What are some examples of situations where this problem arises?

When you have this problem,

2: What is the worst part of the problem?

3: How is this problem affecting your life? What are some of the difficulties this problem has created
for you? In particular, are there activities you have stopped doing or are avoiding because of the
problem? Are there activities you have started doing or are doing more of because of the problem? If
avoiding…. I follow up by asking what she thinks would happen if she did not avoid them.

4: What have you done to try and cope with the problem? Have any of your coping methods helped?

5: When did this problem start?

Question to explore strength….Are there any areas of your client’s life that are going well, or any
areas where your client has persevered in the face of difficulties or adversity?

Has your client been able to accomplish developmental tasks?

Does your client have a responsible and caring relationship with either a person or an animal?

Is your client acting according to her values or goals?

Is your client accomplished or competent in a specific area?

Goal expln-I have heard a bit about your problems and how they are affecting your life. I use a CBT
model,a goal-oriented form of therapy. I am going to ask you to set some goals for yourself in
therapy and together we are going to focus on working toward them. Therapy will involve us first
understanding your problems by identifying your thoughts, feelings, physical reactions, and behavior
and how they fit together. We will then start to help you make some changes by focusing on one of
these factors at a time. Since they are all related, a change in one factor will influence all of the other
factors.

I also want to spend some time making your goals as specific as we can, as I find the more specific
the goal, the more helpful it is. Specific goals can also help us measure whether therapy is working
for you. As we talk about each goal, I would like to write it down. Would that be okay with you?

When asking these questions, you can substitute one of your client’s general goals for “less
depressed.” : Are there specific situations that you would like to be handling differently? How would
you like to behave in these situations?

If you met your goal (e.g., to be less depressed), what would you be doing differently? Or how would
you be reacting to situations differently?

If you met your goal (e.g., to be less depressed), how do you think your life would be different?

Structure expln-We’ve spent some time getting an idea of your problems and setting goals for
therapy. I want to explain how I’d like to structure the actual therapy sessions. Each week when you
come in I want to start with a brief check-in so that you can bring me up to date on anything that has
happened in your life since our last session and we can get a sense of how you are doing. Then I want
to make a list of what you would like to talk about during our therapy session. I find this helps make
our sessions more focused, and that way I can be sure that we talk about what is most important for
you. I call this setting an agenda. Often you and I will have decided on some homework that you are
going to try in between sessions. If you had any homework, I will check on how it went. At the end of
the session, we’ll spend some time summarizing what we’ve covered and make sure that we are on
the right track for you. We will also see if there is any homework that makes sense for you to try
before our next session. How does that sound to you?

Set an agenda?

What would you like to focus on today?

What shall we put on the agenda for today?

Should we make a list of what you would like to talk about today, and then choose where you would
like to start….

Homework

Review

Before we end, let’s take a moment to review. What was most important to you from our session
today?

Before our session is up, let’s take a moment to think over what we talked about today. I think we
talked about some very important things, and I want to be sure that we don’t forget them. Could you
write down anything you would like to remember?

I was thinking it would be helpful to stop and just summarize what we talked about. How could you
put what we talked about into your own words?
CLIENT IMAGES

Start with a general question. Do you have any images or memories connected with this situation?
When you think of this situation, does it bring up any images or memories?

Explore worries. Many clients who are anxious have very clear images of their feared event
occurring. If your client has a worst-case scenario, be sure to ask whether he actually sees the worst
case happening in his mind.

Ask about images that accompany your client’s feelings. Do you have any images or memories that
accompany your feelings? When you have this feeling, do you ever see pictures or images in your
mind of yourself or other people?

Ask about images that accompany your client’s verbal thoughts. Clients often have thoughts about
themselves (I don’t fit in); thoughts about others (my father is always critical of me); and thoughts
about the future (my boss will refuse to pay me overtime). You can ask, “When you have this
thought, do you see or imagine this happening? Do you get a picture in your mind of yourself or the
other person? What do you see yourself or the other person doing or saying?”

THOUGHTS

What were you thinking? Any other thoughts?

• When a client’s mood shifts, ask about thoughts.

• What does the situation mean to you? OR What does the situation mean about yourself, others, or
your future? • How is this situation a problem for you?

• What are some of the thoughts that go with your feelings?

• Let’s make a list of your worries. Do you have a worst-case scenario?

• Do you have any images?

• If the thought is a question: How do you answer this question in your mind?

• If the thought is a hope: What are you worried about?

Understand(don’t ask) . Is the situation a factual description of what occurred or does it include
feelings, physical reactions, behaviors, or thoughts? 2. Is the feeling really a feeling or is it a thought
or behavior? 3. Did the client rate their feelings and physical reactions? 4. Is the behavior a factual
description or does it include feelings, physical reactions, or thoughts? 5. Are the thoughts hot
thoughts? a. Are the thoughts about self, others, or the future? b. Are the thoughts related to the
client’s feelings?

COGNITIVE COPING You did a really good job of identifying your thoughts and catching the negative
thoughts that cause you to feel bad. I am wondering if you would be willing to examine your
thoughts. I would like to look at the evidence that supports your negative thoughts, and also at
evidence that doesn’t support your negative thoughts. Negative thoughts are like thought habits. By
that I mean they are ways of thinking that you are used to, but you have not examined whether they
are accurate. When we look for evidence, I want us to focus on facts. That way, we can evaluate the
accuracy of your thoughts. Would that be okay with you? We need to pick one thought that we want
to examine. I want to look over the thoughts you identified that go with your negative feelings and
see if we can pick one that feels the most central to you, or is the most related to your strongest
negative emotional reaction.

Questions to Identify Evidence Against Negative Thoughts • What would you say to someone who
thought this way? • What do you think a friend or someone who cared for you would say if he or she
knew you had this thought? • If you were in a better mood, what would you think? • Five years from
now, looking back, what might you think? • Is there any information that contradicts your
interpretation? Even small pieces of information? • Is there any positive information that you are
ignoring?

Questions to Gather More Information about the Situation • How did this situation come about? •
Who are the other people you will be working/interacting with? • Is there any information that
contradicts your interpretation? Even small pieces of information? • Is there any positive information
that you are ignoring? • Have you ever behaved in a similar way? What was your motivation?

Questions for a Balanced Thought • When you look at all of the evidence, what does this say about
your original hot thought? • When you look at all of the evidence, what would be a more accurate
thought? • What might be a thought that captures all of the evidence? • Let’s take a moment and
look at all of the evidence. What did you learn? • You initially interpreted the situation in a specific
way. When you look at the evidence, is there another interpretation that either makes more sense or
might be equally true? • What would you tell someone who thought the way you did, and had all of
this evidence?

Understand(don’t ask) Checklist of Common Problems with Thought Records • Is the situation a
factual description of what occurred? • Did my client identify and rate their feelings? • Did my client
identify their physical reactions? • Is the behavior a factual description of what my client did? • Is the
thought my client wants to focus on a hot thought? • Is the thought about self, others, or the future?
• Is the thought related to their negative feelings? • Does the evidence against address the hot
thought? • Does the balanced thought address the hot thought?

Questions to Help Define the Problem • What happened or did not happen that bothers you? • Who
is involved? Where does the problem happen? When does the problem happen? • Why is this
problem difficult for you? • What do you currently do to handle the problem? Are you avoiding, or
acting in an impulsive manner? • What do you hope will happen as a consequence of your behavior?

Questions to Help Define Goals • How would you like the situation to change or be different? • How
would you like other people in the situation to change or be different? • How would you like to
change or be different?

Questions to Help Find New Solutions • What are some different ways you could handle your
problem? • What would you suggest to someone who has had this problem? • What do you think a
friend or someone who cared for you would suggest if she or he knew you had this problem? • How
have you handled similar situations in the past? • How do you overcome obstacles in other areas of
your life? • Is there any positive information that you are ignoring that could be helpful in solving this
problem? • Is there an aspect of the problem that cannot be changed and that you have to accept?
(The challenge is to accept what cannot be changed and find coping strategies for what can be
changed.)

Questions to Help Choose a Solution • What are the short-term and long-term benefits of each
solution? • What are the short-term and long-term drawbacks of each solution? • How will this
solution affect me, other people, and the situation? • How will I feel after implementing this
solution? • Is this solution consistent with my values? Will implementing this solution be important
to me in terms of acting on my values? • Does the situation generally feel doable? • Does the
situation feel doable in terms of time and effort required?

When will I try my solution? • Where will I try my solution? • How can I plan for obstacles? • What is
the first step in implementing my solution?

Explain Problem Solving to Your Client Here is how I explain problem solving. We have been talking
about your problem and how hopeless you feel. Sometimes people get into negative cycles and don’t
see alternative possibilities. I am wondering if you would be willing to see if we could find some
other ways of coping with your problem. I want to explain a process called problem solving. We start
with identifying a specific problem and then we brainstorm to try to think of different possible
solutions. We are looking for as many solutions as we can find, without judging them. Once we have
thought of some alternative ways of handling your problem, I want to spend some time evaluating
the different solutions to see if there is one that makes more sense. Would you be willing to try?

Questions to Develop Coping Thoughts • What could you say to yourself that would help you cope
with this situation? • What advice could you give a friend in terms of helpful coping thoughts? •
What would someone who knows you well suggest as helpful coping thoughts? • If you were in a
more optimistic mood, what might you think? • When you have coped successfully in the past, either
with a similar or a different type of situation, what have you told yourself?

Questions to Explore a Mood/Activity Relationship • Do you see an activity/mood relationship? •

Questions to Assess Your Client’s Safety Behaviors • Are there things or situations you avoid because
of your anxiety? • Are there things you do to make yourself feel safe, or to be prepared in case of
danger, such as carrying things or being with certain people? • Is there anything you do to make
yourself feel comfortable in situations where you feel anxious?
Explain Exposure to Your Clients

We have been talking about how you avoid situations that make you anxious. We have also talked
about how avoiding these situations has not helped and has actually caused you some difficulties.
We have also talked about how being able to do the activity you have been avoiding is related to
some very important values for you. (Only say this if you have been able to make the link to your
client’s values.) I think exposure therapy would be a very helpful treatment for you. Exposure therapy
involves facing your fears. We will make a list of the situations that make you anxious, starting with
situations that are fairly easy and going up to situations that are hard for you. We will start with the
easiest and see if together we can help you learn to cope with the situation. Once you have learned
to cope with the easiest situation, we will progress to more difficult ones. We will work together and
go at whatever pace works for you. How does that sound to you? (I pause to check if my client has
any questions.) As you face your fears, you will learn not to be afraid. I want to talk a bit about
anxiety. You will feel some anxiety as we do the exposure tasks. But that’s okay; you need to feel
some anxiety for exposure to be effective. We’ll go slowly. Also, the more we face what makes us
anxious, the less anxious we feel. This means that the more you do the exposure tasks, the less
anxious you will feel and the more you will learn to manage your anxiety

Questions to Identify Your Client’s Predictions During Exposure Start by saying, “When you think of
doing the exposure task”: • What is your worst-case scenario? • What is your worst fear about what
will happen, including how other people will react? • What is your worst fear about how you will
feel, including your worst fear of the symptoms you will have? • What is your worst fear about what
you will do or how you will behave? • What do you imagine will happen? Do you see it happening?
(Clients often have images of what will occur during the exposure task.)

Questions to Identify How Your Clients Learned Their Core Beliefs • How did you learn those core
beliefs (mention the specific belief)? • What kinds of experiences did you have that taught you think
that way about yourself or others? • How do you think you learned to believe your core belief
(mention the core belief)? • Was there anything your mother, father, siblings, teacher, or other adult
did in your childhood that either taught you to believe these core beliefs or reinforced them?

Questions to Gather Evidence to Support Your Client’s New Core Belief • Can you think of any times
when this new belief was true, even a little bit? • What evidence could a friend, family member, or I
tell you about that would support this new belief? • Do you think there is any event in your life that
you tend to minimize that would support this new belief? • Are there positive experiences in your life
that you are ignoring? • If you believed your new core belief, are there aspects of your life that you
would see differently and more positively? • Are there areas of your life that are going well? • Is
there anything you did today, even a really small thing, that supports your new core belief? • Did
anyone behave toward you today in a way that supports your new core belief?

Questions to Explore the Outcome of an Experiment • What does the outcome of this experiment
suggest about your old belief? • Given this experiment, do you think your old belief is always true? •
Does the outcome of this experiment change your mind in any way about your old belief? • What do
you think might be a possible new belief, based on the outcome of the experiment?

Good Sleep Guidelines If your client has experienced persistent sleep difficulties over a significant
time period, they may benefit from CBT for insomnia, often called CBT-I. CBT-I is CBT that has been
specifically designed to address insomnia and other sleep difficulties. However, many clients can
make significant improvements to their sleep by following some simple guidelines. While these
guidelines don’t guarantee a good night’s sleep every night, they will significantly improve your
clients’ chances of having a better night’s sleep, especially if practiced regularly. By the way, many
people don’t follow these guidelines and have no trouble sleeping; that’s fine. These guidelines are
for people who do have sleep difficulties and are based on evidence of what we can do to promote
good sleep. There are roughly two types of worry thoughts that interfere with sleep. The first is
worry associated with events in your client’s life. For these types of worries I help my clients
distinguish between worries that need to be addressed and worries that need to be accepted. For
example, if I am worried that I am unprepared for a talk, I need to make a work plan. However, if I am
worried about the results of a medical test, I need to accept the uncertainty until I have the results. If
my client has a worry that needs to be addressed, I discuss how bedtime is not a good time to
problem solve. I encourage my clients to make a list of these worries and address them during the
day. If it is a worry that needs to be accepted, I encourage clients to allow themselves not to worry
and to remind themselves that they don’t know the outcome. We discuss the variety of possible
outcomes and make sure to look at any possible neutral or positive outcomes. Often distraction
methods are helpful, such as a relaxation tape. The second type of worry thoughts are worrying
about not sleeping. Clients lie in bed catastrophizing about not sleeping. For example, they worry
they will never fall asleep, or that they will be too tired to function the next day or that not sleeping
is bad for their health. I try to examine the reality of their thoughts. Most people can function, and
even function well, with a few bad nights of sleep. Plus we tend to have unrealistic expectations
about sleep needs. No matter what type of thoughts are keeping your client awake, they can often
benefit from following basic sleep guidelines (Carney & Manber, 2013; National Sleep Foundation
website, 2020). In addition, if a client is going through a stressful time, they often change their sleep-
related behaviors in ways that promote poor sleep. For example, they may stay up late binge
watching Netflix to “calm” themselves. I usually go over the Good Sleep Guidelines, which follow,
with my clients. We target one or two changes they would like to try that they think would make the
most difference. I encourage them to monitor their sleep for a week and see if the changes made a
difference.