How to Structure a CBT Session: A Practical Guide for New Therapists

Start by reconnecting with the person in front of you. Before moving into techniques, make space to understand how they have been since your last meeting.

You might ask:

• “What has stood out since we last met?”

• “What has been difficult, and what has gone well?”

• “Is there anything important you want me to know today?”

Listen for changes, strengths, and possible priorities. Reflect what you hear and check your understanding. These opening minutes can help you recognise what needs attention before agreeing on the session’s focus.

A brief mood check gives you a starting point for understanding the client’s current experience. Ask about a specific emotion and define the scale clearly:

• “On a scale from 0 to 10, where 0 means no anxiety and 10 means the most intense anxiety you can imagine, how anxious do you feel right now?”

Distinguish current feelings from the client’s experience over the week. Ask what has influenced the rating and how they have been managing daily activities. Where appropriate, incorporate validated measures into progress monitoring. Ratings become more useful when they inform the conversation and treatment plan.

A mood score alone does not establish safety. If concerns arise, assess and respond to them according to your clinical training, supervision, and service procedures.

Introduce a shared agenda before the opening discussion becomes the whole session. Invite the client to identify what would make today useful, then add any priorities you would like to discuss.

For example:

• “You’ve mentioned the meeting at work and the argument with your sister. I’d also like us to review the plan we made last time. Where would you most like us to focus?”

Choose a manageable focus together. Agenda setting gives clients an active role in deciding how to use their time and helps establish shared expectations.

Keep the agenda open to revision if something more pressing emerges.

Reviewing between-session practice connects one appointment to the next. Explore what the client tried, what happened, and what they learned.

Useful questions include:

• “What did you notice when you tried it?”

• “How did the outcome compare with your prediction?”

• “What helped, and what got in the way?”

If the activity did not happen, explore the barriers with curiosity. Perhaps the plan was too demanding, unclear, or difficult to fit into the client’s circumstances. Use this information to make the next step more workable.

The term action plan can help communicate the purpose of this practice: applying learning outside therapy through activities agreed on together.

Once you have agreed on a focus, move from a broad description to a particular example.

If a client says, “I always struggle at work,” you might ask:

• “Could we look at a recent moment when that feeling was especially strong?”

Explore what happened, what went through their mind, what emotions and physical sensations appeared, and what they did next.

For example, in a fictional scenario, a client might describe:

• Situation: Their manager requested changes to a report.

• Thought: “They think I’m incompetent.”

• Emotion: Anxiety and shame.

• Physical response: Tightness in the chest.

• Behaviour: Avoiding the report and delaying a reply.

This makes the experience specific enough to examine together. The cognitive model considers how interpretations of situations relate to emotional, behavioural, and physical responses.

Ask what the situation meant to the client. “What felt most upsetting about that?” may reveal more than immediately naming a thinking pattern.

You might also ask:

“What were you afraid would happen next?”

Let the emerging understanding guide your next step. Depending on the client’s needs, you might evaluate a thought, practice a skill, solve a practical problem, or plan a behavioural intervention. Exploring deeper beliefs can be useful when relevant, but it need not happen in every session. Technique selection should follow the formulation and be collaborative.

When evaluating a thought is appropriate, approach it as a question to investigate together. Avoid assuming that a distressing thought must be inaccurate. Clients may be responding to real difficulties, loss, discrimination, or uncertainty.

Questions could include:

• “What makes this interpretation feel convincing?”

• “Is there anything that points towards another explanation?”

• “What would you say to someone you cared about in this situation?”

The aim is to help the client examine their experience and develop a useful response. CBT emphasises collaborative exploration; telling someone that their thinking is wrong can leave them feeling misunderstood.

If the discussion leads to a different perspective, help the client express it in their own words.

In the fictional workplace example, that might be:

“Being asked to revise a report doesn’t tell me everything my manager thinks about my ability. I can clarify the feedback and work through the changes.”

Ask how believable this feels. If the statement sounds reassuring but unconvincing, explore what is missing. The client does not need to agree with wording that fails to reflect their experience.

Then connect the learning to a practical question:

“What might you do differently if you kept that in mind?”

Agree on an action that follows from the session and connects with the client’s goals. Make it specific enough that they know when and how to begin.

For a behavioural experiment, clarify the prediction and what the client will observe. In the workplace example:

“I predict that asking one clarifying question will make my manager criticise my ability. I’ll ask the question and record what they actually say.”

Consider whether the activity is appropriate in the client’s real circumstances. Discuss likely obstacles, adjust the size of the task, and agree on how they will remember it. Record the plan in a format they can use between sessions.

Leave time for the client to describe what they are taking away. Ask:

“What feels most useful from today’s conversation?”

Add anything important they have missed and confirm the action plan. You can revisit the opening mood rating, while remembering that immediate relief is only one aspect of progress. Changes in everyday functioning and movement towards treatment goals also matter.

Finally, invite feedback about the session:

“Was there a point when I misunderstood you or moved too quickly?”

Respond openly and use the answer to shape your work together. Feedback is part of maintaining collaboration throughout CBT.

As a new therapist, you may initially need a brief reminder of the session’s main elements. With practice and supervision, moving between them can feel more natural.

Use the structure to support your attention to the client. Keep checking whether you share the same focus, whether the intervention fits their needs, and whether the next step feels meaningful and achievable. A useful session gives the client room to be understood and an opportunity to practice something that matters in their life.