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CBT Session Structure Outlines: A Therapist’s Guide

This article is an excerpt from the Shortform book guide to "Cognitive Behavior Therapy: Basics and Beyond" by Judith S. Beck. Shortform has the world's best summaries and analyses of books you should be reading.

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

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

Keep reading to find outlines of exemplary CBT session structures.

CBT Session Structure: Types of Sessions

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

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

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

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

The Evaluation Session

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

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

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

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

Set the agenda and convey expectations for the session.

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

Conduct the assessment.

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

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

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

Relate your impressions.

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

Set initial broad goals.

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

Elicit feedback from the patient.

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

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

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

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

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

Create goals other than what the patient has articulated.

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

Initial Therapy Session

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

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

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

Do a mood check.

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

Get an update.

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

Discuss the patient’s diagnosis.

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

Identify problems and set goals.

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

Educate the patient on the cognitive model.

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

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

Set homework. 

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

Summarize at the end of a session.

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

Elicit feedback.

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

Each Session Thereafter

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

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

Prepare for the session yourself.

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

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

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

Check on mood and medication.

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

Set the agenda.

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

Get an update on the week.

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

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

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

Prioritize the agenda.

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

Problem-solving.

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

Summarize often.

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

Obtain feedback from the patient.

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

Take notes after the session.

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

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

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• How to use CBT to overcome anxiety, sadness, anger, frustration, and stress
• How to address traumatic events earlier in your life, so that they have less hold on your thinking today
• The key ways to build rapport as a cognitive behavior therapist
• ← How to Follow Through on Commitments: Simple Skills
• Roger Revelle’s Impact on the Climate Change Debate →

Elizabeth Shaw

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

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The first CBT session

Assessment and formulation of the presenting problems.

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

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

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

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

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

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

I then begin the assessment by saying:

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

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

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

Figure: funnel style of questionning

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

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

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

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

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

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

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

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

Summary points

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

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

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

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

Dr Anita Goraya

Press and Interviews

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

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

The interview starts at minute 4:40

Adrian Chiles - Guardian Article 30 Sep 2020

read the article here...

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

© 2024 Dr Anita Goraya

Websites for therapists by : YouCan Consulting

CBT Techniques: 25 Cognitive Behavioral Therapy Worksheets

It’s an extremely common type of talk therapy practiced around the world.

If you’ve ever interacted with a mental health therapist, a counselor, or a psychiatry clinician in a professional setting, it’s likely you’ve participated in CBT.

If you’ve ever heard friends or loved ones talk about how a mental health professional helped them identify unhelpful thoughts and patterns and behavior and alter them to more effectively work towards their goals, you’ve heard about the impacts of CBT.

CBT is one of the most frequently used tools in the psychologist’s toolbox. Though it’s based on simple principles, it can have wildly positive outcomes when put into practice.

In this article, we’ll explore what CBT is, how it works, and how you can apply its principles to improve your own life or the lives of your clients.

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

This Article Contains:

What is cbt, cognitive distortions, 9 essential cbt techniques and tools.

• Cognitive Behavioral Therapy Worksheets (PDFs) To Print and Use

Some More CBT Interventions and Exercises

A cbt manual and workbook for your own practice and for your client, 5 final cognitive behavioral activities, a take-home message.

“This simple idea is that our unique patterns of thinking, feeling, and behaving are significant factors in our experiences, both good and bad. Since these patterns have such a significant impact on our experiences, it follows that altering these patterns can change our experiences” (Martin, 2016).

Cognitive-behavioral therapy aims to change our thought patterns, our conscious and unconscious beliefs, our attitudes, and, ultimately, our behavior, in order to help us face difficulties and achieve our goals.

Psychiatrist Aaron Beck was the first to practice cognitive behavioral therapy. Like most mental health professionals at the time, Beck was a  psychoanalysis  practitioner.

While practicing psychoanalysis, Beck noticed the prevalence of internal dialogue in his clients and realized how strong the link between thoughts and feelings can be. He altered the therapy he practiced in order to help his clients identify, understand, and deal with the automatic, emotion-filled thoughts  that regularly arose in his clients.

Beck found that a combination of cognitive therapy and behavioral techniques produced the best results for his clients. In describing and honing this new therapy, Beck laid the foundations of the most popular and influential form of therapy of the last 50 years.

This form of therapy is not designed for lifelong participation and aims to help clients meet their goals in the near future. Most CBT treatment regimens last from five to ten months, with clients participating in one 50- to 60-minute session per week.

CBT is a hands-on approach that requires both the therapist and the client to be invested in the process and willing to actively participate. The therapist and client work together as a team to identify the problems the client is facing, come up with strategies for addressing them, and creating positive solutions (Martin, 2016).

Many of the most popular and effective cognitive-behavioral therapy techniques are applied to what psychologists call “ cognitive distortions ,” inaccurate thoughts that reinforce negative thought patterns or emotions (Grohol, 2016).

There are 15 main cognitive distortions that can plague even the most balanced thinkers.

1. Filtering

Filtering refers to the way a person can ignore all of the positive and good things in life to focus solely on the negative. It’s the trap of dwelling on a single negative aspect of a situation, even when surrounded by an abundance of good things.

2. Polarized thinking / Black-and-white thinking

This cognitive distortion is all-or-nothing thinking, with no room for complexity or nuance—everything’s either black or white, never shades of gray.

If you don’t perform perfectly in some area, then you may see yourself as a total failure instead of simply recognizing that you may be unskilled in one area.

3. Overgeneralization

Overgeneralization is taking a single incident or point in time and using it as the sole piece of evidence for a broad conclusion.

For example, someone who overgeneralizes could bomb an important job interview and instead of brushing it off as one bad experience and trying again, they conclude that they are terrible at interviewing and will never get a job offer.

4. Jumping to conclusions

Similar to overgeneralization, this distortion involves faulty reasoning in how one makes conclusions. Unlike overgeneralizing one incident, jumping to conclusions refers to the tendency to be sure of something without any evidence at all.

For example, we might be convinced that someone dislikes us without having any real evidence, or we might believe that our fears will come true before we have a chance to really find out.

5. Catastrophizing / Magnifying or Minimizing

This distortion involves expecting that the worst will happen or has happened, based on an incident that is nowhere near as catastrophic as it is made out to be. For example, you may make a small mistake at work and be convinced that it will ruin the project you are working on, that your boss will be furious, and that you’ll lose your job.

Alternatively, one might minimize the importance of positive things, such as an accomplishment at work or a desirable personal characteristic.

6. Personalization

This is a distortion where an individual believes that everything they do has an impact on external events or other people, no matter how irrational that may be. A person with this distortion will feel that he or she has an exaggerated role in the bad things that happen around them.

For instance, a person may believe that arriving a few minutes late to a meeting led to it being derailed and that everything would have been fine if they were on time.

7. Control fallacies

This distortion involves feeling like everything that happens to you is either a result of purely external forces or entirely due to your own actions. Sometimes what happens to us is due to forces we can’t control, and sometimes what it’s due to our own actions, but the distortion is assuming that it is always one or the other.

We might assume that difficult coworkers are to blame for our own less-than-stellar work, or alternatively assume that every mistake another person makes is because of something we did.

8. Fallacy of fairness

We are often concerned about fairness, but this concern can be taken to extremes. As we all know, life is not always fair. The person who goes through life looking for fairness in all their experiences will end up resentful and unhappy.

Sometimes things will go our way, and sometimes they will not, regardless of how fair it may seem.

When things don’t go our way, there are many ways we can explain or assign responsibility for the outcome. One method of assigning responsibility is blaming others for what goes wrong.

Sometimes we may blame others for making us feel or act a certain way, but this is a cognitive distortion. Only you are responsible for the way you feel or act.

10. “Shoulds”

“Shoulds” refer to the implicit or explicit rules we have about how we and others should behave. When others break our rules, we are upset. When we break our own rules, we feel guilty. For example, we may have an unofficial rule that customer service representatives should always be accommodating to the customer.

When we interact with a customer service representative that is not immediately accommodating, we might get angry. If we have an implicit rule that we are irresponsible if we spend money on unnecessary things, we may feel exceedingly guilty when we spend even a small amount of money on something we don’t need.

11. Emotional reasoning

This distortion involves thinking that if we feel a certain way, it must be true. For example, if we feel unattractive or uninteresting in the current moment, we think we  are unattractive or uninteresting. This cognitive distortion boils down to:

“I feel it, therefore it must be true.”

Clearly, our emotions are not always indicative of the objective truth, but it can be difficult to look past how we feel.

12. Fallacy of change

The fallacy of change lies in expecting other people to change as it suits us. This ties into the feeling that our happiness depends on other people, and their unwillingness or inability to change, even if we demand it, keeps us from being happy.

This is a damaging way to think because no one is responsible for our own happiness except ourselves.

13. Global labeling / mislabeling

This cognitive distortion is an extreme form of generalizing, in which we generalize one or two instances or qualities into a global judgment. For example, if we fail at a specific task, we may conclude that we are a total failure in not only that area but all areas.

Alternatively, when a stranger says something a bit rude, we may conclude that he or she is an unfriendly person in general. Mislabeling is specific to using exaggerated and emotionally loaded language, such as saying a woman has abandoned her children when she leaves her children with a babysitter to enjoy a night out.

14. Always being right

While we all enjoy being right, this distortion makes us think we must be right, that being wrong is unacceptable.

We may believe that being right is more important than the feelings of others, being able to admit when we’ve made a mistake or being fair and objective.

15. Heaven’s Reward Fallacy

This distortion involves expecting that any sacrifice or self-denial will pay off. We may consider this karma, and expect that karma will always immediately reward us for our good deeds. This results in feelings of bitterness when we do not receive our reward (Grohol, 2016).

Many tools and techniques found in cognitive behavioral therapy are intended to address or reverse these cognitive distortions.

There are many tools and techniques used in cognitive behavioral therapy, many of which can be used in both a therapy context and in everyday life. The nine techniques and tools listed below are some of the most common and effective CBT practices.

1. Journaling

This technique is a way to gather about one’s moods and thoughts. A CBT journal can include the time of the mood or thought, the source of it, the extent or intensity, and how we reacted, among other factors.

This technique can help us to identify our thought patterns and emotional tendencies, describe them, and change, adapt, or cope with them (Utley & Garza, 2011).

Follow the link to find out more about using a thought diary for journaling.

2. Unraveling cognitive distortions

This is a primary goal of CBT and can be practiced with or without the help of a therapist. In order to unravel cognitive distortions, you must first become aware of the distortions from which you commonly suffer (Hamamci, 2002).

Part of this involves identifying and challenging harmful automatic thoughts, which frequently fall into one of the 15 categories listed earlier.

3. Cognitive restructuring

Once you identify the distortions you hold, you can begin to explore how those distortions took root and why you came to believe them. When you discover a belief that is destructive or harmful, you can begin to challenge it (Larsson, Hooper, Osborne, Bennett, & McHugh, 2015).

For example, if you believe that you must have a high-paying job to be a respectable person, but you’re then laid off from your high-paying job, you will begin to feel bad about yourself.

Instead of accepting this faulty belief that leads you to think negative thoughts about yourself, with cognitive restructuring you could take an opportunity to think about what really makes a person “respectable,” a belief you may not have explicitly considered before.

4. Exposure and response prevention

This technique is specifically effective for those who suffer from obsessive-compulsive disorder (OCD; Abramowitz, 1996). You can practice this technique by exposing yourself to whatever it is that normally elicits a compulsive behavior, but doing your best to refrain from the behavior.

You can combine journaling with this technique, or use journaling to understand how this technique makes you feel.

5. Interoceptive exposure

Interoceptive Exposure is intended to treat panic and anxiety. It involves exposure to feared bodily sensations in order to elicit the response (Arntz, 2002). Doing so activates any unhelpful beliefs associated with the sensations, maintains the sensations without distraction or avoidance, and allows new learning about the sensations to take place.

It is intended to help the sufferer see that symptoms of panic are not dangerous, although they may be uncomfortable.

6. Nightmare exposure and rescripting

Nightmare exposure and rescripting are intended specifically for those suffering from nightmares. This technique is similar to interoceptive exposure, in that the nightmare is elicited, which brings up the relevant emotion (Pruiksma, Cranston, Rhudy, Micol, & Davis, 2018).

Once the emotion has arisen, the client and therapist work together to identify the desired emotion and develop a new image to accompany the desired emotion.

7. Play the script until the end

This technique is especially useful for those suffering from fear and anxiety. In this technique, the individual who is vulnerable to crippling fear or anxiety conducts a sort of thought experiment in which they imagine the outcome of the worst-case scenario.

Letting this scenario play out can help the individual to recognize that even if everything he or she fears comes to pass, the outcome will still be manageable (Chankapa, 2018).

8. Progressive muscle relaxation

This is a familiar technique to those who practice mindfulness. Similar to the body scan, progressive muscle relaxation instructs you to relax one muscle group at a time until your whole body is in a state of relaxation (McCallie, Blum, & Hood, 2006).

You can use audio guidance, a YouTube video, or simply your own mind to practice this technique, and it can be especially helpful for calming nerves and soothing a busy and unfocused mind.

9. Relaxed breathing

This is another technique that will be familiar to practitioners of mindfulness . There are many ways to relax and bring regularity to your breath, including guided and unguided imagery, audio recordings, YouTube videos, and scripts. Bringing regularity and calm to your breath will allow you to approach your problems from a place of balance, facilitating more effective and rational decisions (Megan, 2016).

These techniques can help those suffering from a range of mental illnesses and afflictions, including anxiety, depression, OCD, and panic disorder, and they can be practiced with or without the guidance of a therapist. To try some of these techniques without the help of a therapist, see the next section for worksheets and handouts to assist with your practice.

How does cognitive behavioral therapy work – Psych Hub

Cognitive-Behavioral Therapy Worksheets (PDFs) To Print and Use

1. Coping styles worksheet

This PDF Coping Styles Formulation Worksheet instructs you or your client to first list any current perceived problems or difficulties – “The Problem”. You or your client will work backward to list risk factors above (i.e., why you are more likely to experience these problems than someone else) and triggers or events (i.e., the stimulus or source of these problems).

Once you have defined the problems and understand why you are struggling with them, you then list coping strategies. These are not solutions to your problems, but ways to deal with the effects of those problems that can have a temporary impact. Next, you list the effectiveness of the coping strategies, such as how they make you feel in the short- and long-term, and the advantages and disadvantages of each strategy.

Finally, you move on to listing alternative actions. If your coping strategies are not totally effective against the problems and difficulties that are happening, you are instructed to list other strategies that may work better.

This worksheet gets you (or your client) thinking about what you are doing now and whether it is the best way forward.

2. ABC functional analysis

One popular technique in CBT is ABC functional analysis . Functional analysis helps you (or the client) learn about yourself, specifically, what leads to specific behaviors and what consequences result from those behaviors.

In the middle of the worksheet is a box labeled “Behaviors.” In this box, you write down any potentially problematic behaviors you want to analyze.

On the left side of the worksheet is a box labeled “Antecedents,” in which you or the client write down the factors that preceded a particular behavior. These are factors that led up to the behavior under consideration, either directly or indirectly.

On the right side is the final box, labeled “Consequences.” This is where you write down what happened as a result of the behavior under consideration. “Consequences” may sound inherently negative, but that’s not necessarily the case; some positive consequences can arise from many types of behaviors, even if the same behavior also leads to negative consequences.

This ABC Functional Analysis Worksheet can help you or your client to find out whether particular behaviors are adaptive and helpful in striving toward your goals, or destructive and self-defeating.

3. Case formulation worksheet

In CBT, there are 4 “P’s” in Case Formulation:

• Predisposing factors;
• Precipitating factors;
• Perpetuating factors; and
• Protective factors

They help us understand what might be leading a perceived problem to arise, and what might prevent them from being tackled effectively.

In this worksheet, a therapist will work with their client through 4 steps.

First, they identify predisposing factors, which are those external or internal and can add to the likelihood of someone developing a perceived problem (“The Problem”). Examples might include genetics, life events, or their temperament.

Together, they collaborate to identify precipitating factors, which provide insight into precise events or triggers that lead to “The Problem” presenting itself. Then they consider perpetuating factors, to discover what reinforcers may be maintaining the current problem.

Last, they identify protective factors, to understand the client’s strengths, social supports, and adaptive behavioral patterns.

Download 3 Free Positive CBT Exercises (PDF)

These detailed, science-based exercises will equip you or your clients with tools to find new pathways to reduce suffering and more effectively cope with life stressors.

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4. Extended case formulation worksheet

This worksheet builds on the last. It helps you or your client address the “Four P Factors” described just above—predisposing, precipitating, perpetuating, and protective factors. This formulation process can help you or your client connect the dots between core beliefs, thought patterns, and present behavior.

This worksheet presents six boxes on the left of the page (Part A), which should be completed before moving on to the right-hand side of the worksheet (Part B).

• The first box is labeled “The Problem,” and corresponds with the perceived difficulty that your client is experiencing. In this box, you are instructed to write down the events or stimuli that are linked to a certain behavior.
• The next box is labeled “Early Experiences” and corresponds to the predisposing factor. This is where you list the experiences that you had early in life that may have contributed to the behavior.
• The third box is “Core Beliefs,” which is also related to the predisposing factor. This is where you write down some relevant core beliefs you have regarding this behavior. These are beliefs that may not be explicit, but that you believe deep down, such as “I’m bad” or “I’m not good enough.”
• The fourth box is “Conditional assumptions/rules/attitudes,” which is where you list the rules that you adhere to, whether consciously or subconsciously. These implicit or explicit rules can perpetuate the behavior, even if it is not helpful or adaptive. Rules are if-then statements that provide a judgment based on a set of circumstances. For instance, you may have the rule “If I do not do something perfectly, I’m a complete failure.”
• The fifth box is labeled “Maladaptive Coping Strategies” This is where you write down how well these rules are working for you (or not). Are they helping you to be the best you can be? Are they helping you to effectively strive towards your goals?
• Finally, the last box us titled “Positives.” This is where you list the factors that can help you deal with the problematic behavior or thought, and perhaps help you break the perpetuating cycle. These can be things that help you cope once the thought or behavior arises or things that can disrupt the pattern once it is in motion.

On the right, there is a flow chart that you can fill out based on how these behaviors and feelings are perpetuated. You are instructed to think of a situation that produces a negative automatic thought and record the emotion and behavior that this thought provokes, as well as the bodily sensations that can result. Filling out this flow chart can help you see what drives your behavior or thought and what results from it.

Download our PDF Extended Case Formulation Worksheet .

5. Dysfunctional thought record

This worksheet is especially helpful for people who struggle with negative thoughts and need to figure out when and why those thoughts are most likely to pop up. Learning more about what provokes certain automatic thoughts makes them easier to address and reverse.

The worksheet is divided into seven columns:

• On the far left, there is space to write down the date and time a dysfunctional thought arose.
• The second column is where the situation is listed. The user is instructed to describe the event that led up to the dysfunctional thought in detail.
• The third column is for the automatic thought. This is where the dysfunctional automatic thought is recorded, along with a rating of belief in the thought on a scale from 0% to 100%.
• The next column is where the emotion or emotions elicited by this thought are listed, also with a rating of intensity on a scale from 0% to 100%.
• Use this fifth column to note the dysfunctional thought that will be addressed. Example maladaptive thoughts include distortions such as over-inflating the negative while dismissing the positive of a situation, or overgeneralizing.
• The second-to-last column is for the user to write down alternative thoughts that are more positive and functional to replace the negative one.
• Finally, the last column is for the user to write down the outcome of this exercise. Were you able to confront the dysfunctional thought? Did you write down a convincing alternative thought? Did your belief in the thought and/or the intensity of your emotion(s) decrease?

Download this Dysfunctional Thought Record as a PDF.

6. Fact-checking

One of my favorite CBT tools is this  Fact Checking Thoughts Worksheet because it can be extremely helpful in recognizing that your thoughts are not necessarily true.

At the top of this worksheet is an important lesson:

Thoughts are not facts.

Of course, it can be hard to accept this, especially when we are in the throes of a dysfunctional thought or intense emotion. Filling out this worksheet can help you come to this realization.

The worksheet includes 16 statements that the user must decide are either fact or opinion. These statements include:

• I’m a bad person.
• I failed the test.
• I’m selfish.
• I didn’t lend my friend money when they asked.

This is not a trick—there is a right answer for each of these statements. (In case you’re wondering, the correct answers for the statements above are as follows: opinion, fact, opinion, fact.)

This simple exercise can help the user to see that while we have lots of emotionally charged thoughts, they are not all objective truths. Recognizing the difference between fact and opinion can assist us in challenging the dysfunctional or harmful opinions we have about ourselves and others.

7. Cognitive restructuring

This worksheet employs the use of Socratic questioning, a technique that can help the user to challenge irrational or illogical thoughts.

The first page of the worksheet has a thought bubble for “What I’m Thinking”. You or your client can use this space to write down a specific thought, usually, one you suspect is destructive or irrational.

Next, you write down the facts supporting and contradicting this thought as a reality. What facts about this thought being accurate? What facts call it into question? Once you have identified the evidence, you can use the last box to make a judgment on this thought, specifically whether it is based on evidence or simply your opinion.

The next page is a mind map of Socratic Questions which can be used to further challenge the thought. You may wish to re-write “What I’m Thinking” in the center so it is easier to challenge the thought against these questions.

• One question asks whether this thought is truly a black-and-white situation, or whether reality leaves room for shades of gray. This is where you think about (and write down) whether you are using all-or-nothing thinking, for example, or making things unreasonably simple when they are complex.
• Another asks whether you could be misinterpreting the evidence or making any unverified assumptions. As with all the other bubbles, writing it down will make this exercise more effective.
• A third bubble instructs you to think about whether other people might have different interpretations of the same situation, and what those interpretations might be.
• Next, ask yourself whether you are looking at all the relevant evidence or just the evidence that backs up the belief you already hold. Try to be as objective as possible.
• It also helps to ask yourself whether your thought may an over-inflation of a truth. Some negative thoughts are based in truth but extend past their logical boundaries.
• You’re also instructed to consider whether you are entertaining this negative thought out of habit or because the facts truly support it.
• Then, think about how this thought came to you. Was it passed on from someone else? If so, is that person a reliable source of truth?
• Finally, you complete the worksheet by identifying how likely the scenario your thought brings up actually is, and whether it is the worst-case scenario.

These Socratic questions encourage a deep dive into the thoughts that plague you and offer opportunities to analyze and evaluate those thoughts. If you are having thoughts that do not come from a place of truth, this Cognitive Restructuring Worksheet can be an excellent tool for identifying and defusing them.

How is positive cognitive-behavioral therapy (CBT) different from traditional CBT?

Although both forms of CBT have the same goal of bringing about positive changes in a client’s life, the pathways used in traditional and positive CBT to actualize this goal differ considerably. Traditional CBT, as initially formulated by Beck (1967), focuses primarily on the following:

• Analyzing problems
• Lessening what causes suffering
• Working on clients’ weaknesses
• Getting away from problems

Instead, positive CBT, as formulated by Bannink (2012), focuses mainly on the following:

• Finding solutions
• Enhancing what causes flourishing
• Working with client’s strengths
• Getting closer to the preferred future

In other words, Positive CBT shifts the focus on what’s right with the person (rather than what’s wrong with them) and on what’s working (rather than what’s not working) to foster a more optimistic process that empowers clients to flourish and thrive.

In an initial study comparing the effects of traditional and Positive CBT in the treatment of depression, positive CBT resulted in a more substantial reduction of depression symptoms, a more significant increase in happiness, and it was associated with less dropout (Geschwind et al., 2019).

Haven’t had enough CBT tools and techniques yet? Read on for additional useful and effective exercises.

1. Behavioral experiments

These are related to thought experiments, in that you engage in a “what if” consideration. Behavioral experiments differ from thought experiments in that you actually test out these “what ifs” outside of your thoughts (Boyes, 2012).

In order to test a thought, you can experiment with the outcomes that different thoughts produce. For example, you can test the thoughts:

“If I criticize myself, I will be motivated to work harder” versus “If I am kind to myself, I will be motivated to work harder.”

First, you would try criticizing yourself when you need the motivation to work harder and record the results. Then you would try being kind to yourself and recording the results. Next, you would compare the results to see which thought was closer to the truth.

These Behavioral Experiments to Test Beliefs can help you learn how to achieve your therapeutic goals and how to be your best self.

2. Thought records

Thought records are useful in testing the validity of your thoughts (Boyes, 2012). They involve gathering and evaluating evidence for and against a particular thought, allowing for an evidence-based conclusion on whether the thought is valid or not.

For example, you may have the belief “My friend thinks I’m a bad friend.” You would think of all the evidence for this belief, such as “She didn’t answer the phone the last time I called,” or “She canceled our plans at the last minute,” and evidence against this belief, like “She called me back after not answering the phone,” and “She invited me to her barbecue next week. If she thought I was a bad friend, she probably wouldn’t have invited me.”

Once you have evidence for and against, the goal is to come up with more balanced thoughts, such as, “My friend is busy and has other friends, so she can’t always answer the phone when I call. If I am understanding of this, I will truly be a good friend.”

Thought records apply the use of logic to ward off unreasonable negative thoughts and replace them with more balanced, rational thoughts (Boyes, 2012).

Here’s a helpful Thought Record Worksheet to download.

3. Pleasant activity scheduling

This technique can be especially helpful for dealing with depression (Boyes, 2012). It involves scheduling activities in the near future that you can look forward to.

For example, you may write down one activity per day that you will engage in over the next week. This can be as simple as watching a movie you are excited to see or calling a friend to chat. It can be anything that is pleasant for you, as long as it is not unhealthy (i.e., eating a whole cake in one sitting or smoking).

You can also try scheduling an activity for each day that provides you with a sense of mastery or accomplishment (Boyes, 2012). It’s great to do something pleasant, but doing something small that can make you feel accomplished may have more long-lasting and far-reaching effects.

This simple technique can introduce more positivity into your life, and our Pleasant Activity Scheduling Worksheet is designed to help.

4. Imagery-based exposure

This exercise involves thinking about a recent memory that produced strong negative emotions and analyzing the situation.

For example, if you recently had a fight with your significant other and they said something hurtful, you can bring that situation to mind and try to remember it in detail. Next, you would try to label the emotions and thoughts you experienced during the situation and identify the urges you felt (e.g., to run away, to yell at your significant other, or to cry).

Visualizing this negative situation, especially for a prolonged period of time, can help you to take away its ability to trigger you and reduce avoidance coping (Boyes, 2012). When you expose yourself to all of the feelings and urges you felt in the situation and survive experiencing the memory, it takes some of its power away.

This Imagery Based Exposure Worksheet is a useful resource for this exercise.

5. Graded exposure worksheet

This technique may sound complicated, but it’s relatively simple.

Making a situation exposure hierarchy involves means listing situations that you would normally avoid (Boyes, 2012). For example, someone with severe social anxiety may typically avoid making a phone call or asking someone on a date.

Next, you rate each item on how distressed you think you would be, on a scale from 0 to 10, if you engaged in it. For the person suffering from severe social anxiety, asking someone on a date may be rated a 10 on the scale, while making a phone call might be rated closer to a 3 or 4.

Once you have rated the situations, you rank them according to their distress rating. This will help you recognize the biggest difficulties you face, which can help you decide which items to address and in what order. It’s often advised to start with the least distressing items and work your way up to the most distressing items.

Download our Graded Exposure Worksheet here.

Some of these books are for the therapist only, and some are to be navigated as a team or with guidance from the therapist.

There are many manuals out there for helping therapists apply cognitive behavioral therapy in their work, but these are some of the most popular:

• A Therapist’s Guide to Brief Cognitive Behavioral Therapy by Jeffrey A. Cully and Andra L. Teten (PDF here );
• Individual Therapy Manual for Cognitive-Behavioral Treatment of Depression by Ricardo F. Munoz and Jeanne Miranda (PDF here );
• Provider’s Guidebook: “Activities and Your Mood” by Community Partners in Care (PDF here );
• Treatment Manual for Cognitive Behavioral Therapy for Depression by Jeannette Rosselló, Guillermo Bernal, and the Institute for Psychological Research (PDF here ).

Here are some of the most popular workbooks and manuals for clients to use alone or with a therapist:

• The CBT Toolbox: A Workbook for Clients and Clinicians by Jeff Riggenbach ( Amazon );
• Client’s Guidebook: “Activities and Your Mood” by Community Partners in Care (PDF here );
• The Cognitive Behavioral Workbook for Anxiety: A Step-by-Step Program by William J. Knaus and Jon Carlson ( Amazon );
• The Cognitive Behavioral Workbook for Depression: A Step-by-Step Program by William J. Knaus and Albert Ellis ( Amazon );
• Cognitive-Behavioral Therapy Skills Workbook by Barry Gregory ( Amazon );
• A Course in CBT Techniques: A Free Online CBT Workbook  by Albert Bonfil and Suraji Wagage (online here ).

There are many other manuals and workbooks available that can help get you started with CBT, but the tools above are a good start. Peruse our article: 30 Best CBT Books to Master Cognitive Behavioral Therapy for an excellent list of these books.

1. Mindfulness meditation

Mindfulness can have a wide range of positive impacts, including helping with depression, anxiety, addiction, and many other mental illnesses or difficulties.

The practice can help those suffering from harmful automatic thoughts to disengage from rumination and obsession by helping them stay firmly grounded in the present (Jain et al., 2007).

Mindfulness meditations, in particular, can function as helpful tools for your clients in between therapy sessions, such as to help ground them in the present moment during times of stress.

If you are a therapist who uses mindfulness-based approaches, consider finding or pre-recording some short mindfulness meditation exercises for your clients.

You might then share these with your clients as part of a toolkit they can draw on at their convenience, such as using the blended care platform Quenza (pictured here), which allows clients to access meditations or other psychoeducational activities on-the-go via their portable devices.

2. Successive approximation

This is a fancy name for a simple idea that you have likely already heard of: breaking up large tasks into small steps.

It can be overwhelming to be faced with a huge goal, like opening a business or remodeling a house. This is true in mental health treatment as well, since the goal to overcome depression or anxiety and achieve mental wellness can seem like a monumental task.

By breaking the large goal into small, easy-to-accomplish steps, we can map out the path to success and make the journey seem a little less overwhelming (e.g., Emmelkamp & Ultee, 1974).

3. Writing self-statements to counteract negative thoughts

This technique can be difficult for someone who’s new to CBT treatment or suffering from severe symptoms, but it can also be extremely effective (Anderson, 2014).

When you (or your client) are being plagued by negative thoughts, it can be hard to confront them, especially if your belief in these thoughts is strong. To counteract these negative thoughts, it can be helpful to write down a positive, opposite thought.

For example, if the thought “I am worthless” keeps popping into your head, try writing down a statement like “I am a person with worth,” or “I am a person with potential.” In the beginning, it can be difficult to accept these replacement thoughts, but the more you bring out these positive thoughts to counteract the negative ones, the stronger the association will be.

4. Visualize the best parts of your day

When you are feeling depressed or negative, it is difficult to recognize that there are positive aspects of life. This simple technique of bringing to mind the good parts of your day can be a small step in the direction of recognizing the positive (Anderson, 2014).

All you need to do is write down the things in your life that you are thankful for or the most positive events that happen in a given day. The simple act of writing down these good things can forge new associations in your brain that make it easier to see the positive, even when you are experiencing negative emotions.

5. Reframe your negative thoughts

It can be easy to succumb to negative thoughts as a default setting. If you find yourself immediately thinking a negative thought when you see something new, such as entering an unfamiliar room and thinking “I hate the color of that wall,” give reframing a try (Anderson, 2014).

Reframing involves countering the negative thought(s) by noticing things you feel positive about as quickly as possible. For instance, in the example where you immediately think of how much you hate the color of that wall, you would push yourself to notice five things in the room that you feel positively about (e.g., the carpet looks comfortable, the lampshade is pretty, the windows let in a lot of sunshine).

You can set your phone to remind you throughout the day to stop what you are doing and think of the positive things around you. This can help you to push your thoughts back into the realm of the positive instead of the negative.

17 Science-Based Ways To Apply Positive CBT

These 17 Positive CBT & Cognitive Therapy Exercises [PDF] include our top-rated, ready-made templates for helping others develop more helpful thoughts and behaviors in response to challenges, while broadening the scope of traditional CBT.

Created by Experts. 100% Science-based.

In this post, we offered many techniques, tools, and resources that can be effective in the battle against depression, anxiety, OCD, and a host of other problems or difficulties.

However, as is the case with many treatments, they depend on you (or your client) putting in a lot of effort. We encourage you to give these techniques a real try and allow yourself the luxury of thinking that they could actually work.

When we approach a potential solution with the assumption that it will not work, that assumption often becomes a self-fulfilling prophecy. When we approach a potential solution with an open mind and the belief that it just might work, it has a much better chance of succeeding.

So if you are struggling with negative automatic thoughts , please consider these tips and techniques and give them a shot. Likewise, if your client is struggling, encourage them to make the effort, because the payoff can be better than they can imagine.

If you are struggling with severe symptoms of depression or suicidal thoughts, please call the following number in your respective country:

• USA: National Suicide Prevention Hotline at 988;
• UK: Samaritans hotline at 116 123;
• The Netherlands: Netherlands Suicide Hotline at 09000767;
• France: Suicide écoute at 01 45 39 40 00;
• Germany: Telefonseelsorge at 0800 111 0 111 or 0800 111 0 222

For a list of other suicide prevention websites, phone numbers, and resources, see this website .

Please know that there are people out there who care and that there are treatments that can help.

Please let us know about your experiences with CBT in the comments section. If you’ve tried it, how did it work for you? Are there any other helpful exercises or techniques that we did not touch on in this piece? We’d love to know your thoughts.

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

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• Pruiksma, K. E., Cranston, C. C., Rhudy, J. L., Micol, R. L., & Davis, J. L. (2018). Randomized controlled trial to dismantle exposure, relaxation, and rescripting therapy (ERRT) for trauma-related nightmares. Psychological trauma: theory, research, practice, and policy , 10 (1), 67-75.
• Psychology Tools. (n.d.). Retrieved from https://www.psychologytools.com/
• Therapist Aid. (n.d.). Retrieved from https://www.therapistaid.com/
• Utley, A., & Garza, Y. (2011). The therapeutic use of journaling with adolescents. Journal of Creativity in Mental Health , 6 (1), 29-41.

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Thank you for the work put into this amazing article! It encompasses every bit of CBT that is so useful for clients increasing their understanding of how “this” works in a very well-written tone. Well done!

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What is cognitive behavioral therapy (CBT)?

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

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

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

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

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

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

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

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

The cognitive aspect of CBT

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

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

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

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

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

[Read: How to Stop Worrying]

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

The behavioral aspect of CBT

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

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

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

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

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

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

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

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

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

Advantages of CBT

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

Disadvantages

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

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

Some of the main types of CBT include:

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

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

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

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

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

[Read: Therapy for Anxiety Disorders]

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

Speak to a Licensed Therapist

BetterHelp is an online therapy service that matches you to licensed, accredited therapists who can help with depression, anxiety, relationships, and more. Take the assessment and get matched with a therapist in as little as 48 hours.

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

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

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

Your first CBT sessions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More Information

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

More in Therapy & Medication

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What Is Therapy Homework?

Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

Dr. Sabrina Romanoff, PsyD, is a licensed clinical psychologist and a professor at Yeshiva University’s clinical psychology doctoral program.

Astrakan Images / Getty Images

Types of Therapy That Involve Homework

If you’ve recently started going to therapy , you may find yourself being assigned therapy homework. You may wonder what exactly it entails and what purpose it serves. Therapy homework comprises tasks or assignments that your therapist asks you to complete between sessions, says Nicole Erkfitz , DSW, LCSW, a licensed clinical social worker and executive director at AMFM Healthcare, Virginia.

Homework can be given in any form of therapy, and it may come as a worksheet, a task to complete, or a thought/piece of knowledge you are requested to keep with you throughout the week, Dr. Erkfitz explains.

This article explores the role of homework in certain forms of therapy, the benefits therapy homework can offer, and some tips to help you comply with your homework assignments.

Therapy homework can be assigned as part of any type of therapy. However, some therapists and forms of therapy may utilize it more than others.

For instance, a 2019-study notes that therapy homework is an integral part of cognitive-behavioral therapy (CBT) . According to Dr. Erkfitz, therapy homework is built into the protocol and framework of CBT, as well as dialectical behavior therapy (DBT) , which is a sub-type of CBT.

Therefore, if you’re seeing a therapist who practices CBT or DBT, chances are you’ll regularly have homework to do.

On the other hand, an example of a type of therapy that doesn’t generally involve homework is eye movement desensitization and reprocessing (EMDR) therapy. EMDR is a type of therapy that generally relies on the relationship between the therapist and client during sessions and is a modality that specifically doesn’t rely on homework, says Dr. Erkfitz.

However, she explains that if the client is feeling rejuvenated and well after their processing session, for instance, their therapist may ask them to write down a list of times that their positive cognition came up for them over the next week.

"Regardless of the type of therapy, the best kind of homework is when you don’t even realize you were assigned homework," says Erkfitz.

Benefits of Therapy Homework

Below, Dr. Erkfitz explains the benefits of therapy homework.

It Helps Your Therapist Review Your Progress

The most important part of therapy homework is the follow-up discussion at the next session. The time you spend reviewing with your therapist how the past week went, if you completed your homework, or if you didn’t and why, gives your therapist valuable feedback on your progress and insight on how they can better support you.

It Gives Your Therapist More Insight

Therapy can be tricky because by the time you are committed to showing up and putting in the work, you are already bringing a better and stronger version of yourself than what you have been experiencing in your day-to-day life that led you to seek therapy.

Homework gives your therapist an inside look into your day-to-day life, which can sometimes be hard to recap in a session. Certain homework assignments keep you thinking throughout the week about what you want to share during your sessions, giving your therapist historical data to review and address.

It Helps Empower You

The sense of empowerment you can gain from utilizing your new skills, setting new boundaries , and redirecting your own cognitive distortions is something a therapist can’t give you in the therapy session. This is something you give yourself. Therapy homework is how you come to the realization that you got this and that you can do it.

"The main benefit of therapy homework is that it builds your skills as well as the understanding that you can do this on your own," says Erkfitz.

Tips for Your Therapy Homework

Below, Dr. Erkfitz shares some tips that can help with therapy homework:

• Set aside time for your homework: Create a designated time to complete your therapy homework. The aim of therapy homework is to keep you thinking and working on your goals between sessions. Use your designated time as a sacred space to invest in yourself and pour your thoughts and emotions into your homework, just as you would in a therapy session .
• Be honest: As therapists, we are not looking for you to write down what you think we want to read or what you think you should write down. It’s important to be honest with us, and yourself, about what you are truly feeling and thinking.
• Practice your skills: Completing the worksheet or log are important, but you also have to be willing to put your skills and learnings into practice. Allow yourself to be vulnerable and open to trying new things so that you can report back to your therapist about whether what you’re trying is working for you or not.
• Remember that it’s intended to help you: Therapy homework helps you maximize the benefits of therapy and get the most value out of the process. A 2013-study notes that better homework compliance is linked to better treatment outcomes.
• Talk to your therapist if you’re struggling: Therapy homework shouldn’t feel like work. If you find that you’re doing homework as a monotonous task, talk to your therapist and let them know that your heart isn’t in it and that you’re not finding it beneficial. They can explain the importance of the tasks to you, tailor your assignments to your preferences, or change their course of treatment if need be.

"When the therapy homework starts 'hitting home' for you, that’s when you know you’re on the right track and doing the work you need to be doing," says Erkfitz.

A Word From Verywell

Similar to how school involves classwork and homework, therapy can also involve in-person sessions and homework assignments.

If your therapist has assigned you homework, try to make time to do it. Completing it honestly can help you and your therapist gain insights into your emotional processes and overall progress. Most importantly, it can help you develop coping skills and practice them, which can boost your confidence, empower you, and make your therapeutic process more effective.

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Conklin LR, Strunk DR, Cooper AA. Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression . Cognit Ther Res . 2018;42(1):16-23. doi:10.1007/s10608-017-9873-6

Lebeau RT, Davies CD, Culver NC, Craske MG. Homework compliance counts in cognitive-behavioral therapy . Cogn Behav Ther . 2013;42(3):171-179. doi:10.1080/16506073.2013.763286

By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

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CBT: Phase 1

The initial phase is designed to provide assessment and engagement, including the development of a problem list, establishment of shared goals and the collaborative development of a maintenance formulation of a recent incident.

Ideally, a first session should include:

• Explain confidentiality, CT, trial aspects (e.g. treatment window and boosters) • Agree short 6 session contract with expectation of renewal up to 30 hours (including boosters) • Cognitive behavioural assessment of presenting problems and life experiences, based on cognitive model Risk assessment • Normalising if appropriate

Ideally, by session 3, we would have:

• Agreed a shared list of problems and goals (SMART ones suitable for the agreed short-term contract; goals should ideally be related to increasing quality of life and/or reducing distress; in some instances, telling their story may be an appropriate first goal) • Shared formulation (at least a mini-formulation of a recent specific situation, related to a problem from the list, in terms of event, thoughts, feelings and behaviour/responses with appropriate maintenance cycles): What happened – how I made sense of it – how I feel – how I responded

Video Demonstrations:

The following resources consist of video excerpts of role plays filmed by PRU staff which aim to illustrate the relevant processes, principles and strategies within each phase. Where relevant, these videos are supplemented by descriptions and formulations that were shared with the ‘client’.

Assessment of voice hearing and developing a maintenance formulation

Formulation for hearing threatening voices

Assessment of thought broadcast and developing a maintenance formulation

Advantages and disadvantages of paranoia

Identifying goals using a Q sort task

Normalising Voices

Maintenance formulation of threatening voices

Cognitive Behavioural Therapy (CBT) Exercises and Techniques

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

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

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

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

What is cognitive behavioural therapy (CBT)?

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

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

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

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

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

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

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

Examples of thought distortions

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

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

“Bad things always happen to me.”

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

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

Some themes of cognitive distortions include:

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

How does CBT work?

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

Here are three commonly used exercises and techniques for CBT:

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

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

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

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

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

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

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

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Nicole Laoutaris

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

Discover More About therapy techniques (modalities)

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

• Last edited on January 4, 2024

Cognitive Behavioural Therapy (CBT)

Table of contents, indications, how does it work, components of cbt, core beliefs, beck's cognitive triad, automatic thoughts and cognitive distortions, intake assessment, goal setting, first session, agenda setting, thought records, tips and techniques, for patients, for providers.

Cognitive Behavioural Therapy (CBT) is a structured, time-limited (usually 12-16 sessions) psychotherapy that identifies and addresses persistent maladaptive thought patterns to change emotions (e.g. - depression/anxiety/trauma) and behaviours (low motivation/insomnia). It uses strategies such as goal-setting, breathing techniques, visualization, and mindfulness to decrease emotional distress and self-defeating behaviour. Treatment is generally time-limited. CBT can be delivered in a wide variety of formats, including in groups and via remote delivery (online or phone). Although most commonly used for depression and anxiety, CBT has also been specialized to treat other conditions, such as CBT for insomnia (CBT-I) for insomnia disorder , and trauma-focused CBT (TF-CBT) for post-traumatic stress disorder .

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• CBT is used as monotherapy or in combination with medication for major depressive disorder , generalized anxiety disorder , panic disorder, posttraumatic stress disorder, social phobia, somatic disorders, chronic pain, insomnia , and eating disorders .
• CBT with exposure response prevention (ERP) is used on the treatment of obsessive-compulsive disorder .
• If a patient has cognitive distortions and avoidance behaviour, this make them a good candidate for CBT.

CBT techniques include identifying distortions such as overgeneralization of negative events, catastrophizing, minimizing positive events, and maximizing negative events. Patients work with therapists to identify and change cognitive distortions and avoidance behaviours that cause their symptoms. This frequently involves keeping diaries or “thought records” outside of sessions and practicing behavioural strategies learned in sessions.

• CBT is based on an ever-evolving formulation of patients’ problems and an individual conceptualization of each patient in cognitive terms.
• CBT requires a good therapeutic alliance (true for all psychotherapies).
• CBT focuses on collaboration and active participation. Both the therapist and patient should view therapy as teamwork. Together they decide what to work on for each session, how often to meet, and what to do between sessions for therapy homework. At first, the therapist may be more active in suggesting a direction for therapy sessions and in summarizing what's discussed during a session.
• CBT is goal oriented and problem focused. You should ask in your first session for your patient to describe their problems and set specific goals so there is a shared understanding of what they are working towards.
• Self-perception is amenable to change through CBT

The key components of CBT include:

• Goal setting, self awareness (thoughts-feelings-behaviours)
• Cognitive restructuring to address maladaptive thinking and learning coping skills and focused thinking
• Deep breathing
• Progressive muscle relaxation (PMR)
• Guided imagery
• In vivo (in the real situation)
• Imaginal (imagining the situation)
• Live modeling (demonstration of non fearful response)
• Increasing engagement in adaptive activities (things that increase pleasure or mastery)
• Decrease engagement in activities that maintain or increase the risk for the symptoms
• Booster sessions of CBT
• When depression-specific psychotherapies are delivered in routine practice, recovery rates from depression are close to 50%. [3] CBT in groups can work as well as individual CBT therapy. [4]
• There has been some debate over whether the efficacy of CBT is declining over time. [5] [6]
• The average length of a course of CBT lasts between 12 to 16 sessions (i.e. - weeks), with each session of about 50 minutes in length. The course of CBT may be longer or shorter depending on the disorder and severity of symptoms.

Terminology

CBT uses lots of different terminologies, and it can be helpful to spell out exactly what they mean, so both you and your patients can be speaking the same language.

Definitions in CBT

Core beliefs are fundamental assumptions (not truths) that individuals have made about about themselves, others, and the world. These beliefs develop over the course of their lives. Core beliefs influence how a person sees the world around them and themselves. Core beliefs are usually so connected to a person's identity that they stop noticing them or questioning these beliefs. For example, someone in a depressive episode might think “I am a failure” and because these beliefs are not questioned and assumed to be “100% true,” the individual lives and acts as though they beliefs are real and true.

Beck's cognitive triad, also known as the negative triad, is a cognitive-therapeutic model of the three key elements of a person's belief system when going through depression. The triad involves automatic, spontaneous and seemingly uncontrollable negative thoughts about:

• The self – “I'm worthless and ugly” or “I wish I was different”
• The world – “No one values me” or “people ignore me all the time”
• The future – “I'm hopeless because things will never change” or “things can only get worse!”

Thoughts can often come automatically, and CBT challenges us to think more closely about these thoughts. Some automatic thoughts are true, but many are either untrue or have just a grain of truth. CBT requires patients to use a structured method to evaluate their thinking. Otherwise, their responses to automatic thoughts can be superficial and unconvincing and will fail to improve their mood or functioning. Typical automatic thoughts (also called cognitive distortions) include:

Common Automatic Thoughts or Cognitive Distortions

Emotional reasoning example.

• Write this down on sheet of paper: “ I will win the lottery on Friday, Jan 22 ”
• Then write this down on sheet of paper: “ My mother will win the lottery on Friday ”
• Finally, write this down on sheet of paper: “ My mother will die on Friday Jan 20th ”

Notice how the first two sentences don't provoke many emotions, but the third sentence is “emotional reasoning,” you might be “reading” into this feeling, thinking: “Might I be jinxing the universe by writing this down?!” This is a tough thing to overcome for individuals who struggled with the cognitive distortion of emotional reasoning every day.

• Identify your patient's current feelings (“I’m a failure, I can’t do anything right, I’ll never be happy”)
• Identify the problematic behaviours (isolating herself, spending a great deal of unproductive time in her room, avoiding asking for help). These problematic behaviours both flow from and in turn reinforce Sally’s dysfunctional thinking.
• What the precipitating factors that in influenced your patient's perceptions at the onset of their depression? (e.g., being away from home for the first time and struggling in her studies contributed to her belief that she was incompetent)
• Third, I hypothesize about key developmental events and how the enduring patterns of interpreting these events that may have predisposed your to their symptoms (e.g., your patient has had a lifelong tendency to attribute personal strengths and achievement to luck, but views her weaknesses as a reflection of her “true” self).

It is important for the patient to have specific goals they want to achieve by the time they are finished the course of therapy. It is also important to have goals between sessions, that are more attainable and realistic. The SMART goals framework is one way of achieving that. A goal should feel 80% do-able and 20% challenging so as to strike the right balance.

• S - S pecific (well defined, clear, and unambiguous)
• M - M easurable (specific way to measure your progress towards the goal)
• A - A ttainable (something not impossible - “Do something 80% attainable and 20% hard”)
• R - R ealistic
• T - T ime (must have a start and finish date - if the goal is not time constrained, there will be no sense of urgency to achieve the goal!)

Example of a SMART goal could be: “Add more structure to your day” (i.e. - make your bed, eat regular meals, have a regular sleep schedule, and make a regular schedule). Another SMART goal could be: “Have more social interaction by calling one friend each week.”

• Outline that there are tasks (“homework”) for each week, and doing the task is like taking medication. Homework is a vital part of therapy and it is important that the patient is aware of this in the first session.
• Buy a guide book, such as Mind Over Mood
• Outline that there are about 16 sessions in total, again, like medication, it is important to do this
• Photocopy the homework if possible
• PHQ-9 or Beck Depression Inventory for Depression
• SPIN for Social Anxiety
• The way you think, affects how you feel and how you behave
• E.g. - problem = isolation, goal (is something behavioural) = start new friendships, and spend more time with existing friends
• You will help the patient evaluate the validity of her thoughts through an examination of the evidence. They should be able to test the thoughts more directly through behavioural experiments, where they initiate plans with friends. Once your patient recognizes and corrects the distortion in their thinking, they will benefit from more straightforward problem solving to decrease their isolation.

Homework to Assign after Session 1

• Define a goals list
• Begin a thought record. Remind yourself to be skeptical of these thoughts and that they may not always be true
• Be kind to yourself
• Think about things you want to bring up at the next session
• Organize an activity to do (this is “behavioural activation”)

Just like how CBT is a structured-form of therapy, your sessions with your patient should also be structured and modeled on that. A typical CBT session should be structured as follows: [7]

CBT agenda based on a 60 minute session

Homework is an integral part of CBT, and what makes CBT work. There are various types of homework assignments including:

• Behavioural activation
• Monitoring automatic thoughts
• Practicing new skills or implementing new solutions
• Reading assignments (like chapters in Mind Mover Mood)

When Homework Isn't Done

Thought records are done outside of the CBT session, where patients record their automatic thoughts and feelings over the week:

• Rating their feelings
• Noticing which thought matches the feeling
• Rating how much you believe in each thought
• Rating which thought is the most therapeutic
• Evidence for and against the thought

Vague Thought Records

Balancing thoughts.

The goal of CBT is to help your patients correct the automatic thought (sometimes called “hot thought”), by reaching balanced thoughts (e.g. - “Even though [I’m behind on my rent], I can see that [I have a solution now/and a capable person], because [I have support from my family].”) Beware though, of superficial and “fake” balance thoughts. For example, if a patient is constantly worried about having anxiety because their thought is: “I’m a terrible mom.” and her balanced thought is “but I’m a good wife.” Notice that this balanced thought doesn't actually relate to the thought. If the balancing thought does not correspond with the automatic thought, that’s a pitfall the therapist must identify!

Questioning Automatic Thoughts

When addressing automatic thoughts or cognitive distortions, the following questions can be helpful:

• What is the evidence that supports this idea? What is the evidence against this idea?
• Is there an alternative explanation or viewpoint?
• What is the worst that could happen (if I’m not already thinking the worst)? If it happened, how could I cope? (What is the best that could happen? What is the most realistic outcome?)
• What is the effect of my believing the automatic thought? What could be the effect of changing my thinking?
• What would I tell [a specific friend or family member] if he or she were in the same situation?
• What should I do?

When evaluating situations that your patient brings up, here are some helpful techniques:

• Use a pie chart to assess the pie chart contribution of the situation

Percentage Scales

• “If you are a terrible student, then where are you on this continuum,” “Are you a 100% terrible student? 50%? or 0%? Why that percent?”
• “If you feel like you are a failure or people don’t love you, “How much of that do you think is true? 100%, 50%?”

Socratic Questioning

Socratic questioning, or the socratic method, is a key technique in CBT. You help your patient understand themselves by asking questions about their thoughts, examples include:

• “What was going through your mind before you started to feel this way?”
• “What images or memories do you have of this situation?”
• “What does this thought mean about your future, and your life?”
• “What are you afraid might happen?”
• “What is the worst that could happen?”
• “What does this mean about how the other person thinks about you?”
• “What does this mean about the other person or people in general?”
• “Did you break rules, hurt others, or do something that you should not have done?”
• “What do you think about yourself about having done this, or thinking you did this?”

Therapeutic Alliance

• Note any changes in therapeutic alliance, transference/countertransference

When emotions are too much

• When a patient's feelings and thoughts are very valid, and the patient is unable to see alternative ways of scrutinizing them, another one way to help a patient reframe their situation is to ask them how well do they cope with these feelings?
• Mind Over Mood - Teaches skills and principles used in cognitive behavioral therapy, provides worksheets, assignments
• CBT: Beyond the Basics
• MoodGym - Interactive self-help program for preventing and coping with depression and anxiety; teaches self-help skills drawn from CBT
• CBT: An Information Guide (CAMH)
• CBT Psychotherapy Resident Supervision Forms
• Our World: Does the news reflect what we die from?

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What To Expect In Your First Therapy Session

We all know what to expect when we go to our medical doctor’s office. They will typically check our pulse and our blood pressure. Of course, they will also ask if there is something in particular that is bothering us. We usually know how to describe medical ailments. Seeking therapy can be a little less familiar- but it need not be scary! Taking that first step into a therapist’s office can be the hardest one- but it is invariably worth the effort. If we should be concerned about the health of our body, shouldn’t we take equal care of our minds? Though your therapist won’t take your pulse and blood pressure, in a way, they’ll be accomplishing a similar thing. Here’s what you can expect in the first session.

Building Rapport

One of the marked distinctions between seeing a therapist and a medical doctor is the need to build a strong rapport. Perhaps you are coming to share some very personal things that have not been shared with anyone. To do this, you need to feel comfortable talking to your therapist. They will work hard initially, and throughout your therapy sessions, to make you comfortable. Your therapist will help you realize that your concerns are not strange. Many people have the same concerns. Your therapist has developed a sophisticated skillset to help you discover and share what your concerns are.

Confidentiality & Intake Interview

In the first session, your therapist will discuss the confidential nature of therapy and the limits to confidentiality. These limits ensure your safety and the safety of those close to you. They will likely conduct an “Intake Interview,” which is a series of questions to gather relevant background information. Questions will include your current lifestyle, presenting challenges, your family history, and situations that have impacted your wellbeing.

Therapeutic Approach

CBT Psychology for Personal Development has a spectrum of highly qualified therapists , with varying degrees and specialties of service. A member of our dedicated office staff will ensure you are matched with a clinician whose expertise matches your needs.

The hallmark of therapeutic interventions that our clinic uses is, as our name suggests, CBT: Cognitive Behavioural Therapy. However, we also use many other techniques based on the needs of each client. We only use evidence-based approaches to psychotherapy. This means that scientific research has shown the effectiveness of these therapeutic techniques. While some clients seek therapy as an addition to medical treatments of prescribed medications, others find equally effective help for a number of ailments, solely relying on talk therapy. Your therapist will help you learn the power of your own mind to affect change to your state of being.

Developing Therapy Goals

In the first session, the clinician asks what your goals in therapy are. Together with your therapist, you will develop a treatment plan that will assess a starting point, and a desired goal. While it is difficult to generalize treatment plans to all cases, many clients reach their goals in therapy in as little as 10-12 sessions while others get so much value from their sessions that they choose to continue benefiting from this unique and special relationship with their therapist.

Your relationship with your therapist is of utmost importance in the therapeutic process. Because of this, they will likely request feedback from you many times in the process, not just during the first session. This will ensure that you are comfortable with the treatment, and on the same track with the path that is taken in therapy. At CBT Psychology for Personal Development, we are committed to meeting your goals so you can live a meaningful life that makes you feel comfortable, at peace with yourself and empowered. We congratulate you on taking that important first step towards being the best person that you can be, and we are honoured to work with you towards reaching that goal!

Written by Yuval Kernerman; edited by Dr. Silvina Galperin 

About Yuval Kernerman

Yuval is a doctoral student in clinical psychology. He has over 20 years of experience counseling children and families in the educational realm. He has worked with individuals struggling with issues such as depression, anxiety, ADHD, ODD, and a number of other learning disorders. Yuval has also worked as a chaplain, counseling seniors in a nursing home setting. In this capacity, he helped clients with issues such as anxiety, depression, anger management, memory loss, and other challenges associated with aging.

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Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps

1 Discipline of Psychiatry, Department of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada

David Kreindler

2 Division of Youth Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

3 Centre for Mobile Computing in Mental Health, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

4 Department of Psychiatry, University of Toronto, Toronto, ON, Canada

Cognitive behavioral therapy (CBT) is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Homework is an integral component of CBT, but homework compliance in CBT remains problematic in real-life practice. The popularization of the mobile phone with app capabilities (smartphone) presents a unique opportunity to enhance CBT homework compliance; however, there are no guidelines for designing mobile phone apps created for this purpose. Existing literature suggests 6 essential features of an optimal mobile app for maximizing CBT homework compliance: (1) therapy congruency, (2) fostering learning, (3) guiding therapy, (4) connection building, (5) emphasis on completion, and (6) population specificity. We expect that a well-designed mobile app incorporating these features should result in improved homework compliance and better outcomes for its users.

Homework Non-Compliance in CBT

Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [ 1 , 2 ]. It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [ 3 - 6 ]. Homework is an important component of CBT; in the context of CBT, homework can be defined as “specific, structured, therapeutic activities that are routinely discussed in session, to be completed between sessions” [ 7 ]. Completion of homework assignments was emphasized in the conception of CBT by its creator, Aaron Beck [ 8 ]. Many types of homework are prescribed by CBT practitioners, including symptom logs, self-reflective journals, and specific structured activities like exposure and response prevention for obsessions and compulsions. These can be divided into the following 3 main categories: (1) psychoeducational homework, (2) self-assessment homework, and (3) modality-specific homework. Psychoeducation is an important component in the early stage of therapy. Reading materials are usually provided to educate the client on the symptomatology of the diagnosed illness, its etiology, as well as other treatment-relevant information. Self-assessment strategies, including monitoring one’s mood using thought records, teach the patients to recognize the interconnection between one’s feelings, thoughts, and behaviors [ 8 ]. For example, depressed patients may be asked to identify thinking errors in daily life and document the negative influences these maladaptive thinking patterns can produce on their behaviors. Various psychiatric disorders may require different types of modality-specific homework. For example, exposure to images of spiders is a treatment method specific to arachnophobia, an example of a “specific phobia” in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [ 9 ]. Homework is strategically created by the therapist to correct and lessen the patient’s psychopathology. The purpose of these exercises is to allow the patients to practice and reinforce the skills learned in therapy sessions in real life.

Homework non-compliance is one of the top cited reasons for therapy failure in CBT [ 10 ] and has remained a persistent problem in the clinical practice. Surveys of practitioners have suggested rates of non-adherence in adult clients of approximately 20% to 50% [ 10 , 11 ] while adherence rates in adolescents have been reported to be approximately 50% [ 12 ]. Many barriers to homework compliance have been identified in the literature; to facilitate discussions, they can be divided into internal and external factors. Internal factors originate from a client’s own psychological environment while external ones are created by external influences. Internal factors that have been identified include lack of motivation to change the situation when experiencing negative feelings, the inability to identify automatic thoughts, disregard for the importance or relevance of the homework, and the need to see immediate results [ 12 - 14 ]. Various external factors have also been identified, including the effort associated with pen-and-paper homework formats, the inconvenience of completing homework because of the amount of time consumed, not understanding of the purpose of the homework, lack of instruction, and failure to anticipate potential difficulties in completing the homework [ 14 - 16 ]. There is strong evidence suggesting that homework compliance is integral to the efficacy of CBT in a variety of psychiatric illnesses. In the treatment of depression with CBT, homework compliance has been correlated with significant clinical improvement and shown to predict decreases in both subjective and objective measures of depressive symptoms [ 17 - 23 ]. Similarly, homework compliance is correlated with short-term and long-term improvement of symptoms in anxiety disorders, including generalized anxiety disorder (GAD), social anxiety disorder (SAD), hoarding, panic disorder, and post-traumatic stress disorder (PTSD) [ 17 , 24 - 32 ]. Fewer studies have been done on homework compliance in other psychiatric conditions, but better homework compliance has been correlated with significant reductions in pathological behaviors in psychotic disorders [ 33 , 34 ], cocaine dependence [ 35 , 36 ], and smoking [ 37 ]. Two meta-analyses further support the notion that greater homework adherence is associated with better treatment outcomes in depression, anxiety-related disorders, and substance use [ 38 , 39 ].

The Utility of Technology in Enhancing CBT Homework

Despite its demonstrated efficacy, access to CBT (as well as other forms of psychotherapy) remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. With the rise of mass-market mobile communication devices such as the iPhone or other kinds of mobile devices with app capabilities (smartphones), new solutions are being sought that will use these devices to provide therapy to patients in a more cost-effective manner. Mobile phones with app capabilities are portable devices that combine features of a cellphone and a hand-held computer with the ability to wirelessly access the Internet. Over time, ownership of mobile phones in North America has grown [ 41 , 42 ] and progressively lower prices have further reduced barriers to their use and ownership [ 43 , 44 ]. As more and more people acquire mobile phones, the acceptance of and the demand for mobile health solutions have been on the rise [ 45 ]. Boschen (2008), in a review predating the popularization of the modern mobile phone, identified the unique features of the mobile telephone that made it a potentially suitable vehicle for adjunctive therapeutic applications: portability, acceptability, low initial cost, low maintenance cost, social penetration and ubiquity, “always on,” “always connected,” programmability, audio and video output, keypad and audio input, user-friendliness, and ease of use [ 46 ]. Over the last decade, modern mobile phones have supplanted the previous generation of mobile telephones; progressive increases in their computing power, ongoing advances in the software that they run and interact with (eg, JAVA, HTML5, etc.), common feature sets across different operating systems such as Google Inc.'s Android or Apple Inc.'s iOS, and adoption of common hardware elements across manufacturers (eg, touch screens, high-resolution cameras, etc) have enabled the development of platform-independent apps for mobile phones, or at least apps on different platforms with comparable functionality (eg, apps written for Apple's HealthKit or the apps written for Microsoft's HealthVault).

The popularization of the smartphone presents a unique opportunity to enhance CBT homework compliance using adjunctive therapeutic applications such that well-designed mobile software may be able to diminish barriers to CBT [ 40 ] by making CBT therapists' work more cost-effective. However, there are no guidelines and no existing research that directly address the design of mobile phone apps for this purpose. Given this gap in the literature, we searched MEDLINE (1946 to April 2015) and PsycINFO (1806 to April 2015) for all articles related to “cognitive behavioral therapy”, “homework”, “mobile applications” and “treatment compliance or adherence”, and reviewed articles related to (1) mobile technologies that address homework completion, (2) essential features of therapy, or (3) barriers to homework completion in CBT. In this article, we propose a collection of essential features for mobile phone-based apps that will optimally support homework compliance in CBT.

A Proposed List of Essential Features for Mobile Apps That Optimally Support CBT Homework Compliance

In order to be effective for patients and acceptable to therapists, an optimal mobile phone app to support CBT homework compliance should conform to the CBT model of homework while addressing barriers to homework compliance. Tompkins (2002) provides a comprehensive guideline on the appropriate ways to provide CBT homework such that homework should be meaningful, relevant to the central goals of therapy, salient to focus of the session, agreeable to both therapist and client, appropriate to sociocultural context, practiced in session to improve skill, doable, begin small, have a clear rationale, include written instructions, and include a backup plan with homework obstacles [ 47 ]. In addition, the therapist providing the homework needs to be curious, collaborative, reinforce all pro-homework behavior and successful homework completion, and emphasize completion over outcome [ 47 ]. By combining Tompkins' guidelines with the need to reduce barriers to homework compliance (as described above), we obtained the following list of 6 essential features that should be incorporated into mobile apps to maximize homework compliance: (1) congruency to therapy, (2) fostering learning, (3) guiding therapy, (4) building connections, (5) emphasizing completion, and (6) population specificity.

Congruency to Therapy

Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. A mobile app is no exception; apps have to deliver useful content and be congruent to the therapy being delivered. There are different types of homework in CBT, including (1) psychoeducational homework; (2) self-assessment homework; and (3) modality-specific homework. Which types are assigned will depend on the nature of the illness being treated, the stage of treatment, and the specific target [ 48 ]. An effective app supporting homework compliance will need to be able to adjust its focus as the therapy progresses. Self-monitoring and psychoeducation are major components in the early stage of therapy. Thought records can be used in depression and anxiety while other disorders may require more specific tasks, such as initiating conversation with strangers in the treatment of SAD. Therefore, the treatment modules delivered via mobile phones should meet the specific needs of therapy at each stage of therapy, while also providing psychoeducation resources and self-monitoring capabilities.

Psychoeducational Homework

While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Mobile apps can enhance psychoeducation by delivering clear and concise psychoeducational information linked to the topics being covered in therapy. As psychoeducation is seen as a major component of mobile intervention [ 50 ], it has been incorporated into several mobile apps, some of which have been shown to be efficacious in treating various psychiatric conditions, including stress [ 51 ], anxiety and depression [ 52 ], eating disorders [ 53 ], PTSD [ 54 ], and obsessive compulsive disorder (OCD) [ 55 ]. For example, Mayo Clinic Anxiety Coach is a mobile phone app “designed to deliver CBT for anxiety disorders, including OCD” [ 55 ]. The app contains a psychoeducational module that teaches the user on “the use of the application, the cognitive-behavioral conceptualization of anxiety, descriptions of each anxiety disorder, explanations of CBT, and guidance for assessing other forms of treatment” [ 55 ]. The benefits of delivering psychoeducation via a mobile phone app are obvious: the psychoeducational information becomes portable and is easily accessed by the patient. Furthermore, the information is also curated and validated by proper healthcare authorities, which builds trust and reduces the potential for misinformation that can result from patient-directed Internet searches. However, psychoeducation on its own is not optimal. Mobile interventions that also incorporate symptom-tracking and self-help interventions have resulted in greater improvement when used for depression and anxiety symptoms than those that deliver only online psychoeducation [ 50 ].

Self-Assessment Homework

In contrast to conventional, paper-based homework, mobile apps can support in-the-moment self-assessments by prompting the user to record self-report data about the user’s current state [ 56 ]. While information collected retrospectively using paper records can be adversely affected by recall biases [ 57 ], mobile apps enable the patient to document his or her thoughts and feelings as they occur, resulting in increased accuracy of the data [ 58 ]. Such self-assessment features are found in many mobile apps that have been shown to significantly improve symptoms in chronic pain [ 59 , 60 ], eating disorders [ 61 ], GAD [ 62 ], and OCD [ 55 ]. Continuing with the previous example, the Mayo Clinic Anxiety Coach offers a self-assessment module that “measures the frequency of anxiety symptoms” with a self-report Likert-type scale [ 55 ]. The app tracks users’ progress over time based on the self-assessment data; users reported liking the record of daily symptom severity scores that the application provides.

Modality-Specific Homework

Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages (short message service, SMS) to therapists in bulimia nervosa [ 61 ]. Mayo Clinic Anxiety Coach, for example, has a treatment module for OCD that “guides patients through the use of exposure therapy” [ 55 ]; patients can use this to build their own fear hierarchies according to their unique diagnoses. Users reported liking the app because it contains modality-specific homework that can be tailored to their own needs. Novel formats, such as virtual reality apps to create immersive environments, have been experimented with as a tool for facilitating exposure in the treatment of anxiety disorders with mostly positive feedback [ 64 - 66 ]. Apps that provide elements of biofeedback (such as heart rate monitoring via colorimetry of users' faces using the mobile phone's camera), have recently begun to be deployed. So-called ”serious games,“ (ie, games developed for treatment purposes), are also showing promise in symptom improvement in certain cases [ 51 , 67 , 68 ].

Fostering Learning

Doing CBT homework properly requires time and effort. As noted above, any sense of inconvenience while doing the homework may hamper a patient’s motivation to complete the homework. While patients may appreciate the importance of doing homework, they often find the length of time spent and the lack of clear instructions discouraging, resulting in poor engagement rates [ 49 , 52 ]. Therefore, it makes sense that the tasks should be simple, short in duration to begin with, and include detailed instructions [ 47 ], since homework completion rates have been shown to be correlated with patients’ knowing exactly what to do [ 33 , 69 ]. Many apps incorporate text messaging-based services or personalized feedback to encourage dynamic interactions between the therapist and the client [ 59 ]. However, the types of homework delivered by these apps are fixed. An app that adapts the contents to the user’s progress in learning homework tasks would be more engaging and effective since therapy should be a flexible process by nature. Ideally, the app would monitor and analyze the user’s progress and adjust the homework's content and difficulty level accordingly. While the effectiveness of this type of app has not been studied, a similar app has been described in the literature for treating GAD [ 62 ]. This app, used in conjunction with group CBT, collected regular symptom rating self-reports from patients to track anxiety. Based on patients’ ratings, the app would respond with encouraging comments and invite patients to practice relaxation techniques or prompt the patient to complete specific built-in cognitive therapy modules if their anxiety exceeded a threshold rating. Despite the simple algorithm used to trigger interventions, use of the app with group CBT was found to be superior to group CBT alone.

Guiding Therapy

Therapists have a number of important roles to play in guiding and motivating clients to complete homework. First, the therapist needs to address the rationale of the prescribed homework and work with the client in the development of the treatment plan [ 47 ]. Failure to do this has been identified as a barrier to homework compliance. Second, the therapist should allow the patient to practice the homework tasks during the therapy sessions [ 47 ] in order to build confidence and minimize internal barriers, such as the failing to identify automatic thoughts. Lastly, the therapist has to be collaborative, regularly reviewing homework progress and troubleshooting with the patients [ 47 , 70 ]; this can be done during or in between homework assignments, either in-person or remotely (ie, via voice or text messaging) [ 60 , 71 ].

Reviewing and troubleshooting homework has been seen as a natural opportunity for apps to augment the role of therapists. Individualized guidance and feedback on homework is found in many Internet-based or mobile apps that have been shown to be effective in treating conditions such as PTSD [ 72 ], OCD [ 55 ], chronic pain [ 59 , 60 ], depression and suicide ideation [ 71 ], and situational stress [ 73 ]. Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ 74 , 75 ]. However, despite incorporating a variety of features including self-monitoring, psychoeducation, scheduled reminders, and graphical feedback [ 52 ], automated apps with minimal therapist guidance have demonstrated elevated homework non-completion rates of up to 40%, which is less than ideal.

Building Connections

The effects of technology should not interfere with but rather encourage a patient’s ability to build meaningful connections with others [ 76 ]. The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ 77 ] and has been suggested to predict level of homework compliance as well [ 78 ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ 79 , 80 ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ 81 ].

An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems [ 82 ]. Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically. Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ 83 ]. Furthermore, professional moderation of online communities increases users’ trust of the service [ 84 ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.

Emphasizing Completion

A patient’s need to see immediate symptomatic improvement is an impediment to homework compliance since the perception of slow progress can be discouraging to the user [ 35 ]. To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ 47 ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ 47 , 85 ], there is little a therapist can do in between therapy sessions to remind clients to complete homework. In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ 52 , 86 ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ 87 ]. These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ 52 , 54 , 88 ] with significant symptom improvement reported in one paper [ 71 ].

Population Specificity

Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels (including learning or cognitive disabilities). One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design [ 89 ]. In this game, breathing activity is associated with the concept of “Qi” (natural energy) in accordance with Chinese traditions; the name of the game itself references to a famous Chinese novel and the gaming environment features inkwash and watercolor schemes of the East Asian style, making the experience feel more “natural” as reported by the users. A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders. In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration. Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated.

Other Considerations

There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ]. The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ]. Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ]. Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server.

Finally, while this paper focused on “essential” features of apps, this should not be misunderstood as an attempt to itemize all elements necessary for designing a successful piece of software. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ 100 ] and which makes effective use of underlying hardware.

The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. A variety of barriers exist in traditional, paper-based CBT homework that can significantly hamper clients’ motivation to complete homework as directed. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers. Apps should help the therapist guide the client through therapy and not hinder the therapeutic process or interfere with patient’s building connections with others. It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users.

As an example of how this applies in practice, “Mental Health Telemetry-Anxiety Disorders” (MHT-ANX) is a new mobile app developed by the Centre for Mobile Computing in Mental Health at Sunnybrook Health Sciences Centre in Toronto that helps patients monitor their anxiety symptoms using longitudinal self-report. The symptom log is therapy congruent to the practice of CBT since it promotes patients' awareness of their anxiety symptoms and the symptoms’ intensity. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance. The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship. Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use. While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance.

Limitations and Future Challenges

The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. For example, as artificial intelligence [ 101 ] or emotional sensing [ 102 ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states.

This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review. The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done. We would anticipate synergistic effects when homework-compliance apps are used in CBT (eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work), but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation.

Abbreviations

Conflicts of Interest: None declared.