Case conceptualization is the process where you and your therapist work to make sense of the problems that brought you to therapy. This conceptualization begins to form in the first session, but evolves over the course of therapy as new information about your patterns is discovered and incorporated. Through case conceptualization, you and your therapist will develop a common language for describing the different thoughts, emotions, physical sensations, behaviours, and situational aspects of the difficulties you’re experiencing. A case conceptualization also explains how all these aspects of your difficulties fit together over time, including the situations that might have triggered your problems to develop in the first place and the thoughts and behaviours that keep your problems going over time.  A case conceptualization not only helps clients set specific goals for therapy, but also increases their motivation to experiment with new strategies because they can see how it all fits together. Case conceptualization also guides therapists in their selection between the wide variety of cognitive and behavioural strategies available in CBT, which maximizes the effectiveness and efficiency of the treatment they provide. In this way, you can think of the case conceptualization as the roadmap for therapy.

CBT is not done to you, it’s done with you. Your CBT therapist will be the expert on CBT, but you will be the expert on your personal experiences and circumstances. Both of these areas of expertise are equally important in CBT, so collaboration will occur at every stage of therapy, including when identifying your initial treatment goals, deciding how to use your time each session, and choosing between the different strategies for addressing your areas of concern. To achieve this collaboration, a CBT therapist regularly asks for your feedback, for example, on whether they understood you correctly, whether they missed something important, whether they presented information in a way that you understood, and whether their overall style is working for you. This feedback is what allows your therapist to tailor their approach to better meet your needs and preferences.  You can think of the team dynamic in CBT as like that of a pilot and co-pilot. As the pilot of your life, you will be the one deciding your destination, and as your co-pilot, your therapist will offer suggestions for the different routes or strategies you could take along the way to allow for a smoother ride or to help you reach your desired destination faster. Although you each have different roles, the degree of collaboration in CBT contributes to the sense that your therapist is in it with you, with you both rolling up your sleeves to figure out reasonable next steps to help you get where you want to go.

In comparison to insight-oriented therapies, which help you explore your life experiences for the sake of gaining a deeper understanding of your fears and desires and how they developed over time, CBT is an action-oriented therapy. This action-orientation means that CBT will help you describe the nature, severity, and course of your problems only to the degree necessary to identify goals for change towards greater well-being. Insight may develop over the course of CBT, but insight is not viewed as necessary for the change process, and any insight that does develop is not the end goal, but rather is a means to an end (of taking action). Although the problems that bring you to therapy may have started some time ago, the reason you’re taking the step to look for therapy is because you’re experiencing some sort of difficulty now. For this reason, CBT will help you focus on why your problems are problems for you today, which is when you have the power to make changes. With its action-orientation and focus on current problems and goals for change, CBT can help you achieve your desired treatment outcomes as quickly and efficiently as possible.

An integral part of a CBT session involves collaboratively coming up with an action plan for how the client is going to take what they learned in therapy with them. These action plans will depend on your overall treatment plan and goals, as well as your own ideas about what’s realistic for you to commit to trying before the next session. Earlier in therapy, your action plans might involve doing some reading that your therapist recommends to help you better understand the symptoms you’re experiencing, or you might plan to do some self-monitoring to get a better sense of which symptoms occur, how often, and when. Throughout your session, your therapist will often help you jot down some key take-home points from your discussions, and your action plan may involve reviewing these short notes on a daily basis. Later in therapy, your action plans will involve practising some of the new ways of thinking or behaving that you learned in session. To understand the importance of planning the between-session work, think about what would happen if someone who wants to lose weight speaks with a dietician or personal trainer for an hour each week, but then doesn’t change anything in their eating or exercise habits during the other 167 hours of their week. It’s easy to see how this person is unlikely to make magical changes to their physical health by simply talking about it, and it’s no different when it comes to making improvements to your mental health. Indeed, the research is quite clear that one of the best predictors of a positive therapy outcome is the quantity and quality of the action plans that you complete between sessions.

CBT sessions follow a similar format from week to week, with the specific content of sessions depending on the agenda that you collaboratively set with your therapist in the first few minutes of a given session. Your therapist may have some items to put on the agenda that will keep you moving along your treatment plan, and you may identify other items for discussion based on recent or anticipated experiences in your life. Together, you and your therapist will prioritize among these different possible agenda items and set a plan for how to spend the bulk of the session. Usually the first item on an agenda will be to check on your progress towards the action plan you set last session, including addressing any barriers that arose or fine-tuning your new skills. The next items depend on your specific treatment goals, but generally involve identifying the thoughts and behaviours contributing to the difficulties bringing you to therapy and then learning some new cognitive or behavioural strategies to achieve your goals in the situation. You and your therapist will then come up with an action plan for how you’ll put what you just learned into practice outside of therapy. The final few minutes will be spent debriefing on how the session went, including what went well and what you and your therapist could change to make next session even better.

CBT therapists know that establishing and maintaining a strong relationship with their clients will be essential for their clients to remain in therapy and get the most from it. To establish a sense of emotional safety and strengthen the therapeutic relationship, CBT therapists use a style that is warm and genuine; empathic and nonjudgmental; and collaborative and professional. CBT therapists establish this style by asking questions to understand your feelings and difficulties from your point of view and by communicating directly and indirectly that they care about your well-being, are interested in your experiences, and hold you in positive regard. By communicating their understanding and acceptance of the experiences and reactions that bring you to therapy, a strong therapeutic relationship can be established so that you feel open to exploring other ways of thinking or behaving without fear of judgement.

CBT therapists rely on a process called guided discovery, where they use questions to guide clients to find their own answers. Guided discovery questions could include ones that help clients identify the thoughts running through their minds, examine the evidence supporting or contradicting their beliefs, weigh the pros and cons of thinking or responding a certain way, and explore alternative perspectives and strategies for responding to a thought. CBT therapists might also use guided discovery to help clients set up behavioural experiments to test out their current beliefs and use the results to generate new balanced perspectives to match the whole range of their actual experiences. This guided discovery process helps to ensure that CBT therapists don’t end up debating with their clients about their beliefs, lecturing them on different ways to look at the situation, or projecting their own worldviews on clients with different lived experiences. In this way, clients do not become reliant on a seemingly all-knowing CBT therapist; instead, clients learn a process that they can take with them after therapy ends to continue approaching their lives with an air of curiosity, which will allow them to keep updating their beliefs to match their ever-changing environments.

CBT incorporates a lot of psychoeducation, which refers to the information about psychological issues or treatment that is shared with clients. During the assessment phase, psychoeducation might include discussions or readings about what it means to have a certain diagnosis, what to expect in treatment, or how thoughts are connected in various ways to their emotional reactions and behaviour. During treatment, much of the psychoeducation occurs as clients learn concrete strategies for responding to any unhelpful thinking, painful emotions, or problems they may be facing. To help clients remember the psychoeducation provided in session, CBT therapists may ask their clients to write down what they learned in session to review between sessions, read a self-help book or online article about some of the topics covered, or try sharing some of what they’ve learned with friends or family. Through these various psychoeducational experiences, clients set themselves up to become their own therapists over time.

After collaboratively identifying goals for therapy with their clients, CBT therapists will plan how to monitor their clients’ progress. This progress monitoring may involve having clients complete symptom checklists before each session; track the frequency or severity of the symptoms or problem behaviours they’re trying to reduce throughout the week; or keep a log of what happens when they use new skills. By regularly monitoring the impact of treatment, clients and therapists have access to timely information to guide their treatment decisions. For example, when progress occurs as expected and therapy goals are achieved, the client and therapist can have discussions about adding new goals, spacing out sessions, or ending therapy altogether. Alternatively, if progress is not being achieved as expected, adjustments can be made to the treatment to better address the client’s needs and improve their therapeutic outcomes.