713808011-Deborah-Roth-Ledley-Brian-P-Marx-Richard-G-Heimberg-Making-Cognitive-Behavioral-Therapy-Work-Clinical-Process-for-New-Practitioners-The-Guilfor

Prévia do material em texto

MAKING COGNITIVE-BEHAVIORAL 
THERAPY WORK
Also Available
Cognitive-Behavioral Group Therapy for Social Phobia: 
Basic Mechanisms and Clinical Strategies
Richard G. Heimberg and Robert E. Becker
Generalized Anxiety Disorder: 
Advances in Research and Practice
Edited by Richard G. Heimberg, 
Cynthia L. Turk, and Douglas S. Mennin
Improving Outcomes and Preventing Relapse 
in Cognitive-Behavioral Therapy
Edited by Martin M. Antony, 
Deborah Roth Ledley, and Richard G. Heimberg
Social Phobia: Diagnosis, Assessment, and Treatment
Edited by Richard G. Heimberg, Michael R. Liebowitz, 
Debra A. Hope, and Franklin R. Schneier
Making 
Cognitive-Behavioral 
Therapy Work
Clinical Process for New Practitioners
T H I R D E D I T I O N
DEBORAH ROTH LEDLEY 
BRIAN P. MARX 
RICHARD G. HEIMBERG
The Guilford Press
New York London
Copyright © 2018 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com
All rights reserved
Except as indicated, no part of this book may be reproduced, translated, 
stored in a retrieval system, or transmitted, in any form or by any means, 
electronic, mechanical, photocopying, microfilming, recording, 
or otherwise, without written permission from the publisher.
Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
LIMITED DUPLICATION LICENSE
These materials are intended for use only by qualified mental health professionals.
The publisher grants to individual purchasers of this book nonassignable permission 
to reproduce the blank assessment report template. This license is limited to you, the 
individual purchaser, for personal use or use with clients. This license does not grant 
the right to reproduce these materials for resale, redistribution, electronic display, or 
any other purposes (including but not limited to books, pamphlets, articles, video- or 
audiotapes, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides 
for lectures, workshops, webinars, or therapy groups, whether or not a fee is charged). 
Permission to reproduce these materials for these and any other purposes must be 
obtained in writing from the Permissions Department of Guilford Publications.
The authors have checked with sources believed to be reliable in their efforts to provide 
information that is complete and generally in accord with the standards of practice that 
are accepted at the time of publication. However, in view of the possibility of human 
error or changes in behavioral, mental health, or medical sciences, neither the authors, 
nor the editor and publisher, nor any other party who has been involved in the prepara-
tion or publication of this work warrants that the information contained herein is in 
every respect accurate or complete, and they are not responsible for any errors or omis-
sions or the results obtained from the use of such information. Readers are encouraged 
to confirm the information contained in this book with other sources.
Library of Congress Cataloging-in-Publication Data
Names: Ledley, Deborah Roth, author. | Marx, Brian P. | Heimberg, Richard G.
Title: Making cognitive-behavioral therapy work : clinical process for new 
 practitioners / Deborah Roth Ledley, Brian P. Marx, Richard G. Heimberg.
Description: Third edition. | New York : The Guilford Press, [2018] | 
 Includes bibliographical references and index.
Identifiers: LCCN 2018006155 | ISBN 9781462535637 (hardback)
Subjects: LCSH: Cognitive therapy. | BISAC: MEDICAL / Psychiatry / General. | 
 SOCIAL SCIENCE / Social Work. | PSYCHOLOGY / Clinical Psychology.
Classification: LCC RC489.C63 L44 2018 | DDC 616.89/1425—dc23
LC record available at https://lccn.loc.gov/2018006155
To Jenna, who shares my love of the written word 
To Matthew, our inquisitive and empathic Junior Doctor
And to Gary, who supports me in everything I do 
and whom I love to the moon and back
 —D. R. L.
For Colin and Denise, both of whom teach me 
something valuable every single day
 —B. P. M.
To Chris, who always makes me proud
To Connor and Riley, who always make me smile
And, most of all, to Linda, who lights up my life
 —R. G. H.
 vii
About the Authors
Deborah Roth Ledley, PhD, is a psychologist in private practice in sub-
urban Philadelphia. She spent several years on the faculty of the Uni-
versity of Pennsylvania’s Center for the Treatment and Study of Anxi-
ety. Dr. Ledley’s research has focused on the nature and treatment of 
anxiety. She has published over 50 scientific papers and book chapters 
as well as several books, including Improving Outcomes and Preventing 
Relapse in Cognitive-Behavioral Therapy, Becoming a Calm Mom, and 
The Worry Workbook for Kids. She lectures widely on the treatment of 
childhood anxiety. 
Brian P. Marx, PhD, is a staff psychologist at the National Center for 
Posttraumatic Stress Disorder (PTSD), Veterans Affairs Boston Health-
care System, and Professor of Psychiatry at Boston University School of 
Medicine. Dr. Marx has published numerous articles and book chap-
ters on behavior therapy and assessment. His research interests include 
the assessment and treatment of PTSD, identifying risk factors for post-
traumatic difficulties, and the association between PTSD and suicidal 
behaviors.
Richard G. Heimberg, PhD, is the Thaddeus L. Bolton Professor of Psy-
chology and Director of the Adult Anxiety Clinic of Temple at Temple 
University. He is past president of the Association for Behavioral and 
Cognitive Therapies (ABCT) and the Society for a Science of Clinical 
Psychology (SSCP) and former editor of the journal Behavior Therapy. 
Well known for his efforts to develop and evaluate cognitive-behavioral 
viii About the Authors
treatments for social anxiety and other anxiety disorders, Dr. Heimberg 
has published several books and 450 articles and chapters. As an educa-
tor and mentor of clinical psychology doctoral students, he has received 
awards from ABCT, SSCP, the Society of Clinical Psychology, and the 
American Psychological Association of Graduate Students.
 ix
Preface
Back in 1999, when I (D. R. L.) was a postdoctoral fellow at Temple 
University, Brian Marx (who was then an assistant professor), Richard 
Heimberg (who was then my mentor), and I cooked up the idea of writ-
ing a book for beginning clinicians. Even at the fine training programs 
with which we had been involved, we were struck by a gap in train-
ing. Although students knew a lot of facts about cognitive-behavioral 
therapy and the disorders they were treating, they sometimes seemed lost 
in the room with clients. And, as a new clinician myself, I often felt the 
same way! There were so many “What should I do?” questions: What 
should I do when a client asks me personal questions? What should I do 
when a client gets angry during a session? What should I do with my 
feelings of disappointment when clients discontinue therapy when I do 
not think they are ready to do so? There were no books that addressed 
these important questions. My own struggles, and the struggles of our 
collective trainees, inspired us to write Making Cognitive-Behavioral 
Therapy Work.
So much has changed since the first edition of our book was pub-
lished in 2005! I am no longer an inexperienced clinician, and over the 
past decade or more, we have treated and supervised the treatment of 
countless clients. This collective experience has led us to substantially 
revise Making Cognitive-Behavioral Therapy Work for this third edi-
tion. In this new edition, we have included a chapter on working with 
special populations. In that chapter (Chapter 9), we discuss the impor-
tance of providing culturally responsive cognitive-behavioral therapy 
x Preface
and offer guidance on how to work with children and families. We have 
included new cases, includingwho progress through treatment quite unevent-
fully present interesting challenges to think through. Starting out as a 
clinician can indeed be stressful, but we encourage you to embark upon 
this path with a spirit of curiosity.
 26
2
Initial Interactions with Clients
Depending on the nature of your job and the environment in which you 
work, your initial contact with clients will vary. Some clinicians take 
phone calls from potential clients; some are assigned clients and their 
initial contact involves calling to set up a first appointment; and some 
do not have contact with clients until they actually come in for their first 
visit.
In this chapter, we lead you through a hypothetical progression of 
events that is typical, even if it does not exactly match your specific clini-
cal setting. By following this progression, we will be able to illustrate the 
process of becoming acquainted with clients. Most important, we focus 
on establishing rapport with new clients, as well as using early interac-
tions with clients to inform case conceptualization.
THE INITIAL CONTACT
Regardless of the nature of, or reason for, the client’s initial contact, 
taking this first step in seeking help can be daunting to many people. 
We have all met clients who have considered calling for months, or even 
years, before actually doing so. Given these circumstances, be sensitive 
to the client’s situation and any discomfort or awkwardness that he or 
she might be feeling. It is also important to keep in mind that an ini-
tial phone contact is typically not the appropriate arena in which to 
 Initial Interactions with Clients 27
thoroughly assess and diagnose a client’s difficulties. Rather, it should 
be used as the context in which to obtain basic and relevant information 
to determine the next appropriate step.
A good starting place with any potential client is to ask for a brief 
description of the kinds of difficulties that he or she has been having. 
This can be accomplished by asking questions like “How can I help 
you today?”; “What is it that led you to call us today?”; “What sorts 
of difficulties have you been having recently?” Some individuals will 
quite easily and clearly answer the question, providing the clinician with 
an opportunity for further questions. Others might be reluctant to dis-
close information over the phone or talk in detail about their problems 
because of shame or embarrassment about their difficulties or the need 
to seek treatment. In these situations, it is essential that you communi-
cate your willingness to help the individual and your comfort and famil-
iarity with information that callers typically share. It is only after you 
have adequate information that you will be able to make appropriate 
recommendations.
Beginning and experienced clinicians alike often struggle with how 
much time to spend on the phone with prospective clients. During our 
training, when we might have to call a new potential client every few 
weeks, time is a luxury. We can spend ample time on the phone let-
ting callers describe their concerns, coaxing them to share if they are 
reluctant, and answering their questions. This changes for more senior 
practitioners, who might have 10 such calls to make in a week! How do 
we balance our limited time with making callers feel heard? It is key to 
return to the purpose of the initial phone call. As we already mentioned, 
the purpose of these calls is to learn if the caller has the kind of diffi-
culties that might be served by the setting in which we work. Emphasis 
is placed on the word “might” because we don’t need to answer every 
question during the phone call. In fact, on an initial phone call, we don’t 
want the caller to share so much information that it begins to feel like 
we have established a therapeutic relationship. We have not established 
a therapeutic relationship until consent is provided. We want to gather 
basic information that allows us to know if we should bring the potential 
client in for an assessment, or if we should provide referral information. 
It is perfectly appropriate to start a phone call by saying, “I have 10 
minutes until my next patient. Let’s spend that time discussing how I 
might be able to help you.” It is also OK to gently interrupt a caller and 
say, “That is really useful for me to know. Let’s talk about that in more 
detail at our in-person meeting.” If a caller gets very agitated by time 
limits and by requests to hold off on more information until an in-person 
28 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
meeting, this response serves as useful information for the case concep-
tualization.
Making Recommendations
The clinician’s goal for the initial conversation is to make a recommen-
dation for how the individual should proceed. There are many options 
to consider. One possibility is to bring the person in for a more in-depth 
evaluation. Another option is to refer individuals to another professional 
or clinic if neither you nor any of your colleagues are able to treat them. 
This process should be handled in a way that is sensitive to the possibil-
ity that the caller may feel rejected by such a suggestion. For example, he 
or she can be told, “It sounds like your main problems right now have 
to do with your marital relationship. We don’t do couple therapy at our 
clinic, so let me give you some good referrals in the area where you can 
pursue that kind of treatment.” It is always best to give callers a few 
options just in case a particular clinician is not taking new clients or 
does not take the kind of insurance that the person has. It is also good 
practice to invite the individual to call you back if none of the referrals 
work out.
Sometimes individuals contact clinicians to gather information 
rather than to seek treatment. In some cases, they just are not ready 
to commit to therapy but are at the stage in which they want to learn 
more about their problems or might consider attending a support group. 
Again, information should be briefly provided, along with an invita-
tion to call back should they want treatment in the future. At other 
times, we as clinicians might sense that treatment is not necessary. For 
instance, individuals might call and describe very minimal symptoms, 
and might feel concerned about finding time to come in for treatment. 
In such cases, recommendations for self-help books, websites, or local 
support groups can be provided. Clinics and individual practitioners 
can maintain a website with this information to which the caller can be 
directed. These more minimal interventions can be sufficient for some 
people; others might give them a try and then see that it is worth mak-
ing the sacrifices required for participation in more traditional therapy.
In general, when potential clients call a clinician, they want to come 
away with something: an appointment, a referral, or information. Leave 
them with the sense that calling to speak to a clinician was a positive 
decision, resulting in some positive changes. During this initial con-
tact, be sure to provide information slowly and in terms that are easy to 
understand. Avoid psychological jargon, keep information simple and 
 Initial Interactions with Clients 29
straightforward, and make sure that you provide an opportunity for the 
individual to ask questions.
Before moving on, be sure to discuss contact made via electronic 
mail (e-mail). Throughout the book, we will discuss communicating 
with clients via e-mail. It is essential to note that major health systems 
and even smaller group practices have strict rules about e-mail contact 
that must be followed. Guidelines for e-mail communication are dis-
cussed in Chapter 6 for clinicians who are at liberty to establish their 
own rules and standards (e.g., clinicians in private practice). At this early 
point of initial contact, it is best to shift from e-mail communication to 
phone communication as soon as possible. E-mail should only be used 
(wherepermitted) to respond to the simplest of questions, such as pro-
viding the address of the clinic or answering a question about services 
offered. E-mail should not be used to discuss clinical matters. In Chapter 
6, we discuss in more detail why e-mail should not be used to discuss 
clinically relevant information.
Making the Arrangements for a First Visit
Let’s assume the caller is a suitable candidate for assessment at the clinic 
where you work. The next step, then, is setting up an initial visit. When 
inviting individuals to come in, clinicians should inform them of the pur-
pose of the visit and what it will entail. Keeping in mind that anxiety can 
make it difficult for people to attend to details, make sure that they are 
clear on when the session will be held (date and time), how long the ses-
sion will last, and, most important, how to get there. Some individuals 
will be so focused on making the initial phone call that they might forget 
to ask for these details and might then feel ashamed about needing to call 
back for further information. Be sure to provide all the necessary infor-
mation, and make sure that all of it is clear. If a website is available that 
includes all this information, be sure to give the web address to callers.
Asking Permission to Send an Advance Mailing
When a first session is arranged, an advance mailing can be sent remind-
ing clients of the time of their appointment and providing them with 
directions for how to get there, contact information should they need to 
change their appointment, and perhaps some general information on the 
clinic or on the types of difficulties for which the individual is seeking 
help. It can also be very helpful to send self-report questionnaires that 
assess relevant problems or conditions of interest to clients and ask that 
30 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
they be completed before the assessment session. In this way, question-
naires can be used to facilitate the assessment process (see Chapter 3).
Before doing any of this, ask clients if it is OK to send them mail. 
Some clients do not want family members to know that they are seeking 
treatment and might prefer that mail not be sent to their homes. When 
mailings are sent, unmarked envelopes should be used and marked con-
fidential. At this point in your contact with clients, it is best to defer to 
their wishes on these issues. Be mindful, however, that these concerns 
can be important to the case conceptualization. Once therapy is under 
way, they might even become a focus of clinical attention. For example, 
a client who is very isolated and perceives that she lacks social support 
might benefit greatly from becoming more open with family members 
about the kinds of difficulties that she is having.
In our increasingly paperless society, much of this initial correspon-
dence is done online. Even private practitioners can have a simple web-
site that includes directions to their office, contact information (with the 
caveat that clients should call 911 or go to the emergency room if they 
require emergent assistance), and initial forms/questionnaires to com-
plete. It can be helpful to also include some basic information on CBT, 
the disorders that you treat, and links to reputable sources for additional 
information. Some clinicians are now using online scheduling for clients 
and having clients complete questionnaires on line. It is essential that 
our websites are secure to protect the identities of our clients.
Setting the Fee
Prior to coming in for an assessment (and prior to beginning therapy as 
well), clients must be informed about how much the assessment will cost. 
In some settings, fee arrangements are handled by a business administra-
tor and kept separate from the therapeutic relationship. In other settings, 
clinicians must take care of these arrangements themselves. Regardless 
of who deals with fee setting and collection, it is essential to note that the 
American Psychological Association’s (APA) Ethical Principles of Psy-
chologists and Code of Conduct (2010a) requires that fees and financial 
arrangements be discussed “as early as is feasible” (code 6.04a). Beyond 
discussing your rates with clients, it is also important that you explain 
your policies on unpaid fees and missed appointments. Be knowledge-
able about the policies at your clinic and be sure to explain these policies 
to clients clearly and in language they can understand. Clients should 
sign a document committing to pay the agreed-upon fee and acknowl-
edging that they are aware of policies pertaining to fees.
 Initial Interactions with Clients 31
BEFORE MEETING THE CLIENT
Come Prepared
When clients come to see clinicians to discuss highly personal difficul-
ties, they are often anxious. It is our job to keep the tone of our sessions 
as calm as possible. This can be challenging since there is a lot to remem-
ber when you first meet with a client. You need general information on 
the client (which might have been collected during an initial phone call), 
any forms that the client needs to fill out (e.g., consent forms, forms 
required by the Health Insurance Portability and Accountability Act 
[HIPAA]), your assessment measures, pens and pencils, and a watch or 
clock to help you be mindful of the time. In some settings, you might 
also need to be prepared to record your session. Remembering all of 
these items and tasks can be even harder if you are seeing clients in an 
office shared by many clinicians, where you do not have all of these 
items at hand. Running in and out of the office/therapy room to retrieve 
important papers, tools, or items will likely make you appear disorga-
nized and unprofessional to your client.
A key to being prepared is to give yourself enough time. If you have 
your first client at 9:00 a.m and know that you have to get set up in an 
office shared by other clinicians, get there a half hour early. Take some 
time to make sure you have everything you need and that the office is 
neat and clean. If you see clients in your own office, organize all the 
materials you need; again, be sure that your work area is clean and 
cleared of any client-related information (e.g., phone messages, files). 
Clients will rightfully doubt your commitment to confidentiality if they 
come into your office and easily see the names of other clients on papers 
scattered around your desk.
An important key to preparation is to silence all cell phones before 
meeting with clients. Even the vibration noise can be distracting and 
can tempt clinicians to look at their phones during time with clients. 
Checking text messages or answering phone calls during a session com-
municates a lack of respect to a client and should not be done. Although 
many of us use our cell phones as our clocks these days, this can be prob-
lematic in the therapeutic session when text messages and other alerts 
pop up on our home screens. It is still best to have a simple clock in the 
therapy room to help with time management.
It is also appropriate to ask clients to silence their cell phones during 
sessions. If clients text or respond to cell phones during sessions, they 
should be asked to refrain from doing so. Their reaction to such requests 
can be very informative. Clients who are overtly resistant to doing so 
32 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
might be trying to show the clinician how important or needed they are, 
or they might have difficulties with authority. This behavior can become 
a topic for the therapy.
One final aspect of preparation happens before a clinician even 
comes into work for the day: what to wear. When making these decisions, 
keep a few things in mind. First, a clinic that provides psychological ser-
vices is a professional setting, just like a law office or a bank. Although 
we have seen trainees over the years come to work looking ready for a 
night out at the bars or a day at the beach, such wardrobe choices are 
not appropriateand might make clients doubt the maturity and serious-
ness of their clinicians. Here are a few general guidelines to consider. 
Women should avoid low-cut tops, short skirts, and clothes that are 
overly form-fitting. Such clothing choices can make clients uncomfort-
able. As an example, a man who is seeking treatment for social anxiety 
and has difficulty interacting with attractive women might be made very 
nervous by a female clinician who is wearing revealing clothing. Simi-
larly, a woman who is seeking treatment for an eating disorder might 
feel uncomfortable if her clinician is accentuating her thinness with very 
tight-fitting clothes. Women should also avoid any distractions such as 
very noticeable make-up, jangly jewelry, or open-toed shoes showing 
off brightly painted toes. Although all of these choices are great for a 
sunny summer day away from the office, they can distract clients who 
are already feeling nervous about their initial meeting with a mental 
health professional. Men’s clothing choices are often less controversial, 
but worth mention. Men should be mindful of looking professional by 
being well-groomed, wearing a collared shirt (accompanied by a jacket 
and/or tie, in many settings), pressed pants (not jeans), socks and dress 
shoes (not sneakers or sandals). Dressing professionally will ensure that 
clients feel more confident about seeing a trainee and that their difficul-
ties are being taken seriously.
Be Mindful of the Focus of Attention
Before moving on to the nuts and bolts of this first in-person interac-
tion, let’s revisit the issue of focus of attention that was introduced in 
Chapter 1. In all our interactions with clients—assessments or therapy 
sessions—our attention should be focused on the client. When people 
are anxious, their tendency is to focus on themselves: “Am I saying the 
right thing?”; “Can the client tell that I’ve never done this before?”; “Did 
I forget a question in that last section of the diagnostic interview?” To 
some extent, it is important to pay attention to such things to make sure 
 Initial Interactions with Clients 33
that the goals of the session are accomplished. However, too much focus 
on how you are coming across to the client can be detrimental. Similarly, 
we will not do our best work if our attention is focused on the rough 
morning that we had at home with our kids, our lengthy to-do list, or a 
session that is likely to be challenging later in the day. Self-focus makes 
you miss out on what the client is saying. It might even make it more 
likely that you will forget to ask something important.
When interacting with clients, we should be focusing as much as 
possible on them. We should be attending to what they say and to what 
they are communicating through their body language and facial expres-
sions. This level of attention will allow you to leave the session with the 
information that you need to make a diagnosis and begin the process of 
conceptualizing the case.
With this being said, there are appropriate times for being more self-
focused. During supervision, you can certainly discuss how you believe 
you came across during your interactions with a client. It can also be 
useful for beginning clinicians to watch (or listen to) their own ther-
apy recordings and identify behaviors that they might want to change. 
For example, you might see yourself as task-oriented to the exclusion 
of being empathic toward the client. This knowledge is useful in future 
therapy interactions.
IN THE WAITING ROOM
The first place that we typically meet clients face to face is the waiting 
room. When greeting clients, it’s essential to put them at ease, while also 
being mindful of confidentiality. If a receptionist checks clients in, it is 
best to ask him or her to indicate which client is yours. Then, approach 
this person, introduce yourself, welcome the client to the clinic, and escort 
the client to your office. If you must call out a name in the waiting room, 
sticking to a first name helps to maintain the client’s confidentiality.
IN THE ROOM WITH THE CLIENT
In the first few minutes of the initial session, what should be foremost 
in your mind are social graces. This seems like silly advice—after all, 
there is a lot of work to get done! Yet we so often rush to get tasks 
accomplished that we forget to greet clients, welcome them to the clinic, 
ask how they are, and introduce ourselves. These first few moments can 
34 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
make a big difference in establishing rapport, setting clients at ease, and 
letting them know that we are interested in them as people and not just 
as clusters of symptoms.
Introductions and Permission to Record
At this point in the session, it is appropriate to ask clients how they are, 
and it is certainly important to address them correctly (e.g., “Would you 
like me to call you Mrs. Jones or Susan?”). In general, it is best when 
you first meet adult clients to call them Mr. or Mrs. X. Many clients will 
immediately ask you to call them by their first name, and it is certainly 
fine to ask clients if they feel comfortable being addressed in that way. 
The overarching rule is to have respect for your clients. Although it is 
our experience that most therapy clients are perfectly fine with being 
called by their first names, asking them first if this is acceptable helps to 
establish good rapport.
When introducing yourself to clients, provide your name and let 
them know what they can call you (e.g., whether you like to be addressed 
as Dr. Smith, Miss Smith, or Jane). You might also want to tell the client 
a bit about your “professional self”—for example: “I’ve been working 
at this clinic for almost 2 years. My main interest in both my clinical 
work and my research is marital relationships. I’ve been working pri-
marily with couples and really enjoy it a lot.” Although this discussion 
of one’s professional self is by no means mandatory, it can break the ice 
and make clients feel more comfortable. Sometimes clients may ask you 
for more information about yourself. They may want to know if you 
are married, have children, where you grew up, as well as other more 
personal information. Such questions may derive from clients’ normal 
curiosity about their clinicians. They may also ask because it seems to 
them that the therapeutic relationship is one-sided. They tell us about 
themselves in great detail while we share relatively little about ourselves. 
Regardless of why clients may ask for more personal details, you may 
find yourself feeling uncomfortable when pressed for more information. 
When deciding how to answer such questions, keep in mind that you 
need to balance the goal of developing therapeutic rapport with the sense 
of how much is too much self-disclosure. How much is too much may be 
determined by many things, including your own personal comfort level 
regarding self-disclosure and, as discussed in greater detail in Chapter 6, 
whether or not additional self-disclosure to a client is contraindicated. 
In many cases, though, it may be acceptable to provide some personal 
 Initial Interactions with Clients 35
detail in order to satisfy a client’s curiosity and for the sake of building 
a strong therapeutic relationship.
One piece of information that you must disclose is your status as a 
trainee. The APA Ethical Principles of Psychologists and Code of Con-
duct (2010a) requires that all clinicians in training tell clients that they 
have a supervisor and provide them with the supervisor’s name (code 
10.01c). The Canadian Psychological Association’s (CPA) Code of Eth-
ics for Psychologists (2000) makes similar requirements (code III.22). In 
Chapter 6, we discuss additional issues that might relate to telling your 
clients about your level of training. For the time being, keep in mind that 
the issue of supervision must be raised early in your initial session with 
a client.
One final piece of business that must be takencare of before pro-
ceeding with the initial session is that of recording sessions. In research 
settings, assessments and therapy sessions are typically recorded; in clin-
ically oriented settings, trainees are often asked to record their assess-
ments and therapy sessions for supervision purposes. In gaining permis-
sion, clinicians should explain to clients why sessions will be recorded, 
who will have access to these recordings, and what precautions will be 
taken to ensure confidentiality (e.g., how recordings are stored, shipped 
to other study sites or to supervisors, or electronically transmitted). In 
general, most clients express little resistance to being recorded after 
they have been properly briefed on confidentiality and are told how the 
recordings will be used in supervision.
Giving an Overview of the Session
Once introductions are finished, clients should be given an overview of 
what the session will entail. Generally, in the first meeting, the clinician 
“takes care of business”—specifically, obtaining consent to do the assess-
ment and discussing confidentiality with the client—and then proceeds to 
the assessment. In the remainder of this chapter, we discuss how to “take 
care of business”; in the next chapter, the process of assessment is out-
lined, including how to initially orient clients to the assessment process.
Taking Care of Business
At the start of the initial session, consent should be obtained, HIPAA 
notices provided (HIPAA will be described in more detail later in the 
chapter), and confidentiality discussed. The client should be given ample 
36 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
opportunity to read the consent and HIPAA forms (see the next section) 
and should be invited to ask questions. Respecting clients’ concerns and 
questions during this process can get the therapeutic alliance off to a 
good start even before clients begin to discuss the difficulties that they 
are having.
Obtaining Consent for Assessment
For which activities do we need to obtain consent from clients? Both 
the APA (2010a) Ethical Principles and the CPA (2000) Code of Ethics 
require psychologists to obtain informed consent for both assessment 
and therapy (see codes 3.10, 9.03, and 10.01 in the APA code and code 
I.19 in the CPA code). Furthermore, it’s necessary to obtain consent “as 
early as is feasible” (APA code 10.01a). In general, written consent is 
superior to simply recording in a chart that verbal consent was obtained, 
although the APA and the CPA permit both methods.
There are some key points to keep in mind when obtaining consent. 
In the case of written consent, it is always a good policy to read through 
the consent form with the client. However, you certainly can highlight 
the key points more informally. In either case, clients should always be 
given the opportunity to read through the consent form at their own 
pace. Once clients have finished reading, it is important to ask them 
if they have understood what they have read and to invite them to ask 
questions. If you sense that clients have not understood the form, it is 
best to review it with them and put it into language they can understand. 
If a client immediately jumps to the signature line and starts to sign his 
or her name without reading the consent form, it is advisable to empha-
size the importance of reviewing the form before signing. If consent is 
being obtained verbally, the key points that would be included in a writ-
ten consent form should be reviewed with the client and his or her verbal 
consent should be noted in the chart.
Consent forms should include some essential information. These 
essentials are outlined in both the APA and the CPA codes (see codes 
9.03a and 10.01a in the APA code and code I.24 in the CPA code). In 
general:
1. Clients must understand the purpose and nature of the activ-
ity. This section of the consent form should outline for clients what 
the assessment or treatment program will entail and the purpose of 
these activities. These descriptions should be written and also verbally 
explained to clients in lay terms.
 Initial Interactions with Clients 37
2. Clients must be informed about the likely benefits and risks of 
the activity. Although our natural inclination is to tout all the likely ben-
efits of our activities as clinicians, clients cannot be expected to make 
informed decisions about assessment and treatment without being aware 
of risks as well as benefits. On the one hand, it is definitely appropriate 
to point out to clients that CBT has garnered a great deal of empirical 
support for the treatment of a wide variety of disorders. On the other 
hand, clients should be informed that positive outcomes cannot be guar-
anteed for any one client. It is also appropriate to point out to clients 
that making the cognitive and behavioral changes that are essential in all 
CBT programs might, in the short term, be difficult and stressful.
3. Clients must be told of alternatives to the activity (e.g., other 
treatments) and likely consequences of nonaction. Although many clini-
cians feel committed to the school of treatment to which they subscribe, 
we are ethically obligated to let our clients know of other treatments 
that might help them. For example, “Other options are available such 
as other forms of psychotherapy, pharmacotherapy, or not seeking treat-
ment at all. You [referring to the client] should understand that seek-
ing no treatment at all might lead to continuation or worsening of your 
symptoms.”
4. Consent forms must also make clear that clients can refuse to 
participate in the given activity or withdraw at any time without preju-
dice.
5. Consent forms must also include a discussion of confidentiality 
protections and limitations. The issue of confidentiality must be dis-
cussed with each and every client prior to the initiation of assessment 
or therapy.
Discussing Confidentiality
Confidentiality is assured to clients in two ways: through consent forms 
and through HIPAA forms. To summarize, HIPAA is a law that, among 
many other things, ensures that health information is kept private. The 
privacy-rule component of HIPAA regulates the way that protected 
health information is communicated between various entities includ-
ing health care professionals and insurance companies. Protected health 
information basically includes any information related to a medical 
record or payment history that can be linked to a particular individual. 
38 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
When clients are first being seen for mental health treatment, they must 
receive a statement of the clinic’s privacy practices. This statement pro-
vides another layer of assurance of confidentiality in addition to the con-
sent form.
Regardless of the exact nature of the paper document being handed 
to clients, clinicians should discuss confidentiality at the initial meet-
ing and at any other time it becomes a concern for clients. Some clients 
will be very clear with you that this is a concern for them. They might 
worry about information being released to their family members or to 
their employers. Most clients, whether they say so or not, are likely to 
be concerned about confidentiality, and rightfully so, given that therapy 
involves discussing deeply personal matters with a complete stranger. 
The bottom line is that without the protection of confidentiality, many 
clients would not consider therapy in the first place or, alternatively, 
would enter therapy but withhold discussion of issues that might be very 
relevant to the difficulties they are having.
How can clients be reassured about this very important issue? First, 
you can tell your clients how important confidentiality is to you and the 
other staff at your clinic and that you are bound to maintain confiden-
tiality (under most circumstances) not only by ethical codes but also by 
law. Tell your clients that you will not speak about them with anyone 
except your supervisor,other clinicians who attend group supervision 
or consultations meetings, or other people at the clinic who are directly 
involved in their care (e.g., the psychiatrist at your clinic who takes care 
of medication for clients).
If you have spent some time practicing in a particular geographical 
area, you might find that you see your clients when you are “out and 
about.” Although it can be a good idea to limit your practice so that you 
don’t treat clients who attend your place of worship or who go to school 
with your children, this is not always feasible (particularly in small com-
munities). Even with these limits in place, we have all run into clients 
at the movies, at restaurants, or even on vacation! If you sense that you 
might run into clients outside the therapy environment (e.g., you are 
treating a child in your child’s school, but not in his or her grade), this is 
important to discuss. You could say, “I know you got my name from the 
school counselor at Happiness Elementary School and you know that 
I have kids there. Let’s talk about what will happen when we see each 
other there.” The rule of thumb is that we should never approach our 
clients outside the therapy setting. Clients should understand that we do 
this to protect their confidentiality and we should reassure them that 
we don’t intend to be rude (this is particularly important when working 
 Initial Interactions with Clients 39
with children who might not really understand—or care about—confi-
dentiality). If the client approaches his or her therapist in public, that is 
his or her choice, but we should still try to ensure confidentiality. You 
might say, “If you come up to me to say ‘Hi’ at school, I will not be tell-
ing my kids or my friends that I know you because you are my patient. 
That would break confidentiality.”
Just as important as discussing the maintenance of confidentiality, 
you must discuss the specific circumstances under which confidentiality 
must be broken. These circumstances are mandated by the laws of each 
state or province and should be clearly understood by both you and each 
client with whom you work. If you are not aware of the rules, ask your 
clinical supervisor to explain them or contact your state or provincial 
licensing board and have the information sent to you. The Association 
of State and Provincial Psychology Boards (www.asppb.net) provides 
contact information for all state and provincial licensing boards.
In general, clients should be told that confidentiality will be breached 
if (1) they threaten to harm themselves; (2) they threaten to harm spe-
cific other persons; (3) they tell you about the abuse of a child or an 
elder; or (4) their records are subpoenaed by a court of law. Some states 
and provinces also have other mandatory reporting laws (e.g., manda-
tory reporting of abuse of adults who cannot protect themselves). It is 
worth reemphasizing that a discussion of confidentiality, and limits to it, 
should occur as early in your contact with the client as possible. We will 
discuss issues of confidentiality when working with youth in Chapter 9.
An important issue related to confidentiality arises when you are 
working for a third party—for example, when you are doing employee 
assessments for an employer, student assessments for a school district, 
or assessments that are ordered by the court. In such situations, the rules 
of confidentiality change. Here, you do not work for the person you are 
assessing but rather for the employer, the school district, or the court 
and, as such, they have access to the information that you collect from 
the client. In these situations, all parties must be made aware of the lim-
its of confidentiality. Some tips to remember about the process of obtain-
ing consent from clients are summarized in Table 2.1.
THE CASE CONCEPTUALIZATION (THUS FAR)
It might seem, at this point, that our trip itinerary is blank! We haven’t 
yet added a single destination or plan—or have we? In fact, even after 
these limited interactions with clients, we might have gleaned very useful 
40 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
information for our case conceptualization. We might not know yet how 
it all fits together, but it is worth noting. Did your client become argu-
mentative during a discussion about fees or the rules of therapy? Did he 
seem nervous and unassertive when planning the next meeting time? 
How did she react to the discussion of confidentiality? Unusually strong 
reactions during these informational discussions might lead the clinician 
to hypothesize that a particular issue is sensitive and should be explored 
more thoroughly during the assessment process. Client reactions during 
this time may also provide information about how he or she reacts to 
interpersonal conflict or difficult issues more generally. The bottom line 
TABLE 2.1. Obtaining Consent
As early as is feasible in your clinical activities with patients, it is essential to 
obtain consent.
Important points to remember
• Consent must be obtained for assessment and therapy.
• Written consent is superior to oral consent.
• Let clients read through consent forms at their own pace, check that they have 
understood what they read, and invite questions.
• Clients should also be presented with a statement of the clinic’s privacy practices 
(HIPAA document).
Essential information to cover when obtaining consent
• Clients must understand the purpose and nature of the activity.
• Clients must be informed about likely benefits and risks of the activity.
• Clients must be told of alternatives to the activity (e.g., other treatments) and 
likely consequences of nonaction.
• Consent forms must also make clear that clients can refuse to participate in the 
given activity or withdraw at any time without prejudice.
• Consent forms must also include a discussion of confidentiality protections and 
limitations.
Discussing confidentiality
• Reassure clients about how important confidentiality is to you and your clinic 
staff. Explain to clients that you are bound to maintain confidentiality according 
to both ethical codes and the law.
• Discuss the specific circumstances under which confidentiality must be broken.
• Discuss the way in which protected health information is communicated between 
various entities including other health care professionals and insurance compa-
nies, as per HIPAA requirements.
 
 Initial Interactions with Clients 41
here is that the observed reactions of clients during initial discussions 
can be informative for the clinician as they might suggest what to expect 
in future sessions and in situations outside of therapy when similar and 
other difficult topics are discussed.
A CASE EXAMPLE
At this point, we introduce a case example as a means of demonstrating 
the initial contact and the start of the assessment process. Janie S. was 
referred for treatment of depression. Janie called the practice after being 
pressed to do so by her primary care physician—she herself was not sure 
that she actually needed (or wanted) treatment.
Initial Phone Contact
CliniCian: What can I do to help you, Janie?
Janie: Oh, well, my primary care doctor told me to call. She says I’m 
depressed.
CliniCian: Do you agree with her?
Janie: Well, my husband kind of intervened. He called to talk to her, so 
she called me in and asked me a bunch of questions. She says I’m 
depressed.
CliniCian: So, it sounds like your husband is concerned and your doc-
tor is concerned. What do you think?
Janie: I think I am just bored, a little lost. My oldest is in high school 
this year and my youngest started middle school. No one really 
needs much from me. I don’t know what to do all day when they 
are at school.
CliniCian: Do you work outside the home?
Janie: That’s a whole other issue, I guess. I always said I would go back 
to work when my kids got older. But I just can’t seem to decide what 
to do with myself. I haven’t worked since before I had them.
CliniCian:Sounds like a big adjustment for you. Depression or not, 
many women find it beneficial to talk to a therapist at this stage 
in life. It can be very hard to refocus after years home raising kids.
Janie: Yeah, I guess.
CliniCian: Would you be willing to come in and talk? We can 
do an assessment, see what’s going on, and then I can make a 
42 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
recommendation. Maybe therapy is right for you, maybe not. There 
might be other options that make more sense, like seeing a voca-
tional counselor, or attending a women’s support group.
Janie: OK. I just don’t want to be pushed into anything.
CliniCian: I understand. There’s no pressure here.
Making a Recommendation
At the end of this phone call, the clinician booked a time for Janie to 
come in for a more thorough assessment. Their brief discussion left 
a lot of possibilities swirling in the clinician’s mind. First, was Janie 
depressed? It was certainly possible, but not clear from their conversa-
tion. Her husband was concerned and her doctor was concerned, but 
Janie had not identified too many thoughts or feelings associated with 
depression at this point. Of course, saying she was “bored” and “hav-
ing difficulty making decisions” could be depression or could just be a 
problem associated with Janie’s stage of life. And how would this general 
malaise impact Janie’s motivation for treatment?
Second, were there interpersonal issues that needed to be addressed? 
Had Janie’s husband called her doctor with her consent or behind her 
back? Was he pressuring her to go back to work? When her husband 
said she could be doing more with her days, was this a sign of a demand-
ing husband, or a concerned spouse watching a wife barely function? 
Finally, were there other difficulties interfering with Janie’s functioning 
such as anxiety or substance use? Her clinician was sure that their initial 
meeting would be very interesting and informative.
In-Advance Arrangements
At this point, Janie and the clinician set up a 2-hour appointment. This 
would afford enough time for the clinician to assess the client thoroughly 
and discuss treatment recommendations. The clinician provided Janie 
with a link to her website where Janie would find directions to the clinic 
and print out and complete the consent form and questionnaires before 
coming in for her assessment.
The First Visit: Assessment
Janie arrived for her assessment interview on time. She came with her 
questionnaires fully completed and cordially greeted the clinician in 
the waiting room. She was dressed nicely and was well-groomed. The 
 Initial Interactions with Clients 43
clinician led her to an interview room. Prior to the appointment, she 
had set out a copy of the assessment interview (the Anxiety and Related 
Disorders Interview Schedule for DSM-5 [ADIS-5]; Brown & Barlow, 
2014), a pen, and her watch. She also brought in a “cheat sheet” on score 
interpretations for the measures that Janie had completed at home, as 
well as a copy of the Desk Reference to the Diagnostic Criteria from 
DSM-5 (American Psychiatric Association, 2013). She had silenced her 
cell phone.
Introductions and Taking Care of Business
Introductions were exchanged and the client asked that she be called 
“Janie.” The clinician asked Janie if she had any questions about the 
consent form, reviewed confidentiality with her, and briefly checked 
over Janie’s self-report measures to get an idea of things that might be 
problematic for her. The only notable findings were relatively high scores 
on measures of depression and social anxiety and low scores on a mea-
sure of quality of life.
Giving an Overview of the Session
CliniCian: For the rest of today’s session, we are going to be doing a 
structured clinical interview. This interview assesses a range of dif-
ferent psychological difficulties. It is a way to make sure that we 
“cover all of our bases.” We are going to talk about your mood, 
and about anxiety and some other issues. Some of the questions 
I ask will be relevant to you, and we will focus on these sections. 
Other questions won’t apply to you, and we’ll just move past those 
sections. The goal of our time together today is to get a sense of the 
kinds of difficulties that you are having and how we might best go 
about treating them. How does that sound?
Janie: Fine.
CliniCian: Do you have any questions for me?
Janie: Nope. Let’s just get going.
CliniCian: Janie, I am curious about how you feel being here today. 
When we spoke on the phone, it sounded like your husband and 
your internist has suggested you come in. You sounded a little less 
sure.
Janie: Well, I told you on the phone. I am bored. The kids are growing 
up. It’s just a transition time for me. Normal stuff.
44 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
CliniCian: Do you have friends going through this right now too, with 
same-age kids?
Janie: Why do you ask that?
CliniCian: I was wondering if you had anyone to share your thoughts 
and feelings with at this time—moms who have been home and now 
aren’t as busy with kids and maybe are also feeling a bit lost.
Janie: I am not a social butterfly.
CliniCian: What do you mean by that?
Janie: You know, I’ve always just done my thing. I’m with my kids and 
my husband. We have family in town and we do things with them. 
That takes up all my time. (Pauses, looks down.)
CliniCian: Janie, what are you thinking right now?
Janie: I just feel really judged by you already. This is why I didn’t want to 
come here. I don’t need someone telling me all the stuff I do wrong.
CliniCian: I’m so glad you shared that with me, Janie. My job here is 
to help you, not to judge you. The best way to help me figure out 
what’s causing problems for you and how to help you is to be open 
and honest and not worry too much about how you are coming 
across. Why don’t we get started with the interview and see how it 
feels?
At this point, Janie’s clinician encouraged her to request a break 
if she needed one and then progressed into the demographic section of 
the assessment interview. Let’s pause here in the case of Janie. We will 
return to Janie’s interview in Chapter 3 after first discussing assessment 
goals and methods.
 45
3
The Process of Assessment
Let’s return to our trip metaphor. The process of assessment places us 
at the beginning of our trip. We need to get the lay of the land. Perhaps 
we hop on a tour bus or go on a long walk to get an overview of the city. 
Maybe we go to a visitor center to gather brochures and maps. Our goal 
is to get an idea of what is out there and what we want our trip to entail.
Assessment is much the same as these first few days of a trip. We 
have a bit of information from our early contact with a client, but we 
don’t know much. We need to gather information and get a sense of 
what is happening in the life of our client. This will help us to form 
our case conceptualization and treatment plan—in other words, how 
therapy will likely proceed.
In this chapter, we offer some general guidelines for the assessment 
process, discuss the goals of the assessment process and the tools that 
can be used to meet these goals, and then return to the case of Janie to 
see how a typical assessment might proceed.
BEING MINDFUL OF YOUR REACTIONS
During assessments, clients reveal all sorts of information, some of 
which will be unusual or upsetting. Clinicians’ reactions to information 
that clients share can significantly affect the therapeutic relationship. 
If clinicians’ reactions reinforce clients’ negative beliefs about sharing 
information with others (e.g., “They will think I am odd”; “They won’t 
want to help me”), clients may (rightfully) feel hesitant to share any more 
46 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
information with the clinician. It is essential to react with sensitivity to 
what our clients tell us.
Let’s discuss the ways in which one should not react. It almost goes 
without saying (although wewill say it anyway) that clinicians should 
not tell clients their experiences are odd, unusual, or distasteful. What 
might be more difficult for clinicians to do is to refrain from subtle reac-
tions that could make clients feel bad. These more subtle reactions might 
include negative facial expressions or taking a longer than usual time to 
react to what a client has said or not reacting at all, leaving an uncom-
fortable silence in the room. Even when clients reveal difficult informa-
tion, make sure to acknowledge that you have heard them by nodding or 
by saying “I see” or “I understand.” When clients tell us something very 
difficult to hear, it can also be beneficial to let them know you are glad 
that they shared this information since it helps you to better understand 
the experiences they are having and decide how to help them.
What clients define as odd, unusual, or troubling about themselves 
will often be “all in a day’s work” for clinicians. Although beginning cli-
nicians have not seen many cases, they do possess knowledge from read-
ing, watching recordings of sessions, and participating in group supervi-
sion meetings in which they are exposed to many other cases beyond the 
ones they have treated themselves. As we gain more experience, things 
new clients tell us will map onto things we have heard from other clients 
with whom we have worked. Thus, when clients reveal experiences or 
feelings, we are rarely as shocked as they expect us to be. Clients often 
feel comforted to know that other people experience similar symptoms 
and that their symptoms can be ameliorated with treatment. With all 
this in mind, a general rule of thumb is to try to normalize clients’ dif-
ficulties without minimizing them. A phrase like “I see a lot of clients 
here with concerns like that” can go a long way.
At times, however, we do come across clients whose symptoms or 
experiences are unique. This leaves us unable to say, “Yes, of course I’ve 
seen clients with concerns similar to yours.” It is often the case, how-
ever, that we can draw parallels to similar cases. As an example, cases 
of hoarding can often be quite unusual, with clients hoarding anything 
from rotting food to their own bodily waste. Such cases can be shocking 
even to experienced clinicians. And, not surprisingly, when client reveal 
such deeply personal information, they often ask if clinicians have ever 
before seen cases like theirs. Even when a clinician has not, it is helpful to 
say, “I haven’t seen a case exactly like yours. Yet you have much in com-
mon with other clients who engage in hoarding. You are holding on to 
stuff because you worry that you might need it in the future or because 
 The Process of Assessment 47
you worry that you might lose part of yourself by disposing of things 
that were a part of you or that have some meaning to you. Regardless of 
what clients hoard, we treat hoarding in the same way.” By responding 
in this way, clinicians can acknowledge that a client’s case is unique, but 
they can also draw parallels with other cases, helping clients see that 
they are understood and that an effective treatment plan can be devised.
It is also important to note that clients might assume we are react-
ing in ways that we are not. In the case of Janie, she came right out and 
said she felt judged by her clinician. In fact, the clinician was concentrat-
ing and going about her day’s work without much judging at all! Many 
clients will not be so direct. Some might suddenly clam up or might 
express hopeless beliefs in general. It is important for clinicians to check 
in: “You seem to have started to hold back on answering my questions. 
Are you worrying about what I am thinking about you?” We can start 
demonstrating how cognitive-behavioral therapy works by posing ques-
tions like these. If a client says, “I feel like you are judging me badly,” the 
clinician can reply, “It’s really interesting that you thought that. I was 
actually thinking about how impressed I am by your strength in a diffi-
cult situation. In cognitive-behavioral therapy, we talk about how people 
aren’t mind readers. I am glad I asked you what you were thinking and I 
am glad I had a chance to tell you what I was thinking.”
One final issue deserves mention. Beginning clinicians often worry 
about expressing emotion in front of clients when they share very pain-
ful or frightening stories. One thing to keep in mind is that having an 
extreme reaction (e.g., tears streaming down your face) is quite unlikely. 
Our reactions to clients whom we are meeting for the first time will likely 
be quite different from our reactions to family members or close friends 
whom we have known for years. Even on this different level, though, 
therapy is an interpersonal relationship, and reacting to a particularly 
sad or frightening story is only natural. It is completely appropriate to 
express emotion to a client (e.g., “I am so sorry that that happened to 
you”; “I am sorry for your loss”). It is even fine if, from time to time, 
clinicians notice that tears well up in their eyes during a particularly 
sad story. Clinicians should not be terribly concerned about such reac-
tions—if anything, they communicate empathy to clients and validate 
the emotional experience that they had to the event they are describ-
ing. With that being said, clinicians should let their supervisors know if 
they are regularly having a difficult time remaining composed in therapy 
sessions. After all, the emotional reaction of the clinician should not 
draw attention away from the client. Supervisors may be able to offer 
beginning clinicians some advice on how to best address this kind of 
48 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
difficulty (see Chapter 10 for further discussion about the supervisory 
relationship).
THE ASSESSMENT PROCESS: WHAT ARE THE GOALS?
With the emotional tone for the evaluation set, we now turn to the con-
crete goals of the assessment process. One goal of the assessment process 
is to arrive at a diagnosis per our current psychiatric diagnostic system. 
Doing so is important for insurance coverage, for communicating diag-
noses to other professionals, and for selecting appropriate treatments 
(e.g., if my client has social anxiety disorder, I can use a social anxiety 
disorder treatment manual to guide our treatment). Simply giving a set 
of symptoms a name, however, does not mean that we understand the 
client. This leads us to the second goal of the assessment process. We use 
what we learn during the assessment to arrive at a tentative explanation 
of the client’s symptoms in cognitive-behavioral terms (this is the case 
conceptualization) that can then be used to make a treatment plan. We 
will discuss the case conceptualization and treatment plan in more detail 
in Chapter 4.
TOOLS FOR ACCOMPLISHING ASSESSMENT GOALS
In this section, we describe tools that can be used for accomplishing 
assessment goals. Since the key to doing a complete assessment is gather-
ing information from multiple sources, we will cover a number of assess-
ment tools, including interviews, questionnaires, and behavioral assess-
ments. We also discuss how to go about gathering information from 
individuals who are familiar with the client’s difficulties.
Semistructured Clinical Interviews
One of the most popular assessment techniques is the clinical interview. 
Many clinicians routinely administer a clinical interview to identify the 
difficulties that clients are having and to plan a course of treatment for 
them. Interviews vary in the degree to which they are structured. In 
some settings, particularly those in which research is carried out, semi-
structured interviews are typically used. Commonly used interviews 
of this type include the Structured Clinical Interview for DSM-5, Cli-
nician’s Version (SCID-5-CV; First, Williams, Karg, & Spitzer, 2015) 
 The Process of Assessment 49
and the Anxiety and Related Disorders Interview Schedule for DSM-5(ADIS-5; Brown & Barlow, 2014). The goal of this kind of interview is 
to arrive at a diagnosis (or diagnoses) based on current (fifth edition) 
diagnostic criteria of the Diagnostic and Statistical Manual of Mental 
Disorders (DSM-5).
When novice clinicians first begin using semistructured or struc-
tured clinical interviews, they typically have several concerns. Some 
beginning clinicians may worry that the interview will sound stilted and 
impersonal. This is certainly possible, particularly when clinicians are 
not yet comfortable with the interviews. Beginning clinicians tend to be 
more wedded to reading questions verbatim (as all clinicians should, in 
fact, according to the instructions for administering these interviews!) 
and are often so focused on keeping on track with the interview that 
they indeed may come across as stilted and not particularly interested 
in the client.
Rest assured that your interview style will improve over time. As you 
become more comfortable with these interviews (as well as the disorders 
and conditions that you treat), you will be less focused on keeping track 
of which questions to ask and more focused on what the client is saying. 
Once you become comfortable with them, semistructured interviews are 
not quite as structured as they might seem at first glance. Although sev-
eral of the questions should be read verbatim, simply reading the writ-
ten questions to clients will not yield much useful information. It’s key 
to ask follow-up questions that will help you arrive at a decision about 
whether or not a client indeed meets criteria for a particular disorder. 
As an example, in the ADIS interview, the initial inquiry question for 
obsessive–compulsive disorder (OCD) asks, “Currently, are you both-
ered by thoughts, images, or impulses that keep recurring to you that 
seem inappropriate or nonsensical but that you can’t stop from coming 
into your mind?” If clients respond “Yes,” they are asked to specify 
examples. If clients respond “No,” it might still be useful to probe with 
a few examples. The clinician might ask, “For example, do you have 
thoughts about dirt or germs, or worries about forgetting to lock the 
door or turn appliances off?” These specific questions might be more 
meaningful to a client than the initial probe.
When using semistructured interviews, it is also essential to be 
mindful of rapport. As already noted, your tone might be quite formal 
when you are a novice interviewer. After a couple of years of doing clin-
ical interviews, when you can practically recite the questions in your 
sleep, you might begin to sound bored and uninterested. To avoid either 
situation, focus on what the client is saying. Although you might be 
50 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
asking the same questions you always ask, you will never get exactly the 
same reply. Be attentive to what clients are saying, follow up with ques-
tions that are relevant to them, and above all, be warm and empathic. 
These qualities can turn a potentially staid interview into a very positive 
experience for clients, during which they feel understood and come to 
believe that you will be able to offer them some solutions to their dis-
tress.
Unstructured Clinical Interviews
In some settings, less importance is placed on whether or not clients meet 
strict diagnostic criteria for a particular disorder. In fact, many practi-
tioners of various theoretical orientations do not believe in the value of 
DSM diagnoses (see Sadler, 2002, for a discussion of these issues). Of 
greater interest to them might be how their clients are functioning across 
a number of different areas (e.g., family life, work life) and how clients 
deal with the challenges of life (e.g., coping style, social support). In 
this light, interviews can be less directive and more flexible, while still 
allowing the clinician to gather sufficient information to develop the 
case conceptualization and devise a treatment plan.
Unstructured interviews are associated with some unique wor-
ries for beginning clinicians. Semistructured interviews, although cer-
tainly requiring clinical skill and intuition, provide interviewers with a 
framework for completing the assessment process. In the unstructured 
interview, that “crutch” is unavailable. Or is it? Most clinicians who 
use unstructured interviews as their primary means of assessment use a 
standard outline of topics that their interview will follow. In Table 3.1, 
we have provided a set of guidelines that you might want to follow and 
then adjust as you develop your own style.
Demographic Information: A Good Starting Point
Gathering some demographic information is frequently a good place to 
start. Questions of this nature are usually nonthreatening and help to 
establish rapport. They can also paint for you a very preliminary picture 
of how the client is functioning. Although we might not want to get into 
too much detail yet, we can be mindful of issues we should probe later in 
the interview. If we learn here that a client is unemployed and single, we 
know that we must ask later if this is a change from previous functioning 
and if his or her employment and relationship status is due to his or her 
presenting problem(s).
 The Process of Assessment 51
In this initial section of the unstructured interview, we can also ask 
clients some questions about themselves: What are their hobbies and 
interests? What do they like to do in their free time? What are their 
plans for a current holiday (Christmas) or season (summertime)? These 
kinds of questions help to establish rapport, particularly when work-
ing with children and teenagers. The answers to them can also be very 
illuminating. Perhaps a client who used to volunteer at a homeless shel-
ter hasn’t gone in months because he is too depressed. Or perhaps a 
TABLE 3.1. Summary of Topics for an Unstructured Clinical Interview
Demographics
	• Name; date of birth/age
	• Ethnic/religious background
	• Current work status/educational status
	• Current sexual orientation/relationship status/family structure
	• Current living arrangements
Presenting problem
	• Description of the problem
	• Onset and course of the problem; frequency of symptoms/episodes
	• Antecedents of the problem (e.g., situational triggers, life events)
	• Thoughts associated with the problem (e.g., automatic thoughts, beliefs)
	• Reactions to the triggers/life events (e.g., emotional, physiological, and 
behavioral reactions)
	• Intensity and duration of the problem
	• Previous treatment for the problem
	• Additional problems
Family background
	• Ages of parents and siblings
	• Upbringing and family relations
	• Parents’ marital history
	• Parents’ occupations, socioeconomic status
	• Family medical and psychiatric history
Personal history
	• Developmental milestones
	• Early medical history
	• Adjustment to school and academic achievement
	• Presence of acting out
	• Peer relations
	• Hobbies/interests
	• Dating history
 
52 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
teenager expresses how much she would love to have a solo in her school 
orchestra if she didn’t have such terrible social anxiety. Knowing about 
clients’ hobbies and interests can also help later during psychoeducation 
and treatment. Tying the lessons of treatment and their treatment-related 
metaphors to a client’s interests makes them more meaningful and easier 
to remember.
It can be uncomfortable to ask clients whom we have just met about 
their sexual orientation, relationship status, and religious practices. Yet 
this information is important to our case conceptualization. We should 
view these questions as being as innocuous as questions about where 
clients went to school and what their employment status is. If we don’t 
ask, we might miss out on learning that a teen is struggling with his 
sexual orientation, for example. Similarly, we might inadvertently send 
a message of intolerance if we assume heterosexuality in our choice ofpronouns and other language (e.g., by always asking male clients what 
their wives’ names are).
The Presenting Problem
With this demographic information in hand, it is appropriate to ask the 
client about his or her presenting problem. A good way to ask this ques-
tion is “Can you tell me briefly what brings you here today?” or “Can 
you tell me briefly about the difficulties that you’ve been having?” You 
might notice the use of the word “briefly” in both of these questions. 
Some clients, when given a chance, will speak without interruption for 
an hour without allowing the clinician to get a word in edgewise. Set 
the expectation that the answer to this initial question should be brief. 
If you get the sense that clients have a lot to share, provide a bit of reas-
surance. You can say, “I am going to have lots of questions for you today 
and I think we will cover all the important information. I will be sure to 
check back in at the end to see if I missed anything.” If clients do go on 
without pause, break in politely—for example, “I can tell you have lots 
to say. We have a system here that we go through to ensure that we get 
all the important information. Let’s try having me ask some questions, 
just so we make sure to get to everything today.” A client’s reaction to 
this prompt, or his or her ability to follow the instruction, provides use-
ful information for the case conceptualization.
Always let clients explain their problems in their own words. As 
you continue to discuss these issues during the interview, try to use their 
words. If a client refers to a panic attack as a “stress attack,” you may 
want to ask him later in the interview to tell you more about his “stress 
 The Process of Assessment 53
attacks” rather than to tell you more about his “panic attacks.” In dis-
cussing the presenting problem, it is important to get a sense of its his-
tory—when it began and what kind of course it has taken. For disorders 
of an episodic nature (e.g., recurrent episodes of major depression), you 
should assess how many separate episodes the client has experienced 
and the nature of the client’s functioning between episodes. You can 
also gather information on the frequency of symptoms (e.g., the number 
of panic attacks a person has each week or the amount of time taken up 
each day by obsessions and compulsions for a client with OCD).
When working with children and adolescents, it is often best to 
begin the evaluation process by first meeting with their parents alone. 
This allows parents to provide relevant background and discuss their 
own worries and struggles without the child present. When the child 
does come in, it can be really informative to ask the parent(s) and child 
to take turns explaining the presenting problem. Ask families to give 
each member time to respond with no interruptions or disputations 
(acknowledging that different people come into a therapy situation with 
different beliefs). Again, this kind of information feeds directly into the 
case conceptualization and treatment plan. Work with children and 
families is discussed in more detail in Chapter 9.
For example, let’s consider a teenager with trichotillomania (a dis-
order characterized by repeated hair pulling). When asked for the pre-
senting problem, her mother tearfully describes the terrible state of her 
daughter’s hair and how embarrassing it is for her daughter and for her-
self. Just moments later, the daughter says the trichotillomania is not 
a problem at all. She claims that no one gives her a hard time about it 
(except her mother) and that she really has no interest in working on it. 
Hearing these two perspectives informs the case conceptualization and 
influences the treatment plan.
In keeping with the cognitive-behavioral model, there are a number 
of things that clinicians should learn about a client’s presenting problem 
beyond its onset and course. Keeping Figures 1.1 and 1.2 in mind, cli-
nicians should start “filling in the blanks” of the cognitive-behavioral 
model to better understand the case. A good place to start is with situa-
tions and events that bring on the problematic thoughts and behaviors. 
Clients can be asked what was going on in their lives immediately before, 
and in the several months before, a problem began or intensified (e.g., 
“What was going on in your life before you started feeling depressed?”); 
which stimuli trigger their current symptoms (e.g., “In what sorts of 
situations do you experience panic attacks?”); and the larger contexts in 
which their difficulties are experienced.
54 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Clients should then be asked what they think about in these situa-
tions. This line of questioning begins to tap into automatic thoughts and 
deeper, more long-standing core beliefs. For example, a woman whose 
depression began following her divorce might report, “I won’t ever be 
happy again.” Similarly, a person who experiences panic attacks on sub-
ways and trains might report that when she is on trains she always thinks, 
“My heart is beating so fast that I am going to have a heart attack.” As we 
have explained, a single situation or event can mean very different things 
to different people, so time must be spent during this part of the assess-
ment understanding the client’s unique interpretation of key situations.
Based on their differing interpretations, clients will react to similar 
situations in very different ways. Therefore, clients should be asked about 
their emotional, behavioral, and physiological reactions to these trigger 
situations. For example, the client with panic disorder can be asked how 
she feels and behaves when she thinks that she is going to have a heart 
attack on the subway. She would likely report that she feels terribly anx-
ious (emotional reaction); that she sweats, shakes, and feels her heart 
pounding in her chest (physiological reaction); and that when she feels 
this way she gets off at the next possible stop (behavioral reaction). Simi-
larly, the client who became depressed following her divorce can be asked 
how she feels and behaves when she has the thought that she will never 
be happy again. She might report that she feels very sad and angry (emo-
tional reaction) and that she virtually never goes out anymore (behav-
ioral reaction) because she is so sure she will have a bad time.
It is also important to inquire about escape and avoidance behav-
iors, since these will be the target of much behavioral work in CBT. To 
tap into this, clients can be asked questions like “What sorts of things 
are you not doing right now because of your difficulties?”; “How would 
your life be different if you didn’t have these symptoms?”; and “What 
do you do to try to make your situation more manageable?” Whereas 
some behavioral responses will be quite obvious (e.g., “I don’t ride on 
subways anymore at all”; “I never go out with friends anymore since my 
divorce”), others will be more subtle. Time should be spent gathering 
this very important information. For example, our client with panic dis-
order might get off the train several stops early and walk if she is feeling 
anxious, or she might get on the subway only if she is accompanied by 
someone who could help her if she were to have a heart attack, or she 
might ride the subway only if she has a cell phone with her and some 
antianxiety medication. This sort of information is essential to concep-
tualizing the case and making a plan for treatment.
 The Process of Assessment 55
When we gathered demographic information, we got the basics of 
what our client’s life is like at the current time. Now that we know more 
about the presenting problem, we can return to these basics and find out 
how the current difficulties have impacted the client’s work, educational, 
and social functioning. You should assess whether the difficulties have 
recently resulted in a significant change from previous functioning. For 
example, a mother with small childrenand a part-time job may tell you 
that she used to be able to easily balance her family and work respon-
sibilities but that since she started feeling depressed, she finds even the 
most menial tasks overwhelming. In contrast, some clients have never 
functioned much differently than they are currently functioning. In such 
cases, it is essential to assess whether clients are functioning in a way 
that is expected given a particular stage in life. For example, it would 
be notable if a 30-year-old man was still living at home with his parents 
and had never finished school or held a job.
Before moving on to other problems that clients have, it is also 
important to ask about past treatment. Some clients will be very good 
historians, able to recall every therapist they have seen and every medi-
cation they have taken. Others will not be as adept. We should try our 
best to gather as much information as we can and then evaluate whether 
the client received adequate and appropriate therapy and/or medication 
for the presenting problem. This information assists treatment planning. 
For example, for clients who had a full and well-delivered course of CBT 
in the past and found it to be effective, some booster sessions may be an 
efficient way to deal with a recurrence of symptoms. On the other hand, 
for clients who believed they that they were getting “CBT” but actually 
had therapy that lacked the critical ingredients of CBT (e.g., a client 
who had CBT for an anxiety disorder, but never did any exposure to his 
feared situations), an appropriate treatment plan might be to start from 
“square one” with a course of therapy that includes all of the empirically 
supported components.
Information about treatment history may also be helpful in dealing 
with clients’ beliefs about subsequent therapy in other ways. For exam-
ple, a client with a fear of flying may tell you he is worried that nothing 
can help him since past treatment has always been a complete failure. 
Upon probing, you may learn that he spent a few years in psychody-
namic therapy that was not targeted at his fear of flying. It would then 
be useful to share with the client our knowledge about treating flying 
phobias, letting him know that he has not yet tried the treatment that 
has the best evidence in support of its effectiveness.
56 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Additional Problems
It is also important to ask clients if they have any problems in addi-
tion to their most pressing problems. At this point in the interview, it 
may be helpful to run through some screening questions for psychiat-
ric disorders, similar to those used in semistructured interviews. Clients 
should be asked about difficulties with mood, anxiety, eating/weight/
body image, alcohol and substance use, sleep difficulties, somatic con-
cerns, and sexual/gender identity concerns. Screening should also be 
done for psychotic symptoms. When specific problems are identified, 
CBT clinicians can again use the cognitive-behavioral model as a guide 
to adequately gather information for cognitive-behavioral case concep-
tualization and treatment planning.
Family Background
Once you have a clear sense of the presenting problem and any other dif-
ficulties the client is experiencing, it can be useful to gather information 
on family background and other aspects of personal history. This may 
include information on family socioeconomic status, parents’ occupa-
tions, family psychiatric and medical history, and family relationship 
dynamics. This information may provide important clues as to the etiol-
ogy of an identified problem.
Furthermore, inquiring about family history can help the clinician 
begin to get a sense of a client’s core beliefs. Core beliefs are beliefs 
about oneself, other people, and the world that form during childhood 
based on the experiences that we have as we are growing up (see J. S. 
Beck, 2011). If our recently divorced client grew up in a home in which 
she was constantly told that she could not do anything right, she might 
see her divorce as yet another personal failure and might see her future 
as hopeless. This interpretation would be very different from that of a 
person who grew up in a very loving household. If this person were to 
get divorced, she might be more able to picture establishing a wonderful 
new relationship and eventually being happy again.
The beliefs clients hold about the difficulties they are having can 
also be related to the beliefs held by their families of origin. Clinicians 
should inquire about beliefs held by the family about the etiology of 
mental illness and about the potential effectiveness of therapy, since 
these beliefs will influence the client’s own expectations about being 
able to make positive changes in therapy. If a family member had a 
similar problem and did very well after treatment, clients might feel 
quite hopeful about pursuing treatment themselves. If clients observed 
 The Process of Assessment 57
the converse in their family—namely, an individual who was chroni-
cally impaired—they might feel less hopeful about their own prospects 
for change. They might hold a core belief like “I am flawed” or “I am 
abnormal.” When clinicians know about these beliefs, they can help 
clients to clear up misconceptions that can stand in the way of engaging 
in the therapy process.
Mental Status Exam
If, after conducting an initial interview, you are in doubt about the cli-
ent’s psychiatric status or you are suspicious about the possibility of a 
neurocognitive disorder, you may wish to conduct a mental status exam 
(MSE). According to Kaplan, Sadock, and Grebb (1994), the MSE “is the 
description of the patient’s appearance, speech, actions, and thoughts 
during the interview” (p. 276). The MSE can be performed efficiently 
based on observations made over the course of the assessment, yielding 
a “sum total of the examiner’s observations and impressions of the psy-
chiatric patient at the time of the interview” (p. 276).
The MSE described slightly differently by different authors. In 
Table 3.2, we outline Kaplan et al.’s format and note things to look out 
for during the assessment in order to gather the necessary information.
Alternatively, if you don’t have a lot of time and need to conduct a 
brief assessment of cognitive functioning, you can use the Mini Men-
tal State Examination (MMSE; Shahid, Wilkinson, Marcu, & Shapiro, 
2011). The MMSE is an 11-question measure that assesses five areas 
of cognitive function: orientation, registration, attention and calcula-
tion, recall, and language. Another option is the Montreal Cognitive 
Assessment (MoCA; Nasreddine et al., 2005), a one-page 30-point test 
that briefly assesses several cognitive domains: short-term recall; delayed 
recall; visuospatial abilities; multiple aspects of executive functioning, 
attention, concentration, and working memory; and orientation to time 
and place. The test is available in 55 languages or dialects and a basic 
form is also available to test illiterate or less educated clients.
Other Tools: Using Multiple Sources of Information 
to Round Out the Assessment
Whereas the interview is a part of virtually every psychological assess-
ment, other sources of information can greatly enhance the quality of 
the assessment. Such sources include self-report questionnaires, client 
self-monitoring, speaking with other professionals, speaking with other 
58 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
TABLE 3.2. The Mental Status Exam
General description
• Appearance How is the client dressed and groomed? How is the client’s 
posture?
• Behavior and 
psychomotor 
activity
Is the client exhibiting psychomotor retardation or agitation? 
Does the client have any unusual motor behaviors like tics, 
mannerisms, rigidity?
• Attitude toward 
examiner
How did the client behave toward the clinician? How was 
the level of rapport between clinician and client?
 
Mood and affect
• Mood Did the clientone that readers can follow from assess-
ment through the termination of therapy. This case is more complex in 
nature than the one we had included in the previous two editions of the 
book, inspired by our day-to-day work with clients who do not neces-
sarily fit neatly into a single diagnostic category. We have paid special 
attention to new challenges that clinicians face in the increasingly digital 
world. When we started thinking about this book, we were all worrying 
about computer failure as 1999 became the year 2000, but we had not 
yet encountered social media, texting, telehealth, or sending recordings 
of therapy sessions over the Internet. As new technologies emerge, we 
need to stay mindful of the ethical issues surrounding them, since the 
legalities have lagged far behind. We have tried to articulate how to deal 
with common issues that clinicians face in this new edition of the book.
We hope this book will help to alleviate the anxiety of beginning 
clinicians and will also address the daily challenges faced by more expe-
rienced clinicians. We welcome your feedback about this new edition.
 xi
Acknowledgments
We would like to thank all the wonderful people at The Guilford Press 
for their hard work on the third edition of Making Cognitive-Behavioral 
Therapy Work: Clinical Process for New Practitioners, in particular 
Senior Editor Jim Nageotte and Senior Assistant Editor Jane Keislar.
Deborah Roth Ledley would like to thank Marty Antony, Richard 
Heimberg, Edna Foa, and Marty Franklin for being influential clinical 
teachers during her training and early career. And thank you to Tamar 
Chansky, Lynne Siqueland, Muniya Khanna, Larina Kase, and Chiara 
Baxt, who are the best colleagues and the best consultation group a cli-
nician could ask for.
Brian P. Marx would like to thank his colleagues, collaborators, 
and supervisees at the National Center for Posttraumatic Stress Disorder 
and the VA Boston Healthcare System for their wisdom and inspiration. 
He would also like to give a special thanks to Meaghan Brown, Aaron 
Harwell, Ali Klein, and Sara Pedersen, who assisted in compiling refer-
ences for this edition.
Richard G. Heimberg would like to thank the many doctoral stu-
dents and supervisees who have worked with him over the years in the 
clinical psychology program at Temple University and who have taught 
us so much about the things that clinicians in training need and want 
to know.
Of course, thank you to our clients over the years, who keep our 
work interesting and challenging.
 xiii
Contents
 Prologue: Common Challenges for New Clinicians 1
 1. The Process of Cognitive-Behavioral Therapy 5
 2. Initial Interactions with Clients 26
 3. The Process of Assessment 45
 4. Conceptualizing the Case and Planning Treatment 75
 5. The Bridge from Assessment to Treatment 93
 6. The First Few Sessions of CBT: Goals and Challenges 121
 7. The Course of CBT: Goals and Challenges 145
 8. Terminating Therapy: Goals and Challenges 182
xiv Contents
 9. Doing CBT with Special Populations 199
10. The Process of Supervision: Goals and Challenges 232
11. Revisiting the Common Challenges 252
 Appendix A. Recommended Readings in CBT 259
 Appendix B. Further Reading on Special Topics in CBT 262
 Appendix C. Treatment Manuals and Client Workbooks 264
 Appendix D. Useful Information 266 
 for Cognitive-Behavioral Therapists
 References 269
 Index 279
Purchasers of this book can download and 
print a blank assessment report template at 
www.guilford.com/ledley-materials 
for personal use or use with clients 
(see copyright page for details).
 1
Prologue
Common Challenges for New Clinicians
Every professional must do things for a first time: architects must design 
their first building, teachers must teach their first class, surgeons must 
perform their first surgery. Similarly, beginning cognitive-behavioral 
therapists must see their first clients. Learning new skills as well as devel-
oping one’s own professional identity can be fun and exciting, but also 
overwhelming.
At the outset of this third edition of Making Cognitive-Behavioral 
Therapy Work, we identify challenges commonly experienced by devel-
oping clinicians when starting out. Our goal throughout this book is to 
provide suggestions for addressing these challenges should they arise.
1. Feeling incompetent and/or being perceived as incompetent. As 
we just mentioned, everyone is a novice at the beginning of his or her 
career. Even later in our careers, we might treat a client with a diagno-
sis we have never worked with before, or we might implement a ther-
apy technique that we only recently learned. Feelings of incompetence 
can lead to worries about not being able to help our clients, or maybe 
even making them worse. We might also worry about coming across as 
incompetent to clients and their families, and these worries can distract 
us and actually lead to less competent treatment. In Chapters 1, 6, and 9, 
we discuss how to address our own worries about competence and how 
to maintain focus during treatment.
2 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Beginning clinicians often worry about coming across as incom-
petent to their supervisors as well. In Chapter 10, we discuss how to 
manage anxiety around supervision—and how supervision is in place to 
actually help trainees build competence and confidence.
2. Being seen as not able to relate. Beginning clinicians may worry 
that they will be seen by their clients as not able to relate to what they are 
experiencing. Can someone who is not married relate to a client who is 
dealing with infidelity in his or her marriage? Can someone who doesn’t 
have children coach parents about discipline? Can a seemingly happy, 
healthy therapist understand what it feels like to be terribly depressed? 
In Chapters 6 and 9, we untangle what this kind of question from a 
client actually means within the therapeutic relationship and how to 
respond to it so that clients feel understood.
3. Figuring out how all the pieces of information clients present 
to us fit together. It can be overwhelming to be in the room with a new 
client. In the first few hours that we spend with them, new clients share 
a great deal of information about their current problems and their per-
sonal histories. How do we fit all the pieces together to best understand 
and treat each client we meet? In Chapters 1 and 4, we discuss the impor-
tance of developing a case conceptualization to help us understand the 
client, his or her problems, and how to resolve them. We return to this 
concept throughout the book because the case conceptualization is never 
static—as we work with clients, our understanding of their difficulties 
and how we should treat them continuously evolves.
4. Coming across as rigid and inflexible when performing assess-
ments and using treatment protocols. Many of the assessment tools and 
treatments used by cognitive-behavioral therapists are guided by manu-
als. Adherence to manuals is particularly important during training and 
in the context of clinical trials. Although having a manualized assess-
ment or treatment protocol can be reassuring to a novice clinician, it can 
also cause anxiety. What if I sound like I am reciting facts rather than 
empathically listening? What if using a protocol/manual makes me look 
inexperienced? What if my client brings something up that is not covered 
by the manual? We address these concerns and discuss the art and sci-
ence of using structured assessments (Chapter 3) and therapies (Chapters 
1, 4, 6, 7, and 9).
5. Feeling overwhelmed by the complexity of clients’ lives. Begin-
ning clinicians may feel overwhelmed by the complexities of clients’ 
 Prologue 3
lives. This is particularly the case in settings such as the Department 
of Veterans Affairs (VA) health care system, inner-city school districts, 
and community mental health clinics. Although we are often trained 
to treatspeak voluntarily about feelings? What was 
the depth and intensity of the client’s feelings? Were there 
frequent fluctuations in mood during the interview?
• Affect Was the client emotionally responsive (inferred from facial 
expression, tone of voice, etc.) during the interview? Was 
affect congruent with mood?
• Appropriateness Were the client’s emotional responses congruent with the 
topic being discussed?
 
Speech
 
How was the quantity, rate of production, and quality of the 
client’s speech?
• Perceptual 
disturbances
Did the client experience hallucinations or illusions? If so, 
what sensory system did they involve?
 
Thought
• Process or form 
of thought
Did the client exhibit an overabundance or poverty of ideas? 
Could the client follow the questions that were asked and 
answer appropriately?
• Content 
of thought
Did the client experience delusions? Was there anything else 
remarkable about the content of thoughts such as obsessions, 
preoccupations, suicidal or homicidal thoughts, etc.?
 
Sensorium and cognition
• Alertness and 
level of 
consciousness
Did the client exhibit reduced awareness of the environment?
• Orientation Was the client oriented to time, place, and person?
• Memory How was the client’s recent memory (e.g., what did he or she 
have for breakfast?)? How about his or her remote memory 
(e.g., memories from childhood)? Did the client do anything 
to try to conceal cognitive impairments (e.g., confabulation)? 
 (continued)
 The Process of Assessment 59
people in clients’ lives, and finally, learning from clients’ in-session 
behaviors.
Self-Report Questionnaires
Questionnaires should never be relied on as the sole means of making a 
diagnosis or formulating a case. Yet they certainly can be a useful com-
ponent of the overall assessment process. As we noted earlier, clients can 
be asked to complete questionnaires prior to the beginning of the assess-
ment session or they can be asked to complete them once the assessment 
is over. When questionnaires are given in advance of the assessment ses-
sion, they can be used during the session to facilitate discussion. Clients 
might feel reluctant to reveal personal information when we first meet 
them. Although it is our job to establish a strong rapport that makes cli-
ents feel more comfortable about revealing things to us, questionnaires 
can help. For example, a client might deny suicidal thoughts during the 
assessment interview, but might endorse a self-report item about suicidal 
TABLE 3.2. (continued)
• Concentration 
and attention
Was the client’s concentration impaired during the interview? 
Did it seem to be due to anxiety/mood disturbance or due to 
a disturbance in consciousness or a learning deficit?
• Capacity to read 
and write
Could the client read and write a simple sentence?
• Visuospatial 
ability
Could the client copy a simple figure?
• Abstract 
thinking
Could the client think in an abstract way?
• Fund of 
information 
and intelligence
Can the client accomplish mental tasks that would be 
expected for a person of his or her educational level and 
background?
 
Impulse control
 
Can the client control sexual, aggressive, and other impulses?
 
Judgment 
and insight
 
Did the client exhibit capacity for social judgment? To what 
degree was the client aware of his or her illness and how well 
did he or she understand the illness?
 
Reliability
 
How accurately was the client able to report his or her 
situation?
Note. Adapted from Kaplan, Sadock, and Grebb (1994, p. 276). Copyright © 1994 Lippincott 
Williams & Wilkins. Adapted by permission.
60 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
ideation. The clinician can bring this up in a sensitive manner: “On the 
questionnaires that you completed, you noted that you were having some 
thoughts about suicide. A lot of clients that we see here have a hard time 
talking about these concerns. Can you tell me a bit more about the kinds 
of thoughts you’ve been having recently?”
Keep in mind that if you are planning to use questionnaires during 
the assessment session, you need to know how to administer, score, and 
interpret them correctly. Furthermore, you must know what the score 
means and how it can be used in a clinically useful way. If you use a stan-
dard battery of measures, you can create a “cheat sheet,” noting scoring 
rules and the meaning of specific ranges of scores.
Even when self-report scales are not used to facilitate discussion 
during the session, they yield extremely useful information that can be 
integrated into psychological reports. In many cases, self-report mea-
sures confirm what was learned during the interview. For example, a 
report might read, “Diagnostic criteria were met for major depressive 
disorder. The client also reported symptoms of depression on her ques-
tionnaires. Her score on the Beck Depression Inventory–II was indica-
tive of moderate depression.”
Discrepancies between Interviews and Self-Report Questionnaires
Sometimes clients’ questionnaire responses will be incongruent with 
their interview responses. There are many possible explanations for this. 
Some clients, particularly when they first seek help, might have diffi-
culty articulating exactly what is troubling them. This becomes easier 
after they have received some psychoeducation and have done some self-
monitoring, thereby increasing their own awareness of their problematic 
thoughts and behaviors.
Other clients might respond to questionnaires in a way that makes 
them seem far more or far less impaired than they appeared during the 
interview. For example, a client might appear to be emaciated but report 
very few symptoms on a measure of eating and body image disturbance. 
Similarly, a client might report moderate symptoms of depression during 
the clinical interview but then score in the severe range on a depres-
sion questionnaire. There are various ways to deal with these discrepan-
cies. One is to simply note them in the assessment report. Another is to 
question clients about these inconsistencies. Doing so can help you clear 
up questions that you might have about the information you are being 
given. Clients who underreport or deny symptoms are sometimes not 
 The Process of Assessment 61
ready for treatment. This is important information and should be taken 
into account when formulating a plan for the client. Other clients overre-
port because they are desperate for people to see just how distressed they 
are or because they seek some other outcome (e.g., disability payments). 
These clients can benefit from some reassurance from the clinician that 
he or she recognizes their distress and will try to get them the help that 
they need as soon as possible.
Learning from In-Session Behaviors
Careful observation of the client’s behavior during the assessment is also 
a valuable source of information for rounding out your case conceptu-
alization. Beyond the client’s answers to questions, the way he or she 
behaves in the room with the clinician can be a window into how he or 
she behaves and relates to others in “real life.” Furthermore, some of 
these subtleties can help you to see how therapy might progress.
Is the client quiet, reserved, and reluctant to reveal information even 
as the assessment session progresses? Does he or she become angry as 
you ask questions? Are there numerous topics that are “off limits”? Does 
the client flirt with you or ask you questions of a very personal nature? 
Is the client unhappy with having been assigned a young clinician? Is the 
client hypercritical of you or of the therapeutic process? There are innu-
merable ways that a client can behave during an assessment, and these 
behaviors should be used in conceptualizing the case.
Clinicians should also be cognizant of other, sometimes subtle 
behaviors that may further indicate the client’s difficulties. A client with 
OCD declines to shake hands or use the clinic’s pen at an assessmentses-
sion. A client with a substance use problem comes to the assessment say-
ing he last drank several days ago, but smells of alcohol. A client comes 
to her assessment wearing very revealing clothing, despite reporting that 
she feels terribly embarrassed by her severe skin picking. All of these 
behavioral indicators are interesting and meaningful. The client with 
OCD demonstrates how debilitating his fear of germs is without saying 
a word. The client with a substance use disorder might be trying very 
hard to present himself in a positive light, but may not be able to make 
it through a day without alcohol, much less a day that involves a stress-
ful interpersonal interaction. And the client with skin picking might be 
worried that the clinician will not believe the severity of her problem if 
it is hidden under clothes, or might actually thrive on the attention she 
gets from others for her severe picking (even if that attention is negative).
62 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Self-Monitoring
Self-monitoring is another excellent way to gain perspective on how cli-
ents’ difficulties affect their lives on a daily basis. With this technique, 
the client keeps a record of the occurrence of target behaviors (e.g., 
nightmares, angry outbursts). These records can include the date and 
time of the occurrence, the situation during which the symptom was 
apparent, thoughts at the time that the symptom occurred, and the cli-
ent’s emotional reactions during the occurrence of the symptom. The 
information obtained by self-monitoring (e.g., symptom triggers, avoid-
ance, dysfunctional thoughts, and reaction patterns) can be used in the 
assessment process to more accurately conceptualize clients’ concerns 
and to decide how to go about treating them.
Let’s return, for example, to the client mentioned earlier who was 
engaging in skin-picking behavior. When this client came in, she had 
large welts all over her legs. She was very clear on the trigger for her 
picking—she picked every time she used the bathroom and could see her 
legs. Yet she had no awareness of what made some picking sessions quite 
quick and others last hours. To obtain better information, the clinician 
sent the client home with a chart to monitor her picking for a week (see 
Franklin & Tolin, 2007). When she returned for the remainder of her 
assessment, the client and the clinician were able to review the data col-
lected on the monitoring chart. They learned that she picked quickly 
when her mother was home, particularly if she was waiting to use the 
bathroom. She picked for hours at night, however, when her mother was 
asleep and she had the bathroom to herself. Her monitoring revealed 
that she picked more on days when she was tired or sad about something 
than on days when she felt fine. She also noticed needing to feel “com-
pleteness” with her picking. She would pick at a place until she felt that 
it was “smooth and empty.” Some areas of her skin felt complete sooner 
than others, again affecting the length of a picking episode. Interest-
ingly, she also noticed that she was pulling the hair on her legs. During 
the initial evaluation, this client had reported that she used to pull the 
hair on her head, but she hadn’t done so in years. Monitoring helped her 
to notice a behavior of which she had been completely unaware, but that 
was important to her treatment plan.
Speaking to Other Professionals
Before speaking with other professionals about a client’s case, you must 
obtain permission to do so from the client. Clinicians should explain 
 The Process of Assessment 63
in an easily understandable way why they would like to speak to these 
other professionals. If clients are amenable, they must sign a permission 
form and you must show it to the other professional before such conver-
sations can take place. Keep in mind that information should be trans-
mitted in such a way as to maintain confidentiality. Faxes and e-mail 
messages, while being very convenient modes of communication, can 
be risky in terms of confidentiality, since both can end up in the wrong 
hands. Before using either, check with the staff at the clinic in which you 
work, and familiarize yourself with local and federal regulations.
Many beginning clinicians feel anxious about contacting other pro-
fessionals, fearing that they will come across to the other, more experi-
enced, professionals as incompetent. Furthermore, beginning clinicians 
often expect other professionals to be unreceptive. The first thing to 
keep in mind is that you might be regarded as incompetent if you do 
not consult with other professionals. After all, they possess valuable 
knowledge that will help you to better treat your clients. Furthermore, 
most professionals are happy to share their knowledge. Other clinicians 
often like to talk about their experiences treating clients and ideas that 
they have for further treatment. Professionals who possess expertise that 
you do not possess (e.g., physicians, vocational counselors) are typically 
receptive to explaining unfamiliar information to you.
On occasion, we come across other professionals who are quite 
unreceptive; they do not return phone calls or do so in a very gruff 
and unhelpful manner. For young clinicians, this response can be inter-
preted as a personal affront. Students may assume (and may be right 
in so assuming) that if their supervisor called this same colleague, the 
conversation would be much more fruitful. Some people, however, are 
unhelpful no matter who calls. At such times, it is best to shrug off your 
interpersonal concerns and focus on getting as much information as you 
can even if the situation is unpleasant.
With this being said, speaking to other professionals can be very 
helpful in the assessment process. Sometimes we need to seek input 
from other health care professionals besides clinicians. This situation 
might arise if clients are unclear about the medications they have taken 
or are currently taking or if there are questions about the relationship 
between their physical and mental health. For example, some psycho-
logical symptoms (e.g., depression and anxiety) can be explained by 
medical conditions (e.g., endocrine abnormalities), and it can be helpful 
to consult with a client’s physician with respect to these issues. Some 
psychological conditions can directly impact a client’s physical health 
64 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
(e.g., eating disorders, substance use problems), and it is beneficial to the 
client in these cases for the clinician to be in touch with the individuals 
looking after the client’s physical health (e.g., primary care physicians, 
dieticians). Finally, some medical conditions might have an impact on 
decisions about treatment. For instance, prior to doing interoceptive 
exposure exercises (exercises that are meant to bring on the symptoms 
of panic) with a client who has panic disorder and a medical condition 
like asthma or heart disease, it is wise to check with the client’s physician 
about which exercises are safe to do.
It is also good practice to speak to other professionals who have 
assessed or treated the individual whom you are assessing. When a cli-
ent is referred to you, it is often the case that he or she knows why he or 
she has been referred (e.g., “I went to be assessed by Dr. X., and he said 
I needed help with depression, and he also said your clinic is the best in 
the city for that problem”). At other times, clients are less sure about 
why they have been sent to you, and it can be useful to get in touch with 
the referring individual to obtain more information.
Sometimes referrals are made when a clinician finishes working on 
one issue with a client and feels he or she needs help in another area 
in which the clinician does not specialize. Perhaps a clinician treated a 
client successfully for depression, but the client then needs to deal with 
marital problems. At other times, clinicians of oneorientation will refer 
a client to clinicians of a differing orientation if they believe it to be more 
suitable for the client and/or the kinds of difficulties that he or she is 
having. It can be perplexing when you are asked to treat a client by a cli-
nician who has already tried to treat the target problem using the same 
treatment techniques as you would use. This may cause you to wonder 
whether your work with the client would make a difference. At times, it 
might. There are many variables that influence whether a clinician and 
client work well together, and sometimes one clinician can help a client 
to progress when another clinician could not. It is always useful in these 
situations to speak to the other individual who treated the client.
Consider a client who came to be assessed for treatment of OCD. At 
the time of the assessment, the client was already being seen at another 
clinic known to do good exposure and response (ritual) prevention ther-
apy (EX/RP) for OCD. We wondered why this client had not succeeded 
at EX/RP at the other clinic; when we asked the client, she said she never 
did exposure therapy with her other clinician. This seemed curious, so 
we contacted the clinician to see how the treatment had progressed. The 
clinician informed us that the client completely refused to do exposures, 
 The Process of Assessment 65
despite being provided with a clear rationale for why they were so impor-
tant to getting past the OCD. When we spoke to the client further about 
OCD treatment at our clinic, we were clear that treatment would be very 
similar to that done with her other clinician and asked her if she could 
imagine doing some of the exposures that we believed would be impor-
tant for her. We explained that we would do these exposures gradually, 
only after sufficient education about why they were being recommended. 
We also asked the client if she would like to speak to some former clients 
who had felt doubtful about EX/RP at the start of treatment, but who 
ended up doing very well once they decided to try it. The client said she 
would never consider doing such things and did not believe that anyone 
could convince her to do it. Following this discussion, we referred her 
to a psychiatrist to discuss medication treatment options and left open 
the possibility of her coming to see us in the future if her willingness 
to try EX/RP changed. By speaking to this client’s former clinician, we 
were able to address the client’s concerns in an up-front and honest way, 
providing her with information to make a good decision about treat-
ment. Had we not spoken to her former clinician, it was likely that the 
client would have come to therapy and had another negative experience. 
Rather, we left the door open for her to come back and start when she 
was ready, increasing her chances of success.
Speaking to Other People in the Client’s Life
Other people in the client’s life are another source of useful informa-
tion. This could include parents, spouses, roommates, and, in the case of 
younger clients, teachers. The premise behind seeking this sort of infor-
mation is not to “check up on a client,” but rather to help paint a more 
complete and accurate picture of the client’s difficulties.
When other sources are used, it is again crucial to obtain permis-
sion. You should never speak to a family member without an adult cli-
ent’s explicit consent—even telling a family member that the client came 
to be assessed by you is a breach of confidentiality. In gaining permis-
sion, you should be open with your client as to why you think it would 
be helpful to speak with these other individuals. For example, consider 
a client with sleeping problems who has difficulty sleeping at night, but 
then dozes off during the day. He may have difficulty reporting how 
often he dozes off and for how long he sleeps when it happens. Consult-
ing with the client’s wife and asking her what she has observed will likely 
yield useful information.
66 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
In what context should these conversations occur? If a family mem-
ber or close friend accompanies the client to the assessment, he or she 
can simply be invited to come into the room and contribute to the assess-
ment with the client present. If this is not possible, the discussion can 
be held on the phone. Regardless of the setting, when speaking to other 
individuals in clients’ lives, it is essential to respect their privacy. These 
conversations are not an opportunity for you to tell the family member 
everything the client said during the interview or about your conceptual-
ization of the case (e.g., “I think his extreme perfectionism must have to 
do with what a demanding mother you were when he was growing up”). 
Remember that these conversations can affect your rapport with the cli-
ent. If a client goes home from his session and his mother yells at him for 
saying nasty things about her to his clinician, the client would probably 
feel anger at the clinician (and rightly so!). Rather, you should contact 
significant others with targeted questions that will help you to conceptu-
alize the case. For example, if a perfectionistic client is having a difficult 
time describing how his perfectionism affects his life, you might have a 
discussion with his wife. You could ask her how long he spends cleaning 
up the house each day and also how he reacts when things around the 
house are perceived as imperfect.
Ending with a Preliminary Problem List
In the next chapter, we introduce Jacqueline Persons’s (1989, 2008) 
approach to “case conceptualization,” the process of coming to an initial 
understanding of a case once the assessment is complete. Persons sug-
gests that a problem list should be created at the end of the assessment as 
a starting point for the case conceptualization. She describes the prob-
lem list as an “all-inclusive list of the client’s difficulties” (1989, p. 19). 
In other words, it serves as a summary of all of the key concerns raised 
by the client during the assessment process. The problem list includes 
not only those concerns associated with seeking treatment, like depres-
sion, panic attacks, and binge eating, but also such issues as unemploy-
ment, marital conflict, and medical problems. Although some of these 
problems might not appear to be pertinent to therapy, they may very 
well be. These kinds of problems can precipitate and/or maintain other 
difficulties; for example, marital problems can precipitate binge eating 
as a form of emotion regulation, or unemployment can play a role in the 
maintenance of depression. These problems can certainly interfere with 
treatment (e.g., an unsupportive, critical spouse can impede a client’s 
attempts to regularly engage in exposures to feared situations). After the 
 The Process of Assessment 67
baseline assessment session, the clinician can use this list to begin build-
ing a case conceptualization, with the aim of figuring out how these 
seemingly disparate problems might fit together.
With the assessment process complete, we will now discuss some 
common concerns that beginning clinicians experience at this stage of 
their interactions with clients. We will then return to the case of Janie to 
see how her assessment went.
COMMON CHALLENGES IN THE ASSESSMENT PROCESS
“If I Pause to Find My Place, the Client Will Think 
I Don’t Know What I’m Doing.”
Assessments can be anxiety-provoking for beginning clinicians. Many 
beginning clinicians worry about uncomfortable pauses or silences dur-
ing the assessment because they might need to take a minute to find 
their page in an interview, reflect on whether or not they need to probe 
more about a specific problem, or think about what to ask the client 
next. Usually the concern is that pausing will cause clients to view the 
clinician as inexperienced or unable to figure out their problems. Keep 
in mind that these pauses are likely more noticeable to you than to the 
client.When pauses are noticed by clients, many will assume that the 
clinician is thinking—and when clients come to seek help for a problem 
that is confusing to them, it is unlikely that they will be critical of a clini-
cian who takes a moment or two to mull it over.
Beginning clinicians might find themselves perplexed by a particu-
lar client. Sometimes this occurs when clients behave in such a way that 
carrying out the assessment is difficult. They might refuse to talk, or 
they might speak in a disorganized manner, or they might deny having 
any problems at all. At other times, beginning clinicians might be sty-
mied by complicated cases and might feel that they are simply unable to 
determine a client’s proper diagnosis or which variables may be impor-
tant for treating a particular client. Small pauses can turn into long gaps 
in the assessment, and these can certainly become uncomfortable for 
both client and clinician. In this situation, it is fine in many settings 
to tell the client that you will take a short break. Offer the client the 
opportunity to use the washroom, get a snack, or stretch his or her legs. 
This affords you the opportunity to consult with colleagues, look some-
thing up in your DSM, or simply sit and take stock for a few minutes 
to decide how to proceed. Few clients will be bothered by a short break 
and, in fact, many will be appreciative of it, particularly during long 
68 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
assessments. It is also OK to finish the assessment at a second session. 
Assessments take longer with clients who are particularly complex, and 
in the time between the two assessment sessions clinicians can consult 
with supervisors or colleagues as to how to proceed.
“If I Miss Something Important, the Assessment 
Will Be ‘Wrong.’ ”
Another major concern of beginning clinicians is that they will forget 
to ask a client something important. This realization can strike when 
preparing your report or preparing to discuss the case in supervision or 
in a clinic meeting. Colleagues might ask you questions that would aid in 
conceptualizing the case, and you realize that you simply did not gather 
the appropriate information to answer them. What can you do? It is not 
unheard of to phone clients and ask them a few clarifying questions or 
even call clients in for another meeting. Although beginning clinicians 
might fear looking incompetent, clients typically interpret this as con-
cern and a desire to better understand the client.
One caveat deserves mention here. Beginning clinicians who are 
highly anxious might be tempted to frequently phone clients to ask 
additional questions or call them in to further discuss their case. If 
you find that you are doing this often, you should bring it up with 
your supervisor. He or she can help you to figure out why you are 
“backtracking” so frequently. In some cases, it might be a lack of pro-
ficiency. Not knowing the diagnostic criteria or the structure of your 
assessment instruments might lead you to overlook certain details or 
forget to ask important questions. This problem can easily be remedied 
by additional preparation, observation of more experienced clinicians, 
and discussion with supervisors and colleagues. Another helpful tip is 
for clinicians to try to stay focused on what the client is saying during 
the assessment. Often, beginning clinicians are so focused on seeing 
if clients meet criteria for particular disorders that they do not ask 
appropriate questions to really understand clients’ histories and what 
is maintaining their difficulties.
In other cases, clinicians might have unreasonable expectations of 
what they need to know after an initial assessment. Although it is cer-
tainly important to gather sufficient information to conceptualize the 
case and devise a plan for treatment, be mindful that case conceptu-
alization is an ongoing process. Initially, there might be gaps in your 
understanding. However, your conceptualization of cases will evolve 
 The Process of Assessment 69
and grow more complete as you get to know clients better and as they 
begin to make changes in their lives.
“I’ll Mess Up the Assessment and the Whole Case Will Be 
a Disaster.”
A concern that is related to missing information is the fear of making 
mistakes. Simply put, beginning clinicians are often fearful of assigning 
clients the “wrong” diagnosis or conceptualizing their cases incorrectly. 
For example, a clinician might worry about making errors in differential 
diagnosis or in deciding which problem to focus on first when a client 
presents with multiple difficulties. All clinicians will make “incorrect” 
decisions from time to time. Certainly, this is more often the case with 
clinicians who are less experienced, but even later in one’s career, most 
clinicians have had the experience of figuring out a few sessions into 
therapy that they had been off the mark in their assessment of a client.
Beginning clinicians should remember that supervision is in place to 
catch such errors. Diagnostic decisions and treatment plans are typically 
discussed before therapy begins. Therefore, any problems can be resolved 
and therapy can begin on the right track. Although making errors can be 
embarrassing, they provide important opportunities for learning. Instead 
of focusing on the short-term discomfort of feeling embarrassed when 
errors are pointed out to you, focus on the long-term gain in knowledge 
that will help you the next time you see a similar clinical presentation.
Moving beyond simple diagnoses, beginning clinicians also worry 
about incorrectly conceptualizing cases. Keep in mind that our initial 
conceptualization is based on what we learn in our first contact with cli-
ents. It is our job to gather enough information to form an understand-
ing of what difficulties clients are having and what is maintaining these 
difficulties over time. This information helps us to devise a treatment 
plan, which is always based on a limited amount of data. As we get to 
know clients better, it is reasonable (and expected) that we will make 
adjustments to the way that we think about and manage cases.
JANIE’S ASSESSMENT INTERVIEW
At the end of Chapter 2, we left our client Janie just as the clinician was 
about to begin the assessment interview. We return to the case now to 
see what information was gathered during that process.
70 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Demographic Information
Janie was a 45-year-old, married, stay-at-home mother of two. She was 
born in the town in which she was currently raising her own children. 
Both of her parents were alcoholics and had divorced when she was a 
little girl. Neither had remarried. Janie married Phil, whom she met at 
work, when she was 22. She had completed 2 years of college before 
dropping out to work as a secretary at a manufacturing company. Phil 
had been with this same company ever since, working in sales. Janie had 
left the company when she became pregnant with their first daughter, 
who was now a freshman in high school. Their second child, also a girl, 
was beginning middle school the month Janie came in for her initial 
assessment.
Janie and Phil lived modestly in a nice home, and Janie described 
their finances as “perpetually tight.” As already noted, Janie had not 
worked since her daughters were born. While they were young, Janie 
was active at their school, volunteering in the library and serving as class 
mother. When her first daughter entered middle school, she realized that 
there was very little for parents to do at the that level of school and, 
furthermore, her daughter asked her “to not come and embarrass me.” 
Janie explained that she “dreaded” her second daughter entering middle 
school this fall, because “really no one needs me now.”
Presenting Problem and Its History
When asked what led Janie to seek help, she again reiterated that her 
husband and her family doctor believed she was depressed. When askedif she agreed, she said she did not know. She did admit that she had been 
dreading her daughter beginning middle school. She expressed the feeling 
that “no one needs me” and described her days as “boring and empty.”
Janie denied significant past mental health problems. She explained 
that she had never been a cheerful or outgoing person. She and Phil 
tended to stay home on the weekends or occasionally go out together. 
When the children were younger, they used to keep much busier with 
family activities. Again, Janie noted a recent change, using the words 
bored, empty, and pointless numerous times.
Semistructured Clinical Interview
When beginning a semistructured interview, it is a good idea to con-
sider what sections will likely be receiving relative focus. Although these 
 The Process of Assessment 71
interviews require screening questions for all mental health difficulties, it 
can be less overwhelming to the clinician to start out the process having 
a sense of what sections might be most important. In the case of Janie, 
her clinician knew that she should focus on depression. Given Janie’s 
family history of substance use, this topic too would deserve attention. 
And her clinician was curious about social anxiety disorder, given her 
lack of friends and social interactions.
Janie was assessed using the ADIS-5. Throughout the ADIS-5, 
Janie exhibited an interesting response style. On the one hand, her first 
response to many questions was to deny symptoms. Yet, with some 
probing, Janie became quite tearful and indeed endorsed sufficient 
symptoms to be diagnosed with major depressive disorder and social 
anxiety disorder. Janie was defensive when asked about alcohol use. 
She reported drinking several glasses of wine nightly after her children 
went to bed, but she denied any difficulties with alcohol. Janie said, 
“That’s my parents, not me.” However, when the DSM-5 criteria for 
alcohol use disorder were reviewed, Janie endorsed five items, indicat-
ing that she met criteria for an alcohol use disorder of moderate sever-
ity.
Self-Report Questionnaires
Janie’s self-report measures were consistent with the information she 
provided during the ADIS-5. She reported experiencing moderate social 
anxiety and depression. Interestingly, her self-report measure of qual-
ity of life indicated strong dissatisfaction particularly in the areas of 
self-esteem, money, friends, love, relatives, home, neighborhood, and 
community. Janie’s clinician probed further—this strong sense of dis-
satisfaction didn’t quite gel with Janie’s rather lax attitude about her 
need for therapy.
Upon probing, Janie broke down in tears. She reported feeling 
lonely, isolated, and friendless. She explained, “I poured so much into 
my kids, I never really watched out for me.” Janie also revealed that her 
husband was quite distant. Despite their many years of marriage, they 
rarely spoke about deep topics and spent very little time doing things 
together outside of the home. Janie reported that they did not fight, but 
that there was no “spark or excitement” in their relationship. Having 
access to a quality-of-life measure opened up some very fruitful discus-
sion between Janie and her therapist that had not come out during other 
parts of the clinical interview.
72 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Creating the Problem List
As Janie’s assessment neared its close, her clinician introduced the con-
cept of the problem list to her:
CliniCian: Janie, I’d like to spend a few minutes now summarizing 
what we have discussed today. In doing this, we are going to cre-
ate what we call a “problem list.” This list will really help us to 
take a look at the difficulties you’re facing right now and will help 
us to understand the “big picture” and map out a plan for treat-
ment.
Janie: That’s going to be quite the list.
CliniCian: Well, let’s start and we’ll see. I see three main issues for us 
to work on—depression, social anxiety, and alcohol use. A big part 
of our work together, near the beginning of treatment, will be to 
see how these three problems go together. Many, many people expe-
rience social anxiety, depression, and drinking problems together. 
From your perspective, do you see all of these problems as being 
equal in importance or is there some sort of rank order?
Janie: Well, first off, I don’t have a drinking problem. My parents, they 
drink. I have a few glasses of wine each night. Not a problem.
CliniCian: When formulating a problem list, I think it is really impor-
tant to put the whole range of possibilities on there—even if you 
and I see them as differing in relevance. In my experience, many 
people who feel sad drink to try to feel better and many people who 
are socially anxious drink to make social situations easier for them. 
I am not sure if this is the case for you. What I do know is that you 
are drinking enough to cause some problems for you, as we talked 
about earlier today. I really think we need to look at it as part of the 
big picture.
Janie: Well, we can look at it, but I can’t say I am giving up my wine.
CliniCian: Fair enough. So, what do you see as the biggest problem for 
you right now?
Janie: It isn’t even really depression or social anxiety. It’s just that “loose 
ends” feeling. Where do I fit? How do I fill my days? What’s the 
point?
CliniCian: That’s really important, Janie. Could we call that “identity 
issues?”
 The Process of Assessment 73
Janie: Sure. Sounds about right. Maybe “Who the hell am I issues?” 
(with a laugh).
CliniCian: Got it. What about family relationships, Janie? Where do 
those fit?
Janie: They’re really going down the drain. The kids are so independent. 
They just don’t need me. I guess that makes me sad.
CliniCian: It can be really hard for moms to be so involved with par-
enting for so long, and then to feel less needed. On the one hand, it 
is sad. On the other hand, you must have done something right for 
your kids to have that level of independence.
Janie: I hadn’t thought of it that way. I didn’t expect them to have so 
little use for me already.
CliniCian: This might be a great topic for us to explore together. Some-
times, when people feel depressed, they see things in a biased way. 
It’s possible that your girls need you for more than you think they 
do. Or, that they need you in a different way than they did when 
they were younger, but that you are having trouble recognizing that.
Janie: I think that would be helpful to discuss.
CliniCian: What about your relationship with your husband?
Janie: What about it?
CliniCian: Does it go on our problem list?
Janie: He’d love that. He sends me to therapy and we figure out he’s the 
problem (laughs).
CliniCian: Well, I don’t think we are saying he is a problem per se. It 
sounds to me like you are dissatisfied with how your relationship 
is working right now. Often, when kids grow up, couples need to 
rethink how they relate to one another.
Janie: OK. Might be worth some time.
CliniCian: What I suggest is that we give some thought next time to 
how these problems fit together. We have identity issues and rela-
tionship issues, and we have depression, social anxiety, and drink-
ing. I’d bet these pieces don’t exist in isolation. We can spend some 
time thinking about this, and what we need to work on to help you 
feel less depressed and more satisfied with your life. What do you 
think?
Janie: Sounds like a reasonable plan.
74 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Before concluding the interview, Janie’s clinician asked her if they 
had missed anything and whether she had any questions. Janie was sat-
isfied that she had painted a clear picture of her difficulties and did not 
have any questions about the assessment process. Janie and her clinician 
then set a time for their next session, and Janie was invited to call if she 
had any questions or concerns in the interim.
 75
4
Conceptualizing the Case 
and Planning Treatment
The clinician and clienthave now spent a few hours together. Plenty of 
information has been gathered—not only through the clinical interview, 
but also through other sources, including self-report measures and con-
sultation with other professionals. Data were also obtained by observing 
the client’s behavior throughout the assessment process. What comes 
next?
Beginning clinicians might assume the next step is to grab an empir-
ically supported treatment manual and get to work. Yet there is an essen-
tial step that comes between assessment and treatment: case conceptual-
ization. Through conceptualizing a case, a clinician develops a working 
hypothesis on how the client’s particular problems can be understood in 
terms of the cognitive-behavioral model. This understanding then guides 
the process of treatment; in fact, Persons (1989) has referred to the case 
formulation as “the clinician’s compass” (p. 37) for this reason.
WHAT ARE THE GOALS OF THE CASE CONCEPTUALIZATION?
Why can’t a clinician jump from assessment to treatment? Aren’t treat-
ment manuals meant to work somewhat like a recipe, providing detailed 
instructions for how to effectively resolve a client’s difficulties? Persons 
(2008) highlighted several reasons why case conceptualization is an 
essential step in the transition from assessment to treatment, as well as 
an ongoing part of the treatment process. First, Persons pointed out, 
76 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
although manuals are written as treatments for a single disorder, cli-
ents typically present with multiple disorders or problems. Second, even 
when clients present with a single disorder, there is much heterogeneity 
in symptom presentation, psychiatric comorbidity, treatment response, 
and other potentially important factors from client to client. For exam-
ple, consider the diagnostic criteria for posttraumatic stress disorder 
(PTSD), which were substantially revised for the DSM-5. As part of the 
revision, three new symptoms were added, bringing the total number of 
symptoms included in the diagnosis from 17 to 20. In order to meet cri-
teria for PTSD, an individual must experience an event that qualifies as 
a traumatic stress, report at least one (of five) “intrusion” symptoms, at 
least one (of two) “avoidance” symptoms, at least two (of seven) “nega-
tive alterations in cognition and mood” symptoms, and at least two (of 
six) “alterations in arousal and reactivity” symptoms. Galatzer-Levy and 
Bryant (2013) showed that, given that there are 20 DSM-5 PTSD symp-
toms, there are over 600,000 possible ways to be diagnosed with PTSD. 
This means that one client with PTSD can have a completely different 
symptom profile and clinical presentation than another one. Third, for 
any one problem (e.g., depression), several evidence-based treatments 
may be available, leaving clinicians to wonder which treatment is best 
suited to any one client. And fourth, although a plethora of treatments 
are available for many problems, empirically supported treatments do 
not exist for every possible problem, sometimes leaving clinicians in the 
kitchen with no cookbook at all.
For all of these reasons, clinicians need to learn to think criti-
cally and ask questions in order to put disparate pieces of informa-
tion together. How do my client’s multiple problems fit together? What 
behaviors, thoughts, or feelings are appropriate targets for intervention? 
What factors served to initiate and, more importantly, maintain mal-
adaptive behaviors or cognitions? Which treatment will be helpful for 
this particular client? Or would I do best to blend aspects of various 
empirically supported treatments to best suit my client’s unique needs? 
How can I use my general knowledge of CBT to help a client with a 
problem for which there is no manual or with which I have never worked 
before? This is where case conceptualization comes in.
Persons’s (2008) approach to case conceptualization involves four 
elements: (1) creating a problem list, (2) identifying the mechanisms 
causing the disorders and problems, (3) identifying the precipitants that 
are activating the problems at the current time, and (4) considering the 
origins of the current problems in the client’s early life. These elements 
are summarized in Table 4.1. By carefully considering mechanisms, 
 Conceptualizing the Case and Planning Treatment 77
precipitants, and origins of a problem, a clinician can move from the 
problem list to an initial case conceptualization. According to Persons 
(2008), the case conceptualization “ties all of these elements into a coher-
ent whole” (p. 126). Let’s consider each of these elements in turn, using 
the case of Janie to illustrate how to effectively conceptualize a case.
1. Creating the Problem List
The problem list was described in detail in the previous chapter, but 
to summarize here, it is an “all-inclusive list of the client’s difficulties” 
(Persons, 1989, p. 19). Persons (2008) suggested that clinicians assess 
the following domains in order to create a comprehensive problem list: 
“psychiatric symptoms, interpersonal, occupational, school, medical, 
financial, housing, legal, leisure, and difficulties with mental health or 
medical treatment” (p. 97). In other words, the comprehensive problem 
list encourages clinicians to look beyond specific disorders to how a per-
son is functioning in all aspects of his or her life.
To create this list, the therapist relies on the data collected during 
all of the interactions he or she has had with the client. Although some 
items might seem very obvious (e.g., a person presents for treatment of 
depression and is, in fact, diagnosed with depression), others might be 
more subtle (e.g., noticing that the client’s spouse speaks to her in a 
derogatory and unsupportive way in the waiting room). These subtle 
items are extremely important to include—the client might not bring 
them up, but they are worth asking about and often play a crucial role in 
the origins and/or maintenance of a client’s presenting problem.
Once a rough list is established, the clinician should whittle it down 
to a maximum of five to eight items and rank items in order of prior-
ity for treatment (Persons, 2008, offers excellent guidelines for order-
ing problems—these are summarized in Table 4.2). The clinician and 
the client should review the list together and come to an agreement on 
the items to be included. It is important to emphasize to clients that 
TABLE 4.1. Persons’s Case Conceptualization Model
1. Create a problem list that includes major symptoms and problems in 
functioning.
2. Identify possible mechanisms causing the disorders and problems.
3. Identify the precipitants that are activating the problems at the current time.
4. Consider the origins of the current problems in the client’s early life.
 
78 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
not all items on the list will be a focus of therapy, but that all relevant 
items should be on the problem list so that the clinician and client can 
be mindful of their relationship to the problems that will receive direct 
attention.
At the end of Janie’s assessment, she and her clinician created such 
a problem list. The obvious candidates were depression, social anxiety, 
drinking problems, identity issues (i.e., what should Janie do with her 
life now that her kids need less of her time and attention on a day-to-day 
basis), and family issues. As was noted in the last chapter, Janie did not 
view her drinking as a problem, contrasting it with her parents’ drinking 
habits, which she viewed as much more severe. However, her clinician 
emphasized the importance of including drinking on the problem list for 
a few reasons. First, alcohol use is highly comorbid with both depres-
sion and social anxiety, suggesting that it would be important to disen-
tangle the functional relationship between drinking and her difficulties 
with mood and anxiety. Second, Janie had a strong family history of 
substanceuse. This undoubtedly influenced her beliefs about “normal” 
drinking and the function of alcohol. Third, given how painful it can be 
to grow up with alcoholic parents, it is possible that Janie was very resis-
tant to admitting that she might be putting her own children through 
what she went through at their age.
2. Identifying the Mechanisms Causing the Problems
According to Persons (2008), “the heart of the case-level formulation 
is a description of psychological mechanisms that cause and maintain 
the patient’s problems and symptoms” (p. 126). The ultimate goal is to 
TABLE 4.2. Guidelines for Prioritizing Problems on the Problem List
	• Is there a threat to the life of the client or another person?
	• Do any of the problems undermine or jeopardize the therapy itself?
	• Is there a problem that would prevent solution of any other problem?
	• What problem does the client have the biggest emotional commitment to 
solving?
	• What problem is interfering most in the client’s functioning?
	• What problem, if solved, would solve many or most of the client’s other 
problems?
	• Is there a problem that can be quickly and easily solved?
	• Is there a problem that if solved might actually destabilize the client?
Note. Adapted from Persons (2008, pp. 122–123). Copyright © 2008 The Guilford Press. 
Adapted by permission.
 Conceptualizing the Case and Planning Treatment 79
develop at least one possible explanation for all of the seemingly dispa-
rate problems with which the client presents. Persons outlines three steps 
for developing a mechanism hypothesis: (1) select a symptom or a group 
of symptoms on which to focus, (2) choose a basic theory to account for 
all of these symptoms, and (3) extrapolate from this basic theory to the 
individual case.
In conceptualizing Janie’s case, her clinician focused on social 
anxiety, depression, drinking, identity issues, and relationship problems 
(Step 1). Based on her own clinical orientation, Janie’s clinician relied on 
A. T. Beck’s cognitive theory to develop a hypothesis about the underly-
ing mechanism (Step 2). In light of this choice, the clinician looked to 
the cognitive construct of schemas and their accompanying automatic 
thoughts, feelings, behaviors, and emotions. To extrapolate from basic 
cognitive theory to Janie’s case, her clinician spent time reflecting on 
each of the items on her problem list, paying particular attention to the 
way that Janie thought about situations, as well as to the emotional, 
behavioral, and physiological responses that result from these interpre-
tations. Let’s take a look into these processes.
Depression and Social Anxiety
Janie’s husband and her family doctor first suggested she seek help due 
to depression. Although Janie hadn’t labeled herself as depressed, she 
reported feeling empty, bored, and purposeless. To begin the process of 
conceptualizing Janie’s case, her therapist asked her when she most felt 
this way. She reported that she felt this way most intensely during the 
day when her girls were at school and her husband was at work, as well 
as at school events when parents were socializing casually.
When Janie was in these situations, she experienced an onslaught of 
automatic thoughts: “My life is pointless,” “I’m a loser,” and “No one 
needs me.” Whenever Janie thought about becoming more active (e.g., 
volunteering at the school or going out to do something during the day), 
she thought, “I can’t do this.” In social situations, Janie repeatedly expe-
rienced the thoughts “I’ll look stupid” or “I’ll say something stupid.” In 
general, Janie held strong beliefs about how she compared with others. 
She believed that everyone was happier than her and everyone had a 
well-defined role in life, while she had none. She also believed that she 
lacked any skills and therefore was unable to do much of anything.
These beliefs led to anxiety, sadness, and sometimes anger (emo-
tional reaction). Before, and often during, social situations, Janie expe-
rienced a range of symptoms including racing heart, shortness of breath, 
80 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
and dizziness (physiological reaction). Janie regularly experienced these 
same symptoms at home alone when she thought about doing much of 
anything. Janie explained that this used to only happen when she was 
getting ready to go out and do something “hard,” like attending a school 
meeting or meeting a friend for lunch, but now it was happening even in 
anticipation of doing household chores.
Janie found these symptoms to be very uncomfortable. Her main 
way of dealing with them was avoidance (behavioral reaction). By the 
time Janie came for treatment, she was doing very little outside of the 
house and even avoiding some household tasks. When she and the clini-
cian started to draw out this model, Janie also admitted that this was 
where drinking fit in. Janie explained that she drank in the evenings to 
numb the physical symptoms of anxiety (behavioral reaction). Janie very 
cleverly recognized that drinking led to further automatic thoughts such 
as “I am a loser.”
Identity and Family Issues
Janie stayed home with her children when they were little and did not 
return to her job as a secretary. She became quite involved at their school 
as a volunteer. However, as they entered middle and high school, Janie 
reported that there were far fewer volunteer opportunities for parents. 
At home, her girls also needed her less, doing their homework indepen-
dently and spending more time with friends. Although Janie was proud 
that her girls were growing up to be independent young women, their 
independence left her at a loss. Janie believed she should return to work, 
but she had no college degree, no specialized training, nor any desire to 
be a secretary again.
When asked about her day-to-day activities, Janie reported that 
she was a traditional homemaker. She did the cleaning, shopping, and 
cooking. Lately, however, she was having a difficult time getting these 
tasks done due to avoidance (behavioral reaction). Janie had few friends 
and had always found it hard to make friends due to her social anxiety. 
Her only social interactions during the day were with her parents whom 
she often took to doctors’ appointments. These interactions were often 
riddled with tension (physiological reaction). Janie’s parents were infirm 
and functioned poorly due to their drinking, and Janie admitted to wor-
rying about becoming like them (automatic thought).
What about Janie’s relationship with her husband? By her report, 
they spent very little time interacting. He came home from work after she 
had eaten dinner with the children, and he ate leftovers while watching 
 Conceptualizing the Case and Planning Treatment 81
sports on TV. In the evenings, she watched TV alone in another room, 
and this was when she noticed herself feeling sad (emotional reaction) 
and having a few drinks (behavioral reaction). Janie and her husband 
went out on occasion, but they found little to talk about. She did not feel 
like he understood her current struggles. He encouraged her to get a job, 
but he did not seem to understand how depression and social anxiety 
(not to mention lack of skills and experience) might make that hard. At 
night, Janie often lay awake thinking “I’m a loser” and “Life is point-
less” (automatic thoughts).
At this point in a case conceptualization, the clinician must take 
all of these musings and arrive at a cohesive underlying mechanism to 
explain the client’s problems. Again, guidance comes from cognitive 
theory, which would point us in the direction of some core belief that 
ties together all of Janie’s difficulties. It appeared that Janie held the core 
belief “I’m incompetent.”
Let’s work backward and see if all the aspects of Janie’s case fit with 
this central mechanism.
Janie noticed her depression and social anxiety the most at home 
alone during the day or when she found herself (rarely) in social situa-
tions.When she considered ways to occupy herself during the day (when 
her daughters were at school), she continually returned to this core belief 
that she lacked the skills to do much of anything. More recently, this 
belief had even generalized to housework and daily chores. Her doubts 
about her ability to adequately do daily activities led her to avoid them 
and instead spend the day watching TV or napping. In circular fash-
ion, this confirmed her beliefs about her incompetence. When people 
asked her in social situations what she was up to, she had nothing to say, 
leading her to assume that everyone around her probably viewed her as 
incompetent too.
Janie had consumed alcohol from a young age, with friends in high 
school and later with her husband. Drinking had only become a prob-
lem for her, however, in the past few years. She reported that she had 
started to drink increasing amounts each evening to numb her feelings 
of sadness. Although she never drank in social situations that involved 
her kids, she did report drinking to ease her social anxiety in other situ-
ations like her husband’s work parties or school reunions. When Janie 
was asked how she felt about her drinking, she replied, “I am such a 
loser. Just like my parents. I don’t get why I can’t figure out some other 
way to deal with all this crap.” In other words, Janie’s drinking also fed 
back into her feelings of incompetence.
In her relationships, this sense of incompetence certainly also 
82 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
applied. She believed that her daughters no longer had much need for 
her, causing her to feel incompetent as a mother. Her husband, being 
quite introverted, did not mind coming home and preparing some food 
for himself and relaxing in front of the TV after work. Yet Janie felt 
that she was failing at keeping up the house and taking care of her 
family. When she started falling off on these responsibilities, her hus-
band called their family doctor, and this made Janie believe that he 
did not believe she could make improvements on her own. Historically, 
Janie grew up in a home in which her parents did little to boost her 
self-confidence. As a child and teenager, Janie took care of her par-
ents, and this continued to the present day with Janie taking them to 
doctor’s appointments and ensuring that they paid their bills on time. 
She reported that they rarely thanked her and were often critical. Her 
reality, as well as perceptual distortions on her part (most notably with 
respect to her daughters), continued to feed Janie’s belief that she was 
an incompetent person.
Despite seeming quite divergent, Janie’s problems fit into a clear 
underlying mechanism “I am incompetent.” Figure 4.1 shows how 
Janie’s case fits into the cognitive model.
3. Identifying the Precipitants Activating the Problems 
 at the Current Time
In this stage of the case conceptualization, the clinician considers 
whether the hypothesized mechanism (the central maladaptive belief) is 
meaningfully related to the antecedents of the client’s current problems. 
If Janie’s core belief was “I am incompetent,” then it would be expected 
that the precipitant of her current problems would be an event or situa-
tion that brought up these concerns for her.
A pivotal event seemed to have occurred during the past school 
year when her youngest daughter was in fifth grade. Throughout all her 
daughters’ years in school, parent volunteers had been welcomed. Janie 
has been class mom, a library volunteer, and a lunch monitor volunteer. 
As her children grew older, Janie recognized that fewer and fewer par-
ents volunteered for lunch duty. After all, older children did not need 
help opening their thermoses or clearing their trash from the table. Yet 
Janie continued to volunteer. The school lunchroom was a place where 
she felt comfortable and needed. One day, at the beginning of her daugh-
ter’s fifth-grade year, Janie came in for lunch duty. Her daughter ignored 
her. She whispered to her friends, and they all looked at Janie and 
 Conceptualizing the Case and Planning Treatment 83
laughed. Janie reported feeling “shattered” that day. She felt unwanted 
and totally unprepared for this next stage in her children’s lives. When 
she shared these feelings with her husband, his response was that she 
should get a job because it would help with the family’s finances. When 
she asked him what he thought she might do, he said, “Well, it will have 
to be something pretty simple since you haven’t worked in years and 
don’t have a degree.” Although he accurately stated the facts, Janie’s 
husband missed the emotions that his wife was experiencing and fed into 
her beliefs about her own incompetence.
FIGURE 4.1. Applying the cognitive model to Janie’s underlying core belief. 
Adapted from J S. Beck (2011, p. 37). Copyright © 2011 Judith S. Beck. 
Adapted with permission from The Guilford Press.
Janie’s core belief:
“I’m incompetent.”
Situations/events:
	• Volunteering at 
school
	• Social events
	• Doing daily errands 
and household 
chores
Automatic thoughts:
	• “My life is 
pointless.”
	• “I’m a loser.”
	• “No one needs me.”
	• “I can’t do this/ 
I can’t do anything.”
	• “I’ll look stupid.”
	• “I’ll say something 
stupid.”
	• “I’m like my 
parents.” 
Emotions:
	• Anxiety
	• Sadness
	• Anger
 
Behaviors:
	• Avoidance
	• Drinking
 
Physiological 
responses:
	• Racing heart
	• Shortness of breath
	• Dizziness
Janie’s intermediate beliefs:
	• “Everyone is happier than 
me.”
	• “Everyone has a role in life 
except for me.” 
84 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
4. Considering the Origins of the Current Problems 
 in the Client’s Early Life
In the preceding paragraph, we discussed a significant event that hap-
pened to Janie recently that would support the hypothesized mechanism 
for her difficulties. Janie’s belief that she was incompetent also suggests 
that she had experiences when she was growing up that contributed to 
this concern. Persons (2008) recommends looking further back into 
the client’s personal history to see if there is additional evidence in sup-
port of this hypothesis. This recommendation might seem surprising 
to beginning clinicians since one of the unique aspects of CBT is its 
focus on the present. Certainly, cognitive-behavioral therapists do not 
spend a great deal of time discussing early experiences during treatment, 
focusing instead on resolving current difficulties. Yet spending some 
time exploring early experiences during the assessment can reveal some 
valuable clues to the clinician as to how problem behaviors may have 
developed and why maladaptive thoughts and behaviors are maintained. 
These discussions might also help the client to understand the origin of 
his or her maladaptive beliefs. Rather than blaming him- or herself, the 
client might be able to accept that it is natural to think the way he or 
way she thinks, given his or her early experiences. An important part of 
therapy will be to discuss whether these beliefs still serve the client well 
in the present, even if they make sense given the client’s past experiences.
As we already mentioned, Janie grew up in a difficult home with 
parents more focused on their own lives than on her development. They 
regularly relied on Janie to tend to them if they were sick from drinking 
but never nurtured Janie’s sense of self-reliance. Janie described both of 
her parents as emotionally flat and chronically depressed or drunk most 
of the time. The family did not talk about emotions, and Janie certainly 
never learned how to regulate her own emotional responses. Her parents 
were not successful, competent people, and they failed to model compe-
tence for their daughter.
Janie’s clinician was fascinated by her belief that she did not even 
need treatment. Certainly, she had a difficult upbringing and was deal-
ing with some significant mental health difficulties. In the process of 
case conceptualization, Janie wasasked about this. Janie clearly articu-
lated the belief that she could not change—so why bother with treat-
ment? She was very concerned about the cost of sessions and believed 
that her husband should not have to pay for her treatment (yet she had 
no money of her own to cover the cost of treatment). Again, her clinician 
was struck by how low Janie’s sense of self-worth was. It was unclear at 
 Conceptualizing the Case and Planning Treatment 85
this point, however, how much was her own perception of her situation 
and how much was actually perpetuated by significant people in her life.
HOW DOES THE CASE CONCEPTUALIZATION 
INFORM THE TREATMENT PLAN?
Devising the case conceptualization naturally leads to the evolution of 
a plan for treatment. Of course, this does not mean that modifications 
to the plan are not permitted as treatment progresses. However, when 
modifications are made, they should be based on the ongoing reformula-
tion of the case conceptualization. Remember, the case conceptualiza-
tion is like a trip itinerary—we might put everything on it that we would 
like to do on our voyage, but it is not a static or rigid document.
What Was the Treatment Plan for Janie?
Let’s consider how the conceptualization of Janie’s case informed her 
treatment plan. Janie held a core belief that she was incompetent. She 
looked around her and believed that everyone else had a more important 
role, was more competent, happier, and more satisfied with their lives. 
These beliefs certainly contributed to Janie’s depression and social anxi-
ety. Feeling socially anxious and unmotivated led to two primary behav-
ioral responses: avoidance and drinking. When Janie drank to numb her 
feelings, she ended up feeling even more unhappy and incompetent. And 
Janie’s avoidance of social situations made it impossible for her to boost 
her sense of competence. She was unable to interview for jobs or make 
friends. This social isolation fed back into her depression and drinking. 
Janie was caught in a vicious cycle that seemed impossible to break.
This led Janie’s clinician to conclude that treatment should be 
focused on helping Janie explore her beliefs about incompetence. How 
could CBT be used to accomplish this goal? Janie could be helped to 
directly challenge her dysfunctional beliefs through cognitive restructur-
ing. Throughout their time together, Janie’s clinician sensed that Janie 
had quite a few more skills than she viewed herself to have. Her clinician 
wondered if her relationship with her children was actually much more 
meaningful to them than Janie believed it to be (and that they needed 
her more than she perceived). Janie had been a wonderful school vol-
unteer, organizing everything from bake sales to teacher appreciation 
breakfasts. Clearly, some skills were involved in these activities. Inter-
personally, when Janie was not down on herself, she was a warm and 
86 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
kind person, making her clinician believe that she had quite a lot to offer 
to people around her. Another ripe arena for cognitive restructuring was 
Janie’s belief that everyone else was happier and more competent than 
she was.
Behaviorally, Janie would benefit greatly from exposure to feared 
social situations. Janie believed that if she initiated plans with acquain-
tances or interviewed for jobs, she would be routinely rejected due to 
her incompetence. The only way to test out this belief would be through 
exposure—putting herself out there and seeing what the outcome 
would be. Concomitant with that, Janie and her clinician would need 
to tackle her drinking problem. Janie drank in social situations in order 
to decrease the likelihood of appearing incompetent—but as with most 
safety behaviors, it was quite likely that drinking was having the oppo-
site effect. Exposures would need to be done without the use of alcohol 
to help Janie see that she could manage these situations just fine, and 
probably do even better, without it. Another piece of treatment would be 
to address her solitary drinking. Janie drank at home to numb her nega-
tive feelings about herself. She and her clinician would need to spend 
some time doing exposures to these feelings and figuring out more pro-
ductive ways to resolve them.
These intentional changes in belief and behavior would likely result 
in Janie learning that when she put herself out there, she would see some 
successes and gain confidence. Although no one has success with every 
friendship they initiate or every job they interview for, another impor-
tant piece of treatment for Janie was to see that she could cope even if 
things did not go according to plan.
What about Janie’s other problems? What we have described so far 
does not capture every issue that she was coping with when she came 
into treatment. For example, there were clearly difficulties in her rela-
tionship with her husband. It was unclear how these difficulties would 
impact the treatment plan. Would he undermine Janie’s attempts to gain 
competence? Was he himself dealing with similar issues, including social 
anxiety, which might hold Janie back in the treatment process? Was it 
possible that as Janie made progress and built a meaningful life for her-
self outside her home, her marriage would seem even less satisfying than 
it did now? Although addressing these questions were not specifically 
part of the treatment plan, cognitive and behavioral techniques could be 
employed to deal with Janie’s concerns about her marriage. This could 
happen in the context of Janie’s treatment. Or, in the evolving treat-
ment plan, it might be recommended that Janie and her husband seek 
couple therapy or that Janie’s husband seek individual CBT for his social 
 Conceptualizing the Case and Planning Treatment 87
anxiety. Janie’s clinician knew that she would have to continuously 
revise her conceptualization of Janie’s case and their plan for treatment 
depending on how these, and other, issues evolved.
Before moving on, it is essential to note that a good case concep-
tualization should also help us to predict roadblocks in carrying out 
the treatment. Janie’s clinician saw a few possible roadblocks. At the 
time she presented for treatment, her motivation was quite low. Her days 
were quite empty, and she had little energy to do much of anything. 
Janie’s clinician was concerned about her being able to carry out an 
active treatment like CBT. She also felt concerned about Janie’s lack of 
social support. Although her husband made the phone call that initiated 
treatment, he didn’t otherwise seem committed to helping her get out 
and find a job or make new friends. In fact, he also led quite an isolated 
life with few friends of his own.
Given these factors, Janie’s clinician was mindful of a number of 
potentially beneficial options if roadblocks were indeed encountered. If 
motivation for treatment proved to be a problem, some sessions of moti-
vational interviewing could be undertaken (Rosengren, 2009). If Janie 
was having difficulty energizing herself for regular, daily activities, some 
behavioral activation might be necessary (see J. S. Beck, 2011; Martell, 
Dimidjian, & Herman-Dunn, 2010). To boost social support, bringing 
Janie’s husband into some sessions might be effective. And, although 
Janie’s clinician was quite confident that she had sufficient tools in her 
CBT toolbox to proceed without medication, adjunctive medication for 
anxiety and depression was another option if needed.
COMMON CHALLENGES OF TREATMENT PLANNING 
AND CASE CONCEPTUALIZATION
Once the case has been conceptualized, beginning clinicians often have 
two questions: (1) How do I structure treatment? and (2) If the client 
has more than one problem, where do I begin? In the remainder of this 
chapter, we discuss these two dilemmas.
A Guide for the Treatment: Using Treatment Manuals
With the goals of treatment defined and a rough idea of what must occur 
in therapy to help the clientmeet these goals, the next question is how to 
devise a structure for the therapy. An excellent option, particularly for 
beginning clinicians, is to use a treatment manual. Treatment manuals 
88 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
provide structure for a case, giving clinicians a clear sense of how ther-
apy should unfold to help clients work through a specific problem (e.g., 
depression, body image problems). Manuals help alleviate the anxiety 
that beginning clinicians experience with respect to knowing what to 
say and do in therapy sessions, freeing up attention to focus on the cli-
ent. Therapy manuals typically include some information on the nature 
of the problem that is the focus of treatment, explain how treatment 
should proceed, include helpful forms and handouts, and sometimes 
even include tips for dealing with difficult issues in therapy, like non-
compliance.
An interesting dilemma arises when we are faced with a client who 
meets diagnostic criteria for multiple disorders, like Janie. In some cases, 
one disorder is clearly of principal importance and a manual focusing 
on that disorder can be selected. In Janie’s case, her difficulties with 
depression, social anxiety, and drinking were clearly connected. Tempo-
rally, Janie had experienced difficulties with social anxiety for as long 
as she could recall. Although she would have never described herself as 
a cheerful person, this current depressive episode was her most intense 
and severe. Janie saw her depression in part as a response to her social 
anxiety—she felt so lonely and isolated, yet she was too anxious to get 
out and meet new people or go to job interviews to improve her feelings 
about herself. Similarly, Janie had been drinking for years, but Janie did 
not see her drinking as an isolated problem. She drank to numb her neg-
ative emotions and to manage anxiety in social situations. She believed 
that if she were busier, and less socially anxious when she was when out 
and about, she would be able to cut down significantly on her drinking. 
With all of this in mind, it made sense to Janie and her clinician to make 
use of a social anxiety disorder treatment manual (Hope, Heimberg, & 
Turk, 2010) to guide her treatment. At the end of Janie’s feedback ses-
sion, her therapist reviewed this treatment manual and mapped out a 
treatment plan based on it, with specifically defined treatment goals. For 
illustrative purposes, we have included this treatment plan in Table 4.3. 
The clinician would not necessarily provide a written plan like this to a 
client. Rather, the discussion of the treatment plan and goals occurs col-
laboratively within the session. Some treatment manuals include forms 
in which clients can record their broad therapy goals, and for clients who 
desire, goals can be recorded in a therapy notebook.
Which Problem(s) Should Be Treated First?
Beginning clinicians often have a problem figuring out where to start 
with clients like Janie who have multiple presenting complaints. The 
 Conceptualizing the Case and Planning Treatment 89
TABLE 4.3. Janie’s Treatment Plan
	• Proposed length of treatment: 16–20 sessions (once weekly, 1-hour sessions).
	• Will use Hope et al. (2010) treatment manual for social anxiety.
	• Main treatment goal: To help Janie challenge her beliefs about incompetence. To 
help her redefine her roles both inside and outside the home as her children are 
getting older.
Proposed outline and goals for treatment
Session 1: Educational material on social anxiety
Goals: To normalize the experience of social anxiety; to introduce Janie to the 
cognitive-behavioral model for understanding and treating social anxiety; to 
discuss the relationship between social anxiety and depression; to set the stage for 
a collaborative treatment process in which Janie would learn to become her own 
therapist.
Session 2: Finish educational material, design hierarchy of feared situations
Goals: See Session 1. Identify feared and avoided social situations; make a plan for 
how exposure to these situations will proceed.
Session 3: Introduce cognitive restructuring (CR)
Goals: To introduce Janie to the idea that our interpretations of situations are 
problematic—not the situations themselves; to teach Janie how to identify, 
challenge, and reframe dysfunctional thoughts.
Session 4: Continue CR, plan first exposure to low-hierarchy item
Goals: To continue skill building (in relation to the CR); to introduce Janie to the 
idea of using behavioral exposures to further challenge dysfunctional beliefs; to 
teach Janie how to set up a behavioral exposure.
Session 5: Carry out first exposure
Goals: To demonstrate to Janie how exposure to feared situations can result in 
new learning as existing dysfunctional beliefs are challenged. To emphasize the 
importance of doing exposures without safety behaviors (e.g., drinking) so that 
Janie can learn that she can do fine (or even better) in social situations without 
relying on alcohol.
Sessions 6–18: Exposures and continuing CR and examination of core beliefs 
(with flexibility for dealing with related issues)
Goals: To continue using cognitive and behavioral strategies to challenge 
dysfunctional beliefs and change problematic behaviors; to help Janie internalize 
these new beliefs and behaviors and generalize them to situations that have not 
been specifically confronted in therapy; to help Janie use cognitive and behavioral 
strategies to work on some of the other problems in her life (e.g., relationship with 
her parents, relationship with her spouse).
Sessions 19 and 20 (approximately): Relapse prevention, goal setting, termination
Goals: To prepare Janie for termination of therapy; to help Janie have realistic 
expectations for the future; to work with Janie to create goals to continue working 
on when therapy is over; to help Janie feel comfortable with termination by 
reflecting on what she has learned and on her newfound ability to be her own 
therapist.
 
90 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
simple answer to the problem is that it depends! Let’s consider some 
options.
Multiple Disorders That Are Functionally Related
In the case of Janie, her multiple problems appeared to be function-
ally related. One option, and the one her clinician chose, was to select 
one disorder upon which to focus, knowing that cognitive-behavioral 
treatment strategies would likely lead to improvement in the other dis-
orders too. In the social anxiety treatment manual, there is excellent 
material on identifying automatic thoughts, tools to challenge automatic 
thoughts, and guidance on addressing core beliefs. Although clinicians 
might “carve nature at its joints” and see some thoughts as “social anxi-
ety thoughts” and some thoughts as “depression thoughts,” these dis-
tinctions aren’t terribly important to clients. Rather, the process of iden-
tifying and restructuring all of Janie’s negative thoughts would likely 
lead to improvement in her social anxiety and depression.
Similarly, the social anxiety treatment manual discusses the use of 
safety behaviors. Alcohol use is one such safety behavior. In the process 
of doing exposures, Janie would be expected to do exposures without 
the use of alcohol in order to see that she could cope with these situa-
tions without the use of alcohol (and in fact, alcohol might make her 
perform worse). With repeated exposure to social situations without the 
use of alcohol, Janie would be likely to cut down on her drinking.
Another option when treating clients with multiple disorders is to 
use transdiagnostic treatment manuals (e.g., Barlow et al., 2011; Nor-
ton, 2012). These manuals recognize that many disorders share common 
characteristics and that common vulnerabilities put people at risk for a 
range of emotional disorders. For example, Barlow and his colleagues 
developed the Unified Protocol (UP) to treat anxiety disorders and major 
depression. The UP “[distills and incorporates] the commonsingle disorders, using an easy-to-follow manual, all of this 
structure can fly out the window when a client presents not only with 
multiple disorders but also with multiple “problems of living.” What 
happens to the therapy then? Should it stay focused? Should a therapist 
get involved in the numerous problems the client is facing? Or is there a 
different way of viewing these clients’ concerns to which new clinicians 
must adjust? The answers to these questions are addressed in Chapters 
4, 7, and 9.
6. Managing unrealistic expectations about the outcome of ther-
apy. Many of us start our training with an idealized view of the degree 
to which clients will improve over the course of therapy. The data on 
cognitive-behavioral therapy feeds into this view: our treatments are so 
effective that we are swayed into believing that if we stick to a treatment 
protocol, and form a strong therapeutic relationship, every client should 
do well. We forget about the percentage of clients who do not improve as 
much as they (or we) would have hoped. In Chapters 7 and 8, we discuss 
how to think about cases that aren’t going well, and how to deal with the 
disappointment of a client who simply does not get better.
7. Working with clients who are difficult to treat. Beginning thera-
pists often embark on their careers not only believing that they can help 
everyone (see Challenge 6), but believing that everyone wants help. In 
reality, some clients are resistant to making the changes that would be 
necessary to lead a healthier, more productive life. Others might desire 
change but bring various factors to the table that get in the way. In Chap-
ters 6–9, we focus on how to recognize these roadblocks (which can be 
quite subtle!) and how to move past them so that therapy will progress. 
We also discuss how to terminate therapy with clients who are not ready 
to do the work involved in getting well.
8. Managing the emotions that can arise in our interactions with 
clients. Being a clinician is an emotional job. Novice clinicians often 
experience anxiety about their clinical skills and their interactions with 
clients. Although seasoned clinicians might experience less anxiety than 
their novice counterparts, anyone working with clients should expect to 
feel a range of emotions in any given week. We might feel anger toward 
clients who are making bad choices, sadness about the lives our clients 
are leading, and joy when a client experiences a success after many 
4 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
setbacks. How do we manage our own emotions within therapy ses-
sions? We discuss this issue in Chapter 1, as well as in Chapters 6–9 and 
10.
9. Leaving our work emotions at work. Following from the previ-
ous challenge, it is important to point out that the emotions we experi-
ence during therapy sessions can last once our workday is over. A few 
unproductive sessions, or a few sessions with clients who are severely 
depressed or angry, can leave you in a rough mood. For most clinicians, 
we must still face our “real” lives when we leave the office. Knowing 
how to move past these moods and move on with our day is an impor-
tant part of our self-care as clinicians. We cover this issue in Chapters 
6–9.
10. Working with clients who pose a threat to themselves or others. 
Although we feel responsible for every client with whom we work, there 
is no greater sense of responsibility than assessing risk and putting safety 
plans in place for a client who is threatening to harm him- or herself 
or others. Fears of the client actually carrying out his or her plans get 
entwined with fear of protecting ourselves—by legal and ethical stan-
dards, did we make all the “right” decisions? In Chapter 7, we cover 
these complex issues and we return to them in Chapter 10 within the 
context of the supervisory relationship.
11. Knowing how to handle new technologies. Being a clinician 
has become more complex since the advent of e-mail, texting, and social 
media. In a typical week, a clinician might receive a text from a client, 
answer a Facebook friend request from another, and grapple with how 
to write about a clinical issue on a blog without divulging a client’s iden-
tity. New technologies present exciting opportunities for clinicians, but 
also ethical challenges. In Chapter 6, we discuss the most up-to-date 
guidelines on these challenges.
 5
1
The Process of 
Cognitive-Behavioral Therapy
The process of becoming a therapist can be daunting. Clients who are 
suffering with emotional and behavioral problems entrust their thera-
pists with their deepest thoughts and feelings and perhaps share experi-
ences with us that they have never shared with anyone else. They place 
hope in us that we will be able to fix what ails them. This is a great 
responsibility.
Given that psychotherapy is a human interaction, we must remem-
ber that our clients come into this situation with beliefs they held long 
before their interactions with us. Perhaps they had negative experiences 
with other therapists. Maybe they grew up with highly critical parents. 
Years of failure at school and work might have led them to believe that 
they can never succeed, even with great effort. We must accept our cli-
ents as they walk in the door. Whatever they bring with them becomes 
part of our work together.
Engaging in psychotherapy means being faced with emotions all 
day. Over the course of a typical day, a therapist might sit with anger, 
sadness, intense anxiety, or even steely silence that is hard to attach to 
any one emotion. We must learn how to react effectively to our clients’ 
emotional states and how to leave work at the end of the day in a com-
fortable emotional place, rather than carrying the burden of our clients 
into our lives outside of work.
Moreover, being a therapist involves exposure to all sorts of differ-
ent behaviors. Every day, we meet clients who engage in dysfunctional 
6 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
behaviors like smoking, drinking, binge eating, and gambling. We 
encounter clients who fail to engage in the behaviors that might improve 
their lives—for example, a depressed client who stays in bed all day rather 
than getting up and doing things that might help him or her feel better. 
We see clients who miss out on participating in their lives because of fear 
and avoidance. It can also be challenging to regularly meet people who 
hold views we might personally disagree with (e.g., supporting a politi-
cal view we find repugnant) or who engage in behaviors that we find 
morally wrong (e.g., shoplifting, child neglect). In our personal lives, we 
might choose to distance ourselves from such people, but in our profes-
sional lives, this might all be in a day’s work. The range of behaviors 
that presents in our offices can seem overwhelming. We might wonder 
how we can even begin to help every person who walks through the door.
In this chapter, we discuss how you can gain confidence as a clini-
cian. But, first, we offer a useful metaphor for the therapy process—
going on a journey.
THERAPY AS A JOURNEY
Many people love to travel. Some people are “fly-by-the-seat of their 
pants” kinds of travelers, but more often than not people like to make a 
plan before leaving on a journey. After all, time and resources are lim-
ited when we travel, and we like to make the most of it!
Perhaps we begin planning a trip by choosing a general location. 
We can reach this decision based on who is going on the trip, what the 
weather is at the time of year we are traveling, consideration of cost, how 
much time we have, and so forth. Once a general location is selected, 
it can be helpful to print out a map of that area and trace a route from 
place to place that might end up on the itinerary.
It often makes sense to consider the beginning, middle, and end of 
a trip. On the first few days of a trip, we can get acquainted with the 
place we’re visiting—maybe by walking around or taking a bus tourprinciples 
found in existing empirically supported psychological treatments—
namely reevaluating maladaptive cognitive appraisals, changing action 
tendencies associated with disordered emotions, preventing emotional 
avoidance, and utilizing emotion exposure procedures” (Barlow et al., 
2011, p. 3). Transdiagnostic treatments for emotional disorders are gath-
ering more and more empirical support. They have proven superior to 
wait-list controls (Farchione et al., 2012) and essentially equivalent in 
efficacy to well-studied single-disorder approaches (Norton & Barrera, 
2012). Additional research is still necessary, however, to further affirm 
their efficacy (Norton & Paulus, 2016). A transdiagnostic treatment 
 Conceptualizing the Case and Planning Treatment 91
manual could have been another reasonable option for a client with mul-
tiple, related problems like Janie.
Multiple Disorders That Are Not Functionally Related
Some clients have multiple diagnoses that are not necessarily related in 
any functional way. As an example, consider a child with trichotillo-
mania and a specific phobia of dogs. After querying, it is clear that the 
hair pulling and the dog phobia are not functionally related—in other 
words, the child does not pull in response to thinking about dogs, or in 
the presence of dogs. In this case, it is best to simply ask clients which 
problem is the most distressing to them. If a child is unable to go to any 
friends’ houses to play because of her fear of dogs but is only missing a 
tiny bit of hair from the back of her head, she might well choose to work 
on her fear of dogs first.
Treatment of One Disorder Might Be Necessary in Order 
for the Client to Work on Another Disorder
In some cases, it might be essential to work on one disorder in order to 
ready the person for working on the other disorder(s). For example, a 
client with comorbid OCD and depression might tell you that she feels 
so depressed that she is having trouble going about the basic tasks of 
daily living, like showering and eating proper meals. It would be very 
difficult for such a client to engage in an active treatment like CBT for 
OCD. It would be best to work on the depression first and then, once 
the client felt more energetic and motivated, shift to working on the 
OCD.
WHAT’S NEXT?
Most of what has been discussed in this chapter happens outside the 
presence of the client. The clinician, following a thorough assessment, 
spends time thinking through the case, forming a conceptualization, 
and developing a treatment plan. In the case of trainees, these impor-
tant steps must happen in the context of supervision. A good supervi-
sor will help a trainee put all the pieces together from the assessment 
to understand what is happening in the client’s life and how he or she 
might be best helped. Then, there must be a bridge between these “pri-
vate” thoughts and embarking on treatment with the client. Specifically, 
92 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
the clinician will provide the client with feedback from the assessment, 
will discuss the initial case conceptualization, and will present treat-
ment options for the client to consider. This part of our interactions 
with clients is important in terms of building rapport, gaining greater 
understanding of their situation, and helping them to make informed 
decisions about their care. We discuss this bridge between assessment 
and treatment in Chapter 5.
 93
5
The Bridge from 
Assessment to Treatment
We have now finished our pretreatment assessment, and we have 
developed a thorough case conceptualization and treatment plan. Before 
beginning treatment, we still have some important things to do. In this 
chapter, we discuss how to share the case conceptualization and treat-
ment plan with our clients and how to begin orienting them to CBT. We 
also discuss how to write the assessment report.
WHAT ARE THE GOALS ON THE PATH 
FROM ASSESSMENT TO TREATMENT?
Providing Feedback to Clients
Providing feedback from the assessment can be done in various ways 
and is largely determined by the setting in which you work and by your 
level of experience. Trainees typically receive supervision following 
completion of an assessment and then meet with the client again to pro-
vide feedback and outline a treatment plan. Some states and provinces 
forbid nonlicensed clinicians from communicating diagnoses to clients, 
so feedback sessions might include a licensed psychologist. Trainees 
should be sure they understand the laws in their particular jurisdiction. 
For more experienced clinicians, feedback might be given right after the 
assessment is complete. With years of practice, experienced clinicians 
94 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
are more confident in the process of establishing diagnoses, outlining a 
rough conceptualization of the case, and presenting options for treat-
ment.
When considering how much information to give clients, the basic 
rule of thumb is to keep it simple. Providing clients with too much infor-
mation, or information that is too complex, can be overwhelming and 
can result in their leaving the session feeling confused and disheartened. 
The client’s understanding is important not only to the success of the 
treatment, but also because the process of obtaining the client’s informed 
consent to treatment is embedded in the feedback process. The main 
tasks of providing feedback to our clients are (1) to review the client’s 
strengths; (2) to review the client’s problems (problem list) and explain 
the diagnosis (or diagnoses) that fits those problems; (3) to share and dis-
cuss the case conceptualization; (4) to review the treatment options with 
their advantages and disadvantages; (5) to recommend treatment; and 
(6) to respond to client questions. A summary of tips for giving feedback 
is included in Table 5.1.
Reviewing the Client’s Strengths
Feedback can be made more positive by pointing out clients’ strengths. 
We are often so focused on letting clients know what their problems are 
and what they need to do to improve their functioning that we forget 
to also emphasize their strengths. Some clients who have very severe 
problems still manage to function quite well in at least some areas of 
their lives. Other clients are very good at seeking out the help that they 
need, either by soliciting support from significant others or by making 
the effort to learn more about their difficulties and how to treat them. 
Certainly, seeking treatment, in and of itself, is indicative of the client’s 
strength and resolve to address a concern or problem. During the feed-
back process, clients should be commended for these positive qualities. 
In general, feedback should be given in an empathic, positive, and hope-
ful way. Starting with the client’s strengths helps to set this tone.
Reviewing the Problem List and Diagnoses
The second step in providing feedback is to review the problem list with 
the client and ensure that no items are overlooked. Remind clients that 
they will not necessarily work on all of the listed problems during ther-
apy, but it is better to be all-inclusive at this time. The various assess-
ment tools will have identified the specific behavioral, cognitive, and 
 The Bridge from Assessment to Treatment 95
emotional aspects of the main problems. These key symptoms can also 
be briefly described.
As in Janie’s case, the problem list might also include specific psy-
chiatric diagnoses. When this is the case, clinicians should explain how 
these diagnostic decisions were made. In other words, the therapist 
should point out the client’s specific symptoms that led to the specific 
diagnoses. It is imperative for novice clinicians to consider how clients 
may react to receiving a diagnosis and be prepared to process these reac-
tions with them. Some clients associate mental illness with stigma and 
might be resistant to the idea that they have a mental disorder. Other cli-
ents mightaccept the idea that they have a diagnosis but see it as a mark 
of weakness or as an indication that they are in some way flawed. Simi-
larly, some clients may react with feelings of hopelessness, perceiving 
TABLE 5.1. Tips for the Feedback Process
1. Always be mindful of the client’s reactions to the feedback. Help the client to 
process difficult information.
2. Point out the client’s strengths rather than just discussing weakness and 
problems.
3. Propose the problem list, diagnosis, and case conceptualization.
• When discussing the problem list . . . 
• Make sure nothing was left off.
• Ensure the client that the list should err on the side of inclusiveness—the list 
does not necessarily mean that he or she must deal with each of these 
problems.
• When discussing the diagnosis . . . 
• Review the client’s symptoms that led you to arrive at this decision.
• Explain the cognitive-behavioral model for understanding the maintenance 
of these symptoms.
• When discussing the case conceptualization . . . 
• Check that it fits with the client’s view of his or her problems.
• Revise the conceptualization in light of the client’s feedback.
4. Explain treatment options.
• Review how CBT could help the client’s specific problems.
• Outline other treatment options.
• Discuss the benefits and drawbacks of all options presented.
5. Make your treatment recommendations.
6. Make it clear that questions are welcome.
 
96 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
their diagnosis as beyond their control and therefore unchangeable. 
Many clients, however, have quite a positive reaction to having a name 
for their difficulties. They might have spent years feeling different and 
alone. Knowing that their difficulties have a name and that many other 
people have the same problem can be a source of great relief.
In addition to sharing diagnoses, the clinician should also explain 
to the client (in cognitive-behavioral terms) why his or her problems have 
been maintained over time even though the client might have tried quite 
hard to make changes on his or her own. In effect, this discussion begins 
the process of psychoeducation. Beginning clinicians might worry that 
it is inappropriate to cover psychoeducational material during a feed-
back session. Yet doing so briefly (with the plan to cover the material 
again in more detail once treatment begins) can have immense benefit. 
Clinicians can say to clients, “Clients always wonder why their difficul-
ties have stuck around when they have tried so many different things to 
change. Let me take a few minutes to explain how cognitive-behavioral 
clinicians make sense of this and—on a more positive note—what we 
can do together to break this pattern and help you feel better.” Some-
times clients complete even a very positive assessment feeling hopeless. 
They might think, “Yes, this person has nailed all my problems on the 
head. But so have other clinicians in the past and I am still suffering. 
What is this person going to do that is different?” This simple discussion 
about the maintenance of problematic behaviors, and what CBT does 
to break apart these patterns, can instill hope in clients. Furthermore, 
clients often assume that therapy will involve an all-knowing therapist. 
This “dose” of psychoeducation will serve as an early demonstration 
that a goal of CBT is to teach clients what we intend to do: to train them 
to be their own therapists. Leaving with new knowledge can help clients 
feel respected and involved. And, particularly for clients who might have 
gone through a long course of therapy in the past with little benefit, 
they will be pleasantly surprised to leave a feedback session with useful, 
sensible knowledge.
Sharing the Case Conceptualization
With the problem list and diagnoses articulated, the clinician can now 
share with the client his or her conceptualization of the case—in other 
words, how these seemingly disparate problems might fit together and 
how this integrated perspective will inform treatment. Clients can be 
asked, “Does this match how you see your difficulties?” For many cli-
ents, hearing a clinician’s conceptualization can be very reassuring. 
 The Bridge from Assessment to Treatment 97
Knowing that the clinician has been listening and has been working 
hard to put all the pieces together helps build rapport at this early stage 
of treatment.
Other clients will see the conceptualization as “off base”—in these 
cases, clinicians must use their judgment to determine if the conceptu-
alization should be adjusted at this time or not. Although you are the 
expert at assessing clients, conceptualizing cases, and coming up with 
a treatment plan, clients are the experts in what they are experiencing. 
They may indeed point out a gap in your understanding that will lead to 
an adjustment in the case conceptualization.
It is important to remember that some clients will disagree with 
the case conceptualization due to the nature of their difficulties. For 
example, consider a client who has difficulties with substance use. Over 
the course of the evaluation, it becomes clear that the client rarely dis-
cusses emotion and maintains a distance from even the most meaning-
ful people in his life. The case conceptualization might propose that 
this client is using substances to numb uncomfortable feelings, including 
those brought on by the stress associated with his distant social relation-
ships. A client who by nature has difficulty talking about emotion might 
dispute that his drinking has anything to do with his feelings. Rather, 
he might argue that his substance use isn’t a problem, or that he uses 
substances simply because he likes them. This discrepancy in viewpoint 
should be noted, but should not necessarily result in a change in the case 
conceptualization.
Reviewing Treatment Options
Having defined the core problems and proposed a unifying underly-
ing mechanism, the clinician can then present treatment options to the 
client. Various options should be presented (e.g., CBT, other forms of 
psychotherapy, medication) and the advantages and disadvantages of 
each outlined. Throughout, ask the client if he or she understands the 
material being presented. Be mindful that clients can sometimes express 
confusion or uncertainty through their body language and that the very 
problems that bring them to treatment may make it difficult to ask ques-
tions or volunteer that they are having trouble making sense of it all. If 
a client looks confused, it is perfectly appropriate to pause and say, “Do 
you have any questions at this point?” or “Is there anything I can do to 
make all of this clearer?” Through your own behavior, make it clear to 
clients that it is appropriate and, in fact, beneficial for them to ask ques-
tions.
98 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
HELPING CLIENTS TO MAKE AN INFORMED DECISION ABOUT CBT
If you believe that CBT is the right approach for the client (or would be 
an important component of a broader treatment program—e.g., one that 
includes medication), your next job is to help clients make an informed 
decision about whether or not they will pursue this treatment. It should 
be noted that in some settings, clients will be required to sign a consent 
form for treatment that is separate from the consent form they signed for 
their assessment. If that is the case, now would be the time to present 
this form to clients, review it together, and provide the opportunity for 
questions.
Although CBT might seem like a sensible approach to those who use 
it every day, many clients are unfamiliar with it. In presenting treatment 
options to clients, explain the cognitive-behavioral approach and give 
clients all the information they need to make an educated decision about 
whether it is right for them.
It is helpful to provide clients with a “snapshot” of what CBT looks 
like. Keep in mind that clients sometimes do not know what the word 
cognitive means. Explain that when wetalk about cognitions, we are 
simply talking about thoughts, and that CBT helps clients change the 
thoughts that they have in particular situations so that they will begin to 
view the world in a more accurate and adaptive way. Give examples that 
are relevant to clients to help them understand this process.
In briefly explaining the behavioral aspect of treatment to our cli-
ents, we can point out to them that it can be hard to simply change 
our thoughts by focusing on them alone. To make truly meaningful and 
enduring changes in the way that they view the world, clients need to 
have new experiences. In CBT, clients are asked to try out behaviors 
that are entirely new to them or that they have not engaged in for a 
long time, and, often, they are asked to cease dysfunctional or unhealthy 
behaviors. In explaining these changes, again draw on examples that are 
relevant to clients’ experiences.
Describe to clients what CBT is all about and illuminate what is 
unique about it. There are several essential points to share. First, cli-
ents should be told about the stance taken in CBT—one of collaborative 
empiricism, in which clinician and client work together as partners in 
treating the client’s difficulties (see J. S. Beck, 2011). Clients should also 
know that CBT is a time-limited treatment. On this note, clients should 
be told how it is that goals can be accomplished so rapidly in CBT—
namely, that CBT is an active, problem-focused, and present-focused 
approach to treating psychological problems. Finally, clients should be 
 The Bridge from Assessment to Treatment 99
told that cognitive-behavioral clinicians are scientifically inclined and 
emphasize use of techniques that have been shown to be effective in care-
fully performed research studies.
The Stance of Collaborative Empiricism. In our experience, the 
aspect of CBT that most surprises clients is the stance of collaborative 
empiricism that is taken by the clinician and the client. For some, their 
image of therapy often involves an individual who free-associates, wait-
ing for the “all-knowing” clinician to provide an interpretation of the 
origins of the client’s difficulties.
The stance of collaborative empiricism is perhaps best exhibited 
when the clinician uses the technique of guided discovery (see J. S. Beck, 
2011). In other therapies, it is most often the case that the clinician makes 
interpretative statements; in CBT, we ask questions, helping clients to 
make their own interpretations of their thoughts and behaviors. This is 
not to say that we do not have an idea of what we want the client to think 
about particular issues. For example, if a depressed client says, “Things 
will never change for me,” our inclination (and likely what we would 
do when speaking to friends or family members) would be to respond, 
“But of course things will change for you.” There is harm, however, in 
directly challenging automatic thoughts in this way (see J. S. Beck, 2011, 
p. 170). First, it can communicate to clients that their thoughts or beliefs 
are “wrong.” Second, by persuading clients to see the world in another 
way, we deprive them of the opportunity to learn valuable skills. And 
particularly when clients are ambivalent about changing a particular 
belief, trying to convince them of the opposing view can paradoxically 
make them hold on even more strongly to that belief (this is a key con-
cept in motivational interviewing; see Rosengren, 2009). In CBT, we 
want to help clients “determine the accuracy and utility of [their] ideas 
via a careful review of data” (J. S. Beck, 1995, p. 8; see also J. S. Beck, 
2011). Therefore, instead of telling the client that things will change for 
him or her, we could ask, “Do you have any evidence that things might 
change for you in the future?” or “Is there any other way that you could 
think about the future?” Using guided discovery communicates to cli-
ents that you would like to know what they think, that they can help 
you to understand their experiences and, in turn, you can guide them to 
come to their own solutions for a problem.
The Time-Limited Nature of CBT. New clients are also often sur-
prised by the time-limited nature of CBT. Clients often have a vision of 
therapy lasting for years. In CBT, clinicians start a course of treatment 
100 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
having a sense of how long it will last and share this plan with their cli-
ents. This estimate of the duration of therapy is often based on research 
and the recommendations outlined in published therapy manuals, as 
well as experience with other clients. The client’s unique presentation 
might also affect the clinician’s sense of how long treatment might last. 
A client who is having moderately severe panic attacks and engaging 
in very minimal avoidance behavior might do quite well with six to 10 
sessions of CBT. In contrast, a client who is having frequent and severe 
panic attacks and has been housebound for the past 2 years might need 
20 or more sessions of CBT. Although there is no set rule for the dura-
tion of CBT, many specific problems can be treated quite effectively in 
20 or fewer sessions.
CBT Is an Active, Problem-Focused, and Present-Focused Ap- 
proach. Clients should also understand how significant gains can be 
made in CBT in a relatively short period of time. CBT is an efficient 
approach to treatment because it is active, problem-focused, and pres-
ent-focused. Again, if we consider the stereotypical mental image that 
people hold of therapy, it often involves clients spending years talking 
about their early experiences and trying to come to some insight on 
where their difficulties might have come from. In CBT, only minimal 
attention is paid to the origins of a problem, with focus placed instead 
on changing current behaviors and thinking patterns in order to improve 
functioning.
IS CBT FOR EVERYONE?
Despite its broad applicability, CBT is not for every problem or for every-
one. Therefore, when making treatment recommendations, clinicians 
should be open to the possibility that the client might be better suited to 
some other approach.
When might CBT be inappropriate? As we have noted, CBT is an 
active approach to treatment—both in terms of cognitions and of behav-
iors. Clients with severe intellectual impairments are not well suited to 
CBT because it places a heavy emphasis on cognitive components of 
treatment (although more purely behavioral approaches to therapy are 
very beneficial to such clients). Similarly, clients in poor physical health 
might have difficulties with the demands of some CBT programs (e.g., 
behavioral treatment for hoarding disorder; interoceptive exposure for 
clients with panic disorder). Other clients simply might not like the idea 
of CBT. They might prefer a less-structured, supportive psychotherapy 
 The Bridge from Assessment to Treatment 101
instead. Although we should educate clients about what CBT entails 
and how it might help them, if they are not interested in pursuing it, 
we should provide them with appropriate referrals rather than trying to 
convince them that CBT is best for them. We want to get the client con-
nected to the best treatment possible for him or her, not make a convert 
to the cause.
Even if clients are clearly enthusiastic about CBT, it is our respon-
sibility to also let them know about the disadvantages of treatments. 
CBT is time-consuming, requiring regular sessions with the clinician 
and commitment by the client to complete therapeutic activities between 
sessions. It can be costly, and therapy is not always covered by insurance. 
It requires clients to be willing to put themselves into difficult situations 
and make some pretty significant changes to both their belief systems 
and the ways they live their lives. It is important that clients know all 
this before making a decision to pursue a course of CBT.
Before addressing some commonly asked questions that can arise 
during the processof giving feedback, let’s review the feedback that was 
given to Janie following her assessment.
Janie’s Feedback Session
Janie came back to the clinic about a week after her assessment. Her 
affect seemed somewhat flat, and she looked slightly disheveled. When 
the clinician asked Janie how she was doing, she explained that she had 
a bad night’s sleep, a rough morning getting her kids off to school, and 
was not sure she wanted to be at today’s session. Her clinician thanked 
her for her honesty, but rather than focusing on these negatives, decided 
to begin the session by focusing on Janie’s strengths.
Reviewing Strengths
CliniCian: Janie, I give you a lot of credit for coming in today. I hear 
that you are on the fence about treatment. And I can relate to those 
rough mornings with kids! I know it took a lot of effort to get here 
today. What made you decide to come?
Janie: I need it (quietly).
CliniCian: When you were here last week, you weren’t sure. What 
changed?
Janie: After our meeting last week, I really realized what a mess I am. 
I need help.
102 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
CliniCian: Janie, seeking help is a great strength. One choice you could 
make is to accept how your life is right now. You are choosing 
another path—to make some changes for yourself and your family. 
That is really honorable and brave.
Janie: And scary.
CliniCian: Yes. In the short term, changing can be harder than stick-
ing with the status quo. But, in the long run, this is about making a 
better future for yourself. I am looking forward to doing that hard 
work with you.
Janie: Yup. It’s going to be hard, that’s for sure.
CliniCian: Well, all change is hard. However, you have a lot of strengths, 
Janie. Even though it was hard for you, you were always the first 
mom to volunteer for things at school. It sounds like once you get 
into a situation that you cared about, you really gave it your all. 
This tells me that you can fight through anxiety and low energy, 
and it tells me you might be more of a “people person” than you 
think. We can harness these great qualities for our work together.
Janie: I really did feel good doing that stuff. You’re right.
Reviewing the Problem List and Diagnoses and Sharing 
the Case Conceptualization
CliniCian: Janie, let’s start out by reviewing the problem list we con-
structed last week. We discussed the interaction between depressed 
mood, social anxiety, and drinking. Our evaluation showed that 
diagnostic criteria were met for major depressive disorder, social 
anxiety disorder, and alcohol use disorder. All of these problems 
seem to be brought on by a common link—questions you are having 
right now about identity. Where do you fit in your kids’ lives? What 
should you be doing about work? How can you fill your days with 
meaning? When you begin to think about these really important 
questions, a lot of negative thoughts pop up about your abilities 
and sense of competence. It seems that these negative thoughts lead 
to feelings of sadness and often lead you to drink too much. Social 
anxiety as part of this picture makes it even harder for you to put 
yourself out there and look for jobs, or make new friends, or fill 
your day with new activities. Again, leading to sadness and drink-
ing. Does this make sense to you?
Janie: Yes, that sounds about right. But complicated and messy.
 The Bridge from Assessment to Treatment 103
CliniCian: It can sometimes help to draw it out. Let me grab my white-
board and we’ll see how the pieces fit together. (Uses a whiteboard 
to draw out a rough case conceptualization interactively as she 
talks through it with Janie.)
Janie: That makes sense. It looks a little more organized up there than 
it does in my head!
CliniCian: I find it helpful too. Putting together all of the pieces of the 
problem helps us to make a treatment plan. This is a work in prog-
ress, so if I have anything wrong, please don’t hesitate at all to let 
me know. My primary concern is helping you, so don’t worry about 
speaking up if you want to clarify or add or disagree with anything.
Janie: OK.
CliniCian: My sense is that you are thinking a lot about competence 
and that this is the engine behind a lot of your social anxiety. I was 
interested to hear you say that you look around and see everyone 
looking more competent than you—with clearly defined roles and 
a happier life. When you think about getting out there and making 
some new roles for yourself as your kids are getting older, the social 
anxiety really gets in the way.
Janie: I think I really realized that after last week. It’s just paralyzing 
me.
CliniCian: Right. Pretty hard to go out and meet new friends or find a 
job if you worry about saying the wrong thing or being seen as an 
incompetent loser.
Janie: Thanks for highlighting that (with a laugh).
CliniCian: Pretty rough stuff you’re saying to yourself, right?
Janie: Right.
CliniCian: How does that feed into the depression for you?
Janie: Well, as you just said, saying this crappy stuff makes me feel ter-
rible, and also I am just stuck. I can’t do anything. So, I sit at home 
and feel even worse.
CliniCian: And, what else gets mixed up in that?
Janie: (quietly) I drink.
CliniCian: Yup. What does the drinking do for you, Janie?
Janie: Well, I think it’s different than my parents. My parents were 
messy drunks. I don’t know if their drinking really meant much of 
anything. I do it to get rid of the bad. You know?
104 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
CliniCian: Can you tell me more about that?
Janie: It just takes the edge off. It just kind of numbs it all. Just one glass 
of wine and I can relax. I forget that I didn’t do anything all day. I 
can just sit and watch a show and rest my brain and not think about 
all of it.
CliniCian: It sounds like in the short run, the drinking works pretty 
well for you. What about in the long run?
Janie: I know what you want me to say. It fixes nothing. I get that. I am 
sitting at home watching crappy TV with my wine, but nothing has 
changed. Nothing at all.
CliniCian: And then does it feed back into those negative beliefs? My 
life is pointless. I’m like my parents. I’m not competent. We get back 
to that unifying theme about competence. Does this match your 
way of thinking about your situation?
Janie: Well, I hadn’t thought of it in this way, but now that you say it, I 
can really see it.
CliniCian: Good, I’m glad to hear that. It’s also interesting to think 
about where this comes from. Janie, I think you had a really hard 
time growing up. From what you’ve told me, you did not grow up 
in a home with parents who nurtured a strong sense of competence. 
And it sounds like they continue to beat you down even now. I also 
wondered about your husband. I’d be interested to talk a little more 
with you about whether he contributes to these beliefs.
Janie: He’s an interesting case himself.
CliniCian: What do you mean?
Janie: I’m not sure how great he feels about himself. And I know he 
wants me to get moving with my life, but to be honest he doesn’t 
really help me much. I can’t explain it, but it’s like he tells me what 
to do, but it’s empty. Does that make sense?
CliniCian: I think this is something we should talk more about. How 
can a person develop a sense of competence with no one helping it 
along? I think there is a lot of rebuilding for you to do, and we can 
work on that together.
Janie: Where do we even start?
CliniCian: I have some thoughts on what we can do. Can I share them 
and see that you think?
Janie: Sure.
 The Bridge from Assessment to Treatment 105
Treatment Recommendations
CliniCian: So, Janie, we have a complex problem list and a big question 
is: Where should we start? I have a proposal. I think we should start 
by working on social anxiety. It seems like your goal is to get out 
there and build a new identity for yourself as your kids are growing 
up and needing you less. Yet all the things you know you needto do 
are made so difficult because of social anxiety. What I am hearing 
from you is that casual conversation with other moms, going for job 
interviews, all that stuff is just too hard right now because you are 
worried about saying or doing the wrong thing.
Janie: Yup. That’s right. But what about how depressed I feel?
CliniCian: My sense is that as we get you out a little more, and get 
some structure in your life, your mood will improve. I can’t promise 
that, but this is typically how it works with people who have long-
standing social anxiety and a more recent onset of depression. We 
see the depression as almost a reaction to the social anxiety.
Janie: I can see that. Anything has got to be better than sitting home all 
day doing nothing.
Informing the Client about the Specifics of Treatment 
to Obtain Consent
CliniCian: We are going to work on the social anxiety with a formal 
treatment protocol, designed specifically for clients with social anx-
iety disorder. The treatment typically runs for about 20 sessions, 
but we can be flexible. If some of the other problems are getting in 
the way of our progress with the program, we can deviate and deal 
with them. Similarly, if your social anxiety improves more rapidly, 
we will “shift gears” and decide what to work on next.
Janie: That sounds really good. I really like the plan.
CliniCian: Do you have any questions or thoughts about it?
Janie: Well, you mentioned that we would treat the social anxiety disor-
der with a formal protocol. What does that involve?
CliniCian: We’ll start with some psychoeducation. By this, I mean that 
you will learn some things about social anxiety disorder: how com-
mon it is, where it might come from, why it sticks around when you 
don’t want to have it, and how we can treat it. Then we’ll spend 
some time identifying the thoughts that cause your social anxiety 
106 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
and teach you some tools to challenge these thoughts. At that point, 
we get to the crux of the treatment: exposures. We will make a 
list of all of the situations that cause you difficulties and rate each 
according to how anxious it makes you feel. Then, in a systematic 
way, we will confront these situations.
Janie: What do you mean, “confront these situations”?
CliniCian: Yeah, sounds a little scary. Let me explain. A core technique 
of CBT is exposure to feared situations. By confronting situations 
that you have been avoiding, you will come to see that your anxiety 
will decrease with repeated exposures. Also, you will see that your 
feared consequences are pretty unlikely to occur, and if they were to 
occur, the consequences would not be as dire as you might expect.
Janie: Can you give me an example?
CliniCian: Well, we could work on job interviews. We could discuss 
some ways to meet new people, or reconnect with people you 
haven’t seen in a while.
Janie: That sounds awful!
CliniCian: Well, Janie, the important thing to realize is that we’d be 
doing these exposures gradually. For example, we could start with 
some mock job interviews here, just you and me. Then, we could 
send you out for a few interviews for jobs you don’t care too much 
about. We would work up to interviews for jobs you really want.
Janie: Truthfully, it all sounds impossible.
CliniCian: Might seem that way now. But that’s why we do exposures 
gradually. We start with situations that cause moderate anxiety and 
we work up to those that cause a great deal of anxiety. By the time 
clients get to their most feared situations, they sometimes don’t 
seem so scary anymore.
Janie: So, you’re telling me that if I went to enough interviews, I’d get 
less and less anxious?
CliniCian: Probably. Any thoughts on why this could happen?
Janie: I guess as you make me do all of this stuff, I’d learn that I wouldn’t 
totally mess up.
CliniCian: Right. And, let me just add, I don’t “make” people do any-
thing. We will plan all of your exposures together. Although I will 
make lots of suggestions and encourage you to take risks, you are in 
the driver’s seat here.
 The Bridge from Assessment to Treatment 107
Janie: OK. But how do we deal with all my other problems?
CliniCian: Well, a nice thing about CBT is that it provides a framework 
for dealing with all sorts of problems. During the social anxiety 
disorder program, you will learn how to identify negative thoughts 
and how to use specific tools to challenge these thoughts. These 
techniques will be really helpful when we start to work on some of 
the other problems as well. We can also pick and choose from other 
techniques that are part of CBT. When we do work on your related 
problems, I think it will feel like quite a smooth transition from the 
social anxiety disorder treatment, since we will be approaching all 
of these issues from the same general perspective.
Janie: That sounds really good.
Other Treatment Options
CliniCian: There are other options too. You could consider taking med-
ication to help the social anxiety and depression. Is this something 
that you’ve considered?
Janie: Yes, I’ve considered it. But my preference would be to steer clear 
of medications for now. You know, with my family history, I am 
pretty scared of getting hooked on anything.
CliniCian: The medications we currently use for anxiety and depres-
sion aren’t addictive, but I respect what you are saying. I am com-
pletely comfortable starting with CBT and seeing how we do. Let 
me know along the way if you want to revisit the issue.
At this point, Janie was asked if she had any other questions or 
concerns. She did not, and at the end of the feedback session her clini-
cian arranged for her to come back the next week for her first session of 
treatment.
CHALLENGES FACED ON THE PATH 
FROM ASSESSMENT TO TREATMENT
Before concluding this chapter and moving on to actually doing CBT, 
let’s review some challenges that might emerge when clients are consid-
ering options for treatment. Some clients will hear your brief overview 
of CBT, see it as worth trying, and “sign on.” Others will follow your 
overview with questions and concerns. It is important to spend the time 
108 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
answering them and providing clients with the information that they 
need to make an informed decision about treatment.
“Does CBT Work?”
Many clients (understandably) will ask if CBT “works.” Although some 
clients will seek out CBT because they have learned about its efficacy 
from other sources, others will be hearing about it for the first time 
during their initial contact with mental health professionals. Since CBT 
sounds so different from the notion of psychotherapy held by most lay-
people, they might be doubtful about its validity or efficacy. Having 
confidence in the treatment approach can have an impact on therapy 
outcome, so it is very important to try to instill some of the confidence 
that we feel about CBT in our clients.
This can be difficult for beginning clinicians, who sometimes feel 
pressure to “sell” CBT to prospective clients. They might worry that if 
they “pitch” the treatment and clients decide not to pursue it, they will 
be negatively evaluated by their supervisors (we will discuss negative 
evaluation by supervisors in greater detail in Chapter 10). Then, strike a 
balance between providing clients with information that will help them 
to make an appropriate decision about treatment, while not pushing 
them into a treatment program that they do not want to enter.
There are two ways that this “hard sell” can be avoided. First, stick 
to the facts. Tell clients that CBT is an empirically supported approach 
to treatment. Give them specific information about the effectiveness of 
CBT for their particular difficulties. Let clients know that CBT is not a 
new approach to treatment, but rather it has been used to treat psycho-
logical disorders for over five decades. If true, it can also be beneficial to 
mention that you have treated otherclients (being mindful of confidenti-
ality, of course) with similar problems who did well with CBT.
Second, come back to the stance of collaborative empiricism. It is 
fine to share with clients your confidence in CBT, while also appreciat-
ing their doubts. After all, you have seen CBT work effectively, and they 
have not. Clients can be encouraged to try CBT and see how it works 
for them. Although their hypothesis might be that CBT will not work 
for them, they can be encouraged to reevaluate how things are going at 
a certain point in time (e.g., after four to six sessions of therapy) and see 
whether or not their hypothesis has garnered support. Regardless, it is 
critical that clients be open to the possibility that CBT might work for 
them; it would be unreasonable to expect clients to have complete confi-
dence in the approach until they have given it a try.
 The Bridge from Assessment to Treatment 109
“Will We Have Enough Time to Work on My Problems?”
Clients can have different reactions to learning that CBT is time-limited. 
Many clients view this positively—it is comforting to know that their 
problems will not take years to resolve. Furthermore, the time-limited 
nature of CBT can be very motivating for clients. If a therapy assignment 
seems overwhelming, but clients know that they only have a few months 
to work on their difficulties, they might be more willing to push them-
selves to try difficult things.
Some clients, however, worry that the duration of therapy will not 
be sufficient for them to make the improvements they would like to 
make. It is easy to understand these concerns, particularly with clients 
who have been having difficulties for many years. It is hard to imag-
ine working through a problem in a couple of months that has been 
around for 30 years. It can be helpful here to return to what we know 
from research and from our experiences with other clients. CBT has 
been shown to be effective when carried out in a time-limited fashion, 
even with clients who present with severe and long-lasting symptoms. 
This information should be presented to clients, but it is not necessary to 
try to convince them that time-limited treatment will work for them too. 
Rather, return to the empirical stance of CBT and encourage them to be 
scientists—“Why don’t we get started with this plan and see how things 
go?” Another helpful message to deliver to clients is that CBT involves 
ongoing consideration and revision of the case conceptualization. The 
plan for treatment is not written in stone and is frequently evaluated and 
revised as the therapy progresses.
“Why Didn’t CBT Work for Me in the Past?”
Some clients have previously undergone CBT and experienced little or 
no improvement. In this situation, you should spend some time ascer-
taining the exact nature of the previous treatment. Often, you can iden-
tify a clear reason for the treatment failure.
As we noted in Chapter 3, sometimes clients think they have received 
CBT, but when they begin to describe what their treatment entailed, it 
becomes clear that they received something else altogether. Some clients 
might have received only certain components of CBT (e.g., only cog-
nitive work without the behavioral component). They might not have 
had an adequate trial of CBT (e.g., they stayed in therapy for only four 
sessions when CBT for many disorders takes longer than that to work). 
Some clients might have received very good CBT for an adequate period 
110 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
of time, but other variables might have influenced its efficacy. CBT is a 
treatment that requires a commitment of time and effort on the part of 
a client, and some clients will clearly tell you that the last time they tried 
CBT, they were not ready to change or did not have the time to commit 
to getting well. Securing information of this sort from the client is very 
important. Using a cognitive-behavioral approach, misconceptions can 
quite quickly be remedied, placing clients in a better mind-set for begin-
ning CBT again.
On a related note, some clients may say that they have tried to imple-
ment CBT techniques on their own—with little success. Either with a 
self-help book, or through intuition, clients might have tried to chal-
lenge their thoughts, expose themselves to something they are afraid of, 
or replace an unhealthy behavior with one that is more adaptive. They 
might wonder why formal CBT will work if their own efforts had not. A 
good way to respond to this concern is to first commend clients for their 
efforts. Their experiences can then be normalized: most clients have 
tried to improve their lot in life on their own prior to coming for treat-
ment. We can then explain why working with a clinician might be differ-
ent. One of the strengths of therapy is that clinicians can help clients to 
understand the contingencies that maintain their problematic thoughts 
and behaviors and can then teach them specific strategies for making 
desired changes. A good example to consider is dieting—many people 
try to lose weight on their own and fail. They might decide to eat less 
and exercise more, but in reality they cannot accomplish these goals. The 
advantage of therapy is that it helps clients to articulate specific changes 
that must be made to meet these elusive goals. Treatment might start 
with helping the client to identify triggers for overeating and roadblocks 
that get in the way of exercising—in other words, identifying the factors 
that maintain the weight problem in the first place. Then the therapist 
can help the client develop a specific plan for eating less and exercising 
more. If a trigger for overeating is being bored and alone in the evenings, 
the therapist might help the client develop a number of ways to alleviate 
boredom (e.g., get some good books to read, work on a home improve-
ment project) and reduce loneliness (e.g., join an organization, do some 
volunteer work, get together with friends to see a movie). The therapist 
can also help the client examine his or her eating habits and identify 
positive changes that can be made. If the client eats a healthy dinner at 
5:00 p.m. and then binges on junk food at 11:00 p.m., the therapist might 
suggest having dinner a little later in the evening and then also planning 
to have a healthy snack later on. Similarly, the therapist might help the 
client develop an exercise plan that takes into account the roadblocks 
 The Bridge from Assessment to Treatment 111
that previously interfered. If the client does not like exercising in a gym, 
he or she can be encouraged to find a nice walking route in the neighbor-
hood. A client who finds it hard to get motivated to exercise alone could 
be encouraged to find an “exercise buddy,” which could also reduce his 
or her feelings of boredom and loneliness. As these potential solutions 
are generated and applied, the therapist can help the client evaluate the 
results and consider alternative solutions if the initial plan did not work. 
In other words, therapy provides the structure for persevering with solv-
ing a problem, rather than giving up after 1 night of overeating or a 
missed day of exercise. Clients generally appreciate being commended 
for trying to solve their problems on their own and are usually quite able 
to see how a structured cognitive-behavioral approach, with a support-
ive clinician, might lead to better results.
“Should I Take Medication?”
Particularly since pharmaceutical companies now advertise quite regu-
larly on TV, on the web, and in popular magazines, many clients come 
to see clinicians with numerous questions about medication. It is not 
unusual for clients to come in having diagnosed themselves and having 
selected a medication that they think might be of help to them. Although 
most nonmedical clinicians cannot prescribe medication, they should 
be knowledgeable about them and be able to answer the most frequent 
questions that clients ask. It is also advantageousto get to know some 
“CBT-friendly” psychiatrists in your area. These are people to whom 
you can turn with your questions and also individuals to whom you can 
refer your clients. Clients will get the best treatment possible when they 
see a physician for medication with whom you share a good collabora-
tive relationship and who is supportive of CBT.
Some common questions arise when clients are deciding whether or 
not to pursue medication treatment. Many clients ask about side effects 
that they might experience with particular medications. Clients might 
also be interested in the comparable efficacy of therapy, medication, or 
combined treatments. In general, questions about side effects and dos-
ing should be deferred to prescribing physicians. Nonmedical clinicians 
should be able to address questions of relative efficacy of treatments by 
staying up to date with the latest research in their fields.
Nonprescribing clinicians can also discuss the pros and cons of 
medications and therapy with clients, in the context of their lifestyles. 
If clients voice concern about making it to weekly therapy sessions, per-
haps a trial of medication might be a better fit for their lifestyle. If a 
112 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
client reports having had negative experiences with medications in the 
past, he or she might be more suited to a trial of CBT.
WRITING THE REPORT
Once you have worked through the process of case conceptualization 
and have devised an initial treatment plan, you will be ready to write 
your assessment report. There are many different ways to write an 
assessment report. Most agencies will have templates for you to follow. 
In general, certain information should be included in reports regardless 
of the specific format (see Groth-Marnat, 1997).
Some General Rules for Report Writing
One of the most important rules of report writing is to be succinct. You 
do not have to put everything into the report that you learned during 
the assessment. Carefully select the information that is going to best 
capture the client, keeping in mind that other professionals are very busy 
and want to get a clear picture of the client as quickly as possible. Fur-
thermore, when clients read their own reports, they can often feel over-
whelmed with too much information. Keeping it simple and providing 
straightforward recommendations is strongly encouraged.
It is also important to be mindful of your audience. The report’s 
audience should help you to determine what to put into it. This issue is 
most salient when reports are being sent to other people in clients’ lives. 
For example, if an employer requests an assessment to see if an employee 
is able to work, the report should focus on factors relevant to this assess-
ment question. Highly personal information about relationships, sexual 
orientation, family history, and other issues like these typically do not 
have a place in such reports and should be excluded even if they are 
brought up during the assessment.
Keep in mind that clients have a right to see their own reports. This 
does not mean you cannot be honest about difficult issues—rather, you 
should word your comments to be helpful, but not harmful, to clients. 
For example, if a client is very chatty during an assessment, it would not 
be helpful to write, “The client would not stop talking through the entire 
interview.” Rather, you might write, “The client was unable to answer 
questions succinctly during the interview.” You should also be mindful 
of the language that you use, avoiding jargon. This is also important 
when communicating with other professionals who might not be knowl-
edgeable about mental health or the cognitive-behavioral approach to 
 The Bridge from Assessment to Treatment 113
assessment or treatment. If clients do want to see their reports, it is best 
for clinicians to review the report with them and be available to address 
any questions or concerns that may arise.
Let’s now look briefly at each main section that should be included 
in the standard report. In Figure 5.1, we have included a sample report 
based on the case of Janie to demonstrate these key features. (Readers 
can download a blank report template to use with their own clients. 
See the box at the end of the table of contents.) See also Table 5.2 on 
p. 120.
General Information
The report should begin with the client’s name, age/date of birth, and 
sex. It should also include the date of the assessment, the date the report 
was written, and the name of the evaluator. Finally, information should 
be provided about the referral source.
Referral Question
According to Groth-Marnat (1997), “The ‘referral question’ section 
provides a brief description of the client and a statement of the general 
reason for conducting the evaluation” (p. 632). This should be a brief 
section, basically orienting the reader to the content of the remainder 
of the report. A full description of the client can be put in the “Back-
ground Information” section. In this section, the purpose of the evalu-
ation should be indicated. In Janie’s case, she had been encouraged to 
call the clinic by her husband and family doctor because of suspected 
depression.
Evaluation Procedures
In this section, the evaluation instruments that were used should be 
listed and briefly described. Acronyms should not be used until the full 
name of the instrument is introduced. Once an acronym is defined (e.g., 
Beck Depression Inventory; BDI-II), it can be used in the remainder of 
the report. It can be helpful in this section to indicate how long the 
assessment took to complete. Such information can be important for 
case conceptualization and treatment planning.
Behavioral Observations
Focus should be placed in this section on the client’s appearance; obser-
vations of behavior before, during, and after the evaluation; and the 
114 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Confidential Psychological Report
Name: Janie J.
Date of birth: June 8, 1976
Age: 40
Sex: Female
Date of assessment: June 1, 2016
Date of report: June 26, 2016
Clinician: Dr. T.
Referral source: Dr. M., general practitioner
Referral Question: Janie is a 40-year-old white married female 
who presented with complaints of social anxiety and 
depressed mood.
Evaluation Procedures: Janie was administered the Anxiety and 
Related Disorders Interview Schedule for DSM-5 (ADIS-5). 
The ADIS-5 assesses current anxiety, mood, obsessive–
compulsive, trauma, and related disorders (e.g., somatic 
symptom, substance use) according to DSM-5 criteria.
Janie was sent a battery of questionnaires completed 
by all clients who present at our clinic. The battery 
includes a number of measures assessing anxiety and mood 
difficulties. Focus here will be placed on measures of 
social anxiety and depression:
Beck Depression Inventory (BDI-II): The BDI is the most 
commonly-used self-report measure of depressive affect. 
The 21-item scale assesses symptoms of depression that have 
been present in the past week including difficulties with 
sleep, irritability, and suicidal ideation.
Social Phobia Scale (SPS): The SPS is a 20-item self-report 
measure that assesses fear of being scrutinized during 
routine activities like eating or writing in front of 
others.
Social Interaction Anxiety Scale (SIAS): The SIAS is a 20-item 
self-report measure that assesses cognitive, affective, and 
behavioral reactions to social interactions in dyads or 
groups.
Janie came to the evaluation with her self-report 
measures completed. The assessment interview took 2 hours 
to complete.
Behavioral Observations: Janie arrived for her appointment on 
time. She was casually dressed and neatly groomed. She 
seemed quite anxious and uncomfortable at the beginning 
of the interview, but as it progressed she became more 
comfortable and open. However, she maintained some 
FIGURE 5.1. Confidential psychological report.
(continued)
 The Bridge from Assessment to Treatment 115
reluctancethroughout the assessment to discuss very 
personal matters, notably her drinking habits and her 
relationship with her husband. The assessor had no 
concerns about the reliability of the information that 
Janie provided.
Background Information: Janie was born and raised in the 
suburbs of a large city in the northeastern United 
States. She is an only child and grew up in a home with 
her mother and father. Both parents had significant 
alcohol use problems during Janie’s childhood. They had 
difficulty holding down jobs and had a strained marriage. 
They currently continue to drink and are infirm. Janie 
cares for them, and she and her husband help them out 
financially.
Janie described a difficult childhood. As an only 
child, she cared for her parents at a very young age when 
they became intoxicated. She also missed many school 
and social events and was chronically late to school 
because her parents functioned so poorly. Janie described 
having difficulty relating to friends who grew up in very 
different environments than her own.
Janie completed high school and was admitted to a 
local college. She completed 2 years of college before 
dropping out because her parents could not afford her 
tuition and she found it too stressful to work and attend 
school at the same time. She got a job as a secretary 
at a medium-sized company. It was there that she met her 
husband, Phil. They had similar backgrounds, were both 
introverted, and married after dating for only 6 months. 
Janie stopped working when she had their first child, 
Emma, now a freshman in high school. Janie and Phil also 
have another daughter, Adrienne, who is in sixth grade. 
Phil continues to work at the company where he and Janie 
met. Janie described their finances as “tight” because 
they are a single-income family and they help Janie’s 
parents.
Janie described always having been socially anxious 
and feeling “different” from other children her age. 
Growing up, she had a few similarly quiet friends, but she 
was not active socially and rarely dated before she met 
Phil. Janie enjoyed the social aspect of being a young 
mother. With her children along, Janie was able to go to 
children’s activities and volunteer at school. Although she 
experienced significant anxiety at the beginning of any 
new experience, she gradually became comfortable and made 
(continued)
FIGURE 5.1. (continued)
116 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
casual friends with other parents. As her children grew up 
and there were fewer opportunities to volunteer at school, 
Janie began to feel increasingly isolated and her social 
anxiety intensified.
Janie described Phil as a “loner.” They met when they 
were young and did not seriously date other people. Janie 
explained that she was not sure if he experiences social 
anxiety—rather, he just prefers to be alone. As such, they 
rarely go out with other couples or go to parties.
Janie experienced depression from time to time 
throughout her teens and adulthood, but she described 
the current episode as the most severe. She reported 
sleeping more than usual (yet she still feels fatigued), 
feelings of worthlessness, difficulty concentrating and 
making decisions, and loss of interest in activities 
she previously enjoyed. She denied any current or prior 
suicidal ideation.
Janie reported that she began drinking alcohol in her 
teen years. She recalls using alcohol to manage anxiety in 
social situations since then. Her drinking intensified in 
the past 6 months, with a particular increase in solitary 
drinking. Whereas she used to drink a few glasses of wine 
on the weekend, she reported that more recently she had 
been drinking three to four glasses of wine nightly as a 
means of numbing her sadness and anxiety.
Assessment Results:
Diagnostic Interview:
Based on results from the ADIS-5, diagnostic criteria were 
met for social anxiety disorder (F40.10), major depressive 
disorder (moderate severity, recurrent episode; F33.1), and 
alcohol use disorder (severe; F10.20).
With respect to social anxiety disorder, Janie 
endorsed marked fear or anxiety about one or more social 
situations in which she is exposed to possible scrutiny 
by others (Criterion A) and fear of acting in a way or 
showing anxiety symptoms that will be negatively evaluated 
(Criterion B). For Janie, social situations almost always 
provoke anxiety (Criterion C) and are avoided or endured 
with intense fear or anxiety (Criterion D).
Criteria were met for depression because Janie endorsed 
five or more symptoms of major depressive disorder that 
had been present in the same 2-week period and that 
represented a change from her previous functioning. 
Specifically, Janie reported experiencing depressed mood 
FIGURE 5.1. (continued)
(continued)
 The Bridge from Assessment to Treatment 117
(Criterion A1); a loss of interest in her activities (A2); 
hypersomnia (A4); psychomotor retardation (A5); fatigue 
and loss of energy (A6); feelings of worthlessness (A7); 
and diminished ability to think, concentrate, or make 
decisions (A8). Notably, Janie denied any thoughts of 
death, recurrent suicidal ideation, suicidal plans, or 
past suicide attempts (A9).
With respect to alcohol use, Janie endorsed seven 
symptoms—the presence of six or more symptoms warrant a 
severe specifier. Janie reported using alcohol in larger 
amounts than she had intended (A1); many unsuccessful 
efforts to cut down on her drinking (A2); a great deal of 
time spent recovering from the effects of alcohol (A3); 
strong desires to use alcohol (A4); continuing to use 
alcohol despite knowing that it exacerbates her anxiety 
and depression (A9); and tolerance (A10). Janie explained 
that she used to drink one glass of wine to numb her bad 
feelings, but now must drink several glasses to get the 
same effect.
Self-Report Measures:
Scores on self-report measures are generally consistent 
with the findings of the diagnostic evaluation.
BDI-II score = 28. This score is indicative of 
depression in the moderate range.
SPS score = 38. This score is indicative of severe 
social anxiety about being scrutinized by others, well 
above the commonly accepted score of 24 (the score that 
separates individuals with social anxiety disorder from 
those without social anxiety disorder with the greatest 
balance of specificity and sensitivity).
SIAS score = 52. This score is indicative of severe 
social anxiety about interacting with others in dyads 
or groups, well above the commonly accepted score of 34 
(the score that separates individuals with social anxiety 
disorder from those without social anxiety disorder with 
the greatest balance of specificity and sensitivity).
Impressions: Janie is currently experiencing moderately 
severe social anxiety, depression, and alcohol use. Her 
functioning at the current time is quite impaired. She is 
socially isolated, is having a difficult time performing 
some of her day-to-day activities, and has a very negative 
view of herself and her prospects for the future.
FIGURE 5.1. (continued)
(continued)
118 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Recommendations: Cognitive-behavioral therapy (CBT) for 
social anxiety disorder will likely be a good starting 
point for Janie. It seems important to help her learn to 
manage her anxiety better in social situations so that she 
can redefine her life roles as her children grow up. It is 
expected that as Janie becomes more active, her mood will 
improve.
Janie is currently using alcohol to numb her anxiety 
and her negative feelings about herself. CBT will also 
involve developing coping strategies other than using 
alcohol to help Janie cope with negative affect. Janie 
will be encouraged to refrain from alcohol use during all 
exposures to feared social situations in order to learn 
that she can cope with these situations without the use of 
substances.
Janie has never engaged in treatment before. Her 
clinical picture is quite complex, with social anxiety 
datingback to childhood and alcohol use and depression 
emerging in her teen years. Janie had a troubled 
childhood, and her relationship with her parents remains 
complex. It is unclear how much support she receives 
from her husband, and she has no social support to 
speak of outside of the home. These factors present some 
challenges for treatment. Janie is a bright woman, and 
having received no treatment in the past, it is likely 
that cognitive-behavioral skills will be very helpful to 
her. At the same time, it is reasonable to expect that the 
course of therapy might be longer than usual and that some 
sessions should be dedicated to discussing how her past 
and current relationships have impacted her views about 
herself, the world around her, and her future.
Options for medication were discussed with Janie. 
At the present time, Janie is not interested in trying 
pharmacological treatment for social anxiety disorder or 
depression. It seems reasonable to begin CBT and see how 
Janie does. If her depression prevents her from engaging 
in this very active treatment, we will reexamine the use 
of medication as an adjunct to CBT.
FIGURE 5.1. (continued)
nature of the interactions between the client and the clinician. Connec-
tions should also be drawn between these observations and the valid-
ity of the evaluation. If a client is very argumentative and oppositional 
during the evaluation and provides information that seems incongruent 
with his or her behavior, this should be noted.
 The Bridge from Assessment to Treatment 119
Background Information
This section of the report should include information on family back-
ground, personal history, medical history, history of the problem, and 
current life situation (see Groth-Marnat, 1997). It is very important that 
this section be written succinctly. Other professionals are just as busy 
as you are, and the information that they need to help the client should 
be delivered in a concise and organized fashion. Instead of elucidating 
every aspect of the client’s life, focus on information that is relevant to 
the client’s current difficulties. Groth-Marnat (1997) has recommended 
that report writers be clear about the sources of their information. For 
example, a report might read, “According to the client . . . ” or “Discus-
sion with the client’s mother revealed that. . . . ”
Assessment Results
In this section, findings from each assessment tool listed in the “Evalu-
ation Procedures” section are reported. When discussing Janie’s case, 
we noted the diagnosis for which she met criteria. We also reported the 
results of her self-report measures, recording the specific scores in the 
context of clinical data. It is necessary to provide context for the mean-
ing of specific questionnaire scores, as they are uninterpretable without 
this additional information.
Impression and Interpretations
This section should summarize what was learned from the assessment 
process. It should integrate test data, behavioral observations, relevant 
history, and any other data, such as information from other professionals 
or family members (Groth-Marnat, 1997). We have purposefully writ-
ten a very brief impression and interpretation section, since this section 
will vary greatly depending on the setting in which you work. In some 
settings, this section might include a case formulation, as described by 
Persons (2008). In others, it might be less interpretive (as we have done 
here). Here, we have addressed Janie’s general level of psychopathology, 
focusing specifically on both the distress that she is experiencing and the 
degree to which her difficulties are leading to functional impairment.
Recommendations
Again, this section will read very differently depending on your orienta-
tion and the setting in which you work. Here, we have recommended 
120 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
CBT, discussed our expectations for the course of treatment, and sug-
gested possible roadblocks. We also noted that medication options were 
discussed with Janie, but that she was not eager to try medication at this 
time. Table 5.2 summarizes what should be included in the assessment 
report.
TABLE 5.2. Information to Include in an Assessment Report
1. General information
• Client’s name, date of birth/age, sex
• Date of assessment, date the report was written, name of evaluator, referral source
2. Referral question
• Brief description of the client
• Reason for conducting the evaluation
3. Evaluation procedures
• Names and brief descriptions of evaluation instruments to be used
• Length of the assessment
4. Behavioral observations
• Appearance
• General behavioral observations
• Nature of the interaction between the client and the clinician
5. Background information
• Family background
• Personal history
• Medical history
• History of the problem
• Current life situation
6. Assessment results
• List findings from each assessment tool.
7. Impression and interpretations
• Summarize what was learned during the assessment.
8. Recommendations
• Indicate whether or not treatment is recommended.
• If treatment is recommended, note what kind(s) of treatment are recommended 
and why.
• If there are multiple problems, note which one to focus on first.
9. Comment on prognosis
 
 121
6
The First Few Sessions of CBT
Goals and Challenges
In Chapter 1, we talked about making a road map before leaving on a 
trip and considering the beginning, middle, and end of our voyage. In 
this chapter, we return to that metaphor and discuss the first few ses-
sions of CBT. In the following two chapters, we will then outline the 
middle stage of CBT (in which we make use of cognitive and behavioral 
techniques to reduce suffering and improve functioning) and the final 
stage of CBT (termination and relapse prevention). Throughout, we will 
discuss common challenges that can arise during each of these impor-
tant stages.
WHAT ARE THE GOALS 
OF THE FIRST FEW SESSIONS OF CBT?
The goals of the first few sessions of CBT are twofold: socializing clients 
to CBT and establishing a strong rapport. Let’s discuss each in turn.
In the first few sessions of CBT, you have a lot of information to 
share with your clients. If you have not already discussed the basics of 
CBT during the assessment and feedback process, you will certainly 
want to begin by explaining to clients what CBT is and addressing any 
questions they have about it (see Chapter 5). You will then want to dis-
cuss with clients what has maintained their specific difficulties over time 
and what techniques or strategies will be used to break these patterns, 
122 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
resulting in beneficial changes to their lives. Treatment manuals are very 
helpful during these sessions, as they contain the essential information 
that clients should learn at the outset of CBT.
You might have noticed that we chose to use the word share at the 
beginning of the previous paragraph, rather than the word teach. Par-
ticularly for beginning clinicians, early treatment sessions can take on 
a pedantic tone. With manual in hand, beginning clinicians believe that 
they must accurately cover every detail in print. Many of the details 
are important. However, we want these sessions to be a collaborative 
conversation, rather than a one-sided lecture. One way to accomplish 
this goal is to remember that these early sessions of CBT will look differ-
ent with every client because they should be designed with each client’s 
unique concerns in mind. It can be very helpful to have a whiteboard 
or large paper easel on hand to draw out a client’s personal model of 
what is maintaining his or her difficulties and what techniques you will 
use to effect change. Similarly, clinicians can make use of metaphors 
that resonate with particular clients to help explain key concepts. For 
example, if a client is a runner, you might say, “Exposures are a bit 
like running. When people first start running, it is hardto run for long 
distances without feeling exhausted. But, the more we do it, the easier it 
gets. Exposures are the same. Really hard at first, but with practice, they 
do get easier over time.” Using metaphors like this shows clients that we 
are really trying to get to know who they are beyond a list of symptoms.
Another tip for these early sessions is to send clients home with 
reminders of what they have learned. We share a lot in these early ses-
sions and particularly for anxious clients, or clients who are slowed 
cognitively by their difficulties (e.g., severe depression), it can be very 
difficult to take it all in. Encourage clients to snap a picture of material 
written on a whiteboard or take notes or record especially salient points 
on their phones. Give clients cue cards with key information and helpful 
reminders. Have handouts at the ready for clients to take home.
Another crucial goal of these early stages of therapy is to establish 
strong rapport. Clients come into treatment with mixed feelings about 
therapy and their potential for change. They bring to therapy the history 
of all of their other interpersonal relationships—some of which might 
have been quite unhealthy. It is our job to meet our clients where they 
are. We must learn how they feel about CBT and their ability to make 
positive changes in their lives. And we must use interpersonal behavior 
in therapy as a means of getting to know our clients and helping them 
to address issues that might affect their lives outside of therapy. In the 
next section of this chapter, we discuss beliefs that clients might bring to 
 The First Few Sessions of CBT 123
therapy that can interfere with the process of socializing clients to CBT. 
We then discuss how to move past these roadblocks, always being mind-
ful of establishing and building strong rapport.
THE FIRST FEW SESSIONS OF CBT: COMMON CHALLENGES
Client-Related Roadblocks to CBT
Starting CBT is a crucial stage in therapy. It is essential to get clients 
“on board” with the CBT approach to understanding and treating psy-
chological difficulties. Early in therapy, clients should feel some sense of 
hope for the future. They should believe that they are going to acquire 
knowledge and skills that will lead to better functioning. If clients are 
dissatisfied or have doubts early in the therapy process, these concerns 
should be handled promptly and directly.
“My Client Doubts That CBT Will Work for Her.”
From time to time, we see clients who clearly understand the rationale 
for CBT, but for various reasons doubt that it will work for them. These 
are the clients who respond to each suggestion with “I’ve tried that,” 
“That doesn’t work for me,” or “I can’t do that because. . . .” For the 
clinician, working with these clients feels like running a marathon. Each 
step in the process is effortful. These doubtful clients can also make us 
doubt ourselves. Have we conceptualized the case correctly? Have we 
selected the right strategies to share with the client for the problems that 
he or she is having? Did we fail at presenting the rationale for CBT and 
its effectiveness in helping similar clients?
These are all good questions for the clinician to ask him- or herself. 
If clients are having doubts, they might indeed be due to the way that the 
clinician has conceptualized the case or presented the rationale for treat-
ment. However, if it seems all is well in those domains and the client still 
has doubts, it is important to look at other variables.
Rather than becoming frustrated with the client, clinicians can 
approach these situations from a stance of curiosity: “Most of the clients 
I work with are really eager to jump into CBT and open to the idea that 
it will work for them. I’d like to understand why you feel differently. Can 
you share with me some of your concerns?”
Some clients have tried therapy multiple times without as much 
benefit as they (or their therapists) might have hoped. They might 
also have experienced setbacks in several other areas of their lives like 
124 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
relationships, schooling, and jobs. Therefore, a client might state, “I fail 
at everything I do, so why should this be different?” or “Even when I 
make an effort, it doesn’t pay off.” These beliefs are ripe for cognitive 
restructuring. The clinician can help clients to examine the evidence for 
these beliefs (e.g., “I have had 10 jobs over the course of my life and only 
got fired from one”) and consider another way of looking at their pros-
pects (“I won’t know until I try”).
Others may feel uncomfortable in the role of therapy client. Con-
sider a client (we’ll call him Joe) who had worked in a professional field 
and came into each session wearing a suit (despite being unemployed) 
and setting up his laptop in the therapy room before the session started. 
This involved rearranging furniture and sometimes unplugging the cli-
nician’s laptop to plug in his own! Joe spent his first several therapy 
sessions explaining why various cognitive-behavioral techniques could 
not work for him. His clinician felt frustrated with his lack of open-
ness and then his unhappiness at the next session because his situation 
had not improved. A few sessions into therapy, the clinician asked Joe 
why he was bringing the laptop to every session—despite making such 
a big production of plugging it in and setting it up, he was not using it. 
This question led to a very helpful discussion. Joe admitted that he felt 
very badly about how his career had gone and did not want to feel “put 
down” in the therapy setting (as he had felt with past therapists). He 
admitted that he was trying to make therapy feel like a business meet-
ing. He also conceded that needing therapy made him feel very inad-
equate and it was easier to just discredit any proposed technique. His 
therapist then discussed with him the bind he had got himself into—he 
desperately needed help, but he couldn’t accept it. He and his therapist 
agreed that he would leave his laptop at home in future sessions, come 
to sessions in whatever clothes he was wearing that day, and be open to 
trying one new strategy each week. From there on in, therapy became 
slightly more productive.
There are, of course, many reasons why clients might be uncomfort-
able in the role of therapy client. Clients might have grown up seeing 
mental health problems as a source of shame or embarrassment, mak-
ing it difficult for them to fully embrace any approach to treatment. 
Other clients might have always taken a caregiver role in their lives. 
It might be difficult to shift positions and be the person receiving care 
(a great example here is treating a fellow mental health practitioner or 
the child of a mental health practitioner). As you see more clients, you 
will gain more experience discussing doubts and resistance. You will be 
able to draw on past experiences to help clients speak about their own 
 The First Few Sessions of CBT 125
resistance. For example, you might say, “I have worked with a lot of 
children whose parents are psychologists. It can be very hard to see that 
what you’ve tried at home hasn’t worked. Does this make you believe 
that nothing will work?”
Keep in mind that when we try to convince people of something 
about which they feel ambivalent, we can actually cause them to hold 
even more strongly to their opposition. Clinicians should not fall prey 
to providing undue reassurance or, worse, promising that treatment will 
work. A preferable technique is to actually shift the focus away from the 
client and make use of the “hip-pocket patient” (Vitousek, Watson, & 
Wilson, 1998) technique. This technique involves referring to past expe-
riences with other clients (taking the focus away from the client him- or 
herself) to demonstrate how CBT was applied to a particular problem 
and how well it worked. The story of the hip-pocket patient should be 
told in a way that serves to motivateto 
get a sense of what would be interesting to see. The middle of the trip 
can be exciting—maybe a really long, strenuous hike in a national park, 
seeing and hearing an amazing concert, or having a meal at a special 
restaurant. And it’s always nice to leave a day or two at the end of the 
trip to pack up your belongings and get things in order before heading 
back to “real” life.
The process of treatment planning in cognitive-behavioral therapy 
 The Process of Cognitive-Behavioral Therapy 7
(CBT) is like making an itinerary for our trip. This itinerary leads us 
from the beginning of our trip to its end—and spells out all the points 
in between. As with a trip, therapy ideally begins with an acquaintance 
period. Therapist and client get to know each other, learn about the 
style of therapy and the presenting problem together, and discuss par-
ticular therapeutic strategies that may be employed both during and 
between sessions. The “exciting” part of the voyage involves all the tools 
of CBT—cognitive work, exposures, relaxation exercises, mindfulness 
techniques, and so forth—all carefully selected to get the client to an 
end point, some agreed-upon goal. Along the way, we might face chal-
lenges. When we travel, we might get a flat tire, someone might get ill, 
or a long-awaited attraction or destination might be closed for renova-
tion or other unforeseen reason. In therapy, we might encounter clients 
who are resistant to change, clients who lead chaotic lives, or we—as 
therapists—might bring our own issues into the interpersonal relation-
ship that make the process less than ideal. All these challenges must be 
effectively worked through so that the client can attain his or her goals 
in some reasonable time frame.
In the same way that it can be nice to enjoy a calm ending to a trip, 
therapy also should not finish abruptly. There is a way to conclude, to 
consider gains, and to ensure that these gains are maintained into the 
future. In other words, before hopping on a plane back to “real life,” we 
want to ensure that our clients have packed their souvenirs (CBT strate-
gies) in their luggage. Throughout this book, we discuss how to travel 
the path of CBT successfully with our clients.
It is essential to note that mapping out a plan in advance of a trip 
does not mean we cannot deviate from it. Maybe the hotel that looked 
great online turned out to be a dump. Perhaps a place where we planned 
to spend 2 days was so wonderful that we decided to spend 5 days there 
instead. Or, maybe we met a local fellow in a far-off place who took us 
on an adventure we could never have planned with our tour books back 
home. The case conceptualization is just like our trip itinerary. We set 
our itinerary before we leave home, but we always need to allow room 
for adjustments. In CBT, we create a case conceptualization that helps 
us to understand the client, his or her problems, and how we will resolve 
them at the beginning of the therapeutic relationship. But this conceptu-
alization cannot be static. We must constantly examine whether it needs 
to be adjusted to best serve our client’s needs. Throughout this book, we 
also show you how to formulate and revise a case conceptualization so 
that our voyage together is rewarding and effective.
8 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
UNDERSTANDING THE THEORY BEHIND CBT
It is beyond the scope of this book to provide you with an in-depth 
understanding of the theoretical assumptions that guide CBT case con-
ceptualization and practice. Instead, we briefly offer some insights into 
its theoretical underpinnings. A clear understanding of this theory is 
essential while reading this book for two reasons. First, the book dis-
cusses the process of doing CBT. Understanding the theory behind CBT 
helps therapists to see what maintains problematic beliefs and behav-
iors, and what methods may be used to help clients change their lives. 
Second, this book moves beyond technique and uses CBT strategies to 
help therapists overcome difficulties that they might encounter in their 
day-to-day work with clients. The beauty of CBT is that we can use the 
theory and techniques to help ourselves as well as our clients.
CBT is an integration of two originally separate theoretical 
approaches to understanding and treating psychological disorders: 
the behavioral approach and the cognitive approach. The behavioral 
approach (at its strictest) focuses exclusively on observable, measurable 
behavior and ignores all mental events. It views the mind–brain as a 
“black box” that is not easily known and, therefore, not a suitable focus 
of attempts at therapeutic change. It focuses instead on the interactions 
of environment and behavior. The cognitive approach focuses on the role 
of mind and specifically on cognitions as determinants of feelings and 
behaviors.
The Behavioral Approach
John B. Watson (1913), often considered to be the “father of behavior-
ism,” saw all behavior, and all behavior change, as a function of learn-
ing via classical conditioning. He posited that even complex behaviors 
could be broken down into component behaviors that had all been 
acquired through simple learning processes. There are four key elements 
of classical conditioning: (1) the unconditioned stimulus, (2) the uncon-
ditioned response, (3) the conditioned stimulus, and (4) the conditioned 
response. The “unconditioned stimulus” is any stimulus that is capable 
of producing a particular reflexive response. An example of an uncon-
ditioned stimulus is food—it naturally elicits salivation, an uncondi-
tioned response. The “conditioned stimulus” is one that is neutral prior 
to being paired with an unconditioned stimulus. For example, when a 
baby is shown a green light, he has no particular response to it (beyond 
looking at it). However, if the baby is repeatedly presented with the 
 The Process of Cognitive-Behavioral Therapy 9
green light immediately before his mother begins to feed him, he would 
eventually start to salivate in response to the green light alone. Saliva-
tion has now become a conditioned response—with repeated pairings, 
the conditioned stimulus (the green light) now elicits the same response, 
more or less (salivation), that occurred with the unconditioned stimulus 
alone (food). Watson believed that all learning (and thus all behavior 
change) occurred through these types of simple stimulus–response pair-
ings.
Here are some more examples that clearly show classical condition-
ing at work in the kinds of problematic behavior that CBT therapists are 
interested in. Watson and his colleague (and later, wife) Rosalie Rayner 
Watson (see Watson & Watson, 1921) did a famous experiment with a 
little boy named Albert. Albert had never seen a white rat, and thus he 
had no learned response to it. In other words, the white rat was a “neu-
tral stimulus” for Albert. Watson and Rayner showed Albert the rat, 
at the same time pairing it with a loud noise (unconditioned stimulus). 
The noise was known to elicit a startle or fear response (unconditioned 
response) in Albert. With just seven pairings of the white rat and the 
loud noise, Albert came to exhibit a fear response (conditioned response) 
to the rat alone (conditioned stimulus). Albert had “learned” to fear the 
rat. In fact, Albert came to fear many white, furry objects, including 
rabbits and a mask of Santa Claus. In behavioral terms, Albert’s fear 
“generalized” to other white, furry objects. Another study, referred to as 
the case of Little Peter (Jones, 1924), demonstrated how fears could also 
be “unlearned.” A young boy named Peter who was afraid of rabbits 
(the origin of his fear was not known) was exposed to a rabbit in its cage 
for many days while he was eating lunch. Peter gradually lost his fear of 
the rabbit, leading the experimenters to assume that Peter developed a 
new association between rabbits and the pleasure of eating lunch, rather 
than between rabbits and fear. Thesethe client (in other words, embel-
lishments or a bit of poetic license are permitted!). Hearing about how 
CBT worked for someone else with a similar problem can sometimes 
prove to be a very effective, albeit indirect, way of motivating a client.
Another helpful strategy is to set a date to discuss how treatment 
is progressing—and until then, table any further discussion about the 
efficacy of CBT. The clinician can say: “I know you are feeling doubtful 
that CBT will work for you. I see things differently and am not doubtful 
because I have seen it work so many times before. So, for now, we can 
agree to disagree, but let’s not spend any more time debating the pros 
and cons of the treatment. Instead, let’s just try it. How about 1 month 
from now, after four sessions, we set aside some time to see how things 
are progressing? We’ll do four really good sessions of CBT, some home-
work between sessions, and then reevaluate. How does that sound?” 
This kind of plan fits very nicely with the empirical nature of CBT—it 
sets up opposing hypotheses, dictates a method for evaluating hypoth-
eses, and spells out an objective means of evaluating the outcome.
“My Client Doesn’t Believe He Needs Treatment.”
In an ideal world, all of our clients would come to therapy because they 
are self-motivated to make positive changes in their lives. Yet we regu-
larly see clients who have come for treatment at the prodding of their 
parents, spouses, schools, an employer, etc. Treatment can be challeng-
ing if the client does not see a need for it.
During the initial assessment, clinicians should be listening closely 
for a “hook” that can be used to help clients who are ambivalent about 
126 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
engaging in treatment. This is a key reason why it is so important to try 
to get to know clients beyond their presenting symptoms. Consider a cli-
ent with severe OCD who came to be assessed after being put on leave 
from his work as an architect. Due to excessive checking, this man was 
not getting work done on time. Coworkers heard him talk to himself in 
his office and were concerned (he was, in fact, doing “verbal checks” of 
his architectural plans). When the client came in for his assessment, he 
stated that he was ambivalent about treatment because he feared that 
giving up his rituals would lead to sloppy work and potential disas-
ters for his buildings. He believed he could simply go back to work, be 
quieter about his checking, and try to work more quickly. During the 
assessment, the client talked about his love of fishing and the fun he had 
with his grandkids. His clinician asked whether OCD interfered in those 
areas. Indeed, he reported that it was very hard for him to participate in 
leisure activities because of his checking and mental rituals. The clini-
cian was able to engage him in treatment by discussing with him how 
nice it would be to spend time with his grandkids without having OCD 
take up his time and energy.
As we will further discuss in Chapter 9, finding the “hook” is 
particularly important with kids and teenagers. Many do not want to 
come to therapy and miss “fun things” and leisure time. Therefore, it is 
essential to ask, “What is hard about having depression?” or “What are 
your panic attacks preventing you from doing that you used to love?” 
Knowing what clients value is essential to having them buy into therapy. 
In addition, reminding the client that CBT is time-limited can be very 
encouraging. The clinician can say, “I don’t want you to miss swim team 
either. It sounds like something you love. If we work really hard, I bet 
you can be back at it in a couple of weeks.”
“My Client Believes It Is Necessary to Delve into the Past 
to ‘Get Better.’ ”
Clients come into therapy with a preconceived notion of what it will be 
like. Some of these notions come from TV and movies—so they might 
expect that they must delve into their past (reclined on a comfortable 
couch, of course), in order to “get better.” Clients might worry that CBT 
will not “work” because it does not involve an extensive exploration of 
the early experiences that might have led to their current difficulties.
This type of concern is often based on misconceptions that clients 
have about CBT or psychotherapy more generally. Many clients (and 
indeed other mental health professionals too) think that CBT completely 
 The First Few Sessions of CBT 127
ignores the past. This is not true. CBT clinicians are certainly inter-
ested in the connection between past experiences and current beliefs and 
behaviors. This interest is perhaps best exhibited through our concern 
with core beliefs, which often develop during childhood and underlie 
psychological problems, as well as in an individual’s reinforcement his-
tory for specific behaviors.
There are many advantages to spending some time with clients 
exploring connections between past experiences and current beliefs and 
behaviors. Most notably, such explorations can help clients to consider 
whether other factors than their own shortcomings played a role in their 
difficulties. Rather than assigning blame solely to themselves, they can 
begin to see how other environmental factors might have contributed 
to the development and maintenance of their problematic thoughts and 
behaviors. Identifying these factors can then shed light on what can be 
done to ameliorate these problems.
Take, for example, a 20-year-old client with an eating disorder. By 
exploring the origins of her excessive concern with shape and weight, 
the therapist learned that (1) she grew up in a home with a mother who 
dieted constantly and was excessively concerned with her own shape and 
weight and that of her daughter; (2) throughout her childhood and ado-
lescence, she attended a school for the arts and majored in dance, thus 
facing undue pressure at school as well to be thin; and (3) she recently 
stopped dancing and felt at a complete loss for what to do with her life. 
This information has great value in developing the case conceptualiza-
tion. It suggested that the client grew up in an environment in which 
value was only placed on shape and weight, to the exclusion of any other 
attributes like intelligence or kindness to others. This value system was 
reinforced throughout her childhood and adolescence not only at home, 
but also in school by her teachers and peer group. It made perfect sense 
to the therapist that a young woman growing up in this environment 
would be at risk for developing problems with eating, and he communi-
cated this belief to the client.
Although cognitive-behavioral therapists explore connections 
between past experiences and current beliefs and behaviors, we under-
stand that it is not possible to modify past behaviors or previous environ-
mental contingencies. Instead, once the case is clearly conceptualized, 
clinicians use CBT techniques to modify currently problematic thoughts 
and behaviors as well as the currently relevant contexts that serve to 
maintain them. Again, this approach does not mean that the past is 
ignored. In fact, many current thoughts are rooted in the past (e.g., “I 
screwed up in my earlier life so I will always be a screw-up”). However, 
128 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
simply understanding the origins of the problem is not considered suf-
ficient to overcome the client’s current problems. Rather, the client must 
take this knowledge and use it to change the dysfunctional beliefs and 
behaviors that are maintaining these problems. In the case of the client 
with the eating disorder, treatment might entail helping her to explore 
other career paths besides dancing, develop new skills and hobbies that 
tap into other talents and interests, work on skills for better communica-
tion with her mother, expand her social group beyond the world of danc-
ing to include people who put value on other attributes besides shape and 
weight, and, of course, learn healthier eating and exercisebehaviors. 
Once clients understand that the past will not be ignored in CBT, and 
that CBT is an effective treatment despite not focusing exclusively on the 
past, these concerns will often be quelled.
“My Client Thinks His Problems Are Biologically Determined.”
Another belief that can interfere in CBT (or in any psychotherapy, for 
that matter) is that psychological difficulties are solely attributable to 
biological factors. It seems odd that clients who hold this etiological 
belief would come to psychotherapy, but they do from time to time, and 
the nature of their attributions can interfere in their progress.
A good place to start with these clients is with some psychoedu-
cation about the relative roles played by biology and environment in 
the development and maintenance of psychological disorders. There is 
ample evidence to suggest that both biological and psychological fac-
tors play a role in the etiology and maintenance of most, if not all, 
psychological problems. It is not surprising, then, that many problems 
seem equally amenable to psychotherapy and medication. Interestingly, 
even CBT alone (i.e., without medication) can impact biology. Clients 
are often very surprised to learn that CBT has been found in numerous 
studies to alter brain structure and/or function (for reviews, see Barsa-
glini, Sartori, Benetti, Pettersson-Yeo, & Mechelli, 2014; Weingarten & 
Strauman, 2015).
It is also prudent to delve into the reasons why clients resist attrib-
uting their difficulties to psychological factors. It is here that cognitive 
work can be very effective. Ask your client what it means to him or her 
to be “mentally ill” or “depressed” or “bulimic,” for example. Often 
clients will reveal a variety of self-deprecatory thoughts associated with 
their difficulties, and some will even tell you that thinking of their prob-
lems as being caused by biology alone is simply “easier.” These kinds of 
thoughts are legitimate targets for cognitive restructuring.
 The First Few Sessions of CBT 129
The issue of biological cause comes up frequently when working 
with clients who present with somatic complaints. For example, cli-
ents are often referred for CBT by physicians or other medical profes-
sionals when they see a potential psychiatric role in chronic medical 
complaints. Sometimes, there is no known biological explanation for 
these medical complaints (e.g., chronic gastrointestinal complaints, but 
no evidence of a physiological problem to explain them) and at other 
times, patients have a medical condition but mental health concerns are 
exacerbating the condition or reducing a patient’s ability to cope with 
it. For example, anxiety might be a cause of chronic migraines and 
migraines might also cause patients to avoid situations when they don’t 
feel physically well.
These cases are difficult, particularly when medical tests fail to 
show any biological cause for a client’s symptoms. Clients have often 
gone to many doctors, enduring numerous medical tests, but they are 
often left feeling that no one believes they are experiencing real pain. 
They might believe that the cause of their problems simply has not been 
found yet. As such, CBT might seem pointless since it will fail to diag-
nose or cure a somatic problem.
The biggest mistake that therapists make in these situations is to tell 
clients that “there is nothing wrong with you.” This is a sure-fire way to 
damage rapport. Rather, we must empathically meet these clients where 
they are—“I know how frustrating it must be for you to not know what 
is causing your pain. And, I know you are in pain.” Acknowledging pain 
and being empathic to suffering can help clients immensely.
We can then explain the association between mental health and 
physical health by sharing with clients the cyclical relationship between 
physical symptoms, cognitions, and behaviors. For example, consider 
a client who is under a lot of stress at work (trigger). This stress, in 
someone with a biological predisposition, can cause a migraine (physical 
symptom). A migraine can lead to numerous cognitions—for example, 
“This isn’t fair,” “I can’t cope,” “When I feel this way, I can’t do any-
thing.” And, the migraine can lead to behavioral responses, like escap-
ing to one’s room and sleeping for hours. What happens to a migraine 
sufferer who gets off her regular sleep and eating schedule? This tends to 
exacerbate her migraine (physical symptom) and increases the likelihood 
of further behavioral avoidance the following day, such as missing work 
or school. The stress of missing work or school (behavior) and the beliefs 
associated with that (e.g., “I am going to get fired,” “I am going to fail”) 
can again feed back into the physical problem of migraine. Drawing 
this cycle out on paper or on a whiteboard can help clients understand 
130 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
how the migraine itself is only part of the puzzle—the response to the 
migraine is also very important. We can also show clients all the possible 
places for intervention that might lead to a reduction in the occurrence 
of migraine. We could help them learn to deal better with the initial 
stress at work via cognitive techniques. We could help them change their 
behavioral response to migraines—taking medication and getting on 
with the day instead of sleeping and skipping meals that can feed back 
into the migraine cycle. We can add other behavioral strategies to a good 
medication regimen, such as relaxation, yoga, or mindfulness exercises. 
And rather than viewing migraines as a failure or as a stop sign in the 
day, we can help them see it as a bump in the road that they can get past. 
This last point is very important. As CBT therapists, our job is not to tell 
clients that they don’t have pain or that their pain isn’t that bad. Rather, 
we accept that they find their pain very troubling, but we want to help 
them live a meaningful life despite the pain. Often, when clients soldier 
on with life despite pain, their pain becomes much less a focus of their 
attention.
Difficult Interpersonal Situations That Can Arise 
in the Therapeutic Context
As we have noted throughout this book, therapy is an interpersonal rela-
tionship. Even early on in our interactions with clients, difficult situa-
tions can arise within this context. Such situations are common—but 
rarely addressed in training programs. Some advance thought about 
them makes them much easier to handle.
“My Client Asks Me a Lot of Personal Questions.”
The therapeutic relationship is, on a personal level, very one-sided. By 
the end of even one session with a client, you will have learned about 
some of the most intimate details of your client’s life. In contrast, even 
after working together for many months, the client will know very few 
details about your personal life. Some clients do not seem to mind this 
and rarely ask questions of a personal nature. Others appear more curi-
ous, asking your age, where you live, where you come from, or whether 
you are in a relationship. Clinicians of different orientations have dif-
ferent views on personal questions, with some seeing them infused with 
meaning and others ascribing less weight to them. In our opinion, it 
seems appropriate to handle questions (and what they might mean) on a 
case-by-case basis.
 The First Few Sessions of CBT 131
BEING ASKED ABOUT AGE AND EXPERIENCE
Being asked about age and level of experience can be unnerving for 
beginning clinicians. Particularly if you look younger than you are, these 
questions/statements may come up quite regularly—and for some time 
after you are no longer a beginning clinician! Clients can ask about a 
clinician’s age for numerous reasons. Therefore, a good way to handle 
this issue is to ask the client politely why he or she is interested in know-
ing. Some clients are simply curious. Some clients are actually interested 
in the clinician’s level of experience, both in therapy and in life (e.g.,a 
couple with marital problems might wonder how a young, unmarried 
clinician could relate to their problems and thus help them effectively; 
a veteran with PTSD might wonder how a young clinician who never 
served in the military could understand his or her experiences).
When clients ask about a clinician’s level of experience, you should 
strike a balance between being honest and instilling confidence. As a 
beginning clinician, it might very well be true that you have never seen a 
client with concerns similar to those of the client asking the question—in 
fact, you might never have seen a client at all! In these situations, a good 
strategy is to emphasize the expertise of the place at which you work 
and the individuals who are supervising you. If a client asks, “Have you 
seen any clients who have panic disorder like I do?,” you might respond, 
“This center is well known for working with people with panic disorder. 
The treatment offered here is really cutting edge and I receive excellent 
supervision.” By focusing on your training setting, rather than on your-
self (the inexperienced clinician), you can respond to this type of ques-
tion in a positive but truthful way.
How should you respond to a client’s concern that you have not 
experienced the difficulties for which he or she is seeking help? In most 
CBT-oriented settings, revealing deeply personal information about 
one’s mental health history is not appropriate. The most obvious reason 
for this is that it takes the focus off the client who is paying money 
and taking time out of a busy life to tend to his or her own difficulties. 
Furthermore, when the clinician shares a personal experience, it can 
be difficult for a client to process. It is also worth noting, and worth 
pointing out to our clients, that most people are unlikely to ask their 
nephrologist is he has had kidney disease or their dentist if she has ever 
had a root canal. We don’t ask these questions because it simply doesn’t 
matter! What does matter is whether these professionals have the exper-
tise to treat our problems. Mental health issues should be viewed no 
differently.
132 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
With this in mind, we should answer these questions by highlight-
ing our professional experiences—“I’ve worked with a lot of clients 
who have PTSD. Although I have not served in the military, I have 
spoken to and spent time with many veterans like you and, through 
them, I have learned about the experiences of returning veterans. The 
treatment that we do here can be very effective in alleviating your pain 
and suffering.”
What should you do if a client continues to voice concerns about 
working with a clinician who is young, on the inexperienced side, or 
cannot personally relate to the issues he or she is going through? One 
option is to return to the stance of a scientist—“I understand your hesi-
tancy here. Why don’t we get started and see in a few sessions how you 
think things are going?” This stance is particularly effective when clients 
have few other options. Trying therapy with an inexperienced clinician 
is typically considered a better choice than doing nothing at all. In our 
experience, few clients continue to complain about being paired with 
an inexperienced clinician once they begin to see some benefit from the 
therapy.
Continuing difficulties with being treated by a beginning clinician 
can also inform the case conceptualization. Consider a client who was 
very concerned about having a young, novice clinician. She was unhappy 
with the arrangement but could not afford treatment by someone with 
more experience. For the first few sessions, the client repeatedly brought 
up the issue—“You wouldn’t understand that since you’ve never treated 
someone with problems like mine” or “I bet you don’t know what to do 
with someone as severe as me.” The clinician sought supervision about 
this problem—she did not want to spend every session trying to convince 
the client of her abilities. Her supervisor advised her to confront the cli-
ent directly about her discomfort. This turned out to be excellent advice. 
The client explained that she would not have a significant problem with 
an inexperienced clinician who was 40, but having one who was in her 
mid-20s was “terrible.” The client, also in her mid-20s, was significantly 
impaired. She was not in school, was working at a menial job, and had 
just left a relationship because of her psychological problems. Looking 
across the room at a person of the same age who was progressing suc-
cessfully with her education and career (and presumably had a fulfilling 
life outside of these arenas as well) was “a slap in the face” for this client.
Her clinician reacted to this explanation with empathy and told the 
client that she was sorry that this was so difficult for her. She then asked 
if there was any way that they could put these thoughts to good use in 
the therapy. The client explained that her reactions to the clinician made 
 The First Few Sessions of CBT 133
her realize how much she wanted to have the life of someone in their 
20s, rather than the isolated life she was leading at that time. After this 
session, the issue of the clinician’s inexperience never came up again.
Obviously, all cases do not end so positively. Some clients stead-
fastly refuse to work with an inexperienced clinician. In these cases, 
time should not be spent trying to reason with clients or convince them 
that they are wrong. Rather, you should provide an appropriate referral.
OTHER PERSONAL QUESTIONS
A whole host of other personal questions can also come up in the thera-
peutic context. Many personal questions are completely innocuous, and 
answering them should not feel uncomfortable. A client might ask where 
you are from, particularly if you speak with an accent or if they look at 
your diplomas on the wall and see that you were not educated in the city 
in which you are currently living and practicing. Before holidays or vaca-
tions, clients might ask you about your plans. It seems more damaging to 
the therapeutic relationship to explain why you cannot answer questions 
like these than to simply say “I am from Canada” or “I am going to see 
my family for the holidays.”
Other questions are not quite as easy to handle, particularly those 
of a very personal nature (e.g., your relationship status, where you live, 
exactly where you are going to be on your holidays). It can be difficult to 
deal with these questions, and for clients who persistently ask personal 
questions, it is worth addressing this issue directly. It can be helpful to 
acknowledge the differential that is inherent in the therapeutic relation-
ship: the client bares all and the clinician is a relatively blank slate. Once 
you have acknowledged to clients that you realize that this imbalance 
can be difficult for the clients, it is necessary to explain why this is the 
case—that therapy is about them and helping them with their difficulties 
and that anything that takes the focus away from this goal is detrimen-
tal.
As we have already noted, it is important to identify the function 
of various client behaviors. A client who repeatedly tries to turn the 
focus onto the clinician might be trying to delay discussing his or her 
own issues. This hypothesis can be presented to the client and discussed. 
Clients who try to get chummy with the clinician might be lonely and 
lacking meaningful relationships in their own lives. Again, this can be 
good fodder for therapy in that clients can be encouraged to start apply-
ing some of their interpersonal skills (e.g., asking personal questions in a 
socially appropriate way) to new relationships outside of therapy.
134 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
“What Do I Do When a Client Brings Me a Gift?”
We all love to receive gifts from friends and family members. However, 
our feelings about gifts can be quite different when the “givers” are our 
clients. You might work in asetting in which accepting gifts from clients 
is completely forbidden. Many settings, however, do not have a clearly 
stated policy and you will have to work out how to deal with the issue 
as it comes up.
Gifts offered during therapy are a bit trickier to deal with than a 
single gift offered at the end of a successful course of therapy. Simi-
larly, gifts offered outside the context of some formal gift-giving occa-
sion (e.g., Christmas) likely have a more complex meaning. It seems to 
be a generally accepted rule that gifts of high monetary value should 
never be accepted from clients. Similarly, never accept cash gifts (“tips”) 
from clients. Caution should also be taken if clients give gifts to you 
of minimal value, but on a frequent basis (like bringing a cup of cof-
fee for you to each session). Although such situations do not come up 
frequently, you should become comfortable with turning these kinds of 
gifts down. You can explain to clients that accepting expensive gifts or 
gifts of money is against the policy of your place of work. If clients are 
insistent or attempt to give you gifts repeatedly, you should explore the 
issue with them and consider how this behavior might influence your 
understanding of the case. Clients may give gifts to clinicians as a means 
of ingratiation. For example, they may think that if they are generous 
with you, you will agree to see them more frequently. Other clients may 
worry about whether or not you like them and may hope that, by giving 
gifts, you will like them more. Clearly, these motives behind gift giving 
are problematic and should be dealt with through the use of cognitive 
techniques. As with so many other issues we have been discussing, cli-
ents’ behavior in session likely mirrors their behavior outside of session. 
Believing that one can use gifts to “buy friends and influence people” is 
not appropriate, and correcting such beliefs in session can be very help-
ful to clients’ lives outside of session.
The aforementioned situations (bringing gifts to almost every ses-
sion, giving very expensive gifts) are obviously problematic. Yet, it can 
also be difficult to know how to react to gifts that are given at holiday 
times or at the end of treatment. As noted earlier, some settings might 
have very clear “no gift” policies; in settings that do not, the cardinal 
rule of not accepting very expensive gifts or gifts of money should be fol-
lowed. Accepting gifts of lesser value, particularly at the last session of 
treatment, can be fine and, in fact, refusing these gifts can offend clients 
who truly want to thank you for your help.
 The First Few Sessions of CBT 135
“My Client Invited Me to a Social Event.”
As difficult as it is to gracefully deal with receiving gifts from clients, 
an even more awkward situation is being invited to a social event by a 
client. The general rule of thumb is that we should never participate in 
social activities like playing golf or going for coffee outside of therapy 
with our clients. If clients repeatedly ask you to do so, it is worth con-
sidering how it might influence the case conceptualization and how it 
can be addressed in therapy. Typically, these frequent invitations are a 
sign of loneliness or misplaced attraction, and time is much better spent 
helping the client to establish appropriate social relationships outside of 
the context of therapy.
These situations can be very difficult when working with youth. 
Young patients often invite clinicians to their school musicals, religious 
events, or sports competitions. Kids can become quite attached to clini-
cians, value their support, and might want to share successes that the 
clinician helped them to achieve (such as the socially anxious child who, 
with the benefit of treatment, plays a prominent role in the school musi-
cal). It is very difficult to say no to these kids, and sometimes we might 
really want to be a part of these events. However, it is best to keep it 
simple and to have a “no” policy. We must explain to kids how this com-
plicates confidentiality. If we are seated at a table at a child’s bar mitz-
vah and our table-mates ask how we know the family, what do we say? 
Although some children will say that they are fine with people knowing 
that they are in therapy, it is our job to help kids see that some people 
may also be fine with it, but other people may not, and we don’t want 
them to have to worry about it on their special night. Some families ask 
clinicians to just make up a way that you are acquainted. For clinicians, 
trying to keep the agreed-upon story straight can be extremely stressful. 
It is best to not put the client or clinician in this situation. In this day 
of easy recording, clinicians can invite clients to bring in a clip of their 
song from the school musical or their gymnastics meet. In that way, the 
clinician can share the excitement of clients’ successes without breaching 
confidentiality.
“My Client E-Mails Me, ‘Friended’ Me on Facebook, Sends Me Texts, 
or Blogs about Our Sessions.”
Electronic modes of communication and other forms of social network-
ing pose complex dilemmas for clinicians (see DeJong, 2014). Let’s start 
this discussion by saying that some settings prohibit any clinician–client 
electronic communication. These regulations must be strictly adhered 
136 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
to. In other settings, clinicians may use e-mail to communicate with 
their clients. Some use it for simple matters like sending directions to 
an initial appointment or scheduling appointments. Many have found it 
extremely helpful for communicating with clients over the course of the 
week. For example, a client might use e-mail to ask a question about a 
homework assignment and the clinician can write back at his or her con-
venience. This “convenient” form of communication can greatly facili-
tate treatment progress.
Much discussion has ensued about whether or not e-mail is permitted 
as a way of communicating protected health information. E-mail addresses 
are “personally identifying information” and when health information is 
attached to personally identifying information, this correspondence is 
considered protected health information. This would make it seem that 
we cannot use e-mail to correspond with our clients. However, e-mail 
correspondence can be acceptable if it is used through a lens of risk 
management (consult www.hhs.gov/hipaa/for-professionals/faq/570/
does-hipaa-permit-health-care-providers-to-use-email-to-discuss-
health-issues-with-patients for more information). Clients should be 
informed that e-mail is not necessarily a confidential mode of commu-
nication and should be asked for permission to communicate via e-mail 
within their treatment consent form.
When using e-mail, you should always try your very best to main-
tain confidentiality. If you work in a setting that encrypts e-mail or uses 
secure messaging services, this is ideal. If e-mails are not encrypted, you 
should be particularly careful about the information that you share. As 
noted, e-mail is very helpful for reminders of session times, for commu-
nicating about changes in session times, and for simple questions about 
between-session assignments. Clients must be made aware that e-mail is 
not appropriate for very personal or complex discussions, or for emer-
gency needs. If a client e-mails in crisis and the e-mail is not seen for 
hours or even days, the client will not get the help that he or she needs. 
Depending on the needs of a particular client, it might also be important 
to discuss how much e-mail correspondence is appropriate. Daily, or 
more frequent, e-mails (unless prescribed as part of treatment) are often 
intrusive to the clinician and a sign of dependence. Clients who e-mail 
too much should be given guidelines for appropriate conditions under 
which to contact their clinician.
It is also quite common now for clinicians to use electronic schedul-
ing sites, to takeelectronic payments, and to have clients complete treat-
ment questionnaires online. With any electronic data, it is essential that 
clients’ identities are protected. Look for sites that are HIPAA-compliant, 
 The First Few Sessions of CBT 137
and again be sure to include in consent forms permission to use these 
platforms. We should always remember to never send group e-mails 
from these sites. It can be tempting to send an announcement to one’s 
whole client list about an upcoming group therapy offering, change in 
fee structure, or an interesting article. Yet, unless we can be perfectly 
sure that one client will not have access to other client’s identities, this 
kind of communication should be avoided.
Texting has become yet another avenue for clients and clinicians 
to communicate. As with e-mail, HIPAA does not prohibit texting so 
long as appropriate precautions are taken. However, it is our impres-
sion that texting should not be used for any clinician–client communica-
tion except discussion of appointment times (or other logistical issues). 
In your personal life, it is likely that you have mistakenly sent a text 
intended for one person to another or got into a misunderstanding with 
a friend or loved one because so much of the subtleties of communica-
tion are missing from texts. Generally, these errors are easy to fix with 
people in our personal lives. They can be very harmful to clients, how-
ever. Ideally, communication should occur in person or on the telephone 
and if some communication must happen electronically (such as discus-
sion of a homework assignment between sessions), e-mail is preferable to 
texts so that information can be more thoroughly provided.
How about social networking sites like Facebook? It goes without 
saying that clinicians should never “friend” clients or former clients. 
Initiating a friend request breaches confidentiality and simply should not 
be done, not even with former clients.
What should a clinician do if a client or former client or family mem-
ber of a client “friends” you on Facebook? Again, the rule of thumb should 
be “Just say no.” Although clients might claim that they are totally fine 
with being “friends” with you in a public domain, it is quite possible that 
they have not thought through the implications with respect to protect-
ing their privacy. Furthermore, you might not want your clients to have 
access to everything about your personal life including your minute-to-
minute musings, political views, your vacation plans, or photos of your 
kids. In this situation, let your client know that you really appreciated 
their friend request but that you make it a rule to not do any social net-
working with clients. A simple explanation like this should suffice.
Another Internet-age dilemma is what to do about blogs and other 
online opportunities to pour out one’s soul. If your client is maintain-
ing one and writes about his or her therapy, you might want to ask that 
he or she not write about you by name. Since all therapy experiences 
pass through the filter of each individual’s experiences, it would be 
138 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
unfortunate to have a client write negative things about your work for 
the public to see.
Similarly, clinicians should be mindful of what they post on the 
Internet. If you maintain a blog, you should not write about experi-
ences with individual clients, even if their identity is protected. If a client 
knows you maintain a blog and sees that you are writing about him or 
her (even in a veiled way), it can be very damaging to the therapeutic 
relationship. Even writing about your personal life can be problematic. 
It can make clients feel sad for their therapists if something difficult is 
going on in their lives, threatening to take attention away from the cli-
ent in future therapy sessions. Furthermore, it can be damaging to the 
therapeutic relationship to read that one’s clinician is not handling chal-
lenges in his or her own life well, particularly if those challenges are in 
the clinician’s specialty area (e.g., reading about the marital problems 
of a marital therapist; reading about the eating struggles of an eating 
disorder therapist). In light of all of these concerns, it is advisable for 
clinicians to refrain from keeping highly personal blogs at all.
“My Client Is Flirting with Me.”
A situation that most clinicians dread is the experience of a client flirting 
with them. “Flirtation” can take many guises. Some clients will compli-
ment their clinicians on their appearance or manner of dress. Some will 
be quite overt about their interest, such as saying, “I’d love to date a man 
like you,” or even asking the clinician out on a date. Even more difficult 
are more subtle cues, such as a client looking at you in an inappropriate 
manner.
When clients engage in overtly inappropriate behavior, remember 
that you can (and should) set limits in the session—“It is not appropriate 
for you to ask me out on dates,” for example. It is more useful, however, 
to try to figure out why clients are behaving in this way toward you. A 
good place to start is with some self-exploration—clinicians should ask 
themselves if they are doing anything (subtly or not-so-subtly) to encour-
age interest or flirtation from the client. Possibilities include manner of 
dress (e.g., wearing revealing clothing), inappropriate self-disclosure 
(e.g., letting a client know that you are single and lonely), or even flirting 
(e.g., regularly complimenting a client on his or her dress or appearance). 
It is essential for clinicians to discontinue these behaviors that can be 
very confusing and potentially hurtful to vulnerable clients. Open, frank 
discussion with supervisors or a consultation group can be very helpful 
with these matters.
 The First Few Sessions of CBT 139
Next, it is essential to consider how the client’s inappropriate behav-
ior fits into the case conceptualization and how it can be addressed pro-
ductively in therapy. Generally, clients who behave in this way are hav-
ing difficulties with romantic relationships in their lives outside therapy. 
They might have very limited social interactions—in fact, they might 
spend more time (and more time speaking about personal matters) with 
you than with anyone else in their lives. Similarly, the kinds of difficul-
ties clients have might preclude them from establishing meaningful rela-
tionships. They might have problems approaching people at all, or they 
might be fine approaching people but then behave in such a way that 
others do not want to establish relationships with them. Your interac-
tions with clients will most likely shed light on the nature of their inter-
personal difficulties. You can then use your own insights as a means of 
helping clients work on these problems during therapy.
Clearly, if clients behave so inappropriately that you feel uncom-
fortable in the room with them, or feel as if you are unable to provide 
them with good treatment, you should discontinue therapy and make 
appropriate referrals. In such situations, ongoing consultation with your 
supervisor is essential, and the decision to terminate therapy should be 
made with his or her support.
Clinician-Related Roadblocks That Can Interfere with Treatment
Up to this point, we have discussed clinical challenges that arise, for the 
most part, with the client. Given that therapy is an interpersonal rela-
tionship between client and clinician, it’s essential to also be mindful of 
what the clinician brings to the table and how our own behavior impacts 
the therapy. In this final section of the chapter, we discuss some of these 
factors and offer suggestions on how to deal with them effectively.
When Clinicians’ Own Issues Affect Their Approach to Understanding 
and Treating a Case
There are bumps along the road of life for all people—even clinicians. 
An advantage of this difficult reality is that clinicians can draw on their 
own experiencesto better empathize with clients. However, it can be 
difficult when clinicians have unresolved issues that interfere with their 
work with clients. For example, clinicians who have issues with shape 
and weight might have a difficult time “selling” the importance of nor-
malizing eating habits to their clients. Clinicians who have experienced 
traumas in their lives might begin to have intrusive thoughts and images 
140 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
when working with clients who have had similar traumas. Clinicians 
who have difficulties with mood regulation might find that spending the 
day talking to depressed clients is just too taxing when they themselves 
are in the throes of depression. Such reactions can most definitely inter-
fere with the competent delivery of psychotherapy. Difficulties working 
with certain clients can also arise for clinicians who do not have any 
significant personal problems. For example, it can be very difficult to 
listen to very sad or traumatic stories even if you have never experienced 
a significant trauma yourself.
Clinicians who have significant psychological difficulties of their 
own should seek treatment. This is particularly the case when the cli-
nicians’ own difficulties interfere in their work with clients or when 
working with clients exacerbates clinicians’ problems. Initially, it can be 
helpful to discuss these issues in a very general way with your supervi-
sor. However, it is essential that the supervisor not take on the role of 
clinician. Rather, clinicians with their own problems should seek treat-
ment from an individual who is in no way involved with their training or 
day-to-day work (as specified in APA code 7.05b).
Clinician Difficulties in the Therapeutic Relationship
It can be awkward for clinicians to admit that, from time to time, they 
dislike a client with whom they are working. They might find themselves 
dreading sessions and wishing each week that the client would cancel. 
Once in session they might have difficulty refraining from saying what 
they really think of this person sitting across from them. In our “real 
lives,” we would simply choose not to associate with someone we dis-
like, but these reactions are more difficult to handle in the context of the 
therapeutic relationship.
Before offering a few tips on coping with this situation, it is impor-
tant to consider what clinicians should do if they frequently, or even 
always, find that they feel irritated by their clients, are uninterested in 
them, or have difficulties feeling sympathy for them. If these reactions 
seem more the norm than the exception, it is best to solicit some guid-
ance from a supervisor. Individuals who habitually experience this type 
of reaction might not be well suited to a career as a clinician. If such 
individuals are interested in the field of mental health, there are many 
other career paths that they can pursue that involve fewer interactions 
with clients, including administrative positions and positions that are 
more research-oriented. The bottom line is that constant irritation with 
clients is not good for anyone.
 The First Few Sessions of CBT 141
With that being said, let us return to ways of coping with occasional 
negative reactions to particular clients. First, remind yourself that ther-
apy is time-limited—you will not be seeing this person forever. Although 
it sounds silly, simply reminding yourself of this fact can be helpful. We 
have often had the experience of using this tactic and then finding by the 
end of therapy that some things about the client were actually endearing. 
Another helpful tip is to remember that you are in control of the tone in 
therapy and can try to limit factors that you find difficult to handle. For 
example, let’s return to the example of Joe, the client described earlier 
who brought his laptop into sessions. After setting up his laptop, he 
would start the session by informing the clinician what they would and 
would not be talking about that day. He demanded that the clinician 
speak to him on “his intellectual level,” which led him to forbid any psy-
choeducation (which he labeled “demeaning”). When the clinician could 
get a word in, Joe would regularly interrupt and negate what she was 
saying. After two or three sessions, the clinician dreaded their sessions.
In such situations, take a step back from frustration and replace it 
with curiosity and a desire to help. Given that our reactions to clients 
are likely very similar to the reactions of people in their “real lives,” 
we can use our own reactions as information. How can our feelings as 
clinicians inform the case conceptualization and, in turn, indicate what 
needs to be worked on in therapy? Over several sessions, the clinician 
began to tackle this difficult interpersonal behavior. First, as we have 
already described, she asked Joe to put away his laptop since it was not 
a necessary part of treatment. This evolved into a discussion of how Joe 
felt better about therapy if he approached it as if it were a business meet-
ing. Let’s pick up that conversation:
Joe: You know it’s hard, being a person like me, being here.
CliniCian: What do you mean, a “person like me”?
Joe: You know, a professional. I have an advanced degree. I made a lot 
of money. I had fancy watches, a great car. I mean I like you, doc, 
because you have a PhD and you look like you earn a nice living. 
You should see the places some of these therapists work. They’re 
dumps.
CliniCian: You might be surprised by the kind of people I treat. Many 
are just like you. What does it mean for you to be a professional, a 
guy who made a lot of money, and a guy who needs therapy?
Joe: It means I suck.
CliniCian: Excuse me?
142 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Joe: You know, doc, let’s be clear. Yeah, I have the degrees and all. But 
I am in crap financial shape right now because I’ve been fired from 
my last three jobs. I’m here because I suck. Are you happy now?
CliniCian: No, I am not happy at all that you feel this way about your-
self. But I am glad that you might be willing to be authentic and 
honest about what you need. This isn’t a business meeting. You are 
here because you are not accomplishing in the way you think you 
should be. There must be reasons for that. It’s going to be hard to 
look at these reasons, but I hope we can do this hard work together.
A few sessions later, Joe was being slightly more open and honest, 
but still interrupting the clinician and discounting basic CBT techniques 
in every session. Again, the clinician started to dread sessions. They just 
felt like so much work!
CliniCian: You know Joe, when I start to speak, you tend to interrupt. 
It seems like I never quite finish a sentence. This makes it feel quite 
difficult to help you. I think our work together would progress bet-
ter if you heard me out on the suggestions that I make.
Joe: It’s the battle of the egos here.
CliniCian: I don’t understand what you mean by that.
Joe: When you are teaching me this CBT stuff, you’re just showing off 
what you know. I’ve got to compete.
CliniCian: Do you often feel this way? That you have to compete?
Joe: That’s life, isn’t it?
CliniCian: I hadn’t seen it that way. I wonder if we could consider 
another way to look at it. When I am teaching you a CBT strategy, 
is there another way to look at it besides me “showing off”?
Joe: I guess it’s what I am paying you to do.
CliniCian: Yes. But, I don’t sit here seeing dollar signs when we are 
working together. Any other ideas?
Joe: It’s what you know.
CliniCian: Tell me more.
Joe: It’s your area of expertise. You know your stuff.
CliniCian: Yes, I do. And I am here to teach it to you and to help you. 
Much the same as when people seek out your expertise.
Joe: Hard to be on the other side.
 The First Few Sessions of CBT 143
CliniCian: I get that. I am wondering, do you have this style when you 
talk to people outside of here? Does anyone else inyour life feel like 
you try to take control of the conversation?
Joe: Gee, you must have been talking to my wife.
CliniCian: Nope. But why do you say that?
Joe: I need to be right. Always.
CliniCian: And how does your wife feel about that?
Joe: We don’t talk that much. I think she’s just checked out. I guess I can 
kind of see it. I mean, who wants to feel like an idiot all the time?
CliniCian: So, you think you make her feel like an idiot?
Joe: Well, she’s told me so.
CliniCian: I have felt that way in our sessions too. When someone con-
stantly interrupts and thinks what you say isn’t worthwhile, you 
start to doubt yourself. That’s an odd experience for me because I 
am really confident in CBT and my ability to help people. It kind 
of makes me want to check out, just like you said your wife does.
Joe: Are you firing me?
CliniCian: No! But, I am sensing we agree that this is something we 
need to work on. Let’s discuss a plan where I can help you with 
this style, with the goal of it having a really positive effect on your 
relationships outside of this office.
Joe: Guess I’ve got to try. . . . 
From time to time in therapy, our clients might make choices of 
which we, on a personal level, do not approve. For example, clients 
might have extramarital affairs, or engage in shoplifting, or use illegal 
drugs. Consider a woman who repeatedly cheats on her husband and 
then feels very regretful about her behavior. Should a friend share this 
kind of information, our values most certainly would come into play in 
our response. We might say “How could you?” or “I’m really surprised 
that you would do this.” With a therapy client, our response should be 
different. Our values should not matter. Rather, we should use the infor-
mation that the client has trusted us with as a cue to inquire into how 
these lifestyle choices fit into the case conceptualization. For example, 
with the client who repeatedly cheats and then regrets her behavior, we 
should inquire as to whether the client has difficulties with impulsive 
behavior in other areas of her life, such as spending too much money or 
voicing strong opinions without thinking about how she might impact 
144 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
the feelings of others. In other words, we want to use our clinical skills 
to figure out what might be causing the problematic behavior and, most 
important, what is currently maintaining it. Then, cognitive-behavioral 
techniques can be used to ameliorate the problem. Following from the 
above example, a client can be taught strategies to slow down decision 
making and examine the potential long-term consequences of behavior. 
Teaching these skills to a client will lead to a much more helpful course 
of action than scolding or criticizing the client, something clinicians are 
sometimes tempted to do and might in fact do with a friend.
In sum, clients sometimes exhibit behaviors or voice beliefs that we 
find unappealing. In some cases, it is appropriate for clinicians to set lim-
its on clients’ behavior, and, in extreme cases, it can even be appropriate 
to terminate the therapeutic relationship and refer the client elsewhere. 
In most other cases, clinicians should use their reactions to clients as a 
window into the client’s world. Clinicians can effectively use their own 
reactions to help clients improve their behavior, teaching them specific 
strategies that might be of great benefit in their lives outside of therapy.
 145
7
The Course of CBT
Goals and Challenges
In the previous chapter, we discussed the goals and challenges associ-
ated with the first few sessions of CBT. Specifically, we focused on how 
to effectively socialize clients to CBT and how to establish a strong rap-
port with them. Reflecting back to our journey metaphor, we are now 
in the middle of our trip. We are ready to share and employ the tech-
niques of CBT. As we explained in Chapter 1, interesting challenges can 
happen at this point in our voyage. In this chapter, we will discuss how 
to effectively meet the goals and challenges that arise over the course 
of CBT.
WHAT ARE THE GOALS OVER THE COURSE OF CBT?
According to Judith Beck, “the [cognitive behavioral] 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” (2011, p. 2). More broadly, CBT also involves 
helping our clients to live lives that they value. As such, CBT might 
involve helping clients establish new relationships, pursue new career 
paths, or bring activities into their lives that give them a sense of mastery 
or happiness.
146 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
COMMON CHALLENGES OVER THE COURSE OF CBT
Although these goals might sound simple, the road to achieving them 
can be bumpy. In this chapter, we divide challenges into two categories: 
difficulties getting the client to engage in therapy and difficulties within 
the therapeutic relationship.
1. Difficulties with Getting the Client to Engage in the Process 
 of CBT
For CBT to work effectively, clients must see the treatment approach as 
viable, and they must be willing to engage in the core techniques of the 
therapy. Clients who do not “buy” the CBT approach or who may not 
be motivated to change for one reason or another might exhibit various 
behaviors that interfere with treatment. These kinds of behaviors fall 
under the umbrella of noncompliance. Noncompliance is defined as an 
unwillingness to engage in the activities that clinicians know to be inte-
gral to good treatment outcome (for a much more detailed discussion of 
these issues, see Robert L. Leahy’s [2003b] Roadblocks in Cognitive-
Behavioral Therapy and Judith Beck’s [2005] Cognitive Therapy for 
Challenging Problems). Recognizing these behaviors, and knowing how 
to resolve them, are essential skills for the CBT clinician to acquire and 
hone.
Even the most skilled clinicians have difficulty working with clients 
who are not willing to do their part in therapy. Clinicians leave these 
sessions feeling exhausted, as if they did all of the work. Sessions might 
be spent convincing the client of the rationale, bargaining about cer-
tain assignments, or discussing very rigidly held beliefs. Given the active 
nature of CBT, most therapy sessions do involve hard work, but there is 
certainly a difference between climbing a mountain together and climb-
ing the mountain dragging the client behind you.
The way noncompliance is perceived by the therapist can make a 
large difference. Rather than seeing it as a source of frustration and 
annoyance, view it with curiosity and use it to inform the case conceptu-
alization. Try to figure out what is driving the noncompliance, and then 
come up with a solution for working around the roadblocks that you 
identify. Keeping this emotional distance from the problematic behav-
ior will have a clear advantage with respect to the therapeutic relation-
ship: rather than taking the behavior personally, you maintain a focus 
on how to help the client. Therapy can be extremely rewarding when a 
 The Course of CBT 147
noncompliant client begins to engage in treatment and ends up having a 
successful outcome.
Let’s examine now some common examples of therapy noncompli-
ance and consider ways to understand and work through them.
“My Client Comes to Sessions Inconsistently.”
Many new clinicians feel pressured to get clients to attend sessions on a 
weekly or biweekly basis because this is how protocols typically describe 
treatment (Antony & Barlow, 2010). In reality, many clients come to 
treatment intermittently. Clients lead very busy lives, and the demands 
of work, school, and family can get in the way of regular treatment. 
Holidays and bad weather can interfere, as can the demands on clini-
cians themselves, like having a child home sick or attending a conference 
or a continuing education program. Sometimes, there is nothing more tointermittent attendance than this—life!
When a week is missed here or there, it is unlikely to cause a prob-
lem in the outcome of treatment. However, research has shown that 
patient engagement in treatment is a predictor of treatment outcome. 
A recent study by Glenn et al. (2013) examined treatment dose and 
patient engagement as predictors of treatment outcome among patients 
who received CBT for anxiety disorders. Results of this study showed 
that better compliance (i.e., completing exposures and other homework) 
and high treatment attendance predicted better outcomes at 12 and 18 
months, and high CBT commitment predicted better outcomes at 18 
months. Other studies have similarly found that better session atten-
dance and higher session frequency are associated with better treatment 
outcomes (Bowen, South, Fischer, & Looman, 1994; Craske et al., 
2006: Gutner, Gallagher, Baker, Sloan, & Resick, 2016; Taft, Murphy, 
Elliott, & Morrel, 2001). These studies suggest that it would be a dis-
service to both clinician and client to ignore chronic absenteeism and 
lateness.
SOLVING THE PROBLEM
A good first step to solving this problem is to simply ask clients directly 
why they were late or missed a session. Some will come right out and 
say, “I did not want to do that exposure we had planned for today” or 
“I ended up getting really drunk last night and didn’t wake up in time 
for our session.” When clients are frank in this way, their concerns can 
be dealt with directly. When clients say that they do not know why they 
148 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
behaved the way they did, clinicians can pose questions to guide this 
discussion and help clients arrive at some potential explanations.
There are so many reasons why clients might come to sessions 
inconsistently. Clients might be fearful of CBT or might doubt their 
ability to change. By not coming to sessions at all, clients can avoid the 
hard work of therapy. Coming late can also be seen as an example of 
avoidance behavior—the session time that remains when clients finally 
arrive is often spent discussing their lateness. The hard work of therapy 
is put off until the following session. Missing sessions and coming late 
can also be seen as self-handicapping strategies. If clients do not do the 
work of therapy, they cannot feel bad about themselves if it does not 
work effectively for them.
Clients should be asked if they had a negative experience with what 
occurred in the previous session, if they were nervous about what was 
supposed to be happening in the session that day, or if they were worried 
about being judged negatively for not having completed a homework 
assignment. They should also be asked if their thoughts about treatment 
or doubts about their ability to make positive changes got in the way. For 
example, clients can be asked, “Are you worried that the treatment isn’t 
going to help you?”
Attending sessions inconsistently often highlights how clients’ pre-
senting problems are impacting their day-to-day life. A depressed client 
might not be able to motivate herself to get out of bed for her session. A 
client with generalized anxiety disorder might get caught up in complet-
ing a task perfectly at work, losing track of time, and missing the therapy 
appointment. Many clients exhibit difficulties with planning and other 
executive functions (see Goldstein & Naglieri, 2014). These executive 
functioning difficulties might not be the reason the client sought treat-
ment, but they might emerge as essential issues to address. Regardless of 
the problem that prevented a client from coming to a session, or caused 
the client to arrive late, it is important to discuss how these same prob-
lems also impact the client’s life outside of therapy—whether they can 
get to work on time, get their children to school on time, or pay their 
bills on time. Seeing this big picture can help clients see how cognitive-
behavioral strategies will not only help the client attend therapy consis-
tently, but also engage more fully in their lives outside of therapy.
Some clients have not made therapy a priority. Let’s consider a young 
client with illness anxiety leading to school avoidance. Her mother had 
a difficult time scheduling appointments around her own work schedule 
and an exercise class she was not willing to miss. She brought her daugh-
ter to sessions only at times of crisis, particularly when the school was 
 The Course of CBT 149
threatening disciplinary action for missed days. In this case, the clinician 
met with the mother to discuss the ideal treatment plan (weekly meet-
ings, with parent and school involvement) and to hear her views on the 
need for treatment at this time. The mother explained that she had been 
through anxiety issues with her older children who had “aged out of it.” 
She also explained that she was working on a big deal at work that was 
very important to her and that her exercise class (which happened at the 
same time as one of the clinician’s open slots) was important for her to 
manage her stress. The clinician took a nonjudgmental stance, accept-
ing the mother’s current predicament. Yet she also voiced her doubt that 
the daughter would simply “age out” of her problems. She explained 
that both academically and socially, it was paramount for this middle 
schooler to get back to school as soon as possible, armed with skills 
to manage her illness anxiety. The session concluded with the mother 
deciding that the timing simply was not right for pursuing treatment.
One last issue deserves mention. Beginning clinicians are often wor-
ried about being liked by their clients. Therefore, they tend to be overly 
flexible about rebooking appointments, seeing clients even when they 
arrive late, and so on. Although most clients will miss an appointment or 
come late to session from time to time, bending to the requests of clients 
who are chronically late or regularly miss sessions does them no favors. 
Keep in mind that clients’ behaviors in therapy are a window into their 
lives outside of therapy, and these clients likely have the same problems 
with work, social commitments, and other appointments. Although we, 
as clinicians, might understand such behaviors, others in clients’ “real 
worlds” are unlikely to be as generous. With this in mind, therapy is the 
perfect venue for helping clients see the negative effects of their tardiness 
and absenteeism on others and on themselves and developing strategies 
for preventing it.
“My Client Refuses to Do the Work I Suggest during Our Sessions.”
Even for more seasoned clinicians, it is always a challenging experience 
when clients continue to come to therapy sessions regularly but stead-
fastly refuse to do most of what is suggested to them. It is almost as if 
the client would like the clinician to wave a magic wand and make all 
his or her problems disappear. As with clients prone to absenteeism or 
tardiness, clinicians may understandably believe that they are wasting 
their time with such clients, and they might feel resentful that clients 
who actually would make an effort in therapy are waiting for treatment 
while places are taken up by ones who are making no effort whatsoever. 
150 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Although these situations are undoubtedly frustrating, it is essential to 
try to understand what is blocking the client’s progress.
SOLVING THE PROBLEM
Fear and uncertainty are very often obstacles for clients who come to 
therapy and do not do the required work. In this section, we discuss how 
to move clients beyond these roadblocks, but before doing so one caveat 
is worth mentioning. From time to time, clients will come to therapy 
and refuse to do work because the simple act of being physically present 
at sessions provides significant reward for them. Monetary gain (e.g., 
disability payments) or other benefits (e.g., convincing one’s spouse that 
one is “making an effort”) might be more importantto the client than 
actual change in his or her life. Remember that clinicians have no obli-
gation to treat clients who will not engage in treatment, and it would be 
unethical to complete paperwork (e.g., for disability benefits) saying that 
clients are truly engaged in treatment when they are not.
With that being said, let us to return to the more common scenario: 
clients feeling worried about what will happen if they engage in CBT. A 
good starting point is to simply ask clients what they fear—sometimes they 
will reveal fears that are completely irrational and that can be corrected 
through simple psychoeducation and the use of cognitive-behavioral tech-
niques. Many clients with eating disorders, for example, fear that if they 
begin to eat “normally” they will gain weight and that their weight will 
then escalate indefinitely (e.g., a person who weighs 100 pounds will 
soon weigh 300 pounds). One client with panic disorder was afraid that 
if she experienced panic symptoms, she might never “come out of it” 
and might end up becoming “psychotic.” The client feared an escala-
tion that would land her in the locked ward of a psychiatric hospital 
for the rest of her life. Rather than risk this outcome, the client rarely 
left her house—the one place where she did not experience panic symp-
toms. Brief psychoeducation can be used to teach clients that, although 
normal eating might lead to some weight gain, it is unlikely that weight 
gain will never cease. Similarly, there is no evidence to suggest that 
panic symptoms lead to psychosis. For some clients, psychoeducation is 
sufficient to ameliorate their fears and facilitate their engagement with 
therapy.
For others, psychoeducation will not be enough. The conundrum is 
that the best way to dispel clients’ faulty beliefs is through direct experi-
ence. For example, by normalizing eating, clients will learn that weight 
will not increase indefinitely. Similarly, by inducing panic symptoms, 
 The Course of CBT 151
the client will learn that she will not become psychotic and that she can 
actually cope with the symptoms quite well. However, selling this ratio-
nale to clients can sometimes be difficult. One helpful tool is to remind 
clients that changes in CBT are made relatively gradually. Although 
they must make some changes right from the start of therapy, clients are 
encouraged to build on their experiences in CBT—tackling increasingly 
difficult tasks as they gain a sense of self-efficacy and are able to dispel 
some of their dysfunctional beliefs.
An important point to make here is that we should always try to 
meet clients where they are—doing so is far preferable to losing them 
from treatment completely. One great way to accomplish this goal is to 
ask clients what they can do instead of spending session time talking 
about what they are not willing to do. Consider a client with OCD who 
wore three sets of rubber gloves each time he used the bathroom. The 
idea of going to the bathroom with no rubber gloves was horrifying to 
him. Had he been told to do that early in treatment, he surely would 
have dropped out. When he was asked what he could do, he replied that 
he might be able to use the bathroom with two sets of rubber gloves. 
Although this was difficult for him, he accomplished this goal and stuck 
with it until his anxiety decreased. He then went down to one pair of 
gloves, and finally was able to use the bathroom with no gloves at all. 
Although this progression took many weeks, because the therapist met 
the client where he was, the client stuck with treatment and improved 
greatly.
A statement that often comes up in therapy is: “I’m not ready.” 
Knowing how to handle this common phrase is an important therapeu-
tic skill. Again, cognitive techniques are helpful in tackling this com-
mon scenario. Clinicians should ask a client, “What does it mean to be 
‘ready’?” or “How would you know that you are ‘ready’?” Often, clients 
will state that they would be ready if their presenting problem was gone: 
“I would be ready to do those exposures to public speaking if I wasn’t 
anxious” or “I would be ready to clean the house if I wasn’t depressed 
anymore.” When clients make these statements, clinicians should ini-
tially empathize with them, but then quite quickly help them see the 
inherent conundrum. A clinician might say, “I wish it worked that way. I 
really do. However, what cognitive-behavioral therapists know so well is 
that cleaning up the house is actually something that is going to help lift 
your depression. Waiting for the depression to go away often just leads 
to more depression.” Often, in clients’ lives outside of therapy, loved 
ones have agreed with these kinds of beliefs and have facilitated con-
tinued avoidance because they want to make the client feel better. The 
152 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
clinician who helps clients dispute their unproductive thoughts can often 
jolt them into action.
Another tool we have found useful is getting clients to think about 
how they would feel if they accomplished a difficult task. Clients some-
times like to think in terms of analogies that are removed from their own 
issue of concern. A helpful example is exercising. Very few of us leap out 
of bed at 6:00 a.m. to exercise. A good motivating tactic at that hour of 
the day is reminding yourself how you will feel when it is over. If we do 
not exercise, we might spend the day regretting it; if we do, it is unlikely 
that we will have any thoughts except positive ones.
The client who was scared of having a psychotic break as a result 
of her panic symptoms was asked how she would feel if she were finally 
able to take her children to school one day in the near future. Her imme-
diate response was that it would be terrifying. She was then asked, “But 
what if you were able to do it and your feared outcomes did not occur?” 
This client, who had never before taken her young children to school, 
looked at the clinician almost in awe and responded, “That would feel 
so amazing.” The idea of this feeling of accomplishment was incredibly 
motivating to the client; throughout treatment, she often reminded her-
self of how good she would feel once she accomplished difficult tasks.
On a more long-term scale, it is also useful to help clients conduct 
a cost–benefit analysis. Do the potential benefits of treatment outweigh 
the costs of doing the treatment? Inevitably, clients recognize that poten-
tial gains will outweigh potential losses. One problem that we some-
times encounter is that clients do not know what they would like to gain. 
Some clients come to therapy with a clear picture of what life would be 
like if they no longer experienced the difficulties that are causing them 
so much distress and impairment. Perhaps they want to spend more time 
with their children, start dating, go back to school, or pursue a desired 
job. Articulating these desires can be very powerful for clients and can 
be used as a hook to draw them back in to the process of therapy when 
they are resistant to a particular intervention.
Some clients have more trouble articulating these “What would life 
be like?” scenarios. This often occurs with clients with very long-standing 
difficulties, who perhaps do not have a good baseline of functioning to 
which they would like to return. With these clients, it is worth spending 
some time establishing goals and doing some problem solving about how 
to accomplish them. For example, for a client who has not worked in his 
or her adult life, a referral for vocational counseling might be helpful. 
Assisting the client in formulating some long-term goals can be very 
motivating during treatment.
 The Course of CBT 153
To summarize, clients who keep coming to sessions but refuse to do 
the work of treatment are indeed perplexing. This behavior, although 
frustrating to the clinician, often indicates that the client wishes to 
change but that something is standing in his orher way. It is our job to 
uncover what that roadblock might be. In some cases it is fear, and you 
can use CBT techniques to help clients work past it. In other cases, the 
difficulties lie in the client’s motivation to change. Helping clients to see 
what life would be like once they have made some difficult changes can 
be a very positive step in the therapy process.
“My Client Is Always Bringing Things Up That Feel ‘Off Topic.’ ”
Some clients come to therapy and appear more than willing to work, but 
they seem to constantly try to put off working on the problem for which 
they sought treatment. This issue most often presents itself in the form of 
clients who seem to experience a new stressful event every week. Perhaps 
a client has presented for treatment of panic disorder but comes in each 
week wanting to talk about a fight with her boyfriend, a visit home to 
see her parents, or her unhappiness with her weight and shape. Trying 
to stick to an empirically supported treatment for panic disorder with a 
client like this can be challenging.
SOLVING THE PROBLEM
It would be nontherapeutic to shut our clients down every time they 
bring something up that seems “off topic.” Rather, we should always 
take a few minutes to communicate empathy, understanding, and com-
passion—“I am sorry you had a fight with your boyfriend this morning. 
That is such a hard way to start the week.” Then the therapist can say, 
“I know we planned on doing our subway exposure today. Can we go 
along with this plan, or should we table that for next week?” Sometimes, 
clients will be fine being redirected and at other times, there is good rea-
son for the therapist to be flexible and shift the plans for the day. Agenda 
setting is also very useful in this regard. The clinician can say, “How 
would it be to do our interoceptive exposures we had planned for today, 
but leave 15 minutes at the end of our agenda to discuss the fight?” In 
this way, the whole session is not taken up with the new issue, but some 
time is dedicated to dealing with it.
If shifting the plans becomes the norm rather than the exception, 
try to uncover why attention is being diverted from the problem meant 
to be the focus of treatment. Clients sometimes use other issues as a 
means of avoiding working on the presenting problem. By distracting 
154 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
the therapist with various issues, they might not have to do that hard 
exposure planned for the day! The only way to find this out is to ask 
the client—“I am getting the sense you might be trying to put off the 
exposure we had planned for today.” If that is the case, clients can be 
encouraged to advocate for themselves in the future. It is always best to 
ask for a more manageable therapeutic exercise than to waste a session 
on nothing in service of the presenting problem. Therapists should also 
return to the rationale for treatment—“Remember that the key to treat-
ing your panic disorder is to confront the things you fear. It seems you 
come in wanting to talk about a lot of different issues and wanting your 
panic to get better. If we don’t stick with our treatment plan, you are not 
going to meet that goal.”
At times, clients come in every week in crisis over seemingly minor 
events. Despite originally presenting for treatment of a specific disorder 
or problem, it becomes clear that the overarching problem is a lack of 
emotion regulation skills. Minor interpersonal interactions, stressors in 
the workplace or at school, and little irritations like traffic jams cause 
undue suffering. For these clients, it might be worth considering a shift 
in the case conceptualization and treatment goals. Rather than focusing 
on a treatment for a specific psychiatric disorder, these clients often do 
well with a treatment geared at teaching emotion regulation and coping 
skills (e.g., Sprandlin, 2003).
“My Client Never Does His Homework.”
Although many clients initially balk at the idea of once again having 
homework in their lives, many are quite agreeable to doing it once they 
understand the rationale. However, good intentions do not always trans-
late into positive actions. You will become all too familiar with clients 
who come to sessions not having done their homework. Failure to do 
homework can result from many different factors; understand what 
happened in order to achieve better compliance with homework in the 
future.
SOLVING THE PROBLEM
Difficulties involving homework compliance can usually be traced to the 
client, but they can sometimes be attributed to the clinician. Clinicians 
might forget to assign homework at the end of a session, or they might 
assign it but neglect to review it at the beginning of the next session. This 
makes clients believe that homework is not important to the treatment 
and will likely lead to noncompliance in the future.
 The Course of CBT 155
Session agendas are very helpful for managing this problem. Make 
sure to leave enough time at the end of the session to assign homework 
for the coming week. Encourage clients to record their homework assign-
ments in a therapy notebook to serve as a reminder of what they need to 
do during the week. You should also record their assignment(s), and the 
first agenda item in the next session should be to return to that list and 
discuss each item on it.
Another difficulty that clinicians have is taking too much control 
over the decision about what should be assigned for homework. Early 
on in therapy, it is appropriate for the clinician to design the homework. 
Later on, this task should be collaborative and ultimately shifted com-
pletely to the client. Although the clinician should obviously serve as a 
guide in this process, clients will be more likely to complete homework 
assignments if they design them. Along these same lines, homework 
assignments should be relevant to clients’ concerns. If a client with panic 
disorder and agoraphobia lives in a small town outside a big city and 
rarely needs to go into the city, it would not be useful for the clinician 
to assign as homework riding on the subway or taking an elevator to the 
top of a tall building. Rather, the client might tell the clinician that she 
would like to visit her local supermarket and take her children to the 
library. Not only will clients be more likely to comply with homework 
assignments that are relevant to them, but they will also gain much more 
from the treatment in terms of improved functioning in their everyday 
lives.
Clinicians should also be flexible about the way that homework 
assignments are completed. For years, we have relied on paper and pen-
cil for thought records, activity monitoring, journaling, and other writ-
ten homework assignments. In recent years, with the advent of all sorts 
of new technologies, clients might be more compliant with homework 
if they can be creative with the way they do their assignments. This 
might be encouraged by clients’ use of their computers, phones, or tab-
lets. There are many excellent CBT apps that clients can also use to 
advantage between sessions (see Appendix D).
Flexibility is particularly important for young clients. It is often 
wise to avoid the label “homework” and instead refer to “between-
session activities” or some other name devised collaboratively in the 
session. Young clients are also particularly amenable to the use of new 
technologies. Recently, one of us had a young client who made videos 
of his thought records on his phone. He started by “venting” about 
whatever the problem was that led to a shift in his mood, took a deep 
breath (visible on the video clip!), and then refuted the faulty thoughts 
156 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
using very good cognitive skills. The client then came to his sessions and 
shared these video clips with the clinician. It worked great. The clini-
cian got a sense of his anger right in the heat of the triggering situations 
and was able to do some coaching on what theearly experiments in learning and 
unlearning are important to our current understanding of how people 
acquire fears and how we can then help to extinguish these fears.
B. F. Skinner (1976) was another key figure in the rise of behav-
iorism. Skinner’s theories of conditioning were more sophisticated than 
Watson’s; they focused on operant rather than classical conditioning. In 
operant conditioning, stimuli are not thought of as eliciting responses. 
Instead, as organisms interact with their environments, they emit all 
sorts of responses (called operants); when the organism is rewarded for a 
particular response, the response is more likely to occur again; in behav-
ioral terms, it has been “reinforced.” Let’s look at an example of oper-
ant conditioning at work in the kinds of problem we see as clinicians. 
10 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Consider a child who cries before school and is then permitted by his 
mother to stay home from school. He greatly enjoys his day at home, 
spending time alone with his mom (whom he usually has to share with 
his siblings), watching TV, and playing video games. This child is likely 
to continue crying each morning since he has learned that this behav-
ior yields a desired consequence. If the mother then reads in a parent-
ing magazine that she should make her child go to school regardless of 
his crying, the crying behavior will eventually be extinguished since the 
child will learn that crying no longer yields the desired outcome. In other 
words, he will unlearn the association between crying and being permit-
ted to stay home from school.
The purely behavioral approach does apply to some of the problems 
that we see as cognitive-behavioral therapists. However, simple stimulus–
response associations cannot explain all learned behaviors. As the com-
plexity of behavioral phenomena increases, we require more complex 
explanations for behaviors. Knowing what people are thinking and feel-
ing is also important to understanding their behavior.
The Cognitive Approach
The cognitive approach most clearly deviates from the strictly behavioral 
approach when contrasted to the staunch behaviorists’ “black-box” view 
of the mind. The cognitive model is interested in the mind. Specifically, 
thoughts are considered important because they serve as intervening 
variables between stimuli and our responses to them.
The cognitive model, and the therapy associated with it, is most 
closely associated with Aaron T. Beck (1979; see also Beck, Rush, Shaw, 
& Emery, 1979). Beck developed cognitive therapy in the early 1960s 
as a treatment for depression, but it has since been applied to virtually 
every psychiatric disorder, as well as to general “problems of daily liv-
ing.” Cognitive therapy is based on the cognitive model, which proposes 
that distorted or dysfunctional thinking underlies all psychological dis-
turbances. Furthermore, dysfunctional thinking has an important effect 
on our emotions and behavior. The key concept of the cognitive model, 
which dates back to the writings of the ancient Greeks, is that it is not 
events themselves that affect our behavior, but rather how we perceive 
events (see J. S. Beck, 2011, p. 31).
The cognitive model starts with a situation or event. Consider this 
situation: Emily makes plans to meet a friend for a movie at 7:00 p.m. It is 
now 7:30; Emily’s friend has not arrived and the movie is about to begin. 
At this point, Emily experiences automatic thoughts. These are “quick, 
evaluative thoughts [that are] not the result of deliberation or reasoning” 
 The Process of Cognitive-Behavioral Therapy 11
(J. S. Beck, 2011, p. 31). Beck points out that automatic thoughts can 
be so quick that we might not even be aware of them. Rather, we might 
only notice the emotions or behaviors that follow from them.
When Emily’s friend does not arrive for the movie, her automatic 
thoughts are as follows: “She must have had a car accident” and “Some-
thing terrible has happened.” Emily also has images of her friend in a 
totaled car in the middle of the freeway.
This interpretation of the initial event (her friend being late for 
the movie) leads to several reactions. Emily feels terribly anxious and 
worried (emotional reaction). She begins to repeatedly text her friend 
(behavioral reaction). When she does not get a text back, she notices her 
heart racing and her hands sweating (physiological reaction).
Another person might have a different reaction. José’s automatic 
thoughts in the same situation are “She doesn’t like me” and “She’s out 
with other friends instead.” These thoughts lead to sadness and anger 
(emotional reaction), and José goes home alone and drinks far too much 
(behavioral reaction). Taylor, also in the same situation, assumes her 
friend just forgot to meet her, as she has often done in the past. This 
might leave Taylor feeling annoyed (emotional reaction), and she might 
then decide to head into the theater on her own (behavioral reaction). 
Kevin might think that maybe he got the time or date wrong (“I’m so 
stupid”; automatic thought). This would leave him feeling rather sad 
(emotional reaction), and he might head to the store on his way home 
to buy the appointment book that he has been meaning to get for weeks 
(behavioral reaction). A single situation can elicit various emotional, 
behavioral, and physiological responses, depending on how the person 
perceives the situation. This is really the crux of the cognitive model.
Why do people experience such different automatic thoughts in the 
same situation? Taking a step further back from automatic thoughts, the 
cognitive model further posits that our core beliefs play an important 
role. These beliefs about oneself, other people, and the world develop 
during childhood based on the experiences that we have as we are grow-
ing up. Core beliefs are “understandings so fundamental and deep that 
. . . the person regards these ideas as absolute truths, just the way things 
‘are’ ” (J. S. Beck, 2011, p. 32). Core beliefs are global and apply to 
situations in general. This is in contrast to automatic thoughts, which 
are described as “the actual words or images that go through a per-
son’s mind” (J. S. Beck, 2011, p. 34) and which are situation-specific. 
In between core beliefs and automatic thoughts are intermediate beliefs, 
which consist of “attitudes, rules and assumptions” (J. S. Beck, 2011, 
p. 35). Let’s return to our example of Emily to illustrate these concepts. 
It is certainly possible that Emily holds a core belief that “I’m an unlucky 
12 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
person.” In between this core belief and her automatic thought (“My 
friend was in an accident”), Emily might hold a variety of intermediate 
beliefs, including “Bad things will happen to people I am close to” and 
“The world is full of danger.”
The cognitive model posits that when people find themselves in situ-
ations, automatic thoughts are activated that are directly influenced by 
their core beliefs and their intermediate beliefs. Automatic thoughts then 
influence our reactions. Because our most fundamental beliefs impact 
our thoughts in any given situation, different people have very different 
reactions to the same situations. Figure 1.1 illustrates the cognitive model 
and Figure 1.2 shows a cognitive conceptualization based on Emily.
How Does the Cognitive Model Inform Treatment?
So, how does CBT work? We discuss the workings of CBT throughout 
this book, but, on the most basic level, techniques that fall under the 
umbrella of CBT work to change parts of this chain of events from situ-
ation to interpretation (automatic thoughts) to reaction. As illustrated in 
Figure 1.3, CBT involves both cognitive and behavioral treatment tools. 
It would be overly simplistic, though, to think that cognitive techniques 
only target cognitions and behavioral techniques only target behaviors. 
As Figure 1.3 shows, change in one of these systems undoubtedlyclient said to himself 
to work through the anger. Incidentally, the client started to use these 
video clips after several months of refusal to do written thought records. 
The client figured out a format that was more comfortable for him, and 
the therapy started moving forward.
A final difficulty that clinicians sometimes have is failing to ade-
quately reinforce clients for doing homework. Although it is certainly 
important for clients to feel inherently good about having done home-
work, receiving encouragement from the clinician can also go a long 
way. Clinicians sometimes need to be cheerleaders for the very hard 
work their clients do.
Homework noncompliance can also stem from factors more clearly 
related to the client (rather than to how the clinician assigns the home-
work). One of the most common reasons that clients will give for home-
work noncompliance is a lack of time. Beginning clinicians, wanting 
to be empathic to their clients, can fall into the trap of accepting lack 
of time as an excuse. This does a disservice to clients. Homework is an 
essential part of CBT—the more time that clients commit to working on 
their difficulties, the more likely it is that they will make positive gains 
during treatment.
The “I didn’t have time” excuse should be dealt with early in ther-
apy. One solution is to help clients work through the process of planning 
when and how to do their homework. This seems quite simple, but it 
can be a substantial roadblock for many clients. They might be over-
whelmed with so many other things in their lives that it is hard for them 
to put plans into action. For example, exposures for young clients with 
separation anxiety disorder can be built into the regular family plans for 
the week. Exposures could include a child staying home alone when a 
parent goes outside to get the mail or the newspaper, and then for longer 
periods when a parent goes out to walk the dog. These exposures don’t 
take any special planning—the family simply needs to embrace working 
on anxiety throughout the week as opportunities in their day-to-day 
activities present themselves.
Homework cannot always be so gracefully integrated into clients’ 
days. Rather, clients need to see how important it is to make time for 
homework, in much the same way that they would make time to call 
a friend, pay their bills, or go to the gym. Clients who have a great 
 The Course of CBT 157
deal going on in their lives might actually have to put some other activi-
ties on hold during therapy to have time to commit to their homework. 
If clients are resistant to making adequate time for homework, a good 
strategy is to return to the rationale and review with clients why home-
work is so important to the therapy process. There is no doubt that CBT 
is hard work: clinicians must emphasize to clients that change will not 
come about without effort. At the same time, however, clients should be 
encouraged to reward themselves for doing homework. Clients might 
choose to reward themselves with a favorite food (e.g., “After I do this 
homework assignment, I am going to have some nachos”) or activity 
(e.g., “Once I do my thought records, I am going to watch my favorite 
TV show”). Some clients with whom we have worked have planned a 
special reward for themselves once therapy is complete, such as going on 
a weekend trip or buying some new clothes.
Another roadblock to homework compliance, which can be attrib-
utable to the clinician and/or the client, is assigning homework that is 
too difficult or too time-consuming. Some clients will tell their clinicians 
that this was the problem; others will say that they did not have time to 
do homework, but with some probing will admit that this was the real 
reason. Early in therapy, we want our clients to have positive experi-
ences. We want them to see that they can manage the treatment and that 
doing treatment-related activities can have a positive effect. Therefore, 
if clients complain early in treatment that they were assigned too much 
homework or that the homework assignments were too hard, it might 
well be appropriate to make some alterations. Do not cut out homework 
altogether, just assign something that is more manageable. Although the 
assignment might seem simple, the client who succeeds at a simple home-
work assignment will be more likely to complete future, harder home-
work assignments. Later in therapy, clients should be encouraged to take 
a more active role in designing their homework assignments. Sometimes 
clients “bite off more than they can chew” and feel ashamed to report 
that they did not accomplish what they had planned. Ideally, the clini-
cian will recognize such a problem as the homework assignment is being 
designed. If this does not happen and clients report “failure” at the next 
session, the clinician can help them to identify the factors that prevented 
them from doing the homework and design an assignment for the next 
week that takes these factors into account.
Finally, some clients avoid doing homework because they are wor-
ried about doing it “incorrectly” and being judged negatively by the cli-
nician. The best way to deal with this potential problem is to ward it off 
158 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
right from the start of treatment. The first time homework is assigned, 
let clients know that a lot of other clients worry that you will judge them 
based on their homework and that this prevents some clients from doing 
homework at all. Tell clients you are there to teach them new skills and 
not to judge them. This is a message that should be repeated regularly 
throughout treatment.
Another way to prevent this problem is to be mindful of your reac-
tions to clients’ homework. Often, clients do not do homework exactly 
as we had hoped, particularly early in treatment. Although it is impor-
tant to fix mistakes, it is even more important to not damage rapport. If 
you would like to correct something that a client has done, first reinforce 
him or her for what he or she has done and then gently make some sug-
gestions for improvements on the next assignment.
An Issue to Consider: Are Clients Afraid of a Life without 
Psychological Problems?
Some clients come to therapy seemingly eager to make changes but do 
very little to move themselves in that direction. They might not come to 
sessions, they might come late, or, when they do come, they might be 
highly resistant to our suggestions. Clinicians should always consider 
whether clients are nervous about making changes in their lives—mostly 
because of what life will hold for them once they have resolved their 
difficulties. As we noted earlier, some clients have a clear vision of what 
life will be like when they are no longer impaired by the difficulties that 
brought them in to therapy. This seems to be particularly true for clients 
who, at one time, were functioning well. They might want to get back 
to a job they loved, be able to spend more time with friends or family 
members, or perhaps try to accomplish new goals that were stymied by 
psychological problems. Other clients might not have something that 
they want to get back to per se, but might still be able to conjure up an 
image of a better life.
Be aware that some clients who have suffered for a long time with 
psychological difficulties might feel as if they have missed out on life. 
They might look around and see that people with whom they grew up 
(friends, siblings, classmates) have accomplished things in life that they 
have not been able to accomplish. For example, a client’s sibling might 
have bought a home, married, had children, and established a career. 
For a client who, at least in part because of psychological problems, 
has remained single, lost friends, not established a career, and struggled 
 The Course of CBT 159
financially, this comparison can be devastating. Furthermore, clients 
might believe that they have “missed the boat” and that it is now tooresults 
in change in the other system.
Core Beliefs
Intermediate Beliefs
 
Situation/Event
Automatic Thoughts
Reactions (emotional, behavioral, physiological)
FIGURE 1.1. The cognitive model. Adapted from J. S. Beck (2011, p. 36). 
Copyright © 2011 Judith S. Beck. Adapted with permission from The Guil-
ford Press.
 The Process of Cognitive-Behavioral Therapy 13
Core Beliefs: “I’m an unlucky person.”
Intermediate Beliefs: “The world is dangerous.”
 
Situation/Event: Friend being late to the movies.
Automatic Thoughts: “Something terrible happened.” 
“She’s been in an accident.”
Reactions (emotional, behavioral, physiological): 
Emotional: anxious, worried 
Behavioral: repeatedly texting 
Physiological: heart racing, hands sweating
FIGURE 1.2. The cognitive model as applied to Emily. Adapted from J. S. 
Beck (2011, p. 37). Copyright © 2011 Judith S. Beck. Adapted with permis-
sion from The Guilford Press.
FIGURE 1.3. Basic model for cognitive-behavioral case conceptualization.
14 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
Let’s consider first how this applies to cognitive techniques. Our 
primary cognitive tool is cognitive restructuring, which involves iden-
tifying and reframing maladaptive thoughts. Rather than treating auto-
matic thoughts as “truths,” cognitive restructuring involves questioning 
our thoughts and reframing them if they are irrational, inflexible, or 
otherwise unhelpful. Let’s return to Emily, but imagine that this same 
scenario plays out when Emily is just starting CBT. Early in treatment, 
Emily might still experience the same automatic thoughts in response 
to her friend being late—“Something terrible has happened” and “She’s 
been in a terrible accident.” However, given her newfound CBT skills, 
she is now able to question these thoughts. Emily asks herself, “Do I 
know for certain that something bad happened?” and “Is there another 
way of looking at this situation?” By responding to these key questions, 
Emily quickly realizes that she has jumped to conclusions and that it is 
unlikely that her friend is seriously injured. Furthermore, Emily recog-
nizes that there are all sorts of possible reasons why her friend has not 
arrived yet—she might be running late, might have gotten lost, might 
have had something come up at work, and might have also forgotten to 
turn her cell phone on. These realizations may lead to a very different 
behavioral response. Emily decides to text her friend, saying she is going 
to go in and see the movie and telling her friend to either come in and 
meet her if she is running late or text later to let her know what hap-
pened. This is a very different behavioral outcome than standing outside 
the movie theater, repeatedly texting her friend. Emily is also likely to 
have different emotional and physiological reactions. As she settles in to 
the theater and begins to enjoy the movie, she will likely feel calm and 
relaxed rather than terribly anxious.
What did Emily learn from using the skills she had been taught in 
her first few sessions of CBT? Her most important lesson was that a 
single situation has many possible interpretations. She also learned that 
there are various ways to react to a single situation. She learned that 
texting her friend in a panic would not have been of any benefit (to her, 
or to her friend!), and she learned that going to see the movie turned out 
to be pleasant and had no negative consequences (e.g., her fear of being 
unavailable to a friend in need was not realized). The act of cognitive 
restructuring positively affected Emily’s beliefs (as we would expect), her 
behavioral responses, and her emotional and physiological responses to 
a potentially stressful situation.
How does this reciprocal relationship apply to behavioral tech-
niques? There are many behavioral tools under the umbrella of CBT, 
such as in vivo exposure, social skills training, relaxation training, and 
 The Process of Cognitive-Behavioral Therapy 15
structured problem solving. However, a commonality of all these tools, 
as with cognitive restructuring, is that they are based in learning theory 
and involve unlearning old, maladaptive associations between stimuli 
and our responses while also learning new ones. In vivo exposure, for 
example, involves helping people to confront harmless stimuli that cause 
them to feel anxious. The purpose of repeated exposure to such triggers 
is to help the client to learn that his or her fears are unfounded, or at 
least exaggerated. Take, for example, Stan, a man with a terrible pho-
bia of snakes. For as long as he could remember, Stan was terrified of 
all snake-related stimuli (e.g., pictures of snakes, snakes in movies). He 
recently purchased a house and relished the idea of gardening. However, 
he soon learned that his garden contained small garden-variety snakes. 
The few times that he saw one, he had terribly frightening thoughts (e.g., 
“It’s going to bite me”; “I’m going to die from its venom”; “I can’t cope 
with this”). These thoughts led him to feel very anxious (emotional reac-
tion) and experience a racing heart and profuse sweating (physiological 
reactions). Each time he saw one of these tiny snakes in his garden, he 
ran away and would not come outside until someone could come over 
to his house and confirm that the snake was no longer in the garden, 
sometimes days later (behavioral response). His garden soon became 
overgrown from neglect, and the neighbors started to complain. Fur-
thermore, Stan was missing out on the fun experience of gardening.
Stan decided to get some treatment and chose to see a behavior 
therapist. Treatment involved repeated exposure, first to snake-related 
stimuli, and gradually to real snakes. With repeated exposure, Stan 
slowly came to exhibit a neutral response to snakes and, later, was able 
to return to gardening. On the rare occasions that Stan did see a snake in 
his garden, he simply noticed it and moved on with his task, rather than 
reacting with fear and terror.
It seems as if Stan’s treatment was purely behavioral—with repeated 
exposure, he set up a new stimulus–response association. Yet, how did 
this new association become established? It certainly seems that Stan 
developed some new beliefs about snakes. As he learned more about 
them through exposure, he learned that most snakes where he lived do 
not bite and are not poisonous. He learned that snakes do not feel slimy 
(as he predicted before his first exposure), but that they are actually dry, 
smooth, and quite nice to touch. And he also learned that it could be 
enjoyable and interesting to watch snakes move through various habi-
tats and engage in their natural behaviors, like eating and burrowing 
under the sand. These learning experiences led to an extinction of one 
stimulus–response pairing (snakes–fear) and the formation of a new 
16 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
stimulus–response pairing (snakes–interest). This new association led to 
a shift in beliefs (“Snakes aren’t scary”) and a shift in behavior (e.g., 
gardening, spending more time outside), even though treatment—on the 
surface—appeared to be focused simply on “behavior.”
GETTING READY TO DO THERAPY
Now that we have introduced the theory underlying CBT, let’s return to 
our trip metaphor. When we go on a trip, it is ideal to do some prepara-
tion before we depart. It can be interesting to read about the history of a 
place, sleuth out the best sights and restaurants, and talk to friends who 
have been there. Beginning therapists must also prepare before seeing 
their first clients. Following a cognitive-behavioral model, the “Getting 
Ready” section of this chapter is divided into two parts: “Managing Our 
Thoughts” and “Engaging in Helpful Behaviors.” Beginning clinicians 
have many beliefs about their ability to do therapy, and managing these 
beliefs is perhaps the first step to getting into the room with a client.
Managing Our Thoughts
We asked a group of beginning therapiststo reflect back on the first 
client they had seen. What did they remember thinking and feeling? 
What were their worries and concerns? We noted a number of common 
themes. We have tried to articulate these themes as typical automatic 
thoughts, using the downward-arrow technique (see J. S. Beck, 2011, 
pp. 206–207), to get at the beliefs underlying these thoughts. We discuss 
ways for beginning therapists to counter them, using CBT techniques.
1. I don’t know what I’m doing. → The client will find out. → He/
she will drop out/ask for another therapist/won’t get better. Many begin-
ning clinicians mentioned experiencing “the imposter syndrome”—feeling 
concerned that the client would find out he or she was their “first” client 
and, related to this worry, that the clinician really had no idea what he or 
she was doing. Underlying this notion is the belief that, without “boots on 
the ground” experience, we are incompetent.
In cognitive therapy, we can probe for a deeper thought by asking 
“So what?” or “What would this mean for you?” or “What would the 
consequence of this be?” If the client did know you were a new, inexpe-
rienced therapist, what then would happen?
Our novice therapists expressed worries that their clients would 
 The Process of Cognitive-Behavioral Therapy 17
drop out of therapy or request a different (older, better, more experi-
enced) therapist. Presumably, this would reflect badly on the trainee and 
also deprive the trainee of getting the experiences he or she would need 
to become a better therapist. Perhaps most importantly, an incompetent 
therapist would simply not be able to help the client get better.
One way to address these assumptions is to turn to the data. 
Research examining the relation between clinician experience and ther-
apy outcome is surprisingly inconsistent—even within single data sets 
(e.g., Huppert et al., 2001). Some studies have found a positive correla-
tion between experience and outcome (e.g., Crits-Christoph et al., 1991; 
Driscoll et al., 2003; Smith & Glass, 1977), which is what beginning cli-
nicians and their supervisors generally expect, but in general these cor-
relations have been modest. It is possible that therapist experience really 
matters with complex cases but that it does not influence the outcome 
of more straightforward cases (see Beutler, Bongar, & Shurkin, 1998). 
Other studies have found clinician experience to be unrelated to treat-
ment outcome (e.g., Shapiro & Shapiro, 1982) or to therapy dropout 
rates (Wierzbicki & Pekarik, 1993). Interestingly, there is actually little 
evidence that age or similarity of therapist and client attributes contrib-
utes to treatment outcome (Beutler et al., 2004).
In light of these findings, beginning clinicians can be open to the 
possibility that their lack of experience will not negatively affect their 
clients. In reality, most clients who work with therapist trainees see ben-
efits in this arrangement. Trainees tend to be attentive and committed 
to helping. Many clients who work with trainees cannot afford therapy 
with more experienced clinicians. They are often grateful to receive the 
help they are getting.
So, if therapist experience does not affect outcome, then what does? 
Another body of literature from which novice therapists can draw when 
faced with self-doubt focuses on the therapeutic alliance. Many individ-
uals choose to become therapists at least in part because they naturally 
possess the qualities that Carl Rogers (1957) identified as being essential 
to the effective clinician. These qualities are empathy (the ability to see 
clients’ worlds from their point of view), genuineness (allowing what we 
say and how we behave to be congruent with what we think and feel), and 
nonpossessive warmth (caring for clients, treating them with respect). 
Rogers also encouraged a stance of unconditional positive regard, in 
which clients are accepted and valued for who they are. This idea of 
unconditional positive regard fits well with the stance of CBT clinicians, 
who typically do not blame clients for their symptoms. Symptoms are 
thought to be maintained via cognitive and behavioral pathways, not 
18 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
by laziness, lack of motivation, or weakness. Taken together, these Rog-
erian qualities have been found quite reliably to be associated with posi-
tive treatment outcomes in many forms of therapy, including CBT (see 
review by Keijsers, Schaap, & Hoogduin, 2000).
According to Hardy, Cahill, and Barkham (2007), “a good relation-
ship between client and therapist is, at the very least, considered to be 
the base from which all therapeutic work takes place” (p. 24). In fact, 
across diverse therapy approaches, a significant relationship has been 
found between the quality of the therapeutic relationship and treatment 
outcome (Lambert & Bergin, 1994), particularly when the quality of the 
therapeutic relationship is based on ratings made by the client rather than 
by the therapist him- or herself or independent raters (see Hardy et al., 
2007). Interestingly, the relationship between the therapeutic alliance and 
treatment outcome tends to be stronger than the relationship between 
specific therapy techniques and treatment outcome (Hardy et al., 2007). 
Norcross (2002) estimated that the therapeutic relationship accounts for 
approximately 30% of change in psychotherapy. Martin, Garske, and 
Davis (2000) conducted a comprehensive meta-analysis of the relation-
ship of the therapeutic alliance to therapy outcome and found that the 
average weighted correlation between alliance and outcome was r = .22.
Unfortunately, when beginning clinicians focus too much on how 
they are coming across to their clients, their empathy, warmth, and gen-
uineness can get lost. To ameliorate this problem, beginning clinicians 
should make every effort to focus their attention outward toward the 
client. Pay attention to what the client is saying and how the client is 
reacting to what you are saying. As you focus attention on the client and 
his or her difficulties rather than on yourself, it is likely that he or she 
will feel more comfortable, supported, and understood.
2. There is so much to teach in CBT. → I will leave important stuff 
out/make mistakes. → The client won’t do well. Many novice clinicians 
expressed worry about getting through all the psychoeducational mate-
rial at the beginning of most CBT treatment manuals. They believed 
they had to cover every last bit of material, perfectly, without boring the 
client. They often felt guilty about talking too much and not letting the 
client talk. One beginning clinician expressed the belief that he or she 
was “pushing an agenda” and had to communicate it “just so” in order 
for CBT to “work.”
There is undoubtedly a bit of a conflict operating here. In many 
training programs, trainees are evaluated on how closely they adhere 
to manuals (e.g., a supervisor might note that point 5 on page 23 was 
 The Process of Cognitive-Behavioral Therapy 19
forgotten!). For the purposes of training (or if one is serving as a thera-
pist in a randomized controlled trial), it might be important to get all 
the information across in a specific way. This can make it hard to focus 
on the client and how he or she is reacting to the material. As clinicians 
become more comfortable with the CBT model, they will develop their 
own style for communicating the essentials of CBT to their clients. The 
process will become more interactive and more relevant to each individ-
ual client. As we gain confidence, this will shine through in our interac-
tions. Time is a really great teacher in this regard!
The bottom line is that there is key material we must communicate 
to our clients—but the importance of a lot of the accompanying detail 
has not been studied. We do want our clients to know what is maintain-
ing their current difficulties, in a way that is tailored to their own situ-
ation. And we want to themto understand what we are going to do to 
help them break these patterns. For example, let’s take a client with a 
phobia of dogs. It is important to teach this client about the three com-
ponents of anxiety—thoughts, feelings, and behavior—and how these 
components interact to maintain his phobia. It is also essential that we 
teach the client that we can help him reduce his fear of dogs by target-
ing these components. We can challenge his beliefs about the danger of 
dogs, and even more importantly, we must help him change his behav-
iors around dogs (which will feed back into his beliefs about them and 
the feelings he has in their presence). Although it might be interesting to 
share our knowledge of the incidence of dog phobias, and the causes of 
dog phobias, and the age of onset of dog phobias, skipping this mate-
rial or making an error here or there will likely not affect the clinical 
outcome of the case.
3. I have a lot of knowledge about X disorder, but the client has Y 
disorder. → I have no idea what to do. → I will not be able to help/I will 
make the client worse. One of our favorite “first therapy experience” 
stories came from a clinician who was primarily interested in anxiety 
disorders. She had read extensively on the topic and had watched therapy 
sessions by more experienced therapists. Then she was assigned her first 
client, and he turned out to have schizophrenia! This therapist panicked. 
She knew tons about anxiety disorders, but not about schizophrenia.
This brings us back to beliefs we hold about our abilities. Just 
because we have not treated a client with Y disorder, or even read much 
about it, does not mean we have no skills to aid us. First, we possess 
listening skills and warmth. Second, CBT affords us an amazing tool-
box of skills that can be applied to a vast array of situations, mental 
20 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
disorders, and behavior problems. In the case of the client with schizo-
phrenia, for example, a skilled CBT therapist could hone in on the envi-
ronmental factors that prevent the client from taking his medication on 
a daily basis. She could then put a behavioral plan into place to increase 
the likelihood that the client will take his medication.
We will not be able to successfully treat every client who comes 
through our doors. Many of us have focused during our training on 
particular areas of expertise and simply do not have the experience (or 
interest) to treat some other problems. That is OK! We can do an amaz-
ing service for clients by simply assessing them, figuring out what ails 
them, and then referring them to other professionals who specialize in 
those particular concerns.
Engaging in Useful Behaviors
A great deal of learning about the process of therapy can occur before 
we even set foot in the room with a client. In the next section of the 
chapter, we talk about the background learning that should occur before 
therapeutic encounters begin. As with examining and correcting faulty 
cognitions, engaging in useful behaviors can work wonders in alleviat-
ing the anxiety experienced by novice clinicians.
Doing Coursework
In an ideal world, you will have completed a host of relevant coursework 
before seeing your first client—courses on the nature and treatment of 
a range of mental disorders; courses on testing and assessment; courses 
on professional conduct. In reality, however, this often does not occur. 
In many training programs, students are expected to work with clients 
before having completed all of these courses. This makes it all the more 
important that students take the initiative to adequately prepare them-
selves via the methods outlined below.
Reading
Many of our memories of graduate school involve hauling around 
immense piles of articles—and reading, and reading, and reading. If you 
are particularly interested in CBT (as we hope you are, if you are read-
ing this book), you should supplement your course work with further 
reading. We suggest here a selection of books that will help you to gain 
an understanding of the theory underlying CBT and how to conduct 
 The Process of Cognitive-Behavioral Therapy 21
CBT (see Appendix A for further reading). This is not meant to be an 
all-inclusive list, but certainly these books are “must-reads” for people 
who work in the field of CBT.
A great place to start is with the classics, Aaron Beck’s Cognitive 
Therapy of Depression (Beck et al., 1979) and Cognitive Therapy and 
the Emotional Disorders (Beck, 1979). To learn the basics of CBT, we 
also recommend:
•	 Cognitive-Behavioral Therapy: Basics and Beyond (2nd ed.) by 
Judith S. Beck (2011).
•	 Feeling Good: The New Mood Therapy (rev. ed.) by David Burns 
(2008).
•	 Mind Over Mood: Change How You Feel by Changing the 
Way You Think (2nd ed.) by Dennis Greenberger and Christine 
Padesky (2016; see also Padesky and Greenberger’s [1995] Clini-
cian’s Guide to Mind Over Mood).
•	 Cognitive Therapy Techniques: A Practitioner’s Guide by Robert 
L. Leahy (2003a).
•	 Core Competencies in Cognitive-Behavioral Therapy: Becoming 
a Highly Effective and Competent Cognitive-Behavioral Thera-
pist by Cory F. Newman (2013).
•	 Evidence-Based Practice of Cognitive-Behavioral Therapy (2nd 
ed.) by Deborah Dobson and Keith Dobson (2017).
•	 Clinical Practice of Cognitive Therapy with Children and Ado-
lescents: The Nuts and Bolts (2nd ed.) by Robert D. Friedberg 
and Jessica M. McClure (2015) and Cognitive Therapy Tech-
niques for Children and Adolescents: Tools for Enhancing Prac-
tice by Robert D. Friedberg, Jessica M. McClure, and Jolene Hill-
wig Garcia (2009).
Once beginning clinicians have a handle on the core techniques of 
CBT, they must acquire knowledge about cognitive-behavioral theo-
ries and therapy for specific psychological problems. A good place to 
start is with a broad book like the fifth edition of David H. Barlow’s 
(2014) Clinical Handbook of Psychological Disorders: A Step-by-Step 
Treatment Manual. The book includes chapters on a number of specific 
psychological problems that outline the nature of each problem, offer 
cognitive-behavioral models for understanding them, and describe how 
to use CBT to treat them from initial assessment to termination. The 
book provides an excellent model of how CBT is applied to different 
psychological problems and a balanced blend of data (prevalence rates, 
22 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
findings from treatment outcome studies) and practical knowledge (case 
examples, sample dialogues, forms for clients to complete, etc.).
When you begin to treat clients with specific difficulties, more in-
depth reading in specific areas is also important. This in-depth reading 
should include research-oriented books (e.g., books that discuss epide-
miology, etiology, diagnostic issues, approaches to treatment), as well as 
treatment manuals (see Appendices B and C). Some manuals include brief 
overviews of research on the specific problem, but are, of course, most 
specifically focused on guiding clinicians through the treatment process. 
Although it might make most sense to only read manuals focused on the 
disorders you are most likely to treat, it can be very interesting to explore 
more widely. A useful technique can sometimes be found in a CBT man-
ual designed for a disorder you are not focusing on in your studies.
Unfortunately, simply reading books and treatment manuals will 
not allow you to keep up to date on cutting-edge knowledge in our field. 
Practicing clinicians should make a habit of keeping up to date on influ-
ential treatment outcome studies, as well as studies that help us to bet-
ter understand the nature of various psychological disturbances. There 
are too many excellent journals in our field to list them all here, but we 
have included the names of some that beginning clinicians might want 
to start keeping up with in Appendix D. It can also be helpful to sign up 
for blogs, newsletters, and listservs thatsummarize important, current 
research in your areas of interest (see Appendix D).
From Memory (or, Almost)
There are certain skills that become easier with practice, but it is a good 
idea to become familiar with certain information before getting into the 
room with clients. As we discuss in Chapter 3, diagnostic interviews 
and assessment measures can be complicated to administer. Therefore, 
be familiar with them (how they are administered, what page to flip to 
after a skip-out, etc.) before actually doing them with clients. Similarly, 
it is important to have a good working knowledge of the diagnostic cri-
teria for the most common psychiatric disorders. In this way, the correct 
questions can be asked to make differential diagnoses and, therefore, get 
treatment off to a well-thought-out start. Finally, cognitive-behavioral 
therapists (even beginning ones) should be able to explain what CBT is, 
how cognitive-behavioral theory helps us to understand the maintenance 
of problematic thoughts and behaviors, and how CBT works to change 
these behaviors. In effect, people who do CBT need to be cheerleaders 
for CBT. When we first meet with clients, we need to communicate that 
 The Process of Cognitive-Behavioral Therapy 23
CBT is worth the time, money, and effort. If we are flipping through 
notes, taking painfully long pauses to answer questions, or saying “I 
don’t know” to basic questions, our clients might come away with seri-
ous doubts about our competency, as well as the effectiveness of CBT.
Watching the Masters
In addition to reading, beginning clinicians can also prepare to conduct 
CBT by watching more experienced clinicians. It can be quite informative 
(and fun) to watch the “masters” of CBT. The Association for Behavioral 
and Cognitive Therapies (ABCT) has created a series called the “Clinical 
Grand Rounds” that shows world-renowned cognitive-behavioral clini-
cians treating mock clients. These DVDs afford the opportunity to see 
excellent CBT, often from the individuals who created the treatments for 
specific problems.
Even easier to access than these DVDs are YouTube and other 
Internet-based resources. A caveat is worth mentioning—as with every-
thing on the Internet, the quality of videos discussing or demonstrating 
CBT varies widely. Try to seek out well-known clinicians, centers, or 
professional organizations. As an example, the Beck Institute for Cogni-
tive Behavior Therapy has its own YouTube channel that includes many 
clips of Dr. Aaron Beck explaining CBT concepts and demonstrating 
CBT techniques.
These aforementioned resources all show an abridged version of 
therapy with mock clients. Although they are extremely valuable to the 
beginning clinician, he or she should also try to secure recordings of 
entire cases with real clients. Many training clinics maintain recordings 
of interesting cases for trainees to watch. By watching a case from start 
to finish, you will not only to be exposed to many different therapy tech-
niques but also to issues that can come up at different stages of the ther-
apy process. Whenever possible, novice clinicians should discuss their 
observations with a more experienced clinician, ideally the clinician who 
did the treatment. In this way, you can ask the clinician to explain why 
he or she made the decisions that were made as the therapy progressed.
Therapy sessions can also be observed in real time from behind a 
one-way mirror or in the room with the clinician and client. This is an 
excellent way to learn, particularly if you can spend some time with the 
clinician after each session to discuss the case and ask questions. If you 
are able to be in the room with the clinician and client, you might also 
be able to take a gradually more active role, depending on the style of 
the clinician and the willingness of the client. These parameters should 
24 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK
be discussed with the clinician, and also with the client, prior to the 
beginning treatment so that everyone is clear on the nature of your role.
Making Good Use of Supervision
Beginning clinicians can ease some of the anxiety they experience by 
making good use of supervision (we discuss supervision in greater detail 
in Chapter 10). Beginning clinicians might feel alone when they start to 
see clients, but in fact they are not. Because developing clinicians are not 
yet self-sufficient and independently competent, they require monitoring 
by a clinical supervisor whose job is to provide support and feedback 
during the training process. From a didactic perspective, there are mul-
tiple goals of supervision. The most obvious goal is to teach students the 
skills they require to offer psychological services. Supervisors also teach 
trainees about being clinicians. They help trainees learn how to manage 
unanticipated difficulties that can arise with clients over the course of 
therapy. They also teach beginning clinicians how to practice psychol-
ogy ethically and responsibly by introducing them to the ethical codes 
that govern our work and helping them to resolve ethical dilemmas as 
they arise. Finally, supervisors often serve as mentors, helping trainees 
to chart their career paths, including developing their own supervisory 
skills (For more on the topic of supervision of CBT, see Newman & 
Kaplan, 2016; Sudak et al., 2015, and other books listed in Appendix A).
Perhaps the biggest concern for trainees in the context of the super-
visory relationship is the prospect of evaluation by supervisors. This 
concern is not unfounded since supervision typically involves receiving 
“constructive criticism.” Furthermore, in supervision, we tend to bring 
in segments of therapy sessions that were problematic. If a supervision 
meeting comes off as negative in tone, trainees might become anxious 
about the next one. This can have an adverse effect on therapy, since 
trainees will be so focused on doing the “right thing” for fear of being 
reprimanded during supervision that they will not be able to attend to 
the client.
One way to deal with fear of negative evaluation is to reframe the 
way in which you perceive the supervisory experience. Supervision, both 
from supervisors and from peers, can be amazingly educational, even 
if at times it is hard to swallow. Beginning clinicians need to develop 
a thick skin and remember that feedback is not intended as a personal 
affront, but rather as a means to help them grow. When beginning clini-
cians learn to be in supervision meetings and not take feedback person-
ally, they get a great deal more out of it.
 The Process of Cognitive-Behavioral Therapy 25
Becoming Part of a Community
As a beginning CBT clinician, it is also advisable to join international, 
national, or local organizations (see Appendix D for more information). 
Membership in these organizations allows you to keep informed about 
current developments in cognitive-behavioral research and practice. 
These organizations also sponsor conferences where you can learn by 
attending workshops and talks and where you can meet other individ-
uals who are also interested in CBT. These organizations include the 
ABCT and the International Association of Cognitive Psychotherapy 
(IACP), as well as more specialized organizations like the Anxiety and 
Depression Association of America (ADAA). The Academy of Cognitive 
Therapy (ACT) is another excellent resource. The ACT offers certifica-
tion to individuals with advanced expertise in CBT and offers resources 
pertinent to beginning clinicians, including listings of clinical psychol-
ogy doctoral programs, internships, and postdoctoral fellowships that 
have a CBT focus.
Being a clinician is an exciting career choice. Most of us embark 
on this path because we want to help people. The process of doing so is 
never boring. Each client we see is unique, both in terms of his or her 
clinical presentation and in terms of the alliance he or she forms with the 
clinician. Even clients