that is CBT.”
—Rob Willson, Cognitive Behavioural Therapist
How to Get the Most
Out of CBT
A client’s guide
Windy Dryden
First published 2015
by Routledge
711 Third Avenue, New York, NY 10017
and by Routledge
27 Church Road, Hove, East Sussex, BN3 2FA
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2015 Windy Dryden
The right of Windy Dryden to be identified as author of this work has been asserted
by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents
Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilized in
any form or by any electronic, mechanical, or other means, now known or hereafter
invented, including photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered
trademarks, and are used only for identification and explanation without intent to
infringe.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Dryden, Windy.
How to get the most out of CBT : a client's guide / Windy Dryden.
pages cm
1. Cognitive therapy—Popular works. I. Title.
RC489.C63D79 2015
616.89ʹ1425—dc23
2014036342
ISBN: 978-1-138-80402-9 (hbk)

ISBN: 978-1-138-80403-6 (pbk)
ISBN: 978-1-315-74954-9 (ebk)
Typeset in New Century Schoolbook and Frutiger
by Apex CoVantage, LLC
Dedication
I dedicate this book to my clients past, present and future

and to the MSc REBT/RECBT students whose education
I had the pleasure of overseeing at Goldsmiths, University
of London from 1995 to 2014 and to those who taught and
supervised these students.
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Contents
Introduction ix
1 Decide If CBT Is for You 1

2 Make Practical Agreements With
Your Therapist 11
3 Make Therapeutic Agreements
With Your Therapist 19
4 Prepare for Your CBT Sessions 31
5 Understand the Process of Change 35
6 Apply What You Learn 41
7 Understand and Deal With Lack
of Progress 51
8 Become Your Own CBT Therapist 67
Appendices 79
Introduction
I have written this book for people who are either considering
consulting a cognitive behaviour therapist or who are actu-
ally consulting such a therapist. You can either read the book
in one go, seek advice from a particular chapter or section
that deals with an issue with which you are currently con-
cerned or read it first and then seek advice.
What This Book Does

I have written this book to help guide you through the cogni-
tive behaviour therapy (CBT) process from the point at which
you are trying to decide if CBT is for you to the point where
you have largely gone through the process and are learning
how to be your own therapist. In doing so, I have discussed a
variety of points of which I think CBT clients should ideally
be aware. These are, of course, personal, and other CBT thera-
pists would no doubt choose other points. What lies behind
my choice of points to discuss in this book is not only my per-
sonal knowledge and experience as a CBT therapist and a
trainer of CBT therapists, but also my knowledge of more
general therapeutic issues and my willingness to learn from
practitioners of other approaches to therapy.
What This Book Does Not Do

What I have not done in this book is to discuss any specific
CBT methods that you can use to help you deal with your
problems or to take any specific CBT line. In my view, CBT
x INTRODUCTION
is a psychotherapy tradition and not a specific psychotherapy

approach. It is an umbrella term under which specific CBT
approaches such as Beck’s Cognitive Therapy, Acceptance and
Commitment Therapy, Mindfulness-based CBT, Metacogni-
tive Therapy and Rational Emotive Behaviour Therapy can
be placed. This book aims to guide you through the process no
matter which CBT approach your therapist practises.
Windy Dryden
London, Eastbourne
1
Decide If CBT Is for You
How is it that you have ended up either consulting or thinking

of consulting a cognitive behaviour therapist? How much do you
know about CBT? Have you actively sought out a CBT therapist
or were you recommended to do so? These are some of the ques-
tions that come to my mind as I invite you to decide whether
or not CBT is for you. Indeed, these are some of the questions
that I do ask people who come to see me, either to consult me
as a CBT practitioner or to seek my help to determine which
approach to therapy is best suited to them. Since I don’t know
your answers to these questions, let me deal with the issue of
how you can best decide if CBT is for you in a more general way.
Common Factors That Span Different

Psychotherapeutic Approaches
In the field of psychotherapy and counselling, it is recognised
that different approaches have both common factors (i.e. com-
mon to all therapeutic approaches) and specific factors (i.e.
specific to the particular approach under consideration). The
main common factors include:
• the development and maintenance of an effective working

alliance between you and your therapist;
• the provision of a safe space in which you can discuss what-
ever is important to you;
• the mobilisation of hope whereby you come to see that you
can effectively address your concerns; and
2 DECIDE IF CBT IS FOR YOU
• experiencing your therapist as someone who is genuine

with you, understands you and accepts you.
As I have said, these factors are common to all approaches

to therapy and are not specific to CBT.
While I have entitled this chapter “Decide If CBT Is for
You,” when it comes to the presence or absence of these com-
mon factors, I suggest that your focus be more on deciding
whether or not the therapist whom you have come to see is
the right person for you to consult than on whether or not CBT
is right for you. Thus, your therapist may be technically pro-
ficient in CBT, but if you don’t feel safe talking to her1 about
what really matters to you, you are right to have doubts about
your therapist. Based on the above, here are some questions
to ask yourself to help you make your decision about whether
or not to work with your particular therapist:
• To what extent does my therapist understand my problems

from my perspective?
• To what extent does my therapist accept me the way I am?
• To what extent is my therapist genuine in the way she
interacts with me?
• To what extent do I feel safe to discuss what really matters
to me with my therapist?
• To what extent does my therapist inspire hope in me that
I can effectively deal with my problems?
• To what extent does my therapist foster a working rela-
tionship with me focused on dealing with my problems?
While it is unrealistic for your therapist to score top marks

on all these points, she should score highly enough for you to
consider working with her over time. If she scores poorly on
all these points, then, in all probability, she will not be able to
help you much despite her proficiency in CBT. If the therapist
scores highly on all but one or two points, then you should
consider discussing your feelings with her on the points where
she does not score highly. I will address the importance of dis-
cussing with your therapist matters to do with your therapy
later in this book. For now, let me make two points. First, if
you don’t feel able to discuss your concerns with your thera-
pist, then this may, in itself, indicate that your therapist is not
DECIDE IF CBT IS FOR YOU 3
right for you. Second, if you do decide to discuss your concerns

with your therapist on these matters, the way your therapist
responds is important. If she takes your concerns seriously
and responds without defensiveness, then these are good
signs that you can work with the therapist and that you can
deal with any rifts in your relationship that may occur over
the course of therapy. However, if your therapist appears to
dismiss your concerns and/or responds defensively, then this
does not augur well for the future and you should consider
finding yourself a different therapist.
Having made this point, don’t forget that therapists are
human too and may have their off days. However, if a thera-
pist responds dismissively and or defensively more than once,
then I do urge you to think very carefully about continuing to
work with that person.
CBT’s Main Specific Factors

In making a decision concerning CBT’s suitability for you, it
is important for you to understand some of the therapy’s main
features. I made the point in the introduction that CBT is, in
fact, a psychotherapy tradition and that there are a number
of different approaches that come under the umbrella of the
CBT tradition. Having said that, let me outline some of CBT’s
main specific factors.
CBT Focuses on the Way You Think and Act in the

Context of Your Emotions and in the Situations in
Which You Experience These Emotions
CBT stands for “cognitive behaviour therapy,” and thus you
would expect that the therapy would focus on cognition and
behaviour.
Focus on Behaviour
Let’s start with behaviour, as this is the easiest of the two
terms to grasp. Your CBT therapist will focus a lot on the
ways in which you behave, particularly in situations in which
you experience your problem(s). However, your CBT therapist
may also be interested to understand what may be termed
“action tendencies.” These describe situations in which you

feel an urge to act in a certain way but don’t actually do so.
Such action tendencies are particularly valuable in helping
your therapist discover your hard-to-identify emotions (such
as envy and hurt). Understanding the difference between
an action tendency and an overt behaviour may also help
you see that you don’t have to act on your action tendency,
which is particularly important with problems of anger and
self-discipline.
The focus on behaviour in CBT is particularly linked
to an understanding of your goals and values. Thus, expect
your CBT therapist to enquire about the extent to which your
problem-related behaviour helps you to meet your goals and to
what extent it is consistent with your personally held values.
Consequently, during therapy you can expect your therapist
to encourage you to act in ways that help you to achieve your
goals and are consistent with your values as well as to help
you to identify, reflect on and deal with obstacles to the execu-
tion of such behaviour.
A particular focus on behaviour that your therapist may
well take, particularly if you have problems with anxiety, is to
consider your use of safety behaviours (i.e. behaviours which
you use to keep yourself safe from threat, but in ways that
may serve to maintain your anxiety problems). CBT practice
is strongly underpinned by research, and while studies in the
past showed the negative effects of such safety behaviours,
more recent studies have shown that they may be useful in
encouraging you to face your fears. Effective CBT therapists
keep abreast of the research literature and modify their prac-
tice accordingly.
Focus on Thinking
While the word “cognitive” is derived from the Latin verb
cognoscere, meaning “to know,” in CBT it is used to refer to
your thinking and particularly thinking that has a bear-
ing on how you feel and act. Thinking can occur at different
levels of your mind. There is surface-level thinking, which
occurs in the form of automatic thoughts (i.e. thoughts that
pass through your mind and are easily identifiable) and there
is deeper-level thinking, which is less easily identifiable and

takes the form of underlying beliefs. CBT therapists may
vary in how much emphasis they place on these different
levels of thought. If they deal with both levels, they may dif-
fer concerning the order in which they focus on them. What
is important is that your therapist helps you to understand
the role that your thinking (at whatever level) plays in your
problems and elicits your agreement concerning how best to
deal with them.
Another type of thinking that CBT therapists are inter-
ested in concerns where you place your attention when you
are experiencing your problems. This is known as your atten-
tional focus and is a useful area for you to explore with your
therapist, whatever problems you have, for what you pay
attention to tends to be closely related to your behaviour and
emotions.
With respect to thinking, a recent development in CBT
research and practice has been on ruminations, thoughts that
go round and round in your head which you just can’t seem
to stop. It has been known for many years that such thinking
is a key component of worry or generalised anxiety disorder
(GAD), but more recently its important role in the perpetu-
ation of depression and unhealthy anger, to take but two
examples, has come to be realised.
You should be aware that CBT therapists from differ-
ent approaches tend to vary concerning how they address
your thinking. For example, practitioners of a CBT approach
known as rational emotive behaviour therapy (REBT), pio-
neered by Dr. Albert Ellis, will help you early on in therapy
to identify and challenge one or more of four deeper-level
unhealthy beliefs (known as irrational beliefs) using argu-
ments designed to encourage you to consider how consistent
with reality these beliefs are, how logical they are and how
useful they are. These therapists will also help you to con-
struct healthy (or rational) alternatives to these beliefs
which are more consistent with reality, more logical and
more useful to you.
Other CBT therapists will focus initially on your more
accessible surface-level thinking and help you to examine
such thinking for its practical utility and to construct more
helpful alternative ways of thinking. Later on these thera-

pists, who have been trained in cognitive therapy, pioneered
by Dr. Aaron T. Beck, will help you to identify and again
examine for their practical utility a deeper set of underly-
ing beliefs known as schemas and to construct more useful
schemas. Unlike their REBT colleagues, cognitive therapists
consider that the form of such schemas can vary greatly from
individual to individual rather than be grouped into one or
more of REBT’s quartet of unhealthy (irrational) and healthy
(rational) beliefs. Also, cognitive therapists are primarily con-
cerned with the practical utility of thinking, and while they
are also concerned with how consistent with reality such
thinking is, they are less concerned with the logical status of
such thinking.
While I have touched on some differences between REBT
therapists and cognitive therapists, both are concerned to
help you to focus on thinking that underpins your emotional
problems with a view to help you to stand back and respond
to it in some way. Other CBT therapists believe that encourag-
ing you to respond to such thinking only results in you getting
increasingly caught up in such thinking and may unwittingly
help you to ruminate. For these therapists, who practise a
form of CBT known as acceptance and commitment therapy
(ACT), problem-related thinking is best dealt with by your
accepting its existence without engaging with such thoughts
(e.g. by challenging them) and by committing yourself to
value-based behaviour despite the presence of these thoughts
in your mind. These therapists do not speak of thoughts being
distorted or realistic or beliefs being irrational or rational
because they consider thoughts to be very much influenced
by the context in which you find yourself rather than by the
realistic or rational status of the thoughts.
From a therapeutic point of view rather than a scientific
perspective, what really matters is whether the explanation
provided to you by your CBT therapist concerning the role
your thinking plays in your problems and what to do about it
makes sense to you and whether you are prepared to proceed
with a therapy that is based on these ideas. That is why it is
so important in CBT for the therapist to be transparent in
explaining her position on these issues to you.
CBT Focuses on How You Unwittingly Maintain

Your Problems Rather Than on How They
Originally Began. Consequently, CBT Focuses on
What You Can Do Now to Address Your Problems
It is often thought that CBT therapists are not interested in
your past. This is not correct, and in CBT you may talk about
whatever it is you are bothered about, be it your past, your
present or your future. Having said this, CBT therapists tend
not to believe that helping you to understand the past roots of
your present problems will be curative in the long term without
you doing something about these problems in the present. CBT
therapists generally hold to the view that relevant past experi-
ences may have contributed to your current problems but do
not account fully for these problems. CBT therapists explain
this by pointing out that if 100 people all experienced exactly
the same past experiences as you, not all of them would have
developed the same problems as you. Some may have developed
other problems and others would not have developed problems
at all. Rather, it is the views you took from these experiences
and still hold currently that largely account for your problems
together with the behaviour that stems from these views.
For example, take the problem of jealousy. If you have such
a problem, it may well be the case that you felt jealous of your
sibling as a child. However, this insight will not help you if you
continue to act in jealous ways in the present (e.g. by prevent-
ing your partner from doing things, checking on his or her
whereabouts). Such behaviour will reinforce and strengthen
the beliefs that underpin your jealous feelings and will nullify
any effect that insight into the possible roots of your problem
might have. As a result, unless your CBT therapist helps you
to deal with the ways in which you currently, but unwittingly,
maintain your problem, then it is unlikely that you will gain
much long-term benefit from therapy.
CBT Focuses on Helping You to Put Into Practice

Between Sessions What You Learn in Sessions
When you consult a CBT therapist, it is unlikely that you will
derive any benefit unless you learn something in the therapy
sessions. However, such learning is likely to be academic and

thus of limited value to you unless you put it into practice
between therapy sessions. Consequently, in CBT, expect your
therapist to negotiate with you on ways of implementing
your session-derived insights into relevant situations in your
everyday life. The extent to which you do so will determine
how much you get from CBT. Thus, I am often asked whether
CBT is helpful. What is my answer? Yes, if you use it; no, if
you don’t! I will discuss the issue of applying what you learn
in Chapter 6.
CBT Focuses on Helping You to Become

Your Own CBT Therapist
While all approaches to counselling and psychotherapy have
as an aim you learning how to help yourself in the future
after therapy has ended, CBT therapists, more than other
practitioners, implement this aim in specific ways. They do
this by teaching their clients CBT self-help skills through-
out the therapy process. Thus, your therapist may well use
a CBT-related framework to teach you how to assess your
own problematic thinking, feeling and behaviour in problem-
related episodes and how to respond productively to these
situations. You will then be encouraged to use this framework
for yourself between sessions and helped to refine your devel-
oping skills in subsequent sessions by your therapist when
you report back on how you implemented your skills. Given
this emphasis on helping you to become your own CBT thera-
pist, it is likely that your therapist will give you increasing
responsibility to help yourself as therapy progresses. She will
do this by gradually fading her own active contribution to the
process, becoming more of a consultant and giving you feed-
back on your developing self-helping skills than by actively
taking the lead as she did at the beginning of therapy.
Because CBT emphasises teaching clients self-help skills,
there are a number of CBT-oriented workbooks available that
can be used as an adjunct to therapy. Your therapist may sug-
gest incorporating such a workbook into your therapy. While
some clients value using such workbooks, others find them too
formulaic and would prefer not to use them.
Flexible CBT therapists will be mindful of the fact that

while CBT does emphasise the teaching of self-help skills as
an integral part of the therapy, some clients do not want to
learn these skills in such a deliberate manner. These flexible
therapists adjust CBT accordingly. I will discuss the issue of
becoming your own CBT therapist more fully in Chapter 8.
In this chapter, I have set out to give you a flavour of some
of CBT’s distinctive features while acknowledging that dif-
ferent CBT approaches emphasise some and de-emphasise
others. I have also stressed that as CBT values explicitness, it
is very likely that your therapist will make clear to you how
she will use CBT to understand and deal with your problems.
Thus, it should be easier for you to judge whether or not CBT
is for you than it would be if you were consulting a therapist
who practises a non-CBT approach. If you are still in doubt,
most CBT therapists will suggest a brief “trial period” of ther-
apy where you can experience CBT for yourself as a way of
judging whether or not you wish to make a firm commitment
to becoming a CBT client.
If you have decided that CBT is for you and you have found
a properly trained therapist2 to work with, you will need to
make a number of practical agreements with her to ensure
that therapy gets off on the right foot. This will be the subject
of the next chapter.
Notes
1. In this book, when I refer to the therapist, I will refer to the person
as “she.” This was determined by the toss of a coin.
2. I suggest that you conduct an Internet search to locate the appro-
priate professional bodies in the country where you are that
accredit CBT therapists in order to find a properly trained CBT
practitioner if you have not already been referred to one.
2
Make Practical Agreements
With Your Therapist
Therapy, of whatever type, works better if the two involved

parties, namely you and your therapist, agree on a number
of important points. These points can be placed in one of two
realms: the practical realm of cognitive behaviour therapy
and the therapeutic realm of CBT.
The practical realm of CBT involves such matters as your
therapist’s fee, if one is charged, and how it is to be paid; how
frequently the two of you will meet; how many sessions you
will have; and what the cancellation policy of your therapist
is. If your therapist works in a clinic, then there may well be
additional practical issues to be discussed and agreed. I will
deal with such practical agreements in this chapter.
The therapeutic realm of CBT involves such matters
as how you and your therapist see your problems and what
your respective goals are in regard to these problems. It also
involves understanding what steps you are both going to take
to address your problems and help you achieve your goals
and the commitment you are prepared to make with respect
to carrying out these steps. I will deal with such therapeutic
agreements in the next chapter.
While the distinction between the practical and thera-
peutic realm of CBT is somewhat arbitrary—after all, how
you and your therapist negotiate on the practical issues may
either be therapeutic or non-therapeutic—it is a useful way of
separating out issues concerning why you have come for ther-
apy and what you want to achieve (i.e. the therapeutic realm)
and issues that are designed to grease the wheels for both of
you (i.e. the practical realm) as you both strive to achieve your
12 PRACTICAL AGREEMENTS WITH THERAPIST
goals. So here are some of the practical agreements you will

need to make with your CBT therapist.
The Length of Therapy Sessions

One of the practical aspects of your therapy that your thera-
pist should make clear at the outset is the length of therapy
sessions. Actually, when most therapists talk about therapy
“sessions,” they most often refer to the therapeutic hour as
lasting 50 minutes rather than a full hour. The tradition of
the 50-minute therapeutic hour has come about to reflect the
fact that therapists need to take a short break between ses-
sions for several reasons, most typically to write notes, clear
their head, go to the toilet or make and/or take phone calls.
If your therapist operates a 50-minute-hour practice, then
she should make this clear to you. Otherwise, you may think
that your sessions last for 60 minutes and may consider that
you have been short-changed if your therapist stops sessions
after 50 minutes without explanation. If your therapist does
not make this clear, then, by all means, ask her. Sometimes
therapy sessions may be shorter or longer, and if any changes
are made to an established and agreed arrangement with
respect to the length of therapy sessions, then this needs to
be fully discussed, understood by you and your therapist and
agreed to by both of you. Any changes to an established ses-
sion length may result in pro rata changes to any fees that are
being charged (see the next section).
The Fee
If you are seeing your CBT therapist in a National Health
Service (NHS) clinic or facility or in an organisation that does
not levy a fee, then what I have to say does not concern you,
although if this is the case it is very likely that the number of
sessions you can agree to have with your therapist will be lim-
ited (see the section, The Total Number of CBT Sessions, later in
the chapter). However, if it is the case that your therapist levies
a fee, then it is very important that you understand what this
fee is. I have known clients who have not enquired about the
therapist’s fee and have had quite a shock when they received
PRACTICAL AGREEMENTS WITH THERAPIST 13
the latter’s invoice because the therapist, in these cases, had

not told the clients what her fees were. So please do ask your
therapist what her fee is if she does not venture this informa-
tion herself. I suggest that you do this on initial enquiry to save
time. If your therapist’s fees are out of your financial reach, it
is useful to enquire about whether she has a sliding scale, but
if not or if the reduced fee is still out of your range, then it is
useful to ask the therapist if she has a colleague whose fees are
within your range. Be prepared, therefore, to tell the referring
therapist how much you are prepared to pay.
You may well be thinking that how much you can afford
per therapy session will be based on how many sessions you
need, but please bear in mind that therapists cannot tell their
prospective clients how many sessions they may need until
they have carried out a thorough assessment.
When you and your therapist have agreed to a fee, it is
useful to discover if the fee (or part of it) will be levied if you con-
tact and discuss matters with the therapist between sessions
or if the fee will be charged for other matters. For example, I
once saw a client for individual CBT who at the same time was
having couples therapy with a different therapist. The client
had to be hospitalised, but requested a couples therapy ses-
sion with her couples therapist while she was in hospital. The
couples therapist came to the hospital and duly conducted the
session. To my client’s surprise and consternation, the thera-
pist billed the couple for three hours as opposed to the usual
one hour charge for the session. When questioned, the thera-
pist told the couple that he was billing for the one hour session
and the two hours that he gave up to travel to and from the
hospital to carry out the session. The point that I wish to make
here does not concern the rights and wrongs of charging for
two hours travel time, but concerns the fact that the therapist
did not make clear that he was going to do this in advance of
agreeing to carry out the hospital-based therapy session. Also,
the client couple could have asked if there was going to be an
additional charge, as the therapist would have to make the
journey out of his professional time. This failure to make an
agreement about the additional charge, which I argue is in the
practical realm of therapy, had quite an adverse effect on the
therapeutic realm and it took quite a while for the therapist
to regain the couple’s trust in him.
The Cancellation Policy

When you contract with your CBT therapist and if she does
levy a fee, then it is important that you understand what her
cancellation policy is. Once you understand this, you may
wish to suggest amendments based on your unique circum-
stances. This should lead to a discussion and hopefully to a
mutually agreed policy. Possible ambiguities of the terms of
the policy should be highlighted by one or both parties and
clarified. For example, I have a 48-hour cancellation policy,
which, as I point out to prospective clients, is different from
one specifying two days. Thus, if a client and I have sched-
uled for, say, 11 am on Wednesday and he wishes to cancel it
without paying my fee, then he needs to inform me of that by
11 am on the Monday before. If he cancels his appointment at
12 noon on Monday, he will be charged, since he has not given
me the full 48 hours notice.
Some therapists will not charge a fee if you cancel your
session without giving full notice if you become ill or a mem-
ber of your family becomes ill, for example, while others will
still levy their fee under these circumstances. It is important
that your therapist is clear with you about the exceptions she
is prepared to make concerning fee payment when you have
not given full notice, and if she does not do this, then in my
view you should ask her.
Some therapists apply their cancellation policy to them-
selves, while others don’t. For example, if I have to cancel a
client’s session and I have not given him 48 hours notice, then
his next scheduled session is given free of charge. Again, the
therapist should ideally make this explicit to you as her client.
The Total Number of CBT Sessions

If you are thinking about consulting a CBT therapist, it is
likely that you are wondering how many sessions you are
likely to need. However, while this is a reasonable question
to ask your therapist, it is important for you to realise that
the number of sessions you will need cannot be validly deter-
mined by your therapist when you first contact her and give
her very rudimentary information about yourself and your
problems. As I have stated previously, it can only be answered

after your therapist has met with you and carried out a full
assessment of your problems and what you want to achieve
from therapy. Having said that, here is what I say to prospec-
tive clients:
The length of therapy depends on how many problems you

have, what you want to achieve with respect to these prob-
lems, how chronic your problems are and how hard you
work in therapy. So if you have a few problems that are
acute in nature, are prepared to work hard to address these
problems in between therapy sessions and to work towards
achievable, specific goals, then therapy is likely to be short
term in nature. However, if you have a large number of
problems that are chronic in nature, you think that change
will occur in therapy sessions rather than by what you do
between sessions and your goals are vague, then therapy is
likely to be longer term.
The Frequency of CBT Sessions

Normally, you will see your CBT therapist once a week until
you make progress, and then sessions are likely to be spaced
out more. This is because a major goal of CBT is for you
to become your own therapist, as I mentioned in Chapter 1
and as I will discuss more fully in Chapter 8. As you learn
the skills of CBT, you will be encouraged to take increas-
ing responsibility for applying them in your life, and the
increasing spacing out of therapy sessions encourages you
to do that.
There may be times when you may see your therapist
more than once a week. This may reflect the complexity of
your problems or that you are going through a crisis; both
of these situations indicate that you need more therapeu-
tic input than weekly sessions. However, even under these
conditions, you will be encouraged to take responsibility
for dealing with these issues as far as you are able and to
reduce the frequency of sessions when you are ready to do
so. This readiness will be assessed by you and your therapist
together.
Confidentiality
You may think that the contact between you and your CBT
therapist is completely confidential, but in reality, this is
unlikely to be the case. Here is a list of situations where your
therapist may reveal information about you or take action
without your permission:
• when mandated to do so by the courts

• to protect your well-being when you are not able or will-
ing to do so
• to protect the well-being of others when you pose a threat
to them without yourself taking steps to protect them
• if you steadfastly refuse to pay your therapist’s fees so that
she has to take legal action to be paid
Your therapist may have additional exceptions to com-

plete confidentiality, and if so, she should inform you about
these. This latter point is the main one that I wish to stress.
One of the ethical principles that counselling and psycho-
therapy is based on is known as informed consent. From your
perspective as a client, this means that you need to be clearly
informed about something before you can properly consent to
it. Because one of the features of CBT is its explicitness, its
practitioners should, ideally, make explicit all the exceptions
to complete confidentiality. However, should this not happen,
take responsibility and ask your therapist directly.
The Form of the Contract

So far, in this chapter, I have focused on the practical agree-
ments that you need to make with your therapist if you are
to get the most out of CBT. While the important point is that
these agreements should be made, you and your therapist
need to determine together the form that they will take. Thus,
such agreements may be made informally or formally.
An informally made agreement tends to be verbal and as
such it is open to misinterpretation and misunderstanding.
Thus, earlier I mentioned that I have a 48-hour cancellation
policy. If I explain what this means verbally, the client may
not understand what I have said or forget the nature of the

policy. This may lead to problems later when the client fails to
give the stated notice and questions why he has to pay for the
cancelled session.
A formally made agreement tends to be written and may
even be signed by both parties. While such an agreement is not
open to misinterpretation or misunderstanding, it may well
put off some clients who complain that it is too businesslike
and indicates that the therapist does not trust the client. In
Appendix 1, you will find an example of a formal agreement.
My point here is to state the importance of you and your
therapist agreeing to the form of the contract that you have
decided to make in light of the fact that both forms have
advantages and disadvantages.
Having dealt with the practical agreements that you will
need to make with your CBT therapist, I now, in the next
chapter, consider the therapeutic agreements you will need
to make with her.
3
Make Therapeutic Agreements
With Your Therapist
In the previous chapter, I discussed a number of practical

agreements that it is important for you to make with your CBT
therapist if your working relationship with her is going to get
off on the right foot and stay that way. However, most of these
practical agreements are common to most, if not all, approaches
to therapy and are certainly not unique to CBT. In this chapter,
I am going to focus on the therapeutic agreements you need to
make with your CBT therapist that do pertain to CBT and con-
cern why you have come for therapy: to address your emotional
problems and get on with the business of living. While clients
who are seeing non-CBT therapists will make similar agree-
ments, I will concentrate here on agreements that typify CBT.
As I have already mentioned, one of the features of CBT
that characterise this therapeutic tradition is its emphasis on
explicitness. This means that you can expect that your CBT
practitioner will spell out what she means about a number
of important issues, as we shall see. If you think that your
CBT therapist is not being clear about something, then ask
her. She should tell you. If not, she should tell you why she
is not prepared to tell you. The distinct advantage of thera-
pist explicitness is that it enables you to understand where
your therapist is coming from and to agree or disagree with
the explicitly expressed points she has made. In this chapter,
I will discuss the nature of the therapeutic agreements that
you need to make with your therapist that ideally are very
much facilitated by her explicit style of communication. Later
on in this chapter, I will discuss the importance of speaking
up if there is anything you don’t understand about what your
20 THERAPEUTIC AGREEMENTS WITH THERAPIST
therapist is saying, if you disagree with anything that she

says or if you find anything that she says or does unhelpful.
The Nature of Therapeutic Agreements

In this section I will discuss six different types of therapeu-
tic agreements you need to make with your therapist. While
your agreement on some points may be more explicit than
on others, for CBT to be fully effective you need to have clear
agreement on all six points.
Agreements About Your Problem(s)

You have probably come to CBT because you have one or more
emotional or behavioural problems for which you are seeking
help. It is important that your therapist listens carefully to
these problems, communicates that she understands how you
see these problems from your frame of reference and acknowl-
edges that you want to address them. Later, she will, in all
probability, offer you a CBT-based understanding of these
problems, but at the outset, it is important that you agree
on which problems you wish to address. Some therapists will
introduce you to the idea of a problem list on which you put, in
writing, what problems you want to cover in therapy. Please
bear in mind that this list is not set in stone and you may add
to it or subtract from it over the course of therapy.
Generally, only problems that are within your control to
tackle should be on the list and those that are outside your
control should not be included.
Alan was having problems with his partner and was

very angry with her because she was very untidy
around the house; Alan responded to this by yelling at
her. When his therapist asked Alan what his problem
was, he said it was his partner’s untidiness. Alan’s CBT
therapist explained to Alan why she did not want to put
this on Alan’s problem list. She helped Alan see that his
partner’s untidy behaviour was under her control rather
THERAPEUTIC AGREEMENTS WITH THERAPIST 21
than his. Alan came to see that what was under his con-
trol were his feelings (anger) and his behaviour (yelling).
As Alan’s feelings of anger and yelling behaviour were
unlikely to help him effectively address his partner’s
untidiness with her, his therapist invited him to regard
his feelings and behaviour as problematic in this context and

thus to put his response to her untidiness on the problem list
rather than the untidiness itself.
Generally only emotional and/or behavioural problems
should be put on the problem list and not practical problems.
Thus, if you are experiencing financial problems in your life,
then this, on its own, is not a matter that can be directly dealt
with by CBT. Rather, you need to consult a debt counsellor or
financial adviser for such practical problems. However, you may
also have emotional problems about these practical, financial
problems and these emotional problems can be tackled with
CBT. They may, with your assent, be placed on your problem list.
Agreements About Goals

For every problem that you are seeking help for, it is useful to
have as clear an idea as you can of what you want to achieve
by addressing it with your CBT therapist.
I usually explain the importance of goals like this: Imagine
that you go to a railway terminus and say to the person selling
tickets, “I don’t want to go to Brighton.” This person will either
be at a loss as to what to do or will sell you a ticket for anywhere
that is not Brighton. In either case, you are likely to be unhappy
with the result. In the same way as expressing clearly where
you want to go to a train ticket seller, doing the same thing with
your CBT therapist will aid both of you to collaborate on work-
ing towards achieving your therapeutic goals.
To help you with goal setting, your CBT therapist may
use the acronym “SMART” to indicate the criteria for clearly
formulated goals. Here is what each letter stands for:
• S stands for “specific.” The more specific you can be about

your goals, the more you will be able to see how to achieve
them. Thus, goals such as “I want to be happy,” while laud-

able, are very vague and as such will be difficult to achieve.
On the other hand, a goal of “I want to deal with the pros-
pect of criticism with healthy concern rather than anxiety
and approach people who I think may criticise me rather
than avoid them” is a clearly expressed goal and its speci-
ficity will help you achieve it.
• M stands for “measurable.” The more you can measure
your progress towards your goal, the more likely it is that
you will persist in taking steps to achieve it. For example,
the goal “I want to tidy my house” is difficult to measure,
whereas the goal “I want to spend one hour a day tidying
my house” is measurable and you can track your progress
towards achieving it.
• A stands for “attainable.” It is important to set goals that
can actually be achieved by you. Thus, the goal “I want to
be free from anxiety” is probably unachievable, whereas
the goal “I want to respond to feeling anxious by working
towards feeling healthy concern” is achievable.
• R stands for “realistic.” You may set a goal that is attain-
able (e.g. “I want to exercise in the gym for an hour a day”),
but it may not be realistic for you to achieve it. Thus you
may live very far from a gym, and your work and family
commitments may be too onerous for you to achieve this
goal. While it is attainable in the sense that you have the
ability to do it, it is not realistic in that you cannot find the
time to do it. By contrast, “exercising for twenty minutes
a day by running around the nearby park” may be both
attainable and realistic.
• T stands for “time-bound.” It is important for you to set a
time frame for achieving your goal. If you do not do this,
you may be tempted to keep postponing working towards
achieving it. Thus, compare “I want to write my paper”
with “I want to write my paper by the end of this month.”
While it is important to give yourself a specific time frame
to achieve your goal, ensure that this frame is realistic and
gives you some margin for error.
While your CBT therapist will keep the concept of SMART

goals in mind when working with you, she will not try to
impose it on you in a slavish manner. As I stress throughout

this book, competent CBT therapists are flexible, and while
they may think that encouraging you to develop SMART goals
is the best way of helping you to get the most out of CBT, they
also recognise that you may not find the development of such
goals helpful, or your problems may not lend themselves to
such an approach to goal formulation. In such cases, you and
your therapist should ideally strive to formulate goals that
make sense to both of you. You and your therapist may need
to engage in some negotiation over this point, but a jointly
agreed goal is more likely to be achieved than one that is
either imposed on you or one that your therapist has serious
reservations about.
Before leaving the topic of goals, I want to make one
other important point. You are more likely to achieve your
goals if you are prepared to commit yourself to achieving
them and to accept the sacrifices that goal pursuit inevitably
involves.
Two friends, John and Jack, struggle with procrastina-

tion and are falling behind in their studies as a result.
Both want to begin key essays and do sustained work on
those essays so that they can submit them on or before
the deadline. John is committed to achieving this goal
and is prepared to tolerate not attending a number of
social events that he would like to attend in order to
achieve this goal. In other words, he is willing to put up
with the sacrifices that working towards achieving his
goal would entail. Jack is also committed to achieving
his goal but, unlike John, is not prepared to miss out on
attending the same social events. In other words, Jack
is not willing to put up with the sacrifices that pursuing
his goal would entail.
It will come as little surprise to learn that John
was successful at achieving his goal, while Jack was
unsuccessful.
Agreements About the CBT Focus

An idea that is widespread about therapy in general is that
when you go to see a therapist, you spend a lot of time talk-
ing about the past roots of your problems rather than about
your problems as they exist in the present. The idea here is
that if you understand how you acquired your problems in the
first place, this will help you to address them in the present.
However, CBT has attracted the opposing viewpoint: that when
you go to see a CBT therapist, you talk about the present and
the future but not about the past, and you focus on how you
unwittingly maintain your problems rather than on how you
originally acquired them. While there is an element of truth
about this latter view, it is not quite accurate. First of all, your
CBT therapist will encourage you to talk about whatever you
are troubled about. So, if you are preoccupied with events in
the past, then your therapist will help you to talk about them.
Having said that, while CBT therapists recognise that your
past experiences contribute to your present problems, they also
argue that your current thoughts and beliefs about these expe-
riences play a large role in why your problems persist.
So, while you will be allowed to discuss whatever you are
preoccupied with in CBT and while due weight will be given to
the influence of the past on the present, a distinctive feature
of most approaches within the CBT tradition is that a clear
focus will be placed on how you currently think and currently
behave as a way of helping you to address your problems
effectively. If you cannot agree on such a focus with your CBT
therapist, then CBT may not be the right therapy of choice for
you. If this turns out to be the case, your therapist will discuss
with you a judicious referral to a therapist who practises an
approach that better meets your ideas on the issue of what to
focus on in therapy.
Agreements About the Therapist and Client Roles

I sometimes hear it said about therapy that it is a process
that involves you talking and your therapist “sorting you out.”
This is very much at variance with what role your therapist
plays and what role you are expected to play in CBT. Most
CBT therapists view the therapeutic relationship as collab-

orative, which means that you work together in the service of
your psychological health. However, both parties bring differ-
ent resources to this collaboration, and in this section I will
outline what these resources are. Collectively, these resources
add up to your respective roles.
Your Therapist’s Role in CBT

• To bring her CBT knowledge to bear on the assessment
and formulation of your problems and to communicate this
clearly and explicitly
• To suggest and explain ways of tackling your problems and to
make clear how these relate to the assessment/formulation
and how they will help you to achieve your goals
• To engage you as an active participant in a collaborative
relationship where you work together in the service of your
therapeutic goals
• To identify and respond to anything that you are unclear
about or have reservations about in the therapeutic process
• To identify potential and actual obstacles to goal achieve-
ment and to deal with these in a sensitive way
• To ask for feedback about the therapeutic process and dis-
cuss your suggestions for modifications to your therapy
Your Role as Client in CBT

• To speak openly about your problems, but to do so in a way
and at a rate that is helpful for you
• To be active in the therapeutic process; to speak up and
give your opinion about salient aspects of the therapy. You
might think that as your CBT therapist is the expert in
CBT, then she should know what she is doing, and thus, if
you don’t understand a point she is making, then that is
your fault. Fortunately, this is a misguided view. It is mis-
guided for a number of reasons
First, it assumes that your CBT therapist can do no wrong.

Since your CBT therapist is human first and a therapist a
distant second, she is susceptible to all the vagaries of being

human. In other words, she is fallible and can make mistakes
and get things wrong. Even the most skilful and experienced
CBT therapist may, for example, explain something in a man-
ner that you just don’t understand.
Second, if you assume that your therapist is infallible
and always explains things in an understandable way, then if
you don’t understand a point that she makes, it must be your
fault. The consequence of this view is that you are mainly in
therapy to be the passive recipient of your therapist’s wisdom,
and if you don’t understand something, then there is no point
in bringing this to her attention, since the fault, as I have
already said, lies in you. Again the reality is very different.
CBT is a collaborative exercise and you and your therapist are
equal participants in the therapeutic process. As you are both
fallible, you both can get things wrong, and the best way that
human beings have of putting things right is to communicate
about them. Let’s see what this means in practice.
Fiona was seeing a CBT therapist about her perfor-

mance anxiety. Her therapist assessed her problem and
suggested a way of dealing with it which Fiona only
understood in part. Her therapist assumed that Fiona
understood fully his formulation and treatment sugges-
tions and proceeded accordingly.
Fiona has two basic options here. First, she could
say nothing and hope that she will understand more
fully later her therapist’s conceptualization of her prob-
lem and how she can best deal with it. Second, she
could speak up and tell her therapist that she does not
understand.
I strongly suggest that she do the latter. Here is how
she might address the issue with her therapist:
Fiona: I’m not clear why you think that me doing what
you call “over-preparing” my talk is a problem. Can
you explain what that means, please?
Once the therapist re-explains her point, Fiona is

not entirely convinced.
Fiona: Well, I kind of see what you mean, but your sug-
gestion that I limit my preparation to an hour a day is
not something I am prepared to do. I’ll limit it, but not
to an hour a day.
You can see from this brief vignette that Fiona is

showing herself to be a full participant in the therapy
process, speaking up when she does not understand
something or does not agree with something. In this way
she is discharging her responsibility as a client.
While CBT therapists value such therapist-client collabo-

ration, they cannot check every point with their clients, so
they rely to some extent on their clients speaking up and tell-
ing them when they don’t understand something, don’t agree
with something or think that their therapists have got things
wrong. If you don’t speak up as a client, you will increase the
chances that “resistance” will occur in therapy, which means
that you will “resist” your therapist’s efforts to help you
because in some way you silently have not signed up to certain
key therapeutic points. I will discuss this issue in the context
of dealing with lack of progress in Chapter 7.
• To undertake to carry out agreed tasks in the service of

your goals. I will discuss this further in the next section
and again in Chapter 6. Also, to be open about reasons why
you did not do the tasks if this was the case
If it transpires that there is not a good enough match

between the therapist and client roles as outlined here that
you think will be helpful to you in therapy, then it is important
to discuss this discrepancy with your therapist and decide
together what is the best way forward. If such an agreement
about both of your roles cannot be made, then therapeutic
progress will be severely compromised and you may be better
off seeking help from a therapy who better approximates your

views on such roles.
Agreements About Therapeutic Tasks

CBT involves you and your therapist doing various things
in therapy sessions and you doing things between therapy
sessions to help you achieve your therapeutic goals. For the
purposes of this discussion, I will refer to these as therapeutic
tasks. Note well my point that both you and your therapist
are expected to carry out such tasks in CBT. What kind of
agreements do you and your therapist need to make about
tasks in CBT, whether you do so explicitly or implicitly? Here
are some of the main agreements that you and your therapist
need to make with respect to therapeutic tasks:
• That you both understand what your respective tasks are

and agree to implement them in the course of therapy
• That you both understand how carrying out your respec-
tive tasks will help you to achieve your therapeutic goals
as a client
• That you both understand what your skills and capabili-
ties are as a client to carry out your therapeutic tasks and
are both prepared to take the necessary steps to help you
to implement these tasks if you cannot do so
• That you both agree to make modifications to your respec-
tive tasks should it become necessary to do so
• That you both understand that your therapist will teach
you how to implement your tasks outside of therapy ses-
sions, and the more you are able to do this, the more she
will encourage you to take increasing responsibility to
become your own therapist
Agreements About Ending

I mentioned in the previous section that one of the issues that
you and your therapist need to agree on is when you will take
increasing responsibility in therapy to become your own ther-
apist. When this occurs, then you need to discuss how you are
going to end the process. There are a number of approaches to

end therapy in a planned way:
• to meet regularly (say weekly) and then set a date for the
final session. A review session or sessions may or may not
be scheduled
• to decrease the frequency between sessions before setting
a date for the final session. Again, a review session or ses-
sions may or may not be scheduled
• to decrease the frequency between sessions without setting
a final date so that there are very long gaps between ses-
sions, which effectively serve as review sessions
Here as elsewhere, the important issue is that you agree

with your therapist on the best way to end the process for your
own particular situation.
In the next chapter, I discuss what you can do to prepare
yourself for therapy sessions so that you may derive the most
benefit from them.
4
Prepare for Your CBT Sessions
You may think that now that you are in therapy, all you need
to do is to turn up for your therapy sessions and talk. After all,
isn’t therapy supposed to be the talking cure? Well, yes and
no! Obviously, you need to talk about what you are bothered
about in your life, but one way to get the most out of therapy
based on the principles of CBT is to come prepared for your
therapy sessions.
What preparations you might make will, of course, depend
on what problems you wish to discuss and the phase of therapy
you are in. However, you might find the following guidelines
helpful.
Develop a Problem and Goal List

Develop a Problem List
Before you attend your first therapy session, or as soon as
possible after this session, I suggest that you make a list of
the problems you want to address in therapy. This is known
as a “problem list.” Make sure that the problems on this list
are those that you think that you have and that you want
to address rather than problems that others think you have
and want you to address in therapy. At this point, I suggest
that you phrase these problems in your own words. If neces-
sary your therapist will help you to reword your problems so
that they are expressed in a form that will best help you to
tackle them. This normally involves you and your therapist
32 PREPARE FOR YOUR CBT SESSIONS
working to phrase your problems as clearly and specifically

as possible.
As mentioned in the previous chapter, CBT works best if
you address problems that are within your direct control to
change.
Develop a Goal List

I also suggest that you develop a companion list of what you
want to achieve from therapy with respect to these problems.
So for every problem you have listed, see if you can set a
goal. As you set your goals, bear in mind that the presence
of a healthy state is easier to achieve than the reduction or
absence of a negative state. Thus, the goal “I want to feel
concerned about the possibility of being rejected” is easier to
achieve than “I don’t want to feel anxious about the possibility
of being rejected.”
Again, put your goals into your own words and your ther-
apist will, if necessary, help you to express them in a form
that will best help you to achieve them. Please remember one
important point about therapy goals, though. You probably
won’t achieve them fully. As Marilyn Grey once said: “No one
ever has it ‘all together.’ That’s like trying to eat once and
for all.”
The same point that I made concerning targeting prob-
lems that are within your direct control to change also applies
to the topic of goals. The more your goals are within your power
to achieve, the more likely it is that you will achieve them.
Come With a Clear Idea of What You Want to

Discuss in Each Therapy Session
You have met your therapist and had an opportunity to tell
him or her why you are seeking help, and you have decided to
work together. You could just turn up for subsequent therapy
sessions without doing any preparation, but in my view, you
would not get as much out of these sessions as you would do if
you came with a clear idea of what you want to discuss. Such
preparation can take a number of different forms, of which
the following is a sample:
PREPARE FOR YOUR CBT SESSIONS 33
• Keep a log of events that you found upsetting in the week

preceding your therapy session, perhaps putting these
events in some kind of order in which you want to discuss
them
• Select a problem from your problem list that you want
to address (known as the “target problem”) and choose
a specific example of that problem to discuss with your
therapist
• Take a specific example of your target problem or a specific
event about which you were upset and try to make sense
of it using the framework or model that your therapist out-
lined to you or developed with you
• Bring to the session anything that you want to revisit or
did not understand from the previous session or sessions.
This is an important point that I will address more fully in
due course
Session Agenda
Now, your CBT therapist may well suggest that you develop
an agenda for each therapy session that you attend. The pur-
pose of this agenda is for you and your therapist to ensure
that you cover what you both want to deal with in the session
and for you both to use session time effectively. In addition to
the above items, other items put on the agenda which you can
prepare for beforehand include:
• You completing one or more inventories which provide

your therapist with an objective guide to how your mood is
changing as a result of therapy. To save therapy time, you
may complete such inventories just before your therapy
session.
• A review of any between-session activities you have agreed
to do. I will discuss this more fully in Chapter 6, entitled
“Apply What You Learn.”
The important thing about the session agenda is that

you and your therapist use it flexibly, not rigidly. So, if some-
thing really important comes up in a session that is not on the
agenda, you should have the freedom to explore it rather than
34 PREPARE FOR YOUR CBT SESSIONS
have it ruled “off limits” because it does not feature on the

agenda.
Matters Arising
While I am not suggesting that a CBT session should be
likened to a business meeting, if one is to set an agenda for
therapy sessions, then it makes sense to have an item on that
agenda entitled “matters arising.” This means that you should
bring to the session anything that emerged from the previous
session or the intervening period that you wish to discuss.
This might include:
• Anything you did not understand from the previous session

• Anything you disagreed with from the previous session
• Any doubts and reservations you had about the previous
session or about therapy in general
I will discuss this issue more fully in Chapter 7. In the

next chapter, however, I will outline a process view of CBT so
you can see how your therapy is likely to unfold.
5
Understand the Process
of Change
You may find it helpful to have some idea of the process of

change in CBT so that you can anticipate the process that lies
ahead. As such, I am going to outline a number of stages that
you may go through as you make progress on the problems for
which you have sought CBT. I want to make clear at the outset
that I am not putting forward these stages as those that you
must go through in the order that I present them. Rather, you
should regard them as stages that you may go through, albeit
in a different order to the ones presented in this chapter.
Stage 1: Admitting That You Have a Problem

(or Problems) and Accepting Yourself for
Having It (Them)
While most people who seek CBT do so because they rec-
ognise that they have a problem, this is not universally the
case. Thus, you may have been sent for help or are consult-
ing a CBT therapist because you consider that you have to,
for some reason, rather than you want to do so. Indeed, you
may feel ambivalent about seeking help: part of you wants to,
while another part of you does not. It is important that you be
honest with your CBT therapist about where you are on this
issue so that she can help herself and you discover whether or
not you have a problem, and if so, what might be stopping you
from admitting to having it.
One of the major blocks to admitting that you have a prob-
lem is a sense of shame. Here you believe something like: “If
36 UNDERSTAND THE PROCESS OF CHANGE
I admit that I have this problem, then it would mean that

I am weak, inadequate and worthless.” If this applies to you,
then your therapist will help you to address this self-defeating
idea before moving on to helping you to deal with the problem
about which you feel ashamed.
You may also depreciate yourself even though you are
readily able to admit to having a problem (which I refer to
here as a “primary problem”). While this “meta-problem”
needs addressing at some point, once you have disclosed it
to your therapist, she will help you to determine whether it
needs therapeutic attention before you address your primary
problem or after you have done so. Basically, the more your
meta-problem interferes with you focusing your attention on
your primary problem, either in therapy sessions or between
them, the more likely it is that you and your therapist need
to address your meta-problem before your primary problem.
However, here as elsewhere in the therapy process, such deci-
sions are made jointly between you and your therapist rather
than unilaterally by your therapist.
Stage 2: Understanding Your Problems:

Assessment and Formulation
Some CBT therapists prefer to have an idea of all the prob-
lems for which you are seeking help and to understand the
connections between them before helping you to tackle these
problems one at a time. This is known as a case formula-
tion. This formulation helps your therapist to plan therapy
based on an overall understanding of your problems and the
mechanisms that are at play in their inter-connections. Your
therapist will not do this without your active participation,
and perhaps the most important thing about a case formu-
lation is that it is arrived at jointly between you and your
therapist. This approach may be regarded as a formulation-
based approach to CBT.
Other CBT therapists will prefer to begin therapy by
focusing on the problem you want to start with and will wait
to discover the connections among your problems later. This
approach may be regarded as a problem-based approach to
UNDERSTAND THE PROCESS OF CHANGE 37
CBT. In this approach, the therapist will help you and her-
self understand the dynamics of the problem that you have
selected to tackle first. This is known as problem assessment.
Again, you will be expected to take an active role in problem
assessment providing relevant information and agreeing on
the assessment which you arrive at jointly.
You will see that in both approaches, the therapist carries
out problem assessment and a case formulation, but the order
in which they do this is different.
Stage 3: Focusing on One Problem at a Time and

the Importance of Being Specific
Whether your therapist adopts a formulation-based approach
or a problem-based approach to CBT, when you do begin to
tackle your problems it will likely to be one at a time and,
as you do so, it is also likely that your therapist will ask you
to identify a specific example of the problem. The reason for
this specificity is that, in general, it provides you both with
more valuable information than if you discuss your problems
in general terms. You might wish to select a typical example
of your target problem, a recent example, a vivid example or
one that may occur in the near future. The important thing
about the selected example is that it helps you and your
therapist understand the factors that are at play in your
problem. In discussing this specific example of your prob-
lem, your therapist may help you to do some or all of the
following:
• Describe the situation in which the problem occurred and

what you found most difficult about the situation
• Identify what emotion(s) you felt in the situation
• Identify how you acted in the situation or how you felt like
acting
• Identify what you did to try to cope with the problem
In addition, your therapist will help you to set goals with

respect to the problem which will help you to know what you
are aiming for in similar problematic situations.
Stage 4: Examining Troublesome Cognitions

and Developing Healthy Alternatives to These
Thoughts/Beliefs and Associated Behaviour
In most approaches to CBT, what might be loosely called
troublesome thoughts and beliefs (collectively known as
cognitions) are seen to be at the core of people’s emotional
problems. Some approaches to CBT hold that these thoughts
need to be identified and examined and healthy alternatives
need to be developed and adopted if change is going to occur.
Other approaches to CBT contend that it is our engagement
with these troublesome thoughts that is the problem and that
mindful acceptance of these thoughts and a commitment to
valued action is what is needed. I will discuss the skills asso-
ciated with these different approaches in Chapter 8. In the
meantime, whatever approach your CBT therapist takes or
even if she adopts a mixture of the two, the important point
here is that you understand the role that such thoughts have
on your problems and you agree with the suggested way to
deal with them.
Note that CBT stands for cognitive behaviour therapy,
and thus, you will also be encouraged to consider the role that
your behaviour plays in your problems and will be helped to
develop more constructive ways if appropriate. It is my view
that when your thinking is healthy and your behaviour is
constructive and when you marry the two consistently in deal-
ing with troublesome events, then this constitutes the power
of CBT.
Stage 5: Applying What You Learn

What you learn within therapy sessions1 about the factors
that account for the presence of your problems and how you
unwittingly maintain them is, of course, a central plank of
CBT, for without this you would continue to experience these
problems, particularly if they are long-standing. However,
unless you apply what you learn from these sessions to your
everyday life, then it is unlikely that you will derive any last-
ing benefit from CBT. This is such an important topic that
I have devoted an entire chapter to it (see Chapter 6).
UNDERSTAND THE PROCESS OF CHANGE 39
Stage 6: Generalising Your Gains to

Other Problems
Once you have made progress in dealing with your target
problems, your therapist will help you to generalise what you
have learned in doing so to other problems that you would
like help with.
Fiona learned in therapy that her anxiety about meet-

ing new people was based on her overpredicting the
possibility of rejection and viewing any rejection as
a catastrophe. To deal with her anxiety, she avoided
meeting new people. Her CBT therapist helped her
in three ways: to view the possibility of being rejected
more realistically, to take the horror out of being
rejected and to approach new people while practising
these new ways of thinking. This resulted in Fiona
meeting new people and in a significant decrease in
her anxiety. Fiona’s therapist then helped her to apply
these three learnings—making realistic inferences,
decatastrophising bad events and facing up to unpleas-
ant situations—to her anxiety about public speaking
and taking exams. She also helped Fiona to see that
decatastrophising would also help her in her jealousy
problem, although she had to learn some new skills in
dealing with this latter problem as well.
Stage 7: Maintaining Your Gains

It is tempting to think that once you have made significant
progress in dealing with your problems, then therapy is
over. However, given the fact that we humans seem to have
a talent for lapsing (defined as making slips and return-
ing briefly to the problem) and relapsing (defined as going
back to square one), if you do not deal adequately with these
slips, then it is likely that you will relapse (see Chapter 8 for
more information on this point). It is important, therefore,
for you to recognise that you need to make a commitment to

work consistently to maintain the benefits that you made in
therapy. Also, the more you practise what you have learned
in therapy in a deliberate fashion, the more likely it is
that these learnings will eventually become second nature
to you.
Stage 8: Becoming Your Own CBT Therapist

There is an old Chinese adage which states: “Give a person a
fish and you feed him or her for a day. Teach a person to fish
and you feed that person for a lifetime.” If we adapt this to
CBT we have: “If your therapist helps you to solve a problem
with CBT, then she will have helped you with that problem. If
she teaches you how to become your own CBT therapist, then
she will have equipped you for life.” Thus, if it is feasible and
you are interested, then the final stage of the CBT process
involves you learning to be your own CBT therapist. I will
discuss this issue in Chapter 8.
At all stages of the change process you will experience
obstacles to change, and these need to be identified and
addressed if you are going to get the most out of CBT. I will
deal with the most common obstacles to change in Chap-
ter 7. Meanwhile, in the next chapter, I will deal with a most
important topic: how you can get the most out of CBT in your
everyday life by applying what you learn in therapy sessions.
Note
1. While I have written this book for those of you who are consulting a
CBT therapist in a face-to-face setting, some of my points here are
also applicable if you are following a CBT self-help course either
by reading a book or by being taken through an online computer-
based CBT programme.
6
Apply What You Learn
One of the most robust findings in the scientific literature

on CBT is that people who put into practice between ses-
sions what they learn within sessions get more out of CBT
than people who don’t do this inter-session practice. It fol-
lows from this that if you want to get the most out of CBT,
then you need to apply what you learn from therapy in your
everyday life.
In my view, you need to realise fully that much of what
you can achieve from CBT is within your hands and that mak-
ing a commitment to undertake regular practice of whatever
skills you have learned in your therapy sessions is very impor-
tant if you are going to derive the greatest benefit from CBT.
Let me give you an example of such a commitment from
my own life because I think that it details a number of points
that are relevant to the importance of undertaking a similar
commitment in CBT.
A number of years ago I was diagnosed with a disinte-

grating disc in my back and later with a torn cartilage
in my right knee. I was told that while these two con-
ditions might be helped with surgery, I could manage
both myself by doing a number of relevant strengthen-
ing exercises. Practising these exercises takes me about
25 minutes every day. I decided from the outset that
42 APPLY WHAT YOU LEARN
I would make a commitment to do such practice six days

a week. I do so in the morning before I go to the gym or
jog around the local park. My initial decision was under-
pinned by the following principles:
1. I did not want to subject myself to surgery with its

attendant risks and uncertain outcome.
2. I wanted to take responsibility for my own recovery
rather than handing over such responsibility to other
people.
3. I determined that I would do these exercises whether
I wanted to do them or not. I realised that I didn’t
have to be or feel motivated to do the exercises. I just
needed to do them.
4. I learned to discriminate between good reasons for
not doing the exercises (e.g. “I am not going to do the
exercises because I am ill”) and rationalisations for
not doing them (e.g. “I will do the exercises tonight
when I have more time to concentrate on them”) and
I resolved to respond to the latter and then take con-
structive action (i.e. by doing the exercises).
5. I created favourable environmental conditions that
would help me to do the exercises rather than hinder
me from doing them. Thus, I set my alarm to help me
to get up on time. I make sure that the room where
I do the exercises is suitably heated and that the rel-
evant equipment is to hand.
The five principles that I outlined above are very relevant

to the issue of applying what you learn in CBT sessions to
your everyday life outside these sessions. Thus:
1. The more you keep in mind the purpose of applying what

you learn, the more you will do so. For example, you might
find it useful to keep a clearly written reminder of your
goals to hand to help you see the purpose of putting into
practice what you have learned in therapy.
APPLY WHAT YOU LEARN 43
2. The more you take responsibility for putting into practice

what you learn in therapy, the more you will tend to do this
practice.
3. If you resolve to put into practice what you learn in therapy,
whether preferable conditions exist (e.g. having a feeling
that you want to apply what you learn and having a sense
of motivation for doing so) or not, then you are much more
likely to do such practice than if you insist on the presence
of such conditions.
4. The more you monitor your thoughts relating to the pos-
sibility of you not putting what you have learned in CBT
sessions into practice in your everyday life and the more
you learn to stand back and examine such thoughts, the
more you will be able to discriminate between proper rea-
sons for not taking action and rationalisations for not doing
so. Once you become adept at making such discriminations
you will be able to respond productively to your rationalisa-
tions and thus you will choose not to act on their content.
5. The more you structure your environment to help you
take productive action, the more you will be able to do so.
Structuring your environment depends, in part, on you
understanding how to get the best out of yourself with
respect to putting your CBT-derived learning into practice.
Thus, I am more likely to write when I am in an environ-
ment where there is hustle and bustle around me (e.g. in a
coffee bar) than when I am in a silent environment. Con-
sequently, I seek out coffee bars in which to write. Think
about the importance of structuring your environment
when planning to put into practice what you have learned
from your CBT sessions and choose an environment, if you
can, that will help you to do this practice.
Homework Assignments
CBT therapists often refer to activities that clients under-
take to put into practice what they have learned in therapy
sessions as “homework assignments.” Some people, however,
do not like the term “homework” given the negative con-
notations that it has for them with respect to their school
experiences, for example. If this is the case for you, inform
your therapist and together choose a term that is more

acceptable to you.
In this section, I will deal with two main issues: (i) nego-
tiating homework assignments and (ii) reviewing homework
assignments.
Negotiating Homework Assignments

With respect to negotiating homework assignments with you,
you can expect your therapist to do the following:
Negotiate a Homework Assignment With You

Your therapist will not tell you what to do between therapy
sessions. Rather, she will negotiate a suitable homework task
with you.
Help Ensure That the Homework Assignment Is a

Relevant One
Such a task should follow logically from what you have dis-
cussed in the therapy session. It may involve you reading
something, identifying certain types of thoughts, examin-
ing such thoughts, imagining acting differently or actually
doing so. The type of homework assignment should also be
relevant to the stage reached by the two of you on the problem
or issue you are working on together.
Ensure That You Understand the Nature of the

Negotiated Task and Its Therapeutic Purpose
If you don’t understand what you have agreed to do or why
you have agreed to do it, it is important that you speak up
and say so.
Work With You to Select a Homework Task That Is

“Challenging, but Not Overwhelming” for You
Thus the task should not be too easy for you (and thus of very
limited therapeutic power) or too difficult for you (in which
case you will not do it).
Introduce and Explain the “No Lose” Concept of

Homework Assignments to You
Your therapist will explain that if you do the assignment,
then that is good because it is likely that you have benefit-
ted from doing so, and if you don’t do the assignment, good
can come out of that too, since this will help you to under-
stand more about both the nature of your problem and the
obstacle(s) to making progress. I will discuss this latter issue
in Chapter 7.
Ensure That You Have the Necessary Skills to

Carry Out the Homework Assignment and
Believe You Can Do It
If you lack the skills to carry out a homework assignment,
then no amount of determination will make up for this lack.
If you do lack certain skills that are important for you to
acquire before you do the assignment, then your therapist
will help you to acquire them. If, on the other hand, your
therapist thinks you have such skills in your repertoire
and you don’t, then it is important that you speak up and
tell her.
Allow Sufficient Time in the Session to Negotiate the

Homework Assignment Properly With You
Novice CBT therapists know that they “should” negotiate
homework assignments with their clients, but often lose track
of time in therapy and realise, often very late, that the therapy
session is ending and they have not helped their clients set
homework. Consequently, they panic and often end up by uni-
laterally “giving” their clients homework assignments rather
than taking their time to negotiate such assignments prop-
erly with their clients. If your therapist is experienced, then
she will manage the session sufficiently to enable her to
spend time on negotiating a suitable homework assignment
with you. If not—and don’t forget your therapist is human—
remind her about the topic of homework if it looks as if she
may have forgotten.
Elicit a Firm Commitment From You That You Will

Carry Out the Homework Assignment
It is one thing for you to agree to carry out a homework assign-
ment, it is another thing to commit yourself to doing so. Thus,
you can expect your CBT therapist to ask you for a firm com-
mitment to do the task that you have both negotiated and to
explore any reluctance that you have to do so.
Help You Specify When, Where and How Often You Will
Carry Out the Homework Assignment
The more specific you can be concerning when, where and how
often you will carry out the negotiated homework assignment,
the more likely it is that you will do so. Thus, you can expect
your therapist to ask you to give her such specific undertak-
ings. Otherwise, you may be tempted to delay carrying out
the assignment, perhaps leaving it till the last minute. If this
happens, it will mean, in all probability, that you won’t get the
most out of doing the agreed assignment.
Encourage You to Make a Written Note of the Homework

Assignment and Its Relevant Details and to Refer to It
When Appropriate
When clients do not carry out their homework assignments,
one of the main reasons they give is that they forgot what the
homework was and that they hadn’t made a written note of
the task. Thus, you can expect your therapist to ask you to
make a written note of the agreed assignment and to suggest
that you refer to this written note periodically so that you do
not forget what it was when you come to do it.
Elicit From You the Potential Obstacles to

Homework Completion and Help You Deal in
Advance With Any Such Obstacles
In the next chapter, I will discuss the more general issue of
why you may not be making as much progress in CBT as you
may reasonably expect. One of the main reasons for lack of
progress is failure to complete homework assignments. Thus,
you can expect your therapist to explore with you, in advance,
possible obstacles to homework completion and how these

might be dealt with. If you have continued difficulty in car-
rying out such tasks, I suggest that you fill out the form in
Appendix 2 and discuss your responses with your therapist.
Help You to Rehearse the Homework Assignment in

the Session, If Practicable
If doing so is practicable and there is sufficient time, then your
therapist may suggest that you rehearse your agreed home-
work assignment in the therapy session. The reason for this is
twofold. First, it gives you experience of doing the assignment
in controlled conditions so you can get a sense of what doing
it in the outside world might be like. Second, it may help you
and your therapist to identify and problem-solve an obstacle
to carrying out the assignment not already identified.
Reviewing Homework Assignments

Unless you review your homework assignments with your
therapist in the following sessions in which they were nego-
tiated, it is unlikely that you will consider them to have the
level of importance that they actually have in CBT. Again, it
is worthwhile keeping in mind that one of the most robust
research findings in CBT is that people who routinely carry
out homework assignments get a lot more out of the process
than those who do not. With this in mind, with respect to
reviewing homework assignments with you, you can expect
your therapist to do the following:
Check With You Whether or Not You Did

the Homework Assignment
Unless your therapist checks with you concerning whether
or not you did the task and what your experiences of doing so
were, then she will be implicitly communicating to you that
doing such tasks are not important in CBT when, in reality,
they are. Such a review is usually done at the beginning of
the next session so that you can usefully prepare what you
are going to say about doing (or not doing) the assignment in
advance of the session, as I discussed in Chapter 4.
Determine the Reasons Why You Did Not Do the

Assignment as Agreed, If This Was the Case, and
Address With You Any Obstacles
If you did not do the homework assignment, then you may
expect your therapist to explore with you the reasons for this.
You might usefully prepare for this discussion by complet-
ing the form to be found in Appendix 2 and bringing your
responses to therapy. Ideally, your therapist’s stance here
should be to be genuinely interested in identifying any obsta-
cles to homework completion with a view to helping you to
address these obstacles rather than to reprimand you for not
doing the assignment. If the latter is the case, speak up if
you can and tell your therapist that her stance is not helpful
to you. I will discuss the issue of you speaking up and giving
your therapist feedback in greater detail in Chapter 7.
Check Whether You Made any Modification(s) to

the Assignment and If So, Determine the
Reasons for the Modification(s)
You may have done your homework assignment and you may
have thought you had done so successfully, but you may have
changed the assignment to make it easier for you to carry it
out. In doing so, you may have reduced the therapeutic power
of the assignment. Given this, you may expect your thera-
pist to enquire in some detail about what you actually did
to determine whether or not this was the case. If it was, your
therapist will help you to discover what led you to make the
modification and to deal with this factor if it helps you unwit-
tingly to maintain your problem. It is important that your
therapist both acknowledges what you achieved by doing the
assignment as well as pointing out to you the problems raised
by the modification you made to it.
Bernice agreed to deal with her anxiety about going shop-

ping and losing control in supermarkets by practising her
newly developed belief about the “horror” of not feeling in
control and doing so on her own in a supermarket with-

out access to support from others. She reported that she
did this and that the prospect of losing control seemed
more manageable. However, on closer questioning, Ber-
nice admitted that during the task she had phoned her
daughter for support and even though she did not speak
to her daughter, she gained support from knowing that
her daughter was there on the open phone line should she
need her. The therapist acknowledged the stride forward
that Bernice had made by going to the supermarket on
her own, but discussed with her that she only thought
that she could do so if she had direct contact with her
daughter. This led to an exploration of Bernice’s nega-
tive thoughts about doing the task without such support
and a negotiated new assignment where she went to the
assignment without her mobile phone based on the work
she and her therapist did on her negative thoughts.
Review What You Learned From

Doing the Assignment
Doing the assignment as agreed is important, of course, but
what you learned from doing so is, in some ways, more impor-
tant. So expect your therapist to ask you what you learned
from doing the task. Sometimes what you learned may not be
that helpful to you. Thus, you may learn from giving a public
speech that nobody laughed and that nobody will laugh when
you give the speech as a homework assignment. While it is
good for you to learn that nobody laughed when you predicted
that everybody would, it is unreasonable to jump to the con-
clusion that nobody will laugh in future. Here, your therapist
might suggest that it would be helpful to prepare for being
laughed at even though this event may be unlikely.
Deal With Homework “Failure”

You may have done the assignment and derived no benefit
from it and thus you may consider the homework to have been
a failure. As discussed earlier in this section, there are times

when your therapist will carefully examine what you did,
what happened and your thinking about the experience, and
exploring homework “failure” is one of those times. Remember
what I said earlier in this chapter about the “no lose” concept
of homework completion. If your homework was a “failure,”
then that is bad, but the good thing to come out of it is under-
standing reasons for the failure and using what you and your
therapist discovered in this process to help yourself more
effectively in the future.
Capitalise on Your Success

While I have concentrated on some of the difficulties that you
might experience in the area of homework assignments in
CBT, I want to stress that very often clients do their tasks
as agreed and gain a lot from doing so. When this happens,
you can expect that your therapist will help you to capital-
ise on your success and encourage you to use your derived
learning to further your progress on the problems that you
are focusing on and perhaps to apply this learning to your
other problems as well.
Applying what you learn from therapy sessions to your
everyday life is the heart of CBT, in my view. However, as we
have seen, CBT does not always go smoothly, and in the next
chapter, I will focus on the issues that emerge when you don’t
make the expected progress from your therapy.
7
Understand and Deal With
Lack of Progress
Sometimes in therapy people do not make the progress that

they can be expected to have made and it is important that
you realise that this may happen with you. If it does occur,
you should ideally be prepared to join your therapist in look-
ing for reasons for such lack of progress and in dealing with
these obstacles to change accordingly. In this chapter, I will
consider some of the common reasons for lack of progress and
suggest ways in which you can best deal with them.1 I will use
the following structure in this chapter:
• Lack of progress due to problems in the working alliance

• Lack of progress due to client factors
• Lack of progress due to therapist factors
I will discuss the most common obstacles to progress that

occur in each of the above categories before discussing the
more general issue of how you and your therapist can address
such obstacles.
Understanding the Sources of Lack of Progress

Lack of Progress Due to Problems in
the Working Alliance
Having a good working alliance with your therapist is what
sustains therapy over the course, and thus if you are not
making progress, it is important that you and your therapist
investigate the possibility that there is a problem in the alli-
ance that needs addressing.
52 UNDERSTAND LACK OF PROGRESS
The Therapeutic Bond Between You and

Your Therapist Is Not Good
The bonding aspect of the working alliance concerns the
feeling tone that exists in the relationship between you and
your therapist. Thus, if you don’t have good feelings for one
another, this may have a negative effect on your progress. My
view is that while you can still make progress in therapy if
you and your therapist don’t like one another, it is more dif-
ficult to do so if there is not mutual respect or if you do not
have confidence in your therapist’s expertise.
The Therapeutic Bond Between You and

Your Therapist Is Too Good
You may think it strange that getting on too well might be a
reason why you may not be making progress in CBT, but it
certainly can happen. You and your therapist may enjoy each
other’s company so much that you may drift away from the
primary objective concerning why you are seeking therapy—
to address your emotional problems.
I introduced the following points in Chapter 3 when I was
talking about the therapeutic agreements that you need to
make with your therapist in CBT, but since disagreements on
these points may explain lack of progress, I will discuss them
briefly here (see also Chapter 3). Please note that while the
disagreements that I discuss below may be clear and explicitly
stated, they are more often implicit and therefore not stated.
You and Your Therapist Disagree on

the Nature of Your Problem(s)
If you consider that you have a problem with guilt, for exam-
ple, while your therapist considers that your problem is one of
shame, you may end up by talking at cross purposes, and since
these two emotions are underpinned by different thoughts/
beliefs and associated with different behaviours, this may
result in you focusing on the wrong factors and may result in
lack of progress.
UNDERSTAND LACK OF PROGRESS 53
You and Your Therapist Disagree About

the Goals of Therapy
You and your therapist may agree on the nature of your prob-
lem, but may disagree concerning the goals of therapy with
respect to this problem. Thus, you both may agree that you
have a problem with extreme suppressed anger, for example,
but while you think that the goal of therapy should be to help
you to get your anger out of your system, your therapist may
think that the goal should be to help you to express yourself
with respectful annoyance. If this is the case, you will be going
in one direction while your therapist will be going in another,
which again may result in lack of progress.
You and Your Therapist Have Disagreements

About the Focus of Therapy
While nothing is ruled out when it comes to you discussing
your problems, as I pointed out in Chapter 1, the focus of CBT
is largely on the present and the future, and when the past is
discussed it is done so in a way that facilitates understand-
ing of these two foci. Thus, if you want to discuss your past
experiences extensively without regard to the present and the
future, then you may not make progress if your therapist does
not join you in a comprehensive examination of your past.
CBT theory would also hypothesise that you may not make
much progress even if your therapist does join you in this
exploration, since while you are going over the past with her,
you are still being influenced by the cognitive-behavioural
factors that underpin your problems both in the present and
going forward into the future.

Your Respective Roles
As discussed in Chapter 3, CBT involves you and your thera-
pist both adopting an active and collaborative role in therapy,
and when this does not happen for any reason, you may not
make as much therapeutic progress as when it does. While the
most common occurrence on this issue concerns the client not

assuming an active role, it may also happen that a therapist
may not be active in the process or may fail to be sufficiently
collaborative with the client.

Therapeutic Tasks or Experience Other
Problems About These Tasks
Therapeutic tasks are activities that you and your therapist
engage in with the purpose of helping you to achieve your
therapeutic goals. If you both do not agree that undertaking
these tasks is helpful, then this may compromise your prog-
ress. Even if you do agree on this point, things may go wrong,
as shown in the following vignette.
Gerald was seeking help from a CBT therapist for

depression and readily agreed with the cognitive-behav-
ioural conceptualisation of his problems. His therapist
taught him to use a form that was designed to help peo-
ple identify and respond to troublesome thoughts that
underpin depression, and Gerald could see the sense
of doing this. However, Gerald had very poor spelling,
about which he was ashamed, and this resulted in his
not completing the forms as requested by his therapist.
His sense of shame prevented him from bringing up this
obstacle with his therapist.
Lack of Progress Due to Client Factors

When I say that you may be largely responsible for your lack
of progress, it is not to blame you, but to help you to address
such obstacles fair and square. With that in mind, let’s look at
some common client obstacles to change.
You Believe That Change Is Not Possible

If you think that change is not possible, you will not engage
fully with the CBT process and consequently you will not get
as much out of the process than if you do think that you can
change.
You Opt for Short-Term “Solutions” to

Your Problem(s)
We, as human beings, generally seek to make ourselves com-
fortable whenever we experience discomfort, and this is not
a problem for us as long as there is no good reason for expe-
riencing such discomfort. Since achieving your therapeutic
goals generally involves discomfort, unless you are prepared
to experience such discomfort, then your progress will be very
limited. Signs that you are opting for the short-term solution
of getting rid of the discomfort associated with your problem
rather than being prepared to experience discomfort in the
short term while facing your problem and dealing with it are
many but include:
• denying that you have a problem,

• overcompensating for your problem
• and using safety-seeking behaviours to avoid experiencing
your problem
Luke was anxious about meeting new people, especially

in social settings. In order to deal with this problem,
Luke would (i) avoid such occasions, or if he could not
do so, he would (ii) pretend that he had lost his voice
so he did not have to speak to people. He would also
(iii) consume quite a lot of alcohol to “take the edge off”
his anxiety, as he put it. In CBT, his therapist helped
him to see that while these three behaviours kept his
anxiety at bay in the short term, they did not help
him deal with his anxiety problem in the longer term.
Luke learned more adaptive ways of dealing with his
anxiety and resolved to put this learning into practice
rather than use the three short-term “solutions.” How-
ever, Luke did not make as much progress as possible
because it transpired that he managed to get one of his
friends invitations to these social events and he spent

time with that person rather than talking to people
whom he did not know while practising the CBT skills
that he learned in his therapy sessions and agreed to
practise for homework.
You Have Doubts, Reservations and Objections to

Aspects of Your Therapy That You Do Not Disclose
CBT is based on a particular way of making sense of your
problems, of explaining how you may have unwittingly main-
tained these problems and what you need to do to address
them effectively. In order to get the most out of CBT, you
need to collaborate with your therapist in developing these
problem-based and therapy-based understandings. When you
don’t make as much progress as expected, it may be due to one
or more doubts, reservations or objections that you have with
respect to these understandings that you have not expressed,
the existence of which have negatively affected your partici-
pation in therapy.
Carol had a problem with chronic guilt and was easily

manipulated by others, with the result that she would
always put others before herself. She worked closely with
her CBT therapist to develop a conceptualisation of her
problems, and together they worked to devise a way of
addressing these problems effectively. However, despite
doing all her agreed homework assignments, Carol did
not make much progress in therapy. After therapy fin-
ished, Carol admitted to her friend that she had several
doubts about the treatment plan that she, at least on the
surface, was involved in developing with her therapist.
She told her friend that she did not tell her therapist her
doubts because she did not want to upset her therapist.
This was the case even though her therapist had asked
her if she had any doubts, reservations or objections to
any aspect of therapy.
You Think That Intellectual Insight

Is Enough to Help You
In CBT there are two forms of insight, what might be termed
“intellectual insight” and “emotional insight.” When you
have intellectual insight, you understand and agree with
some aspect of your therapy, but this insight has not yet
impacted on your feelings and behaviour. Emotional insight,
on the other hand, does impact on your feelings and behav-
iour. Thus, you may know that making an important error
does not make you a less worthwhile person, but this insight
(intellectual) will not impact on your feelings and behav-
iour until you act on it and keep doing so until you come to
believe it. Thus, you may not make much progress in CBT
if you believe that intellectual insight is enough to achieve
your goals.
You Are Not Prepared to Work for Change

As I have discussed throughout this book, CBT depends on
you taking an active role in the therapeutic process both
inside and outside the therapy room. So, if you are not pre-
pared to work for change, then you will not make very much
progress. Here are some common progress-blocking attitudes
that people have in this area:
• “I shouldn’t have to help myself, it is my therapist’s job to

help me.”
• “I’m too lazy to help myself.”
• “I don’t have the time to carry out homework assignments.”
If you hold these or similar attitudes, you need to discuss

them with your therapist.
You Are Intolerant of the Discomfort and

Unfamiliarity Associated With Change
While you can achieve a lot from CBT, you will not do so
(i) unless you are prepared for the discomfort of facing up to
and discussing painful issues and (ii) unless you are prepared
to tolerate the unfamiliarity that you will experience during

the process of change. As I often say: “If it isn’t strange, it isn’t
change.” So if you are intolerant of such discomfort and feel-
ings of unnaturalness, then you will not make much progress
in CBT, and to remedy this, you need to discuss this with your
therapist.
Lack of Progress Due to Therapist Factors

So far I have discussed possible reasons why you have not
made much progress in CBT that are due to problems in
the working alliance that you have with your therapist or
to factors within you as a client. However, your therapist
may be largely responsible for your lack of progress, and I
will briefly discuss some of these therapist factors in this
section.
Your Therapist Lacks Important General

Therapeutic Skills
One of the most common therapist factors that impedes client
progress is that the therapist lacks general therapeutic skills.
When a therapist lacks general therapeutic skills:
• She fails to listen to you or empathise with you

• She consistently puts words into your mouth
• She interacts with you in a way that reinforces your
problems (e.g. she is too active, and this reinforces your
problematic passivity)
• She has unreasonably high or unreasonably low expecta-
tions of you, which results in her either pushing you too
much or too little
• She is too forceful in making points and fails to elicit or
take into account your views
• She misjudges what stage of change you are in and works
with you in the wrong stage of change (e.g. she assumes
that you are ready to change something when you are, in
fact, ambivalent about doing so)
Your Therapist Lacks CBT-Specific Skills

One of the other most common therapist factors that impedes
client progress is that the therapist lacks CBT-specific skills.
This is why it is important that you check the credentials of
your CBT therapist, as there are many therapists who say
that they practise CBT when they are not fully qualified to
do so. However, consulting a qualified CBT therapist, while
important, is no guarantee that the therapist will not lack
core CBT-specific skills. When a therapist lacks such skills:
• She fails to understand accurately your problems in CBT

terms
• She fails to explain clearly her understanding of your prob-
lems even if this may be accurate
• She fails to suggest a CBT approach that, if you both use it
properly, will help you deal effectively with your problems
• She suggests an effective CBT approach to your problems
but implements this poorly
• She is poor in negotiating and reviewing suitable home-
work assignments
• She does not identify and address effectively reasons why
you may not be making expected progress in CBT
Your Therapist Has Personal Issues/Problems

That Interfere With Her Helping You
It is important for you to recognise that your therapist is
human and is not immune from the problems and issues that
all human beings are capable of experiencing. Having said
that, it is realistic for you to expect that whatever problems
your therapist may have will not intrude on your therapy.
Sadly, this is not always the case, and here are some exam-
ples where the therapist’s issues/problems do interfere with
therapy and may help to explain your lack of progress:
• Your therapist has the same problem as you and has not
been able to help herself with that problem, with the result
that she fails to offer you credible help
• She believes that she needs your approval, with the result
that she fails to confront you appropriately
• She believes that her worth depends on your progress, with
the result that she may get angry or defensive if you don’t
make the progress that she expects
• She has a problem with impatience and seems to get impa-
tient or irritable if you fail to understand something or
when therapy does not go smoothly
• She disturbs herself about your problems, with the result
that she cannot gain the professional distance she needs to
help you effectively
Dealing With Lack of Progress

When you are not making as much progress as you might rea-
sonably expect for one or more of the reasons discussed above
(or for other reasons), it is important that you and your thera-
pist address this issue. If you do not do so, it is unlikely that
you will be able, on your own, to overcome these obstacles to
progress.
Most people would say, rightly in my view, that it is mainly
your therapist’s responsibility to initiate a discussion con-
cerning these reasons, even if you have brought up the issue
of lack of progress in the first place. However, you also have a
responsibility to speak up, since your therapist will not be able
to read your mind and deal with matters without your active
participation in this process. I will discuss both your and your
therapist’s responsibility for dealing with lack of progress in
the rest of this chapter.
Your Therapist’s Responsibility for Dealing

With Lack of Progress
If your therapist thinks that you are not making progress
as expected, then it is important that she brings this to your
attention and initiate a discussion about this. Your therapist
should preferably also initiate such a discussion when you
have brought up the issue of lack of progress. When your
therapist initiates such a discussion, then this will go better
if she has already established what is known as a “meta-

therapy dialogue” with you. This is a technical term which
refers to a process where you and your therapist stand back,
as it were, and reflect on issues pertaining to therapy. If your
therapist has already set up such a dialogue with you, then
the subsequent discussion about lack of progress should
go more smoothly than if such a dialogue has not yet been
established.
Once the discussion about lack of progress has been initi-
ated, there are two major things that your therapist needs to
do to increase the chances that this discussion will be fruit-
ful, as discovered by Jeremy Safran and his team at the New
School Center for Psychotherapy Research in New York.
Your Therapist Needs to Adopt a Flexible and

Negotiable Stance in the Discussion
Safran and his colleagues say that when your therapist does
so, then you will say things like:
• “My therapist and I are good at finding a solution if we

disagree.”
• “I do not feel that I have to pretend to agree with my
therapist’s goals for our therapy so that the sessions run
smoothly.”
• “I feel like I have a say regarding what we do in therapy.”
• “My therapist is flexible and takes my wants or needs into
consideration.”
• “I do not feel that my therapist tells me what to do and has
regard for my wants or needs.”
• “My therapist is flexible in her ideas regarding what we do
in therapy.”
As you can see from the above statements, when your

therapist establishes a flexible and negotiable stance, this
will help both of you to reflect on the reasons for your lack of
expected progress as a client. Compare this with what you are
likely to say if your therapist is rigid and not open to negotia-
tion about possible reasons for your lack of progress.
• “I feel that my therapist tells me what to do, without much

regard for my wants or needs.”
• “My therapist is inflexible and does not take my wants or
needs into consideration.”
• “My therapist is rigid in his/her ideas regarding what we
do in therapy.”
• “I feel like I do not have a say regarding what we do in
therapy.”
• “I pretend to agree with my therapist’s goals for our ther-
apy so the session runs smoothly.”
• “My therapist and I are not good at finding a solution if we
disagree about what we should be working on in therapy.”
Indeed, if your therapist routinely displays such closed

mindedness, this may be a prime reason for your lack of prog-
ress. Most therapists at times show a closed-minded attitude,
but if yours does so routinely, then you may need to consult a
different CBT therapist!
Your Therapist Needs to Demonstrate That

She Is Comfortable Dealing With Disagreement
and With Any Negative Feelings That You
Might Express
Safran and his colleagues say that when your therapist does
so, then you will say things like:
• “I feel that I can disagree with my therapist without harm-

ing our relationship.”
• “My therapist encourages me to express any concerns
I have with our progress.”
• “I am comfortable expressing disappointment in my thera-
pist when it arises.”
• “My therapist encourages me to express any anger I feel
towards her.”
• “My therapist is able to admit when he/she is wrong about
something we disagree on.”
• “I am comfortable expressing frustration with my thera-
pist when it arises.”
As you can see from these statements, if your therapist

can comfortably hear and, indeed, invite your negativity about
aspects of the therapy and the way in which she is working
with you, you are likely to feel able, in turn, to be honest about
your negative feelings about your lack of progress and the
things that may be hindering such progress. You will also feel
free to say what you don’t like about the therapy.
Compare this with what you are likely to say if your ther-
apist is uncomfortable dealing with disagreement and with
your negative feelings about her or your therapy.
• “I don’t feel that I can disagree with my therapist without

harming our relationship.”
• “My therapist does not encourage me to express any con-
cerns I have with our progress.”
• “I am not comfortable expressing disappointment in my
therapist when it arises.”
• “My therapist does not encourage me to express any anger
I feel towards her.”
• “My therapist is unable to admit when he/she is wrong
about something we disagree on.”
• “I am not comfortable expressing frustration with my ther-
apist when it arises.”
The chances are that you will be reluctant to be honest

about your thoughts and feelings about why you may not be
progressing in therapy. Most therapists at times show dis-
comfort about disagreement and about hearing something
negative about therapy, but again, if yours does so routinely, a
change of CBT therapist may be in order!
Your Therapist Needs to Give You Honest

Feedback About How Therapy Is Proceeding and
What Factors Might Explain Your Lack
of Progress
To the above factors suggested by Safran and his colleagues
I would add a third. As well as being able to take bad news as
demonstrated above, your therapist also needs to be able to
give bad news in offering her opinion about why you may not
be making expected progress. A good therapist has the ability
to be honest without discouraging you in the process. Thus, if
your therapist considers that a major reason for your lack of
progress is your failure to apply yourself in a consistent way
to carrying out homework assignments, then she should say
so, but in a way that shows that you could apply yourself and,
as importantly, in a way that engages you in an honest explo-
ration of why you may not be applying yourself as consistently
as you might. I should add that it is particularly important for
your therapist to be honest if you have unreasonable expec-
tations about change and you are, in fact, making as much
progress as you might be expected to be making. Encourag-
ing you to develop more realistic expectations about progress
may help you to re-invest in the process of CBT and make
advances in a slower, but perhaps more sustained manner.
If your therapist does not give you genuine feedback, she
may be depriving you of the opportunity to address some
uncomfortable truths which, if addressed, may well help you
to make more progress in therapy.
Your Responsibility for Dealing With

Lack of Progress
Having outlined what responsibility your therapist has in
dealing with your lack of progress, let me be clear and state
that you also have responsibility here. My view is that your
responsibility is to speak up and be honest. Yes, as we have
seen, your therapist can facilitate or hinder you in this regard,
but no matter how facilitative your therapist is, you still have
a choice whether or not to speak up and be honest. You may
well be apprehensive about being assertive in this regard for
fear of hurting your therapist’s feelings, for example, but if
you don’t take the risk, particularly when your therapist has
demonstrated her flexibility and comfort in dealing with diffi-
cult issues, then remember this: your therapist can’t help you
with something about which she does not know.
However, if you don’t feel able to speak up and be hon-
est about something that may be hindering your progress in
therapy, then you can talk about your difficulty about doing
so. In this, your therapist can help in two ways. First, she can
help you overcome your fear of speaking up, and then when
you have spoken up, she can help you with whatever you have
spoken up about.
Violet was seeking help for a chronic problem with pro-

crastination. She was making good progress with this
until her therapist put forward the hypothesis that a
component of her problem was due to autonomy issues.
She privately disagreed with this hypothesis but told her
therapist that she agreed. It was when she stopped mak-
ing progress that her therapist encouraged a discussion
about possible reasons for this. During this discussion,
Violet told her therapist that she found it difficult to be
honest with him. He helped her to investigate this with
him and this then encouraged her to tell him that she
thought he was wrong about his autonomy hypothesis.
He demonstrated comfort with this feedback, and with
therapy properly recalibrated, she began to make prog-
ress again.
By identifying and addressing the reasons for your lack of

progress, you should be able to make the progress you were
expecting and eventually achieve your goals. When this hap-
pens, it may be time to end therapy. However, you also have
the possibility, if practicable, of learning how to be your own
therapist, and I will discuss this issue in the following and
final chapter.
Note
1. In this chapter, when I discuss lack of progress, I refer to instances
when you are not making as much progress as you might rea-
sonably be expected to be making. You may, of course, have
unreasonable expectations of progress with respect to your prob-
lems and are, in fact, making expected progress. This is something
that your therapist will discuss with you, as I will make clear later
in the chapter.
8
Become Your Own
CBT Therapist
One of the major goals that your CBT therapist is likely to

have is to help you to become your own CBT therapist. This
means that you will be helped to develop a number of skills
which you will be encouraged to use increasingly for your-
self over the course of therapy with the aim of using them for
yourself when formal therapy has ended.
While this is a major aim of CBT, it is important to note
that as a client you may or may not be interested in learning
to use CBT-based self-help skills for yourself after therapy has
ended, or if you are, you may be interested in doing this infor-
mally in your own way and may not wish to learn these skills
in a more structured, formal way. The important point, and
one that I have stressed throughout this book, is that effec-
tive CBT therapists are prepared to tailor their approaches
according to their clients’ idiosyncratic situations and prefer-
ences. Having said that, in this final chapter, I am going to
discuss what you can expect from CBT if you are interested
to learn to become your own CBT therapist. In doing so, I will
not discuss specific skills that may or may not be relevant to
you; rather, I will focus on categories of skills that are likely
to have broader relevance.
Learning Assessment Skills

When you are working towards becoming your own CBT
therapist, it is important that you learn how to identify the
important factors that comprise your reactions to situations
68 BECOME YOUR OWN CBT THERAPIST
that are problematic for you. As part of this process, your ther-
apist may suggest that you use a printed form on which there
will be a number of headings and spaces under those headings
for you to write down your responses. There are a number of
such forms and the one suggested by your therapist may be
dictated by the approach to CBT that she practises and/or the
nature of your problem(s) for which you are seeking help.
Assessment forms are usually designed to help you to
assess specific information. They may or may not include infor-
mation detailing how to complete them. Once you have filled
out such a form on a number of occasions, you will be able to
see more general patterns emerge that will help you to antici-
pate how you may respond so that you can help yourself early
on in a problem episode or even in advance of a likely episode.
I will discuss this in greater detail later in this final chapter.
Filling in such forms and thus learning to assess your
problems involves you being able to do the following:
• Identify the kind of situations you find difficult (e.g. speak-

ing in public)
• Identify what you find particularly disturbing about these
situations (e.g. your mind going blank)
• Identify the main troublesome emotions that you expe-
rience in these situations and the major physiological
expressions of these feelings, if relevant
• Identify the behaviours that you carry out to avoid these
situations (or what you find troublesome about them) and
the behaviors that you carry out when you are in these
situations which may make your problems worse. Here you
will also be helped to assess what happens in response to
your behaviours
• Identify how you “feel like” acting in these situations but
do not convert into overt behaviour
• Identify the most relevant cognitions (e.g. thoughts, beliefs)
that you have before, during and after you experience your
problem about the troublesome aspects of the situations
previously identified
Initially, it is likely that you will be shown how to use the

assessment form in a therapy session using a recent prob-
lem episode. Here your therapist will take the lead and guide
BECOME YOUR OWN CBT THERAPIST 69
you towards identifying the relevant information by asking

you focused questions. She will then probably ask you to com-
plete a new assessment form before the next therapy session
on another specific problem episode and will go over your
responses at the beginning of that session. She will then give
you feedback to help you to use the form more accurately. This
process will continue to the point where you can use the form
on your own.
After you have become proficient at using the form, you
will find that you may be able to carry out an assessment
in your head by referring to its categories either before you
encounter a troublesome situation or even while you are in
the midst of one. If you need help to do this, ask your thera-
pist, if she does not offer such help herself.
Learning Thinking Skills

One of the defining features of most CBT approaches is that
thinking, of some sort, is at the heart of troublesome reactions
to situations that you find problematic. I have discussed in the
previous section that one of the ways in which you can become
your own therapist is to learn and apply CBT assessment
skills for yourself. One such skill involves you identifying cog-
nitions that underpin your troublesome reactions. Different
CBT approaches stress the importance of different types of
cognition, and for some of these approaches, the importance
of these different types varies across emotional and behav-
ioural problems. This means that if you consult different CBT
therapists, you might come away being encouraged to look for
different types of cognition as part of learning how to assess
your own problems. Here is an example of the different terms
that CBT therapists use to categorise problematic thinking:
• Negative automatic thoughts (NATs)

• Thinking distortions
• Maladaptive assumptions
• Dysfunctional attitudes or schemas
• Irrational beliefs
Here is not the place to go into the meaning of such terms.

Rather, the point that I wish to make is that the types of cogni-
tion that your therapist will help you to focus on will depend,
in part, on the problem(s) for which you are seeking help, and,
in part, on your therapist’s own particular practice of CBT.
A glance at the above terms shows that problematic think-
ing is categorised as being “negative” in some way and most,
but not all, CBT therapists subscribe to this notion. These
therapists will go on to help you to respond to such thinking
as a means of changing them in some way and will teach you
skills to do this for yourself.
However, other CBT therapists contend that such think-
ing is not negative per se, and makes perfect sense in the
context in which you hold these thoughts. What makes such
thinking problematic for you, say these CBT therapists, is
your relationship with them, categorised largely by your
attempts to get rid of them. These therapists will help you
to accept the presence of such thinking and show you that
you can resume your goal-directed behaviour while accept-
ing its existence. Such practitioners are more likely to teach
you what are known as mindfulness-based thinking skills
in which, as I have said, you are shown how to accept the
presence of “negative” thinking rather than how to modify it.
Different CBT therapists will approach the teaching of think-
ing skills in different ways, and it is important that your CBT
therapist finds out from you how you best learn such skills
and tailors her interventions accordingly.
Learning “Modifying Thinking Skills”

I mentioned above that in CBT, you can be shown how to mod-
ify certain cognitions or to accept their presence. When your
therapist teaches you “modifying thinking skills,” it is likely
that she will do so by using forms that are designed to help
you to stand back, ask questions about problematic thinking
and formulate healthier (e.g. more useful, more valid, more
logical) alternative thinking. As with learning assessment
skills, you are first shown how to use the relevant form to
modify thinking with reference to an example of one of your
problems, then you are encouraged to use the form for this
purpose as a homework task and your therapist will offer
feedback to refine your thinking modification skills once you
have reported on your homework. As you develop competence

in these skills, you will find it easier to modify problematic
thinking for yourself without using the written forms and
you should ideally aim to do this before entering situations
in which you experience your problems, while you are in such
situations, and after you leave them. Once again, your thera-
pist will help you to use these skills “in your head,” should you
require such help.
Learning “Acceptance-Based Thinking Skills”

Acceptance-based thinking skills are not generally taught
by using written forms; rather they are taught experien-
tially (i.e. by gaining experience in the use of such skills).
Here, you may be asked to identify a meaningful metaphor
which helps you to digest the idea that you can recognise the
existence of something without engaging with it, on the one
hand, and without trying to eliminate it, on the other. Your
therapist will introduce you to various exercises which will
help you to develop these acceptance-based thinking skills
and you will be expected to practise these skills in relevant
situations. How and at what rate you do this is a matter for
negotiation between you and your therapist. Finally, you will
be encouraged to practise these skills while pursuing value-
based goals.
Learning Behavioural Skills

Another area in which you can learn to be your own CBT
therapist involves you acquiring key behavioural skills which
will help you to achieve and maintain your goals. Commonly
taught behavioural skills in CBT include:
Communication Skills
Here you learn, amongst others, how to:
• listen actively to what others say

• convey your understanding of what they are saying
• and state clearly what you want to say.
These skills are particularly important to developing and

maintaining good relationships with others.
Assertion Skills
Here you learn how to state clearly your position on various
matters, which serves to help you to maintain healthy bound-
aries between yourself and others. Assertion skills enable you
(i) to convey your negative feelings to others while showing
respect for them and, equally important, they also enable you
(ii) to convey your positive feelings to them. The skills in the
first category are particularly relevant for those who often do
what they don’t want to do and therefore get taken advan-
tage of in relationships, and the skills in the second category
are more relevant for those who other people complain always
focus on negative aspects of their relationships to the exclu-
sion of the positive aspects.
Study Skills
Here you learn, amongst others, how to:
• organise what you have to do on a course of study

• digest information
• and convey your ideas in writing to enable you to achieve
your academic goals.
These are just a sample of behavioural skills that cli-

ents learn in CBT when they do not have such skills in their
behavioural repertoire and the acquisition of such skills are
important in helping them to achieve and maintain their ther-
apeutic goals.
The Process of Learning Behavioural Skills

While your CBT therapist will help you to learn and inter-
nalise the above-mentioned skills in ways that best suit your
learning style, acquiring behavioural skills as part of becom-
ing your own CBT therapist is likely to involve some or all of
the following steps:
• Your therapist will help you identify the relevant behav-

ioural skill deficit and encourage you to see how learning
this skill will help you to achieve your therapeutic goals
and how doing so will stand you in good stead for the
future. As part of this process, you will be encouraged to
share any doubts, reservations or objections to learning the
skill which your therapist will discuss with you in full.
• Your therapist will then outline the skill and break it down
into its constituent parts and will model this skill for you if
necessary and where practicable.
• You will then try out the skill, first in the therapy session if
this can be done, and be encouraged to implement the skill
in your own personal style.
• Then, you will be encouraged to practise the skill before
the next therapy session.
• You will report back on your experiences of implementing
the skill and be given feedback on how to refine it.
• Through this process of skill practice and refinement,
based on experience and feedback, you will internalise this
skill and be able to use it in the future whenever you need
to do so.
• During this process of behavioural skill learning and prac-
tice, you may encounter a variety of obstacles along the
way. I refer you to Chapter 7, where I devoted an entire
chapter to identifying and dealing with obstacles to mak-
ing progress in CBT. I want to make the point here that you
should be prepared to disclose such obstacles to skill learn-
ing and internalisation to your therapist so that together
you may understand and respond effectively to the factors
leading to the obstacle.
Learning Emotion Regulation Skills

A recent development in CBT has been the focus that ther-
apists place on helping clients to regulate their distressed
emotions so that they don’t feel overwhelmed by them. Some
of the skills that I have already discussed form a part of you
learning to regulate your emotions. Thus, looking for and
responding to the thinking that underpins your distressed emo-
tions will generally help to abate them, as will externalizing
them in some way, as it is often the act of suppressing these

emotions that adds to distress. Thus, communicating respect-
fully how you feel to another person helps in this regard, as
does writing your feelings down. In addition, learning to use
mindfulness-based skills, where you acknowledge the pres-
ence of your distressed emotion and you continue to pursue
your goals without engaging with the emotion or trying to
eliminate it, often serves to reduce the subjective nature of
your distress.
In addition to these methods, your therapist may use
some or all of the following to teach you how to regulate your
own distressing emotions:
Developing Unconditional Self-Acceptance

You might find a negative emotion particularly distressing
because you are judging yourself negatively for experiencing
the emotion. The presence of shame for having a feeling is
a good sign that you are doing this (e.g. regarding yourself
as childish and less worthwhile for feeling hurt). Here, your
therapist may teach you to accept yourself as an ordinary per-
son experiencing an understandable emotion and help you to
see that judging yourself on the basis of an experience is nei-
ther valid nor helpful to you.
Learning Self-Validation and Self-Compassion

Self-validation occurs when you are able to reassure yourself
that what you feel inside is real, is important and makes sense
given the circumstances in which you felt it. Self-compassion
extends this in three ways, as noted by the psychologist
Dr. Kristin Neff: (i) by relating to yourself with kindness,
(ii) by encouraging yourself to see that you are not different
from others but are a part of common humanity, as we all
struggle with distressing feelings at times and (iii) by encour-
aging the development of a mindful stance for your feelings
(as noted above). Your therapist will help you to take these
concepts and to use them in everyday ways and suggest the
same process of (i) practice, (ii) feedback and (iii) refinement
that I discussed earlier in this chapter.
Increasing Distress Tolerance

One of the major reasons why you may find your emotions
difficult to regulate is that your stance towards them indi-
cates that you find them intolerable. As a result, you may try
to get rid of them or away from them as soon as you begin
to experience them or you may attempt to avoid situations
in which you predict that you might experience them. Some
CBT therapists call this “experiential avoidance,” where you
literally attempt to avoid experiencing certain emotions.
In order to develop a sense of regulation over these emo-
tions, you need to increase your level of tolerance for these
emotions. As you do so, you will become less fearful of the
emotions and this will help you to deal with the issues that
underpin them.
Using Imagery to Deal With Feelings

Approaches to CBT not only focus on thinking that occurs in
words; they also focus on thinking that occurs in images. Your
therapist can thus help you to use imagery by picturing your-
self in troublesome situations and dealing constructively with
the feelings that you predict you will experience. Rehearsing
such scenarios will help you to become less afraid of your feel-
ings and to face them rather than avoid them.
Using Self-Soothing Skills

In the same way that a mother soothes her baby when the
child is upset, you can utilise your five senses to learn to soothe
yourself as a means of regulating your distressing emotions.
Learning Relapse Prevention Skills

One very important way in which you can be your own thera-
pist is by learning relapse prevention skills. These involve the
following:
• Accepting without liking the reality of lapses or slips (i.e.

temporary and non-serious return to your problems)
• Identifying vulnerability factors (i.e. factors both in the envi-

ronment and inside you that serve as triggers to lapses/slips)
• Developing and rehearsing constructive responses to these
vulnerability factors
• Facing up to these vulnerability factors in a sensible way
so that you can practise these constructive responses
• Accepting yourself if you relapse (i.e. a more serious and
enduring return to your problems) and learning from this
experience
Learning to Generalise Your Learning,

Becoming Less Prone to Emotional
Disturbance in the Future and
Pursuing Healthy Self-Development
Whether you have sought help from your CBT therapist for
one problem or for several problems, you still have the option
to add to your skills as your own therapist once you have
achieved what you were seeking from CBT. First, you can
generalise your learning; second, you can learn to become less
prone to emotional disturbance in the future; and third, you
can pursue matters of healthy self-development. Before I dis-
cuss these three issues, I want to make clear that addressing
them in therapy is dependent on three points: (i) whether or
not you want to learn these skills, (ii) whether or not your
therapist conceives working with these issues as being a part
of her role and (iii) whether or not the context in which you are
seeing your therapist permits such work, given the amount of
time that needs to be devoted to it.
As with other matters, you need to discuss such issues
with your therapist and come to an agreement on them. How-
ever, assuming that both of you want to and are able to focus
on such issues and, if relevant, you have the support of the
organization in which you are being seen, then the following
points should be borne in mind.
Learning to Generalise Your Learning

Once you have achieved your therapeutic goal, or one of them
if you have several, then you have the option of generalising
the learning that you derived from achieving your goal(s) to

tackling other problems that you may have. You do this by
working with your therapist to identify what you learned,
to see if this learning is appropriate to your other prob-
lems, and determining a plan based on your learning to
tackle these problems, if relevant. Answering the follow-
ing questions may help you in your discussions with your
therapist.
• What recurring thoughts, images and beliefs did I iden-

tify as being at the core of my problem(s) and how did I
respond constructively to them? Are these thoughts,
images and beliefs relevant to my other problems and if
so, would responding to them in a similar way also have a
constructive impact as I deal with my new problems? If so,
how can I best do so?
• What recurring behavioural patterns did I identify as being
relevant in understanding how I unwittingly maintained
my problems and what more constructive alternative
behaviours did I implement in achieving my goals? Are
these problematic behaviours also a factor in my other
problems and if so, can I also apply the more constructive
alternative behaviours that I developed in addressing my
previous problems to these new problems?
Becoming Less Prone to Emotional

Disturbance in the Future
If you want to become less prone to emotional disturbance
in the future, you need to learn and apply general patterns
of healthy thinking and constructive behaviour to a range of
adversities that are likely to be troublesome for you. Seek-
ing out such adversities, wherever possible and feasible, in a
sensible way, while using these general patterns, is probably
the best way of doing this. This is best implemented when the
task at hand is difficult, but not overwhelming for you. If you
and your therapist have decided to work on helping you to
become less prone to future emotional disturbance, the extent
to which you agree on how you will approach this task is once
again important.
Pursuing Healthy Self-Development

Have you ever wondered what is the difference between
therapy and coaching? Well, one way of distinguishing the
two is that therapy is more concerned with helping you over-
come emotional problems, whereas coaching is focused on
helping you to pursue goals that are related to healthy self-
development. While the differences are, in fact, more blurred
than this, in reality, it is a useful rule of thumb when con-
sidering the differences between cognitive behaviour therapy
(CBT) and cognitive behavioural coaching (CBC) for our pur-
poses. Thus, when you are predominantly working with your
therapist on matters largely concerned with promoting your
healthy self-development, strictly speaking, you have moved
into coaching and this needs to be acknowledged by both of
you. Most organisations that offer non-fee-paying therapy do
not regard coaching, by this definition, as part of their brief,
and if you are paying your therapist a fee and getting reim-
bursed from a private health organisation, be aware that it is
unlikely that they will pay for coaching as opposed to therapy.
However, if you are seeing a therapist privately, are not seek-
ing fee reimbursement and your therapist also has coaching
as well as therapy skills, then CBC can be seen as a logical
extension of successful CBT.
We have now come to the end of this companion guide and
I hope you have found it useful and that it has helped you get
the most out of your CBT. I would appreciate receiving any
feedback that might improve this guide based on your experi-
ences of using it. Please email me on info@windydryden.com
Appendix 1
Therapeutic Contract
with Windy Dryden
1. Length of Therapy Sessions

Therapy sessions are 50 minutes in length unless other-
wise agreed.
2. Fee
My fee is £……………… per session pro rata. The method
of payment is by mutual agreement. I will give you two
months notice of any increase to my fee.
Please note that as your contract is with me, I expect you
to pay me directly. I do not invoice insurance companies,
but will provide you with receipts for you to claim
reimbursement from them.
3. Cancellation Policy
My cancellation policy is as follows. In order for you to can-
cel a session without charge you need to give me 48 hours
notice. My full fee will be levied if this notice within this
period is not given. An exception to this is if you, or a
member of your immediate family, suffer a sudden serious
illness.
If I cancel a session, I will give you 48 hours notice. If
I do not do so, then your next therapy session will be free
of charge. An exception to this is if I, or a member of my
immediate family, suffer a sudden serious illness.
80 APPENDIX 1
4. Confidentiality Policy
My confidentiality policy is as follows. All sessions are
confidential with the following exceptions:
• If you pose a serious threat to your own life or well-being

and are not prepared to take steps to protect yourself, I
will take steps to provide such protection.
• If you pose a serious threat to the life or well-being of
another person and are not prepared to take steps to
protect them, I will take steps to provide such protection.
• If I am legally mandated to make my notes available.
• If my fees are not paid and I take legal recourse to
recover these fees.
If you wish me to provide information about our sessions

to a third party, I require notification of this request in
writing.
5. My Working Environment
• As I do not have waiting room facilities, I would be
grateful if you would ring my bell at your appointed
appointment time and not before.
• Please do not attend a therapy session if you are intoxi-
cated or are under the influence of a mind-altering drug.
• Also, as the smell of cigarette smoke lingers and may
affect other clients whom I may see after your session,
I respectfully request that you do not smoke an hour
before your session.
I have read, understood and agree to the above points.
Signature of client............... Signature of therapist..................
Print name........................... Print name....................................
Date...................................... Date...............................................
Appendix 2
Possible Reasons for Not Completing

Homework (Self-Help) Assignments
The following is a list of reasons that various clients have

given for not doing their homework (self-help) assignments
during the course of CBT. Because the speed of improve-
ment depends primarily on the amount of such assignments
that you are willing to do, it is of great importance to pinpoint
any reasons that you may have for not doing this work. It is
important to look for these reasons at the time that you feel a
reluctance to do your assignment or a desire to put off doing
it. Hence, it is best to fill out this questionnaire at that time.
If you have any difficulty filling out this form and returning
it to your therapist, it might be best to do it together during a
therapy session.
Rate each statement by ringing ‘T’ (True) or ‘F’ (False). ‘T’
indicates that you agree with it; ‘F’ means the statement does
not apply at this time.
1. It seems that nothing can help me, so there is

no point in trying. T/F
2. It wasn’t clear, I didn’t understand what I had
to do. T/F
3. I thought that the particular method my therapist
had suggested would not be helpful. I didn’t really
see the value of it. T/F
4. It seemed too hard. T/F
5. I am willing to do self-help assignments, but
I keep forgetting. T/F
6. I did not have enough time. I was too busy. T/F
82 APPENDIX 2
7. If I do something my therapist suggests I do, it’s

not as good as if I come up with my own ideas. T/F
8. I don’t really believe I can do anything to
help myself. T/F
9. I have the impression my therapist is trying
to boss me around or control me. T/F
10. I worry about my therapist’s disapproval. I believe
that what I do just won’t be good enough for her. T/F
11. I felt too bad, sad, nervous, upset (underline the
appropriate word[s]) to do it. T/F
12. It would have upset me to do the homework. T/F
13. It was too much to do. T/F
14. It’s too much like going back to school again. T/F
15. It seemed to be mainly for my therapist’s benefit. T/F
16. Homework or self-help assignments have no
place in therapy. T/F
17. Because of the progress I’ve made, these
assignments are likely to be of no further
benefit to me. T/F
18. Because these assignments have not been
helpful in the past, I couldn’t see the point of
doing this one. T/F
19. I don’t agree with this particular approach
to therapy. T/F
20. OTHER REASONS (please write them)

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How to Get the Most

How to Get the Most Out of Cognitive Behaviour Therapy (CBT):

How to Get the Most Out of Cognitive Behaviour Therapy (CBT)

Windy Dryden is in full-time clinical and consultative prac-

“Dryden’s book How to Get the Most Out of CBT: A Client’s

“Informed by a leading expert’s forty years of experience

ISBN: 978-1-138-80402-9 (hbk)

I dedicate this book to my clients past, present and future

1 Decide If CBT Is for You 1

What This Book Does

What This Book Does Not Do

is a psychotherapy tradition and not a specific psychotherapy

How is it that you have ended up either consulting or thinking

Common Factors That Span Different

• the development and maintenance of an effective working

• experiencing your therapist as someone who is genuine

As I have said, these factors are common to all approaches

• To what extent does my therapist understand my problems

While it is unrealistic for your therapist to score top marks

right for you. Second, if you do decide to discuss your concerns

CBT’s Main Specific Factors

CBT Focuses on the Way You Think and Act in the

“action tendencies.” These describe situations in which you

is deeper-level thinking, which is less easily identifiable and

helpful alternative ways of thinking. Later on these thera-

CBT Focuses on How You Unwittingly Maintain

CBT Focuses on Helping You to Put Into Practice

sessions. However, such learning is likely to be academic and

CBT Focuses on Helping You to Become

Flexible CBT therapists will be mindful of the fact that

Therapy, of whatever type, works better if the two involved

goals. So here are some of the practical agreements you will

The Length of Therapy Sessions

the latter’s invoice because the therapist, in these cases, had

The Cancellation Policy

The Total Number of CBT Sessions

problems. As I have stated previously, it can only be answered

The length of therapy depends on how many problems you

The Frequency of CBT Sessions

• when mandated to do so by the courts

Your therapist may have additional exceptions to com-

The Form of the Contract

not understand what I have said or forget the nature of the

In the previous chapter, I discussed a number of practical

therapist is saying, if you disagree with anything that she

The Nature of Therapeutic Agreements

Agreements About Your Problem(s)

Alan was having problems with his partner and was

his feelings and behaviour as problematic in this context and

Agreements About Goals

• S stands for “specific.” The more specific you can be about

them. Thus, goals such as “I want to be happy,” while laud-

While your CBT therapist will keep the concept of SMART

impose it on you in a slavish manner. As I stress throughout

Two friends, John and Jack, struggle with procrastina-

Agreements About the CBT Focus

Agreements About the Therapist and Client Roles

CBT therapists view the therapeutic relationship as collab-

Your Therapist’s Role in CBT