Cognitive Behavioral Therapy:

The Counseling Process from Start

to Finish

James Ikonomopoulos Ph.D., LPC-S

Presentation Objectives
Explain the connection between thoughts,
feelings, and behaviors
Develop a cognitive case conceptualization and
understand its relationship to Cognitive Therapy
Choose and apply cognitive interventions
appropriate for use with children and adults
Choose and apply behavioral interventions
appropriate for use with children and adults
Outline of Presentation
Introduction to CBT
Basic principles and overview of treatment
Cognitive Conceptualization
The cognitive model
The Evaluation Session
Intake and assessment
The Initial Therapy Session
Treatment Planning
The 2nd Session and Beyond
Outline of Concepts
Behavioral Activation
Identifying Automatic Thoughts
Identifying Emotions
Evaluating Automatic Thoughts
Responding to Automatic Thoughts
Identifying and Modifying Intermediate Beliefs
Identifying and Modifying Core Beliefs
Imagery
Homework
Additional Techniques
Introduction to CBT
A revolution in the field of mental health was started
in the 1960’s by Aaron T. Beck
He began as a fully trained and practicing
Psychoanalyst.
He was a scientist at heart, believed theories should be
empirically valid.
Began studying depression, and results of his
experiments lead him to pursue other explanations for
depression.
What is CBT?
Dr. Beck decided to test the psychoanalytic concept
that depression is the result of hostility turned inward
toward the self.
He investigated the dreams of depressed patients,
which, he predicted, would manifest greater themes of
hostility than the dreams of normal control patients.
To his surprise, he ultimately found that the dreams of
depressed patients contained fewer themes of hostility
and far greater themes of defectiveness, deprivation,
and loss. He recognized that these themes paralleled
his patients’ thinking when they were awake.
What is CBT?
He identified distorted, negative cognition (primarily
thoughts and beliefs) as a primary feature of
depression and developed a short-term treatment, one
of whose primary targets was the reality testing of
patients’ depressed thinking.
Aaron Beck developed a form of psychotherapy in the
early 1960s that he originally termed “cognitive
therapy.”
“Cognitive therapy” is now used synonymously with
“cognitive behavior therapy” by much of our field.
What is CBT?
Beck devised a structured, short-term, present-oriented
psychotherapy for depression, directed toward solving
current problems and modifying dysfunctional
(inaccurate and/or unhelpful) thinking and behavior
(Beck, 1964).
Since that time, he and others have successfully adapted
this therapy to a surprisingly diverse set of populations
with a wide range of disorders and problems.
These adaptations have changed the focus, techniques,
and length of treatment, but the theoretical assumptions
themselves have remained constant.
What is CBT?
In all forms of cognitive behavior therapy that are
derived from Beck’s model, treatment is based on a
cognitive formulation, the beliefs and behavioral
strategies that characterize a specific disorder (Alford &
Beck, 1997).
Treatment is also based on a conceptualization, or
understanding, of individual patients (their specific
beliefs and patterns of behavior). The therapist seeks in
a variety of ways to produce cognitive change—
modification in the patient’s thinking and belief
system—to bring about enduring emotional and
behavioral change.
What is CBT?
Beck drew on a number of different sources when he
developed this form of psychotherapy, including early
philosophers, such as Epicetus, and theorists, such as
Karen Horney, Alfred Adler, George Kelly, Albert
Ellis, Richard Lazarus, and Albert Bandura. Beck’s
work, has been expanded by current researchers and
theorists, in the United States and abroad.
Different Forms of CBT
There are a number of forms of cognitive behavior therapy that share
characteristics of Beck’s therapy, but whose conceptualizations and
emphases in treatment vary to some degree.
These include rational emotional behavior therapy (Ellis, 1962),
dialectical behavior therapy (Linehan, 1993), problem-solving
therapy (D’Zurilla & Nezu, 2006), acceptance and commitment
therapy (Hayes, Follette, & Linehan, 2004), exposure therapy (Foa &
Rothbaum, 1998), cognitive processing therapy (Resick & Schnicke,
1993), cognitive behavioral analysis system of psychotherapy
(McCullough, 1999), behavioral activation (Lewinsohn, Sullivan, &
Grosscup, 1980; Martell, Addis, & Jacobson, 2001), cognitive behavior
modification (Meichenbaum, 1977), TF-CBT (Cohen, Mannarino, &
Knudsen, 2004; Cohen,. Mannarino, & Staron, 2006), and others.
Beck’s cognitive behavior therapy often incorporates techniques from
all these therapies, and other psychotherapies, within a cognitive
framework.
The Cognitive Model
“Men are disturbed not by things, but by the view which
they take of them.” - Epictetus

“It’s not the situations in our lives that cause distress, but
rather our interpretations of those situations.”
– Aaron T. Beck
What is the Theory of CBT?
The cognitive model proposes that dysfunctional thinking (which
influences the patient’s mood and behavior) is common to all
psychological disturbances.
When people learn to evaluate their thinking in a more realistic
and adaptive way, they experience improvement in their emotional
state and in their behavior.
For example, if you were quite depressed and bounced some checks,
you might have an automatic thought, an idea that just seemed to
pop up in your mind: “I can’t do anything right.” This thought might
then lead to a particular reaction: you might feel sad (emotion) and
retreat to bed (behavior). If you then examined the validity of this
idea, you might conclude that you had overgeneralized and that, in
fact, you actually do many things well. Looking at your experience
from this new perspective would probably make you feel better and
lead to more functional behavior.
What is the Theory of CBT?
For lasting improvement in patients’ mood and behavior, cognitive
therapists work at a deeper level of cognition: patients’ basic beliefs
about themselves, their world, and other people.
Modification of their underlying dysfunctional beliefs produces more
enduring change. For example, if you continually underestimate your
abilities, you might have an underlying belief of incompetence.
Modifying this general belief (i.e., seeing yourself in a more realistic
light as having both strengths and weaknesses) can alter your
perception of specific situations that you encounter daily. You will
no longer have as many thoughts with the theme, “I can’t do anything
right.” Instead, in specific situations where you make mistakes, you will
probably think, “I’m not good at this [specific task].”
What Does the Research Say?
Cognitive behavior therapy has been extensively tested
since the first outcome study was published in 1977
(Rush, Beck, Kovacs, & Hollon, 1977). At this point,
more than 500 outcome studies have demonstrated
the efficacy of cognitive behavior therapy for a wide
range of psychiatric disorders, psychological problems,
and medical problems with psychological components
(see, e.g., Butler, Chapman, Forman, & Beck, 2005;
Chambless & Ollendick, 2001).
Partial List of Disorders Successfully Treated
Bipolar disorder (with medication)

by CBT Schizophrenia (with medication)

Couple problems
Psychiatric disorders Family problems
Major depressive disorder Pathological gambling
Geriatric depression Complicated grief
Generalized anxiety disorder Caregiver distress
Geriatric anxiety Anger and hostility
Panic disorder Chronic back pain
Agoraphobia Sickle cell disease pain
Social phobia Migraine headaches
Obsessive–compulsive disorder Tinnitus
Conduct disorder Cancer pain
Substance abuse Somatoform disorders
Attention-deficit/hyperactivity disorder Irritable bowel syndrome
Health anxiety Chronic fatigue syndrome
Body dysmorphic disorder Rheumatic disease pain
Eating disorders Erectile dysfunction
Personality disorders Insomnia
Sex addiction Obesity
Habit disorders Vulvodynia
Hypertension
Gulf War syndrome (PTSD and more)
General Principles of CBT
Cognitive behavioral therapy is:
Semi‐structured, time‐sensitive, active;
Based on a case conceptualization;
Focused on skill development; and
Oriented toward a hypothesis‐testing approach.
Clinician and client work collaboratively with a
focus on a strong relationship.
All interventions aim at cognitive change.
General Principles of CBT
Principle No. 1. Cognitive behavior therapy is based
on an ever-evolving formulation of patients’ problems
and an individual conceptualization of each patient in
cognitive terms.
Principle No. 2. Cognitive behavior therapy requires a
sound therapeutic alliance.
Principle No. 3. Cognitive behavior therapy
emphasizes collaboration and active participation.
Principle No. 4. Cognitive behavior therapy is goal
oriented and problem focused.
General Principles of CBT
Principle No. 5. Cognitive behavior therapy initially
emphasizes the present.
Principle No. 6. Cognitive behavior therapy is
educative, aims to teach the patient to be her own
therapist, and emphasizes relapse prevention.
Principle No. 7. Cognitive behavior therapy aims to
be time limited.
Principle No. 8. Cognitive behavior therapy sessions
are structured.
General Principles of CBT
Principle No. 9. Cognitive behavior therapy teaches
patients to identify, evaluate, and respond to their
dysfunctional thoughts and beliefs.
Principle No. 10. Cognitive behavior therapy uses a
variety of techniques to change thinking, mood, and
behavior.
  Like most other therapies, the therapeutic
Importance of the Therapeutic Relationship
relationship is a necessary and critical component of
CBT:
Empathic
Understanding
Warm
Genuine
Direct and sensitive
The Cognitive Model
Your client has been sent to the office for the 4th time
this week!
The family has not returned your calls, and the client
is refusing to talk to you.
What do you think?
How do you feel?
What do you do?
 The Situation The Beliefs The Consequences

This kid is so Feelings of

frustrating! He
isn’t even trying Frustration
The client to get better!
no-shows for
his session
again
His family situation
is so tough right
Feelings of
now, it’s really hard Compassion
for him to get to
sessions.
 Situation

Behaviors Thoughts

Feelings
 Thinking, Feeling, and Behaving
THOUGHTS

FEELINGS BEHAVIORS
 Situation
Get a dirty look from
another kid

Behaviors Automatic Thought

Threaten the kid He thinks he’s
Punch the kid tougher than me. I’ll
Refuse to back down have to show him I’m
not a punk

Feelings
Angry and Offended
Roller Coaster Example
Cognitive Model: Situations
A situation or activating event may be an internal or
external event that prompts an automatic thought.

External event: alarm clock ringing, being interrupted,

called on in class

Internal event: memory, thought, emotion, sensation

Cognitive Model: Beliefs
AUTOMATIC THOUGHTS
Quick evaluative thoughts
INTERMEDIATE BELIEFS
Rules or assumptions about life
“If________, then_____.”
CORE BELIEFS
Deeply held, rigid beliefs about the self, others, and the
world
Cognitive Model: Automatic Thoughts
Quick, evaluative thoughts or images that are
situation specific

Automatic thoughts = interpretations

We are more likely to be aware of the emotion that

follows an automatic thought.
Automatic Thoughts
When you notice a strong reaction (emotional,
behavioral, physiological), ask yourself:

“What was going through my mind just then?”

Eliciting Automatic Thoughts
1. Ask them how they are/were feeling and where in their
body they experienced the emotion.
2. Elicit a detailed description of the problematic situation.
3. Request that the patient visualize the distressing situation.
4. Suggest that the patient role-play the specific interaction
with you (if the distressing situation was interpersonal).
5. Elicit an image.
6. Supply thoughts similar or opposite to the ones you
hypothesize actually went through their minds.
7. Ask for the meaning of the situation.
8. Phrase the question differently.
Intermediate Beliefs
Attitudes, rules, or assumptions that stem from
core beliefs and fuel automatic thoughts

Commonly in the form of “if/then” statements

If I can’t do this perfectly, then why bother trying?
If I open up to people, then I will get hurt.
Core Beliefs
MOST CENTRAL, FUNDAMENTAL BELIEFS
ABOUT OURSELVES, OTHERS, AND THE WORLD
Absolute and rigid beliefs (+ or ‐) in 1‐2 words
“I’m worthless.”
May result in biases in attention, information
processing, and memory.
When activated, we interpret situations through the
lens of this belief.
Not necessarily accurate or helpful
How Core Beliefs Impact Thoughts
Core Belief: I am Stupid Core Belief: I am Smart

Event: Hears that a hard math test is scheduled for next week

Automatic Thoughts and Images

“This is too hard, I’ll never “I’ll really have to pay

understand this.” attention and ask for help”

Reaction and Behaviors

Sad, gives up, avoids Feels determined, seeks

studying, ultimately fails out help, studies, passes
Inaccurate and Unhelpful Beliefs
 WORTHLESS
 I am bad.
 I am a waste.
 UNLOVABLE  I am a burden.
 I am disgusting.
 No one wants me.
 HELPLESS
 People hate me.
 I am incompetent.
 I am vulnerable.
 I am not good enough.
 Common Unhelpful Thoughts
 1. All-or-nothing thinking (also called black-and-white, polarized, or
dichotomous thinking): You view a situation in only two categories instead of
on a continuum.
 Example: “If I’m not a total success, I’m a failure.”
 2. Catastrophizing (also called fortune-telling): You predict the future
negatively without considering other, more likely outcomes.
 Example: “I’ll be so upset, I won’t be able to function at all.”
 3. Disqualifying or discounting the positive: You unreasonably tell yourself
that positive experiences, deeds, or qualities do not count.
 Example: “I did that project well, but that doesn’t mean I’m competent; I just got
lucky.”
 4. Emotional reasoning: You think something must be true because you
“feel” (actually believe) it so strongly, ignoring or discounting evidence to the
contrary.
 Example: “I know I do a lot of things okay at work, but I still feel like I’m a failure.”
 5. Labeling: You put a fixed, global label on yourself or others without
considering that the evidence might more reasonably lead to a less disastrous
conclusion.
 Example: “I’m a loser. He’s no good.”
 Common Unhelpful Thoughts
 6. Magnification/minimization: When you evaluate yourself,
another person, or a situation, you unreasonably magnify the negative
and/or minimize the positive.
 Example: “Getting a mediocre evaluation proves how inadequate I
am. Getting high marks doesn’t mean I’m smart.”
 7. Mental filter (also called selective abstraction): You pay undue
attention to one negative detail instead of seeing the whole picture.
 Example: “Because I got one low rating on my evaluation [which
also contained several high ratings] it means I’m doing a lousy job.”
 8. Mind reading: You believe you know what others are thinking,
failing to consider other, more likely possibilities.
 Example: “He thinks that I don’t know the first thing about this
project.”
 9. Overgeneralization: You make a sweeping negative conclusion that
goes far beyond the current situation.
 Example: “[Because I felt uncomfortable at the meeting] I don’t
have what it takes to make friends.”
 Common Unhelpful Thoughts
 10. Personalization: You believe others are behaving negatively
because of you, without considering more plausible explanations
for their behavior.
 Example: “The repairman was curt to me because I did
something wrong.”
 11. “Should” and “must” statements (also called
imperatives): You have a precise, fixed idea of how you or others
should behave, and you overestimate how bad it is that these
expectations are not met.
 Example: “It’s terrible that I made a mistake. I should always
do my best.”
 12. Tunnel vision: You only see the negative aspects of a
situation.
 Example: “My son’s teacher can’t do anything right. He’s
critical and insensitive and lousy at teaching.”
Coping Strategies
Behaviors that the client engages in that either
support or oppose beliefs

Strategies may involve thinking or doing

something.
 Coping Strategies

Maintaining
Opposing Strategies Avoiding Strategies
Strategies
Try to prove the belief Try not to activate the
Support the Core
is wrong belief
Belief

Behavior generally makes sense to the person

doing it, based on how they see the world,
others, and themselves.
 Coping Strategies

Belief

I’m unlovable

Maintaining
Opposing Strategies Avoiding Strategies
Strategies
Try to prove the belief Try not to activate the
Support the Belief
is wrong belief
Acting in a hostile
People Pleasing Isolating
manner
Beliefs and Strategies
NAME SOME CLIENT BEHAVIORS…
What kinds of beliefs might be associated with these
behaviors?
WHAT KINDS OF BEHAVIOR MIGHT BE
ASSOCIATED WITH THESE BELIEFS?
I’m vulnerable.
I have no control.
Everyone is trying to hurt me.
Case Conceptualization
Foundation of CBT treatment
Brings together all the information into one
coherent story
Takes into consideration life experiences that
lead us to think and behave in specific ways
Based on here‐and‐now functioning and
symptoms
Case Conceptualization
Why use case conceptualization?
To better understand behavior
To increase empathy
To identify ways to engage clients
To identify targets for intervention
To create a shared understanding of a child or
adolescent
Case Conceptualization
History: Critical and abusive family members, undiagnosed
learning disability, neglect

Core Beliefs: I’m worthless. I’m stupid. People are dangerous.

Intermediate Beliefs: It is horrible to make mistakes. If I hurt

people first, then they can’t hurt me.

Coping Strategies and Behaviors: Avoid challenging situations,

aggression, isolation.
Case Vignette: Michele
Please read the vignette about Michele.
When you are finished, please review the case
conceptualization.
WHAT ARE THE IMPORTANT FACTS FROM HER
PAST?
WHAT ARE HER BELIEFS?
WHICH EMOTIONS AND BEHAVIOR DOES SHE
HAVE, AND HOW ARE THEY RELATED TO HER
BELIEFS?
Please be ready to discuss with your group.
Session Structure
Mood check & general assessment
Bridge from the previous session
Agenda setting
Homework review
Discussion of issues on the agenda
Summary and feedback (periodic summaries and
homework assignment)
Behavioral Activation
Situation: Thinking about initiating an activity

[Common] Automatic thoughts: “I’m too tired. I won’t

enjoy it. My friends won’t want to spend time with me. I
won’t be able to do it. Nothing can help me feel better.”

[Common] Emotional reactions: Sadness, anxiety,

hopelessness

[Common] Behavior: Remain inactive.

Behavioral Activation
Evaluating Thoughts
Examine the validity of the automatic thought.
Explore the possibility of other interpretations or
viewpoints.
De-catastrophize the problematic situations
Recognize the impact of believing the automatic
thought.
Gain distance from the thought.
Take steps to solve the problem.
Evaluating Thoughts
1. What is the evidence that supports this idea?
What is the evidence against this idea?
2. Is there an alternative explanation or viewpoint?
3. 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?
4. What is the effect of my believing the automatic thought?
What could be the effect of changing my thinking?
5. What would I tell____________[a specific friend or family
member] if he or she were in the same situation?
6. What should I do?
 Evaluation Session
 Client demographics. 
Medical history and current status.
 Chief complaints and current 
Family psychiatric history and
problems. current status.
 History of present illness and 
Developmental history.
precipitating events. 
General family history and current
 Coping strategies (adaptive and status.
maladaptive), current and historical. 
Social history and current status.
 Psychiatric history, including kinds

Educational history and current
of psychosocial treatments (and
status.
perceived helpfulness of these

Vocational history and current
treatments), hospitalizations,
medication, suicide attempts, and status.
current status. 
Religious/spiritual history and
 Substance use history and current current status.
status. 
Strengths, values, and adaptive
coping strategies.
Goals of First Treatment Session
Establish rapport and trust with clients, normalize their
difficulties, and instill hope.
Socialize clients into treatment by educating them about
their disorder(s), the cognitive model, and the process of
therapy.
Collect additional data to help you conceptualize the
patient.
Develop a goal list.
Start solving a problem important to the client (and/or get
the client behaviorally activated).
First

Treatment Session
Initial Part of Session 1
 1. Set the agenda (and provide a rationale for doing so).
 2. Do a mood check.
 3. Obtain an update (since the evaluation)
 4. Discuss the patient’s diagnosis and do psychoeducation.
Middle Part of Session 1
 5. Identify problems and set goals.
 6. Educate the patient about the cognitive model.
 7. Discuss a problem.
End of Session 1
 8. Provide or elicit a summary.
 9. Review homework assignment.
 10. Elicit feedback.
 2nd Treatment Session & Beyond
 Initial Part of Session
 1. Do a mood check.
 2. Set the agenda.
 3. Obtain an update.
 4. Review homework.
 5. Prioritize the agenda.
 Middle Part of Session
 6. Work on a specific problem and teach cognitive behavior therapy skills in
that context.
 7. Follow-up discussion with relevant, collaboratively set homework
assignment(s).
 8. Work on second problem.
 End of Session
 9. Provide or elicit a summary.
 10. Review new homework assignments.
 11. Elicit feedback.
Tips for Setting Homework
1. One Size Does Not Fit All.
2. Explain In Detail.
3. Set Homework as a Team.
4. Create a Win-Win Situation.
5. Start Homework In-Session.
6. Ask About and Review Homework.
7. Anticipate and Prepare for Problems.
Homework Example Session 1
Read this list twice a day; set an alarm to remember.
1. If I start thinking I’m lazy and no good, remind myself that
depression makes it harder for me to do things. As the treatment
starts to work, my depression will lift, and things will get easier.
2. Read goal list and add others, if I think of any.
3. When I notice my mood getting worse, ask myself, “What’s
going through my mind right now?” and jot down the thoughts.
Remind myself that just because I think something doesn’t
necessarily mean it’s true.
4. Make plans with Friends. Remember, if they say no, it’s likely
that they’d like to hang out with me but they’re too busy.
5. Read Coping with Depression booklet (optional).
Homework Example Session 2
1. Daily: When I notice my mood changing, ask myself, “What’s going through
my mind right now?” and jot down my automatic thoughts (which may or
may not be completely true).
2. If I can’t figure out my automatic thoughts, jot down just the situation.
Remember, learning to identify my thinking is a skill I’ll get better at, like
typing.
3. Ask Friend for help with studying.
4. Daily: Read therapy notes.
5. Continue running/swimming.
6. Plan two to three social activities.
7. Daily: Add to credit list (anything I do that is even a little difficult but I do it
anyway).
8. (Tuesday morning): Review Preparing for Therapy Worksheet for 2
minutes.
CBT Professional Organizations
Academy of Cognitive Therapy (www.academyofct.org)

Association for Behavioral and Cognitive Therapies (www.abct.org)

British Association for Behavioural and Cognitive Psychotherapies

(www.babcp.com)

European Association for Behavioural and Cognitive Therapies

(www.eabct.com)

International Association for Cognitive Psychotherapy (www.the-

iacp.com)
Assessments
The following scales and manuals may be ordered from Pearson (www.­beckscales.com):

Beck Depression Inventory–II

Beck Depression Inventory—Fast Screen for Medical Patients

Beck Anxiety Inventory

Beck Hopelessness Scale

Beck Scale for Suicidal Ideation

Clark–Beck Obsessive–Compulsive Inventory

Beck Youth Inventories—Second Edition

References
Alford, B. A., & Beck, A. T. (1997). The integrative power of cognitive therapy. New York: Guilford Press.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC:
Author.

Antony, M. M., & Barlow, D. H. (Eds.). (2010). Handbook of assessment and treatment planning for psychological disorders (2nd ed.).
New York: Guilford Press.

Arnkoff, D. B., & Glass, C. R. (1992). Cognitive therapy and psychotherapy integration. In D. K. Freedheim (Ed.), History of
psychotherapy: A century of change (pp. 657–694). Washington, DC: American Psychological Association.

Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford Press.

Beck, A. T. (1964). Thinking and depression: II. Theory and therapy. Archives of General Psychiatry, 10, 561–571.

Beck, A. T. (1967). Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.

Beck, A. T. (1987). Cognitive approaches to panic disorder: Theory and therapy. In S. Rachman & J. Maser (Eds.), Panic: Psychological
perspectives (pp. 91–109). Hillsdale, NJ: Erlbaum.

Beck, A. T. (1999). Cognitive aspects of personality disorders and their relation to syndromal disorders: A psychoevolutionary
approach. In C. R. Cloninger (Ed.), Personality and psychopathology (pp. 411–429). Washington, DC: American Psychiatric Press.
References
 Beck, A. T. (2005). The current state of cognitive therapy: A 40-year retrospective. Archives of General Psychiatry, 62,
953–959.
 Beck, A. T., & Beck, J. S. (1991). The personality belief questionnaire. Bala Cynwyd, PA: Beck Institute for Cognitive
Behavior Therapy.
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