Treatment Planning in CBT

Treatment Planning in Cognitive Behavioural Therapy (CBT)

Treatment planning in CBT is a dynamic, collaborative process that is anchored in a developing cognitive conceptualisation of the client’s issues. This conceptualisation serves as the foundation for all therapeutic decisions and is continuously refined throughout the course of treatment.

The process begins with identifying key elements that inform the client’s psychological distress, including:

• Behavioural obstacles – actions or patterns that maintain or worsen psychological symptoms.
• Precipitating factors – specific events or situations that trigger emotional or behavioural responses.
• Key developmental events – formative experiences from the client’s past that may have shaped their current beliefs and behaviours.
• Enduring patterns of interpretation – consistent ways in which the client views themselves, others, and the world.

These elements are used to build a clear, structured understanding of how dysfunctional thinking and maladaptive behaviour contribute to the client’s emotional experience. This framework enables the therapist to:

• Understand the client’s strengths, challenges, aspirations, and emotional triggers .
• Strengthen the therapeutic relationship through transparency and shared understanding.
• Develop a tailored, adaptive treatment plan that evolves as new information emerges.

A central principle of CBT treatment planning is that it is not static. Instead, it is an ever-evolving cognitive conceptualisation, meaning that the therapist and client jointly refine the understanding of the problem as therapy progresses . This allows for flexibility and responsiveness to changes in the client’s experience.

Treatment plans also incorporate evidence-based interventions such as:

• Thought evaluation strategies to challenge maladaptive automatic thoughts.
• Cognitive restructuring techniques to replace distorted beliefs with more realistic ones.
• Behavioural experiments to test the validity of beliefs and reduce avoidance behaviours.
• Problem-solving and role-playing to enhance coping and improve real-world functioning.

Importantly, CBT treatment is culturally adapted and tailored to the individual, ensuring relevance and accessibility across diverse backgrounds. The therapeutic relationship is considered essential, fostering trust and collaboration between therapist and client.

Finally, progress is continuously monitored throughout therapy, allowing for timely adjustments to the plan and ensuring that treatment remains effective and aligned with the client’s goals.

Ideal Formulation Process

1. Assessment
2. Formulation
3. Identify maintaining mechanism
4. Choose intervention targeting that mechanism
5. Test
6. Review learning
7. Update formulation.

Ideal Session Structure

0–5 min — Check-in

• mood/current functioning;
• significant events;
• risk where indicated.

5–10 min — Homework review

• What did you try?
• What happened?
• What did you learn?
• If it wasn’t completed, what got in the way?

10–12 min — Agenda

• therapist item;
• client item;
• agree priority. 12–37 min — Main intervention
• behavioural experiment;
• cognitive restructuring;
• exposure;
• formulation work;
• skills practice.

37–43 min — Consolidate

• “What did you learn today?”
• connect it back to formulation.

43–47 min — Homework

• collaboratively agree on a specific behavioural task.

47–50 min — Summary and feedback

• client summarises key learning if possible;
• “What was helpful?”
• “Anything we should do differently next time?”

Real-World Example: Treatment Planning for Social Anxiety (e.g., Thomas)

Client Presentation: Thomas experiences social anxiety in workplace settings. He fears appearing awkward or making mistakes, which triggers physical symptoms such as sweating and a racing heart. He often ruminates on past interactions and anticipates future social situations negatively. To manage his anxiety, he engages in avoidance behaviours and safety behaviours (e.g., not speaking up, leaving early from meetings). Despite this, he has a stable job and enjoys some activities, indicating protective strengths.

1. Case Formulation Using the 5Ps Model

• Presenting: Social anxiety in the workplace; fear of judgement, physical symptoms during social interactions.
• Predisposing: Introversion and shyness from childhood.
• Precipitating: A recent presentation at work intensified his anxiety.
• Perpetuating: Mental rehearsal, rumination, avoidance, and assuming the worst outcomes.
• Protective: Has a job, engages in some enjoyable activities.

This formulation identifies how early experiences (predisposing), a specific trigger (precipitating), and ongoing thought patterns (perpetuating) maintain his anxiety.

2. CBT Model of Anxiety (The “Three B’s”)

Based on the cognitive-behavioural model of anxiety, Thomas’s experience can be broken down into:

1. Brain — thoughts, predictions, images, attention
2. Body — sweating, trembling, heart racing
3. Behaviour — avoidance, escape and safety behaviours

Situation → Brain ↔ Body ↔ Behaviour → consequences

These three components form a cycle where negative thoughts amplify physical symptoms, which in turn reinforce avoidance behaviours, perpetuating anxiety.

I like to do both the 4/5 P’s model and the CBT model at the same time at least initially. I found that if I relied too heavily on the 5 P’s model I would neglect the CBT formulation (which is not great I know), and then find myself stuck on the next steps.

3. Treatment Plan (10-Session Structure)

10 Sessions due to Mental Health Care Plan (MHCP) in Australia. So, 6 initial sessions, review by General Practitioner (GP), then 4 additional in one calendar year.

Also, remembering sessions last for about 40-50 minutes (hopefully), so we really want to be keeping on agenda. I have struggled with this a lot in my journey in becoming a psychologist because I have not had much experience in a private practice setting. There is more leeway in other settings e.g. school/other settings, and I really think this has been a hindrance to my development as a psychologist.

Session 1 - Assessment, Psychoeducation, & Goal Setting

• 0–5 min: introductions, consent/confidentiality, expectations
• 5–25 min: assessment of presenting concerns, history, functioning, risk
• 25–35 min: collaboratively identify goals
• 35–43 min: simple initial CBT explanation/formulation
• 43–47 min: agreed between-session task
• 47–50 min: summary and feedback
• Also, asking how you found the session, if there are any changes you would like e.t.c. This should be a re-occurrence at every session end if time permits.

Session 2 – Individual CBT Formulation of Social Anxiety

• Check-in and brief risk review, where clinically indicated.
• Review homework and ask what Thomas noticed from monitoring social situations.
• Collaboratively set the session agenda.
• Select one recent social-anxiety episode and reconstruct it in detail:
  • What was the situation?
  • What did Thomas predict would happen?
  • What went through his mind?
  • Did he have an image of how he appeared to others?
  • Where was his attention focused?
  • What did he notice physically?
  • What emotion did he experience?
  • What did he do?
  • What did he do specifically to prevent the feared outcome?
  • What did he think about the interaction afterwards?
• Develop Thomas’s individual maintenance cycle.
• Identify avoidance and safety behaviours such as:
  • avoiding eye contact;
  • rehearsing sentences internally;
  • speaking quickly;
  • saying very little;
  • checking whether he is sweating;
  • gripping objects to hide trembling;
  • leaving meetings early.
• Explain why safety behaviours can paradoxically prevent Thomas from discovering that his feared prediction may not occur.
• Begin developing a hierarchy/list of feared social situations.
• Agree on a simple between-session monitoring task.
• Summarise and obtain feedback.

Session 3 – Self-Focused Attention & Safety Behaviours

Aim

Help Thomas recognise that how he responds to anxiety may actually maintain it.

You have already identified something like:

Situation: Team meeting
Prediction: “I’ll say something stupid and everyone will think I’m incompetent.”
Body: Heart racing, sweating
Attention: “Can they see me sweating? Do I sound nervous?”
Safety behaviours: Rehearses sentences, speaks quickly, avoids eye contact, says very little
Consequence: Gets through meeting, but concludes “I only survived because I kept quiet.”

In session

Check-in → bridge from last session → homework review → agenda

Then review one of Thomas’s examples from the week.

I’d introduce self-focused attention:

“It sounds like when you’re in these situations, quite a lot of your attention moves away from the conversation and onto yourself, how you’re standing, how you’re talking, whether you’re sweating, what your face is doing.”

Then explore what happens as a result.

You can do an attention experiment in session.

For example, have a 2–3 minute conversation twice:

1. Thomas deliberately monitors himself:

   • How am I sitting?
   • How does my voice sound?
   • Am I making enough eye contact?
   • What should I say next? Rate anxiety and perceived performance.

2. Thomas deliberately directs attention externally:

   • What colour is the room?
   • What exactly is the other person saying?
   • What expression are they making?
   • What can I learn about them?

Then compare:

Anxiety: 7/10 → 4/10
Perceived awkwardness: 8/10 → 4/10
Ability to follow conversation: 3/10 → 7/10

Then identify safety behaviours.

Thomas might:

• rehearse sentences;
• avoid eye contact;
• speak quietly;
• rush his sentences;
• overprepare;
• hold his hands together so nobody sees them shake;
• ask lots of questions to avoid talking about himself;
• stay near exits;
• leave meetings early.

Homework

Pick something manageable:

During one workplace conversation, practise shifting attention externally and reduce one safety behaviour. Record what you predicted would happen and what actually happened.

Now you’re preparing for behavioural experiments.

Session 4 – Behavioural Experiments & Initial Exposure

e.g.

“We’ve identified some predictions your anxiety is making. Let’s start testing whether those predictions are accurate.”

Behavioural experiment.

Example

Thomas’s belief:

“If I don’t rehearse what I’m going to say, I’ll say something stupid.”

Ask:

How strongly do you believe that?

Thomas: 85%

What would count as saying something stupid?

Then design an experiment.

Experiment 1

During a conversation with a colleague:

• don’t mentally rehearse the sentence;
• allow yourself to pause;
• direct attention externally;
• speak normally.

Before:

Prediction:
“If I don’t rehearse, I’ll freeze and the conversation will become awkward.”

Likelihood: 80%

After:

What actually happened?

“I paused once. They didn’t seem bothered and just continued talking.”

What did you learn?

“Maybe pauses aren’t as noticeable as I think.”

Exposure hierarchy

For example:

Homework

e.g. Complete 2–3 behavioural experiments, recording: Situation → prediction → belief rating → safety behaviour to drop → outcome → learning

Session 5 – Cognitive Restructuring + Behavioural Experiments

“You predicted there was an 80% chance the conversation would become awkward if you didn’t rehearse. What happened?”

Socratic questioning.

Thomas:

“Everyone thought my presentation was terrible.”

You could explore:

What evidence suggests that?

“Nobody said much afterwards.”

Does nobody saying anything necessarily mean they thought it was terrible?

“Not necessarily.”

What else might explain it?

“They had another meeting immediately afterwards.”

What did people actually do during the presentation?

“They listened. One person asked a question.”

If one of your colleagues gave exactly that presentation, what would you think of them?

“Probably that they were nervous, but it was fine.”

Then identify the distortion:

• mind reading;
• catastrophising;
• emotional reasoning;
• selective attention;
• double standards.

Homework

e.g. Continue behavioural experiments but explicitly test a belief.

For example:

“If I show signs of nervousness, people will think less of me.”

Session 6 – Review Progress + Progress Exposure

Symptoms

Repeat whichever outcome measure you’re using.

For example:

SPIN

• Session 1: X
• Session 6: Y

But don’t rely only on questionnaire scores.

Functional change

Remember Thomas’s original goals.

Maybe:

Goal 1: Stay for entire staff meeting
Goal 2: Contribute at least once during meetings
Goal 3: Give a presentation without excessive rehearsal
Goal 4: Attend workplace social functions

Ask:

“What can you do now that anxiety stopped you doing six weeks ago?”

That can be more meaningful than symptom reduction.

Update the formulation

Your original formulation might have been:

Trigger → “I’ll embarrass myself” → anxiety → avoid/safety behaviour → relief → belief maintained

Now perhaps you’ve discovered:

“I have to come across as intelligent all the time.”

That’s useful new information.

The formulation changes.

Exposure becomes harder

For example:

Thomas deliberately:

• asks a question without rehearsing;
• offers an opinion;
• allows a pause;
• admits he doesn’t know something;
• talks while visibly nervous.

This introduces an important idea:

Deliberate imperfection

Rather than Thomas constantly trying to perform flawlessly:

“What would happen if we deliberately allowed a small imperfection?”

Maybe:

• stumble slightly over a sentence;
• admit “I’m not sure”;
• leave a small pause;
• ask someone to repeat themselves;
• correct himself after making a minor error.

Not to embarrass him for the sake of it, but to test:

“What happens when I’m not socially perfect?”

Session 7 – More Challenging Behavioural Experiments

Majority of therapy is happening outside of the therapy room.

For Thomas this could mean:

“This week our target is speaking during the team meeting.”

Work through it beforehand.

Before

Situation: Weekly staff meeting

Prediction:

“If I say something and stumble over my words, everyone will think I don’t know what I’m doing.”

Belief: 75%

Usual safety behaviours:

• rehearsing;
• waiting until someone else raises the point;
• looking down;
• speaking quickly.

Experiment:

• contribute once;
• no full mental rehearsal;
• speak at normal pace;
• maintain external attention;
• allow anxiety to be present.

Afterwards

“What did you predict?”

“What actually happened?”

“What did other people actually do?”

“Did your safety behaviour make a difference?”

“What does this tell us?”

Session 8 – Anticipatory Worry & Post-Event Rumination

Before

“Tomorrow’s presentation is going to be awful.”

Then:

• rehearses;
• imagines failure;
• checks PowerPoint repeatedly;
• loses sleep;
• visualises people judging him.

After

“Why did I say that?”

“They probably noticed I was nervous.”

“Why didn’t Sarah smile?”

“I sounded like an idiot.”

So even a completely neutral social experience gets mentally reconstructed as a failure.

Anticipatory processing → EVENT → post-event processing

and explain how both maintain the belief.

Intervention

Compare:

What Thomas remembers happening

versus

what objectively happened.

For example:

Thomas:

“I was visibly shaking.”

Ask:

“What evidence do we have?”

He may realise:

“I felt like I was shaking. I don’t actually know whether anyone could see it.”

Excellent example of:

feeling ≠ observable fact.

You can also distinguish:

Productive reflection: “I spoke too quickly. Next time I’ll slow down.”

from

Rumination: “Why am I like this? Everyone probably thinks I’m weird.”

Homework

After a social event:

Write the facts of the event before engaging in an extended post-mortem.

Then compare his prediction with observable evidence.

Session 9 – Underlying Beliefs + Generalisation

You may now start seeing the deeper assumptions driving the pattern.

For example:

Conditional assumptions

“If I make a mistake, people will think I’m incompetent.”

“If I don’t know what to say, people will think I’m boring.”

“I must always appear confident.”

Core beliefs

Potentially:

“I’m inadequate.”

“I’m unlikeable.”

“I’m different.”

I wouldn’t necessarily dive into childhood schema work just because you’re at Session 9.

Instead ask:

“Is this belief still maintaining the current problem?”

If yes, test it.

Thomas might believe:

“Competent people never look nervous.”

Behavioural experiment:

Ask trusted colleagues or observe others giving presentations.

What happens?

He may discover competent people:

• forget things;
• pause;
• lose their place;
• appear nervous;
• say “I don’t know”;
• make jokes about mistakes.

Then develop a more flexible rule:

Old: “I must appear confident or people will think I’m incompetent.”

New: “I can appear nervous or make mistakes and still be competent.”

Generalisation

Also make sure improvement isn’t restricted to work.

Can Thomas apply the learning to:

• meeting strangers;
• parties;
• dating;
• shops;
• phone calls;
• speaking to authority figures?

Where relevant, of course.

Session 10 – Consolidation & Relapse Prevention

Reassess

Repeat baseline measure.

Compare:

Session 1 → Session 10

Also compare goals.

Maybe:

Notice you don’t need:

“Anxiety = 0.”

Thomas can still experience anxiety.

The more meaningful change might be:

Thomas participates despite anxiety.

Review the original formulation

Go back to the model from Session 2.

You might literally ask:

“What kept the anxiety going?”

Hopefully Thomas can now explain:

“I’d assume people were judging me, focus on myself, notice my heart racing, rehearse everything, speak quickly and avoid saying much. Then because nothing bad happened I’d think it was because I’d protected myself, rather than learning that the situation wasn’t as dangerous as I thought.”

That’s a very good indication that he understands the CBT model.

Create a relapse-prevention plan

Identify early warning signs:

“I’m starting to avoid meetings again.”

“I’m rehearsing everything before I speak.”

“I’m spending hours analysing conversations.”

Then:

If I notice this → I will…

• revisit my formulation;
• identify the prediction;
• identify the safety behaviour;
• create a behavioural experiment;
• redirect attention externally;
• approach rather than avoid;
• review what actually happened.

Future experiments

Thomas should leave with things he hasn’t conquered yet.

For example:

Give a larger presentation.

Attend networking event.

Chair a meeting.

Express disagreement with senior colleague.