# 01 - 6. The First Therapy Session

# 6. The First Therapy Session

T
he most important objective in the first session is to inspire hope. 
You do this by providing psychoeducation (e.g., research shows that 
CBT is effective for the client’s condition), reiterating the general 
treatment plan, directly expressing your confidence that you can help 
the client feel better, and identifying the client’s values, aspirations, 
and goals.
You’ll also establish rapport and trust with clients, socialize them 
into treatment, do a mood check (so you can monitor progress and 
adjust treatment), collect additional data for the conceptualization, 
teach clients about the cognitive model, schedule activities or work on 
an issue, develop a new Action Plan, and elicit feedback. See Figure 
6.1 for the structure of the first therapy session. You’ll learn how to 
structure future sessions in Chapter 9.
You’ll find the answers to the questions below in this chapter.
How do you do a mood/medication (or other treatments) check?
How do you set an initial agenda?
How do you ask for an update and review the Action Plan?
How do you provide psychoeducation about depression, negative 
thinking, the treatment plan, and the cognitive model?
How do you elicit values, aspirations, and goals?
How do you set an Action Plan?
How do you summarize the session and elicit feedback?
THE FIRST THERAPY SESSION

Before the first session, review the client’s intake evaluation and 
keep your initial conceptualization and treatment plan in mind as you 
conduct the session. Because it’s important to tailor treatment to the 
individual, be prepared to change course if necessary. Most standard 
CBT outpatient sessions last for about 45 to 50 minutes, but the first 
one usually takes an hour. Try to identify one or more of the client’s 
automatic thoughts sometime during the session. Then you can introduce or reintroduce the cognitive model. Or you can provide clients 
with an example. Also, look for opportunities during the session to 
generate positive emotions, for example, by having clients create a 
visual image in their minds of having achieved their aspirations, by 
having a brief conversation about their interests and values, and/or by 
using self-­disclosure.
CLINICAL TIPS
• You may want to write key words of the structure on your Session 
Notes (Figure 10.1, pp. 176–177) prior to the session, so you can 
remember what to do.
• You’ll provide a significant amount of psychoeducation in the first 
session. A booklet such as Coping with Depression (J. S. Beck, 2020) 
reviews important concepts and can be suggested as an Action 
Plan item.
In addition to the elements listed below, you may interweave psychoeducation, 
eliciting and responding to automatic thoughts, devising Action Plan items, and 
identifying goals throughout the session.
Initial Part of Session 1
  1.  Do a mood (and, when relevant, a medication or other treatment) check.
  2.  Set the agenda.
  3.  Ask for an update (since the evaluation) and review the Action Plan.
  4.  Discuss the client’s diagnosis and provide psychoeducation.
Middle Part of Session 1
  5.  Identify aspirations, values, and goals.
  6.  Do activity scheduling or work on an issue.
  7.  Collaboratively set a new Action Plan; check on likelihood of completion.
End of Session 1
  8.  Provide a summary.
  9.  Check how likely it is that the client will complete the new Action Plan.
10.  Elicit feedback.
FIGURE 6.1.  Structure of the first therapy session.
Cognitive Behavior Therapy: Basics and Beyond

MOOD CHECK
At the beginning of the session, greet the client and do a mood check. 
Research shows that when therapists and clients routinely track progress and therapists use feedback to improve their treatment, outcomes 
are enhanced (Miller et al., 2015). You can use published scales, such 
as the Beck Depression Inventory–­II (Beck et al., 1996), the Beck Anxiety Inventory (Beck & Steer, 1993a), and the Beck Hopelessness Scale 
(Beck & Steer, 1993b). Or you can use scales in the public domain, 
such as the Patient Health Questionnaire (PHQ-9; www.integration.
samhsa.gov/images/res/PHQ%20-%20Questions.pdf) or the Generalized 
Anxiety Disorder Scale (GAD-7; www.integration.samhsa.gov/clinical-­
practice/gad708.19.08cartwright.pdf). If clients are unable or unwilling 
to fill out forms, you can assess their mood by asking them to assign 
a number on a scale (0–10) that represents how they’ve been feeling. 
You might say, “If 10 means the most depressed you’ve ever felt and 0 
means not depressed at all, how strong was the depression for most of 
the past week?” It’s also good to ask clients to rate their sense of wellbeing on a 0–10 scale as illustrated in the dialogue below.
It’s especially critical to check on the level of clients’ suicidality 
(and/or aggressive and homicidal impulses). Elevated scores on items 
of suicidality and hopelessness indicate the client may be at risk. If so, 
do a risk assessment (Wenzel et al., 2009) to determine whether you will 
need to spend the next part of the session (or the entire session) developing a plan to keep the client safe. It may also be important to check more 
specifically about other problems, such as sleep, anxiety symptoms, and 
impulsive behaviors. These issues may be important for the agenda. An 
advantage of having clients fill out symptom checklists is that you can 
quickly identify problems without having to ask additional questions.
If you use symptom checklists, also elicit a subjective description 
(“How have you been feeling this week?”) from clients and match it 
with their objective test scores. Regardless of how you measure their 
mood, make sure that clients are not reporting how they feel just that 
day but, instead, are providing an overview of their mood for the past 
week. Alert clients that you’d like to continue checking their mood 
every week. You might say:
“I’d like you to come to every session a few minutes early so you 
can fill out these forms. [providing a rationale] They help give me 
a quick idea of how you’ve been feeling in the past week, although 
I’ll always want you to describe how you’ve been doing in your 
own words too.”
As you’ll see below, I start the session by checking on Abe’s mood. 
As he’s speaking, I quickly review the PHQ-9 and GAD-7 scales he 
 
The First Therapy Session

filled out just prior to the session. And I ask him to rate his sense of 
well-being. (I want to make sure we’re not only decreasing his depression and anxiety but also helping him feel better more generally.)
Judith: Hi, Abe. How are you doing today?
Abe: Eh, not so good.
Judith: Not so great?
Abe: No.
Judith: Is it all right if I take a look at the forms you filled out?
Abe: Sure.
Judith: Thanks for filling them out. [repeating the rationale] I think 
I mentioned last week that they help both of us make sure you’re 
making progress over time. (looks at forms) Let’s see. How do you 
think your mood is compared to what it was last week?
Abe: Probably about the same.
Judith: That’s what the forms look like too. This one, which measures 
depression (shows him the PHQ-9), was 18 last week and this week 
(pause), and this one, which measures anxiety (shows him the GAD7), is still 8. (pause) Could you also tell me how much of a sense of 
well-being you’ve had for most of the week? Zero means no sense 
of well-being, and 10 means the greatest sense of well-being you’ve 
ever experienced.
Abe: About a 1, I guess.
CLINICAL TIPS
The mood check should be brief. When clients give you too many 
details, you might apologize for interrupting and then say one of 
two things:
“Could you summarize how you’ve been feeling this week in just 
a sentence or two?” or
“Could we put how you’ve been feeling [or the issue you’ve just 
been describing] on the agenda and get to it in a few minutes?”
MEDICATION/OTHER TREATMENTS CHECK
When clients take medication for their psychological difficulties, you’ll 
briefly check on adherence, problems, and side effects. It’s important 
to phrase the adherence question in terms of frequency—­not “Did 
Cognitive Behavior Therapy: Basics and Beyond

you take your medicine this week” but rather “How many times this 
week were you able to take your medicine the way [the provider] prescribed?” (See J. S. Beck, 2001, and Sudak, 2011, for suggestions on 
how to increase medication adherence.)
Whether your client is taking medication or receiving a different 
kind of treatment (e.g., electroconvulsive therapy, transcranial magnetic stimulation, or other brain stimulation therapies), you should 
obtain clients’ permission and then periodically contact the provider 
to exchange information. You won’t recommend changes in medication, but you might help clients respond to obstacles that are interfering with their being fully adherent. When clients have concerns about 
issues such as side effects, dosage, addiction to medications, or alternative medications or supplements, help them record specific questions 
to ask their provider and suggest that they write down the provider’s 
answers. If clients aren’t taking medication, but you believe a pharmacological or other intervention is indicated, you might propose that 
they have a medical or psychiatric consultation.
CLINICAL TIPS
If clients are hesitant to set up a consultation, they may be willing 
to look at the advantages and disadvantages of scheduling a consultation versus the advantages and disadvantages of not scheduling 
a consultation. It’s helpful to suggest to them that they don’t have 
to commit to taking medication or receiving an adjunct treatment; 
they can just get more information and then decide.
INITIAL AGENDA SETTING
Ideally, you set the agenda quickly. Most clients feel comfortable when 
you tell them how you’d like to structure the session. When you explain 
the rationale, you make the process of therapy more understandable 
to clients—­which helps to elicit their active participation in a structured, productive way.
Judith: [being collaborative] If it’s all right with you, what I’d like to 
do now is to set the agenda. [providing a rationale] The reason we 
set an agenda is so I can find out what’s most important to you and 
so we can figure out together how to spend our time. Since it’s our 
first session, we have a lot to cover, and we’ll have less time to talk 
about your agenda items. We’ll have much more time, starting 
next week. (pause) Is that okay?”
Abe: Yes.
 
The First Therapy Session

Judith: You’ll also notice that I take a lot of notes [providing a rationale] so I can remember what’s important. Let me know if that 
bothers you.
Abe: Okay.
Next, you’ll name your agenda items.
Judith: The first thing I want to do is to get an update of what happened between last session and this session [providing a rationale] 
so I can see if there are other important things for us to cover 
today. I’d like to see what you were able to get done on your Action 
Plan and then talk a little bit about your diagnosis.
Abe: Okay.
Judith: Next, we’ll set some goals, and if we have time, we’ll talk about 
some things you can do this week as part of your new Action Plan. 
Or we’ll start working on one of your goals. (pause) And then at 
the end of the session, I’m going to ask you for some feedback. 
(pause) Does that sound all right?
Abe: Yes.
Judith: [eliciting Abe’s agenda items] Anything else you want to make 
sure and talk about?
Abe: No, that sounds like a lot. That’ll be enough.
Be alert for potentially important issues that arise during the session. You and the client may decide together that a new issue is more 
important than the ones on the original agenda. But be careful not to 
let clients drift into talking about a different issue without calling their 
attention to it. If this happens, make a collaborative decision about 
whether to continue talking about the new issue or to return to the 
original one.
UPDATE AND REVIEW OF THE ACTION PLAN
In traditional CBT, we would ask for an update in this way: “What 
happened between last session and this session that I should know?” 
This invariably led to a recounting of negative experiences, especially 
early in treatment. We’d then ask, “What happened that was positive?” As you’ll see below, in CT-R (Beck et al., in press), we tend to 
start with positive experiences and help clients draw adaptive conclusions. The update is frequently intermingled with a review of the 
Action Plan.
Cognitive Behavior Therapy: Basics and Beyond

Judith: You know, Abe, when people are depressed, they’re usually 
preoccupied with all their problems. [providing a rationale] So it’s 
important to focus on what’s actually going okay. I wonder if you 
can think over the past week and tell me when you were at your 
best?
Abe: (Thinks.) That would have been when I took my grandson Ethan 
out for ice cream.
Judith: So you were able to do that?
Abe: Yes.
Judith: [giving positive reinforcement] That’s great. That was part of 
your Action Plan.
Abe: Yeah. It was good.
Judith: [becoming conversational to try to lighten his mood] Did you 
get ice cream?
Abe: Yeah.
Judith: And how about Ethan? Did he have a good time?
Abe: I think so.
Next, I get Abe to focus on this experience and draw positive conclusions about it and about himself.
Judith: So, what was good about taking him?
Abe: Well, just getting out and doing something was good. We were 
outside for a while, but probably just being with him and hanging 
out was the best part.
Judith: [asking more questions to help Abe to reexperience the positive event] What did you talk to him about?
Abe: Mostly about soccer because he’s on a team. So, we talked about 
how he’s doing and how things are coming along for him.
Judith: [being conversational, showing interest] How is he doing? Is 
he a good player?
Abe: Well, according to him, he’s doing pretty well. I haven’t seen him 
lately, so I don’t know. I think so.
Judith: [trying to elicit a positive core belief] Abe, what does it say 
about you that you were able to take him out for ice cream? You 
told me last week that it’s something you hadn’t done in a long 
time.
Abe: Seemed like something I should have done a long time ago.
 
The First Therapy Session

Reinforcing the Cognitive Model
Like many clients, Abe expressed a self-­critical automatic thought. I 
take the opportunity to frame it according to the cognitive model.
Judith: I see. And I bet you wish you had done it a long time ago. [discovering whether Abe has put a negative meaning on his avoidance] Why do you think you haven’t done it for so long?
Abe: I don’t know. I keep thinking, “Everything is too hard.”
Judith: When you have the thought “Everything is too hard,” how 
does that thought make you feel emotionally? [providing a multiple choice] Happy, sad, anxious?
Abe: Sad. Really sad.
Judith: And what do you usually end up doing?
Abe: Just sitting on the couch.
Judith: So, did I get this right? It sounds as if this kind of thing has 
been happening a lot. [summarizing in the form of the cognitive 
model] The situation is that you’re deciding whether or not to 
do something, like taking your grandson out, and you have the 
thought “Everything is too hard.” This thought makes you feel bad 
and you end up usually sitting on the couch.
Abe: That sounds right.
I could then have helped Abe respond to his automatic thought. 
Instead, to stay on track, I continue on with the update.
Judith: Well, maybe we’ll come back to this thought in a little while. 
To get back to the update, did anything else happen between last 
session and this session that I should know?
Abe: Nothing I can think of. I didn’t do much.
Action Plan Review
If you and the client agreed on an Action Plan during the evaluation, 
it’s important to find out what the client did and to what degree it was 
helpful. I start by reviewing the therapy notes we had composed the 
week before.
Judith: Can we look at your Action Plan and see what else you were 
able to get done? Do you have it with you?
Abe: Yeah.
Cognitive Behavior Therapy: Basics and Beyond

Judith: Oh, good. Were you able to put it next to your coffee maker 
and read it every morning and again later in the day?
Abe: I read it every morning, but I didn’t read it much later on.
Judith: Okay. (Makes a mental note to discuss reading the new Action Plan 
twice later in the session.) Could you read the therapy notes right 
now and tell me what you think about them?
Abe: “When I start to feel more depressed, remind myself that the 
therapy plan makes sense.”
Judith: Okay, does it still make sense to you?
Abe: Yes, it still makes sense.
Judith: What else does the note say?
Abe: “With Judy’s help, I’ll be working toward goals every week step by 
step. I’ll learn how to evaluate my thinking, which may be 100% 
true or 0% true or somewhere in the middle.”
Judith: What do you think about that? Because you’re depressed, your 
thinking might not always be completely true.
Abe: Well, mostly up until now, my thinking seems 100% true.
Judith: (making a note) Let’s get back to that in a little while. What’s 
next?
Abe: (reading) “And the way I’ll get better is by making small changes 
in my thinking and behavior every day.”
Judith: Exactly.
Next, we review the activities on the past week’s Action Plan.
Judith: Let’s see what’s next. You were able to take Ethan out for ice 
cream. And how about the third item? Do you want to read that?
Abe: “Give myself credit for doing all of the above, for doing anything 
else that helps me get over the depression, and for doing anything 
that’s even a little difficult, but I do it anyway.”
Judith: So, were you able to give yourself credit for taking Ethan to 
ice cream?
Abe: Not very well, no. I should just do that stuff [automatic thought].
Judith: Well, in a few minutes, we’re going to talk about your depression and how that’s been getting in the way. Were you able to give 
yourself credit for reading your therapy notes every morning?
Abe: I did, most of the time anyway.
Judith: That’s good.
 
The First Therapy Session

Next, I summarize, to make the process of therapy more understandable and to keep us on track.
“Okay, we checked your mood, we set the agenda, you gave me an 
update, and we reviewed the Action Plan. Next, I’d like to talk 
about your diagnosis.”
DIAGNOSIS AND PSYCHOEDUCATION ABOUT DEPRESSION
Most clients want to know their general diagnosis and to establish that 
you don’t think they’re crazy or strange or abnormal. It’s usually better to avoid the label of a personality disorder (and sometimes a serious mental health condition) at the first session and instead describe 
the difficulties the client has experienced, for example: “It looks as 
if you have major depressive disorder. It also seems that you’ve had 
some long-­standing problems with relationships and with work. Is that 
right?”
It’s desirable to let clients know how you made the diagnosis and 
to give them some initial psychoeducation about their condition. We 
want them to start attributing some of their problems to their disorder 
instead of to their character. Thoughts such as “There’s something 
wrong with me”; “I’m lazy”; or “I’m just no good” will negatively affect 
their mood—and probably their behavior—­and thus reduce their motivation.
Judith: I’d like to talk about your diagnosis. Abe, you have a real illness. It’s called depression. Now a lot of people go around saying 
“I’m depressed” from time to time. But that’s very different. When 
people say, “I’m depressed,” usually that’s like having a common 
cold—but [offering an analogy] what you have is like a really bad 
case of pneumonia. You see how pneumonia and the common 
cold are very different?
Abe: Yes.
Judith: You have a real illness that’s called depression. I know that 
because I have a book that helps me diagnose the problems people have when they come to see me. It’s abbreviated as the DSM. 
It lists the symptoms of the real illness called depression. (pause) 
And I found from talking to you last week that you really do have 
this.
Next, I list the symptoms he’s been having that indicate he has the illness of depression.
Cognitive Behavior Therapy: Basics and Beyond

“Tell me if I’m right. You’re tired all of the time. You’ve felt very, 
very depressed for a long time. You’ve lost interest in almost everything. You rarely get a sense of pleasure. Your appetite has been 
off. You’ve been sleeping much, much more. You have trouble concentrating and making decisions, and sometimes you even think 
about death. (pause) These are all symptoms of what’s called a 
major depressive disorder. It’s a real illness.”
Having described his symptoms, I want to offer Abe hope.
Judith: Fortunately, research shows that there’s a really good treatment for it: cognitive behavior therapy. That’s the kind of treatment that I do. (pause) So, what do you think of this idea—that you 
do have a real illness?
Abe: I mean, what you said makes sense, and I do all that stuff. It 
describes me. I don’t know about the idea of illness. A lot of this 
seems like I’m just not doing what I’m supposed to be doing.
Analogizing Depression and Pneumonia
Judith: If you had a terrible case of pneumonia, would you be able to 
do everything that you should be doing?
Abe: No.
Judith: No, because you’d be very tired all of the time, right?
Abe: (Nods.)
Judith: You might even have trouble concentrating if your symptoms 
were really severe. Your depression is every bit as real as pneu­
monia. And part of this real illness, Abe, is your depressed thinking.
Psychoeducation about Depression and Negative Thinking
Clients may start to blame themselves for their symptoms. Here’s what 
I say to Abe to head that off.
Judith: Now, it’s not your fault that you have depressed thinking. 
These thoughts just pop up automatically. In fact, we call them 
“automatic thoughts.” (pause) And depressed automatic thoughts 
are a symptom of depression, just like tiredness and sleeping too 
much and having a depressed mood are symptoms. (pause) Okay?
Abe: Yes.
Judith: Abe, when people are depressed, [offering a metaphor] it’s as 
 
The First Therapy Session

if they’re wearing the blackest glasses imaginable. And they see 
all of their experience as coming through these black glasses. So, 
everything looks very dark and very negative. (pause) What do you 
think about that?
Abe: I guess that could be right.
Additional Psychoeducation about the Treatment Plan 
and Depressed Thinking
Next, to inspire hope, I preview how we’re going to deal with his 
depressed thoughts.
Judith: Because you’re depressed, we know for sure that some of your 
automatic thoughts just aren’t 100% true. Others may be true, but 
they’re really unhelpful. I’m going to teach you how to evaluate 
your thoughts, so you can see for yourself how accurate or helpful 
they are. Okay?
Abe: Okay.
Judith: I also want to give you another analogy. When people are 
depressed . . . well, it’s like horses in races that wear blinders. Why 
do they have them?
Abe: So they don’t get distracted. To keep them looking only straight 
ahead.
Judith: Exactly. And when people are depressed, it’s as if they have 
blinders too. All they can see is what’s immediately ahead of them. 
And all of those things, because they have black glasses on, seem 
really terrible and really negative. One of the things that we’ll do, 
Abe, is to open up those blinders so you can see everything that’s 
going on, not just the negative.
Abe: Okay.
Judith: Do you think it would be helpful to remember that this week?
Abe: Yeah, probably.
Next, we collaboratively create a therapy note for Abe to read daily 
between sessions.
Judith: Do you want to write this down, or do you want me to write 
it down?
Abe: You can.
Judith: Okay. Maybe we should start this out, “When I criticize myself, 
remember . . . ” And what do you think would be good to remember?
Cognitive Behavior Therapy: Basics and Beyond

Asking Abe to summarize in his own words allows me to check on 
his level of understanding, makes him more active in the session, and 
reinforces the adaptive response in his mind.
Abe: I’m only looking at part of the scene.
Judith: Yes, “I’m only looking at part,” and what part are you looking 
at?
Abe: The part through my black glasses.
Judith: Yes. “I’m only looking at part of the scene, and it’s through 
black glasses.”
To make the response more robust, I offer two other ideas.
Judith: And how about “It’s not my fault I’m doing this”?
Abe: (Sighs.)
Judith: Doesn’t sound like you really believe that?
Abe: Not too much.
I don’t want to write down anything Abe disagrees with, so I modify 
the idea.
Judith: How about “Judy says it’s not my fault”?
Abe: Okay.
Judith: Is that all right?
Abe: Yeah.
Judith: “Judy says it’s not my fault.” And why do I say you’re doing 
this?
Abe: Because I have depression.
Judith: Right. “It’s happening because I have depression.” (pause) Do 
you think that this is something that you could read to yourself 
this week?
Abe: Yeah, yeah. I can do that.
Psychoeducation about the Cognitive Model
In the next part of the session, I explain, illustrate, and record the cognitive model with Abe’s own examples. I also ask Abe to put what I had 
said in his own words so I could check on his understanding.
Judith: The next thing I’d like to do is to talk just a little bit more about 
your depressed thinking. Here’s the situation that just happened 
 
The First Therapy Session

a few minutes ago. We were talking about why you hadn’t taken 
Ethan for ice cream for a long time. That was the situation, and do 
you remember what you were thinking? What your thought was?
Abe: I’m not sure.
Judith: You said, “Everything is too hard.”
Abe: Oh.
Judith: Right? And so, when you had that thought, “Everything is too 
hard,” how did it make you feel?
Abe: Really depressed.
Judith: And what did you usually end up doing?
Abe: Just sitting on the couch.
Judith: Let me draw a diagram that shows this.
Situation: Think about doing something, 
like taking grandchildren out

Automatic thought: “Everything is too hard.”
    
      Emotion: Depressed      Behavior: Stays sitting on couch
Now if you’d had another thought, I wonder if you would have 
felt differently. For example, if you had thought “Well, everything 
seems too hard, but because I’m depressed that might not be true. 
Therapy makes sense. Judy says that she can help me, and I already 
did something good by taking Ethan out for ice cream.” If you had 
had those thoughts, how do you think you would have felt?
Abe: Better.
Judith: Exactly. (Pointing to the cognitive model diagram.) It’s not the situation directly that makes you feel tired or bad or depressed. It’s 
what you’re thinking in that situation. So, if you have the thought 
“Everything is too hard,” of course you’re going to feel depressed 
and sit on the couch. If you have a thought like “Well, therapy 
makes sense. Judy says she can help me,” then you might feel a little bit better and you might be a little more likely to do something.
Abe: I can see that.
Judith: One of the things that’s going to be really important in this 
treatment is to have you learn to identify your automatic thoughts. 
This is just a skill, like learning to ride a bike. I’m going to teach 
you how to do it. And then we’re going to figure out whether 
Cognitive Behavior Therapy: Basics and Beyond

a thought is 100% true or 0% true or someplace in the middle. 
(pause) So, I wonder, before you took Ethan out for ice cream, 
were you thinking that it would be a very hard thing to do?
Abe: Yeah.
Judith: And then how did it turn out?
Abe: Pretty good.
Judith: Was it as hard as you expected?
Abe: No.
Judith: So, that’s a really good example of how you could have an 
automatic thought like “This is too hard” or “It’s going to be very 
hard to take him out,” but it might turn out not to be true, or not 
100% true. Is that right?
Abe: Yes.
Judith: So, I wonder, could you tell me in your own words then what 
we’ve just been talking about here?
Abe: Well, I guess you’re saying that I have all these negative thoughts 
because I’m depressed.
Judith: Right. And what effect do these thoughts have on you?
Abe: They make me feel bad and then I might just sit on the couch.
Judith: Oh, well, that’s excellent. You’re right. Your thinking affects 
how you feel and then what you do. In fact, if you had thought “It’s 
too hard to take Ethan out” instead of just “It’s very hard,” what do 
you think would have happened?
Abe: I don’t know. I might not even have called him.
See Chapter 12 (pp. 222–225) to find out what to do when clients have difficulty identifying automatic thoughts. But be careful to 
downplay the importance of identifying automatic thoughts when they 
struggle. You don’t want clients to think they’re incompetent.
CLINICAL TIPS
If you have difficulty identifying one of your client’s automatic 
thoughts, you can provide an example:
Therapist: I’d like to talk for a couple of minutes about how your 
thinking affects how you feel and what you do.
Client: Okay.
Therapist: What would you think if you texted your best friend 8 
hours ago and he didn’t text you back?
 
The First Therapy Session

Client: That maybe there’s something wrong.
Therapist: How would that thought make you feel?
Client: Worried, I guess.
Therapist: And what would you do?
Client: Probably text again, and if I still didn’t hear anything, I’d 
probably call.
Therapist: Okay, that’s a good example of how your thinking influences how you feel and what you do.
Then, if you want to reinforce the cognitive model, you can 
provide a different automatic thought, using the same situation. 
For example, ask what the client would feel and do if she had the 
thought “He’s always doing this to me. He’s so rude.” Next, ask her 
to summarize what she’s just learned.
CLINICAL TIPS
When clients’ cognitive abilities are impaired or limited, you can 
use more concrete learning aids such as cartoon figures with various expressions to illustrate emotions with empty “thought bubbles” 
above their heads.
Setting an Action Plan Item to Reinforce the Cognitive Model
Next, I suggest that Abe look for depressed automatic thoughts during 
the week. I ask him to anticipate an automatic thought and remind 
himself that it might or might not be true.
Judith: Here’s something I’d like you to do this week. Notice when 
your mood is getting worse or when you’re not being productive. 
Then ask yourself, “What was just going through my mind?”
Abe: Okay.
Judith: I wonder if you could predict what one of these thoughts 
might be?
Abe: It could be almost anything. I could be sitting on the couch, and 
I could think about doing anything, cleaning the apartment . . .
Judith: That’s good. So, let’s say you’re thinking of cleaning the apartment. How do you think you’ll be feeling ?
Abe: Probably tired. I’ll probably think, “I’m too tired to do anything.”
Judith: That’s a good example. So, the situation is that you’re sitting 
on the couch, thinking of cleaning, and you think, “I’m too tired 
Cognitive Behavior Therapy: Basics and Beyond

to do anything.” How does this thought make you feel emotionally?
Abe: Depressed.
Judith: And if you believe this thought, that you’re too tired to do 
anything, what do you think you’ll do?
Abe: Probably just keep sitting.
Judith: I think you’re probably right. (pause) Okay, this week, I’d like 
you to notice when you’re feeling really depressed or not being 
productive. Then I’d like you to ask yourself, “What was just going 
through my mind?” (pause) Then I’d like you to jot down your 
thoughts. But then remind yourself that they might not be true, 
or at least not completely true. Okay?
Abe: I’ll try.
Judith: You can write your automatic thoughts on this Identifying 
Automatic Thoughts Worksheet (pulls out worksheet in Figure 6.2) 
or you can use paper or a notebook or your phone. Which would 
be best?
Abe: I’ll try the worksheet.
Remember: Just because I think something doesn’t necessarily mean it’s true. 
When I change my unhelpful or inaccurate thoughts, I’ll likely feel better.
Instructions: When my mood gets worse or I’m engaging in unhelpful behavior, 
ask myself, “What was just going through my mind?” Write down my thoughts 
below.
FIGURE 6.2.  Identifying Automatic Thoughts Worksheet. Copyright © 2018 
CBT Worksheet Packet. Beck Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania.
 
The First Therapy Session

Judith: Good. (Hands Abe the worksheet.) You see it has the directions 
right at the top, the ones I just showed you.
Abe: Okay.
Judith: (Making sure Abe knows what to do.) Could you write your automatic thought on it—“I’m too tired to do anything”?
Abe: Okay. (Writes this thought on the worksheet.)
Judith: I wonder if you’ll need a reminder? Like a sticky note, or you 
could move your watch to your other hand or wear a rubber band 
around your wrist—to remind yourself to look for your automatic 
thoughts.
Abe: I think I need to see something, some kind of reminder that I can 
see. A rubber band would be good.
Judith: I have one here. Do you want to put it around your wrist now?
Abe: Okay.
Judith: (Hands Abe a rubber band; he puts it on his wrist.) So, every time 
you look at the rubber band, what are you going to ask yourself?
Abe: What just went through my mind?
Judith: That’s right, especially if your mood is getting worse, or you’re 
doing something that’s not productive. And you’ll remind yourself 
that the thoughts might not be true.
Abe: Okay.
IDENTIFYING VALUES AND ASPIRATIONS
Eliciting Values
Next, you focus on identifying clients’ values. Values are long-­standing 
beliefs about what is most important in life. People’s values shape their 
choices and behavior. But when they perceive they’re not living up to 
their values, they often become distressed. In a conversational tone, 
you can ask clients, “What’s really important to you in life? Or what 
used to be really important to you?”
CLINICAL TIPS
If clients reply that nothing seems important or if they have difficulty formulating a response, you can offer suggestions: “How 
important is             to you?”
You can ask them to consider areas such as the following:
• relationships (family, friends, intimate partner),
• productivity (work outside the home, managing at home),
Cognitive Behavior Therapy: Basics and Beyond

• health (might also include fitness, eating, sleep, use of alcohol 
or substances),
• self-­improvement (education, skills, culture, appearance, self-­
control),
• community (locally or more broadly),
• spirituality,
• recreation (entertainment, hobbies, sports),
• creativity,
• nature, and
• relaxation.
Having clients reflect on what’s really important to them aids in 
identifying their aspirations and setting goals. These interventions 
can inspire hope, motivate clients to engage in treatment and complete Action Plans, and help them overcome obstacles and problems 
they face day to day.
Judith: Abe, I wonder if we could turn to something else, and that is 
to talk about what’s really important to you in life. What are the 
most important things to you in life? Or maybe before you got 
depressed, what was really, really important to you?
Abe: My kids.
Judith: Yes.
Abe: Grandkids too.
Judith: Your grandkids, okay. What else was really important?
Abe: Well, it was always important to me to work and be productive, 
but I screwed that up.
I had already reviewed the cognitive model with Abe, and I decide it 
would be better to let that automatic thought go unaddressed so we 
can continue identifying values.
Judith: What else has been important to you?
Abe: Friends. Sports, I guess. I’ve always liked sports.
Judith: Oh, that’s good. Playing or watching or both?
Abe: Both.
Judith: Anything else that’s been really important to you?
Abe: I don’t know. I used to go to church, and I used to do things. I 
used to volunteer, help people. I liked helping people.
Judith: Anything else? How about your health?
Abe: Yeah. I used to eat healthy, exercise—­things like that.
 
The First Therapy Session

Eliciting Aspirations
To elicit clients’ aspirations, ask one or more questions such as the following (Beck et al., in press):
“What do you want for your life?”
“What are your hopes for the future?”
“What do you want your future to look like?”
“When you were growing up, what did you want 
your life to be like? What did you hope for?”
It’s fairly easy to elicit Abe’s aspirations.
Judith: I know you’ve been very depressed for quite a while and you’re 
unhappy with your life. (pause) What do you want for your life?
Abe: I want it to be like it was before I got depressed.
Judith: And what was that?
Abe: I want to have a job. I want to have better relationships with my 
family. And with my friends. (Thinks.) I want to take care of myself 
better. And my apartment.
Judith: Anything else?
Abe: (Thinks.) I want to feel good about myself. I want to feel useful, 
helpful.
Drawing Conclusions about Aspirations
It’s not clients’ aspirations and experiences alone that are important. 
It’s the meaning that clients put to them. Help clients draw conclusions 
about having achieved their goals and aspirations, especially in terms of 
improving their life, self-image, sense of purpose and control, and connectedness to others. Ask questions such as these (Beck et al., in press):
“What would be especially good about [achieving 
your aspirations and goals]?”
“How would you feel about yourself? What would 
it say about you? How might other people view 
you or how might they treat you differently?”
“What would it suggest about your future?”
“How would you feel [emotionally] if all this came 
true? Can you get that feeling right now?”
Cognitive Behavior Therapy: Basics and Beyond

I use these questions with Abe.
Judith: Abe, if you had a good job, good relationships with your family and your friends, if you were taking better care of yourself and 
your apartment, if you were helping other people, what would be 
good about that?
Abe: I’d feel good about myself. I’d be productive.
Judith: And what would that show about you as a person?
Abe: I guess it would show I’m a good person, I’m responsible.
Judith: Would it show that you were a good worker, a good father, a 
good grandfather, a good friend?
Abe: Yes.
Judith: And how would other people view you?
Abe: I would hope the way they did before. That I’m reliable, I’m hardworking, friendly.
Judith: And if all these things happen, what do you think your future 
would be like?
Abe: Pretty good, I think.
Judith: And how would you feel about yourself?
Abe: Much better.
Creating an Image of Having Achieved the Aspirations
Using imagery can make aspirations more concrete and lead to clients’ 
experiencing positive emotion in the session.
Judith: Abe, I wonder if you could imagine a day in the future when 
you’ve completely recovered from depression, when all these good 
things have come true? Let’s say it’s a year from now. Where do 
you think you’ll wake up?
Abe: If I was working and had more money, maybe in a different apartment.
Judith: Can you imagine opening your eyes? What does the room 
look like?
Abe: Umm, a year from now? My bedroom would be bigger. There 
would be a lot of light in the room. It’d be neat, well organized.
Judith: And how are you feeling as you wake up?
Abe: Pretty good.
Judith: Looking forward to the day?
 
The First Therapy Session

Abe: If I had a good job? Then yes.
Judith: Can you see yourself getting out of bed? What are you thinking?
Abe: Probably just about what I’m going to do that day.
Judith: And how are you feeling?
Abe: Pretty good.
Judith: What do you think you’d do next?
I continue to coach Abe in imagining this future day, in detail. As he 
speaks, I see his affect start to brighten a little.
SETTING GOALS (PART 1)
Having identified clients’ values and aspirations, you collaboratively 
set goals and record them. These goals are more specific than the 
broad ones you discussed during the evaluation session. Clients with 
depression benefit from identifying goals in a variety of areas (Ritschel 
& Sheppard, 2018). You might suggest that they think about goals 
related to the same areas that were outlined on pages 104–105. Below, 
Abe and I set some goals. Then we address an automatic thought that 
gets in the way, before returning to goal setting.
Judith: Abe, could we talk about some specific goals you might have? 
How would you like your life to be different? How would you like 
to be different?
Abe: I’d like to be the way I used to be, doing all that stuff [we just 
talked about].
Judith: So, you’d like to spend more time your kids and your grandkids?
Abe: Yes.
Judith: (writing it down) That’s a good goal. What else?
Abe: Well, get a good job. But I don’t know how I’m going to be able to 
do these things. I haven’t been able to, up to this point.
Addressing Automatic Thoughts That Interfere 
with Goal Setting
I conceptualized that rather than continuing to set goals, it would be 
important to respond to Abe’s automatic thoughts. I use our discussion to reinforce that
Cognitive Behavior Therapy: Basics and Beyond

• his thinking may be biased and inaccurate,
• we will work together as a team,
• I have good reason to expect treatment to help, and
• coming to treatment is a sign of strength.
I also ask Abe to commit to making a change in the coming week, even 
if he has interfering thoughts.
Judith: Yes, your depression has made it hard for you to do these 
things. So, what’s different now?
Abe: I don’t know.
Judith: Hey, Abe, I’m here. Do you have a sense that I can help?
Abe: I think maybe you could.
Judith: [trying to build hope] Abe, I have to tell you there’s nothing 
about you that makes me think that you’re not going to get over 
this depression. I really think you are. Should I tell you why I think 
that?
Abe: Yes.
Judith: Okay. So, the first thing is that you were willing to come for an 
evaluation last week, even though you were skeptical about treatment. But you did a good job on the evaluation. You were able to 
answer all my questions. We were able to make an Action Plan, 
especially taking your grandson for ice cream. You were able to 
do that, even though you thought it would be very hard. So I see 
that you’re willing to try this treatment. And it’s fine if you’re still 
skeptical about treatment. (pause) You’ll need to see for yourself 
that it’s working. Okay?
Abe: Yes.
Judith: And you’re not in this alone. We’ll be working as a team to get 
you better. We’ll work on the goals, step by step, so it won’t feel 
overwhelming. And there are skills you need to learn, like answering back your automatic thoughts. You don’t know how to do these 
things yet—I’ll need to teach them to you.
Abe: But I’ve always thought I should solve my problems myself.
Judith: Okay. Back to the pneumonia analogy. If you had bacterial 
pneumonia, would you try to cure yourself?
Abe: No. I’d have to go to the doctor.
Judith: And the doctor would help you. (pause) I will too. But instead 
 
The First Therapy Session

of giving you medication, I’ll be teaching you skills to get over 
your depression. Skills that research shows get people better. 
(pause) Okay?
Abe: I guess so.
Judith: You know, I think it’s a sign of strength that you’re willing to 
do something that goes against your grain.
Abe: Maybe I am seeing everything through black glasses.
Judith: Yes, I think you are. And what we have to do together—­note 
I said “together”—is to scratch off the black paint so you can get 
over your depression. (pause) Should we get back to setting goals?
Abe: Okay.
SETTING GOALS (PART 2)
Having responded to Abe’s dysfunctional thinking, we return to goal 
setting. I make sure to avoid overwhelming Abe with too many goals, 
and I limit our discussion so we’ll have time to get to activity scheduling.
Judith: Okay. Do you have other goals?
Abe: I should see my friends more. But they might be annoyed with 
me, so I don’t know if that’ll work [automatic thought]. I haven’t 
been in contact with them for a while.
I conceptualize that it’s more important to keep setting goals than to 
respond to this automatic thought.
Judith: Should we put that down with a question mark?
Abe: Yes.
Judith: Anything else?
Abe: Well, it would be good to clean the apartment.
Judith: And how about your physical health?
Abe: Yeah. It would be good to start eating better and exercising.
Judith: I think this is a really good list. I’ve written your goals here 
on the bottom of your Action Plan. Would you be willing to take 
a look at this list during the week to see whether there are any 
goals that you want to cross off or add or change? I’m thinking 
you might want to have a goal of having more fun, doing more 
pleasurable things, but it’s up to you.
Cognitive Behavior Therapy: Basics and Beyond

Goal List                                      May 13
·  Get a good job
·  See friends more? 
·  Clean the apartment
·  Eat better
·  Exercise
Difficulties in Setting Goals
There are three difficulties that sometimes arise when you’re trying 
to set goals:
1. Clients have difficulty coming up with goals.
2. Clients set goals that are too broad.
3. Clients set goals for other people.
When clients say, “I don’t know” to your goal setting questions, you 
can try a “miracle” question instead. Solution-­focused brief therapy 
(de Shazer, 1988) suggests you ask a question such as the following: 
“If a miracle happened and you weren’t depressed when you woke up 
tomorrow, what would be different? How would someone know you 
weren’t depressed?” Or you can find out whether clients believe there 
are disadvantages to setting goals.
Sometimes clients express goals that are too broad (e.g., “I don’t 
want to be depressed anymore” or “I want to be happier” or “I just 
want everything to be better”). To help them become more specific, 
you can ask, “If [you weren’t depressed anymore/if you were happier/
if everything was better], what would you be doing differently?”
Occasionally clients state a goal over which they don’t have direct 
control: “I’d like my partner to be nicer to me”; “I want my boss to stop 
putting so much pressure on me”; “I want my kids to listen to me.” In 
 
The First Therapy Session

this case, it’s important to help them phrase the goal so it’s something 
they do have control over.
“I don’t want to promise you that we can directly get your sister to 
be nicer to you. What do you think of phrasing it this way: ‘Learn 
new ways of talking to Erica.’ It’s possible that if you take control 
and change what you’re doing, it will have some impact on her.”
For a broader discussion of what to do when clients set goals for others, see J. S. Beck (2005).
CLINICAL TIPS
Add new goals to the list as they come up in later sessions. Note that 
goals are the flip side of problems. For example, if the client says, 
“I don’t know what to do about my teenager,” you can say, “Do you 
want to have a goal to decide what to do?” If the client says, “It’s so 
hard to get everything done,” you can say, “Do you want to have a 
goal to figure out if you can do something to make it easier?”
SCHEDULING ACTIVITIES
If there’s time in this first session, it’s a good idea to help most depressed 
clients schedule activities for the coming week and give themselves 
credit for engaging in these activities. Alternatively, if there’s a pressing problem that needs immediate attention, you can work on that. 
Because Abe has been so inactive, and because he hadn’t brought up a 
more pressing problem, I bring up scheduling activities for the coming 
week. You’ll read about what we did in the next chapter.
END‑OF‑SESSION SUMMARY
The final summary ties together the threads of the session and reinforces important points. Initially, you’ll probably summarize. When 
you think clients are capable of providing a good summary, you’ll ask 
them to do it.
At the end of the first session, you might say something like this: 
“I’d like to summarize what we went over about today, so it’s clear to 
both of us. We talked about your diagnosis and how your thoughts 
influence how you feel and what you do. We identified what’s really 
important to you and what you want for your life. Then we set goals 
and figured out some activities for you to do this week.”
Cognitive Behavior Therapy: Basics and Beyond

The summary also includes a review of what clients have agreed 
to do for their Action Plan and an assessment of how likely they are to 
complete it. You’ll read about this in Chapter 8 (pp. 135–159). Figure 
6.3 presents Abe’s first-­session Action Plan. Make sure to give clients the 
written Action Plan and any other worksheets or notes that they’ll need.
FEEDBACK
The final element of the first session is feedback. By the end of this 
session, most clients feel positive about the therapist and the therapy. 
Eliciting feedback further strengthens rapport, providing the message 
that you care about what the client thinks. It also gives clients a chance 
to express, and you to resolve, any misunderstandings. Clients may 
occasionally make an idiosyncratic (negative) interpretation of something you said or did. Asking them whether there was anything that 
bothered them gives them the opportunity to state and then test their 
conclusions. In addition to verbal feedback, it’s a good idea to ask clients to complete a written Feedback Form (Figure 6.4).
Judith: Abe, can you give me some feedback about this session, [providing rationale] so I can make changes for our next session if I 
need to? (pause) What did you think of it? Was there anything that 
bothered you or anything you thought I didn’t understand?
Abe: No, it was good.
Judith: Is there anything you think we should do differently next 
time?
Abe: No, I don’t think so.
Judith: If you did have any negative feedback, do you think you could 
tell me?
Abe: I think so.
Judith: If you do, the first thing I’ll say is “It’s good you told me that.” If 
there’s something I’m doing that’s not right, I want to know, so I can 
fix it. In fact, you’ll have another chance to tell me. Can I give you 
this Feedback Form to fill out in the reception area? You can give 
it to [the receptionist], and he’ll give it to me. It will help you think 
about the session and whether there’s anything I should know.
Abe: Okay.
Judith: That’s good. Well, I’m so glad that you came in today. Is this 
time good for you next week?
Abe: Yes.
Judith: I’ll see you then.
 
The First Therapy Session

FIGURE 6.3.  Abe’s Session 1 Action Plan.
Action Plan 
 
 
 
 
 
May 13
Read this Action Plan and the one from last week twice a day.
Continue to give myself credit.
How my thoughts affect my reaction
Situation: Thinking about doing something, like taking grandchildren out

Automatic thoughts: “Everything is too hard.”
    
  Emotion: Depressed    Behavior: Stay sitting on couch
When I criticize myself, remember I’m only looking at part of the scene, and 
it’s through black glasses. Judy says it’s not my fault that I’m doing this. It’s 
happening because I have depression.
When I notice my mood is getting worse or I’m doing something unproductive, 
ask myself, “What’s going through my mind right now?” and write down my 
thoughts on the Identifying Thoughts Worksheet. Wear a rubber band to 
remind me to do this.
Remember, black glasses   
 
If I’m feeling really tired and feel like staying on the couch instead of going 
out—or doing something else—remind myself that I have to get back into 
the world. It’s important to go. Not going will probably keep me depressed. 
I want to get back into the world so I can be productive, be better to my 
family. I’ll feel more useful and competent and in control. Going out may or 
may not affect my mood right away. I may need to crank up the jack-in-thebox.
To do:
1. Take Ethan out for ice cream.
2. Go out four times this week. For example, take a 5-minute walk, go to the 
grocery store, or go to the hardware store. Demonstrate to myself that I 
can take control and do things.
3. Look at the goal list. Do I want to add or cross off or change any?
Cognitive Behavior Therapy: Basics and Beyond

FIGURE 6.4.  Feedback Form. Copyright © 2018 CBT Worksheet Packet. Beck 
Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania.
Name  
 
 
 
  Date 
 
   
What do you want to remember from the therapy session today? 
 
 
 
 
 
 
 
Was there anything that bothered you about the therapist or about therapy? If 
so, what was it? 
 
 
 
 
 
 
 
How likely are you to do the new Action Plan? How is it related to your 
aspirations and values? If you do it, what will that show you (especially about 
yourself)? 
 
 
 
 
 
 
 
What do you want to make sure to cover next session? 
 
 
 
 
 
 
 
 
The First Therapy Session

REFLECTION QUES TION
Why is it important to help clients identify their values, aspirations, and 
goals?
PRACTICE EXERCISE
Ask yourself the relevant questions in this chapter to identify your own values and aspirations. Then identify at least one goal and write down one or 
two steps you can take this week toward achieving it.
Cognitive Behavior Therapy: Basics and Beyond