2

Cognitive Restructuring
David A. Clark
University of New Brunswick, Canada

A. T. Beck’s cognitive therapy (CT) has made a substantial contribution to current

evidence-based cognitive behavioral therapy (CBT) for a variety of psychiatric dis-
orders, most notably depression, anxiety, personality disorders, and, more recently,
psychosis. A. T. Beck’s (1987, 1996) cognitive model postulates that biased self-
relevant thoughts, evaluations, and beliefs are key contributors to the development
and persistence of psychopathological states. The biased thoughts and appraisals that
characterize psychopathology are derived from maladaptive mental representations
of reality stored in memory structures called schemas. Schematic content or beliefs
organize and guide the selection, encoding, and retrieval of information. Given their
central role as progenitors of a biased and maladaptive information processing appa-
ratus, the cognitive model considers schematic change essential for significant and
enduring symptom reduction (A. T. Beck, Rush, Shaw, & Emery, 1979; D. A. Clark,
Beck, & Alford, 1999).
The term cognitive restructuring has been used to describe the schematic change
mechanism articulated in CT. It refers to a structured, collaborative therapeutic
approach in which distressed individuals are taught how to identify, evaluate, and
modify the faulty thoughts, evaluations, and beliefs that are considered responsible
for their psychological disturbance (Burns & Beck, 1978; Dobson & Dozois, 2010;
Hollon & Dimidjian, 2009). In their first seminal treatment manual, Beck and
associates emphasized thought self-monitoring, reality testing, external reattribution,
evidence gathering, examining consequences, cost/benefit analysis, generating alter-
natives, and behavioral assignments as key interventions for inducing cognitive change
(A. T. Beck et al., 1979). However, A. T. Beck did not refer to this suite of interven-
tions as cognitive restructuring until the publication of his second treatment manual
for anxiety disorders (A. T. Beck & Emery, 1985). Since then, various descriptions of

The Wiley Handbook of Cognitive Behavioral Therapy, First Edition.

Edited by Stefan G. Hofmann. Volume I edited by David Dozois.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.
DOI: 10.1002/9781118528563.wbcbt02
2 General Strategies

CT have referred to the cognitive interventions utilized to achieve schematic change

as cognitive restructuring (e.g., D. A. Clark & Beck, 2010; Dobson & Dobson, 2009).
In this chapter, cognitive restructuring (CR) is defined as structured, goal-directed,
and collaborative intervention strategies that focus on the exploration, evaluation,
and substitution of the maladaptive thoughts, appraisals, and beliefs that maintain
psychological disturbance. Within this definition both cognitive and experiential or
behavioral interventions are considered CR as long as the intention is cognitive or
schematic change. The remainder of the chapter provides an in-depth examination of
CR. I begin with a conceptual analysis of schemas and the three key components of
CR. This is followed by a review of empirical research that has attempted to isolate
the specific therapeutic efficacy of CR. The chapter concludes with a discussion of
critical research issues pertinent to CR.

The Nature of Cognitive Restructuring

Defining Schematic Change

Since CR is defined in terms of schematic change, a conceptualization of CR is rooted
in the definition of schemas. In A. T. Beck’s cognitive model schemas are meaning-
making constructions of the cognitive organization that have content, structure, and
function (A. T. Beck, 1964). They embody top-down processing in which schema-
driven processes select, organize, and prioritize human cognition. In essence schemas
have an executive function, directing information-processing resources so that
schema-congruent information has priority over schema-incongruent information.
In depression, for example, negative self-referent schemas of loss, failure, rejection,
and hopelessness predominate. As a result the cognitive apparatus of the person
with clinical depression is oriented toward processing schema-congruent negative
self-referent information.
A key goal of CR, then, is to reverse this maladaptive schema-congruent pro-
cessing bias by questioning the automatic acceptance of negative schema-congruent
information and encouraging assimilation of more adaptive schema-incongruent data.
Traditionally, a change in belief ratings is considered a measure of the client’s shift
from maladaptive schematic processing to more normal, adaptive schema activation
(A. T. Beck et al., 1979). Thus a depressed client, in the course of therapy, demon-
strates a reversal in depressotypic schema-congruent processing bias when he or she
professes diminished belief in the view “I am a complete loser who will never amount
to anything,” and greater belief in the idea “I have had some failures in my life but
also many successes; this means I can learn from my failures and forge a brighter
future for myself.” However, it is not clear how well this indicator of change applies to
CR more generally. Belief ratings may be a less sensitive indicator of cognitive change
for some disorders, such as anxiety, and reversal of the dominance of maladaptive
schema-congruent processing is far from a monotonic, linear decline in absolute
influence, as any practitioner can attest. Rather, clients often exhibit a more fluctuat-
ing pattern of shifting schematic processing that is influenced by circumstances and
even mood state, with symptom improvement associated with an eventual dominance
 Cognitive Restructuring 3

of adaptive schematic processing over the maladaptive disorder-related schemas. It

must also be recognized that long-term dominance of maladaptive schema-congruent
processing in distressed individuals poses special challenges for CR because these
beliefs will always seem more intuitive and inherently plausible to the individual. The
more entrenched the maladaptive schematic organization, the less responsive they are
to initial CR efforts.
As well as executive function, schemas also have structural characteristics. A. T.
Beck (1967) noted that maladaptive schemas are inflexible, closed, impermeable, and
relatively concrete systems. Most often they are rooted in negative, or even adverse,
early childhood experiences and are subsequently reinforced and strengthened by
congruent life events in adolescence and adulthood. For example, the person with an
obsessive-compulsive personality disorder will have experiences that appear to confirm
his or her belief that “It is critical that I pay close attention to detail in all that I do
in order to avoid making mistakes.” With repeated activation and reconfirmation, the
maladaptive schemas attain a higher degree of interrelatedness so they gain greater
capability of dominating the information processing system (Segal, 1988). Various
studies have investigated schematic structure in depression. Using a grid task to assess
schematic structure, Dozois and Dobson (2001) found that a clinically depressed
group had more interconnectedness for negative self-referent adjectives and less
interconnectedness for positive adjectives than nonpsychiatric controls, although the
anxious and depressed groups differed primarily in their organization of positive,
rather than negative, schemas. In a later study, Dozois (2007) found that clinically
depressed individuals may exhibit more interrelatedness of negative interpersonal but
not achievement schemas that endures even with remission of the depressive state.
The very structure of psychopathological schemas and their inherent prepotent
nature makes schematic change especially difficult to achieve. In the course of con-
ducting CR, most clients will have great difficulty recognizing schema-incongruent
information, questioning their intuitively based maladaptive schemas, and accepting
more adaptive beliefs. For the individual with health anxiety, the automatic maladap-
tive interpretation “What if the red spot on my arm is cancerous?” will feel more
intuitively plausible because of underlying rigid, highly interrelated, and generalized
dysfunctional schemas about death, disease, and vulnerability. Cognitive therapists
using CR, then, must build into their intervention plan recognition of the relative
impermeability of psychopathological schemas.
It is schematic content that is the primary focus of CR. The content or proposi-
tional elements of maladaptive schemas consist of negative idiosyncratic generalized
attitudes, beliefs, and assumptions about the self, personal world, future, achievement,
and interpersonal relations (Dozois & Beck, 2008; Ingram & Kendall, 1986). A. T.
Beck (1976, 1987) proposed that different psychopathological conditions, as well as
normal emotion states, are characterized by their own unique belief content. Known
as the content-specificity hypothesis (D. A. Clark et al., 1999), the cognitive model
proposes that depression is characterized by themes of loss and deprivation, anxiety by
threat and vulnerability, each of the personality disorders by disorder-specific content,
and psychosis by misinterpretation of subjective experience. This disorder-specific
schematic content will be easily accessed by a wide range of triggering cues and readily
available to guide information processing. Thus, the goal of CR is to modify schematic
4 General Strategies

organization or interconnectedness, reduce the accessibility or activation threshold of

maladaptive schematic content, and strengthen access to competing, more adaptive
beliefs and assumptions.
In sum, the schematic change achieved by CR involves two fundamental processes.
After identifying the key disorder-relevant schemas, the cognitive behavioral therapist
utilizes a series of cognitive interventions to reduce the activation threshold, accessibil-
ity, and availability of the maladaptive schemas. Over time and with repeated effortful
evaluation, the processing priority and interconnectedness of the maladaptive schemas
are weakened and schema-congruent processing becomes less automatic. Second, CR
also involves the process of learning to substitute more normal, adaptive schemas
about the self, world, and future. Lowering the activation threshold and strength-
ening the accessibility and acceptance of competing adaptive schemas that counter
disorder-related beliefs are critical objectives of CR. In the end, CR seeks to elevate
normal adaptive schematic processing through evidence-based thinking so it comes
to predominate the information processing system. It is through this process that CR
achieves enduring symptomatic change and remission of the psychopathological state.

Key Components of Cognitive Restructuring

In order to achieve schematic change, an effective CR program has three critical
components. Each of these components is necessary for the success of CR. If any
component is missing, the intervention would not constitute CR but some other
form of intervention. Each component may consist of various intervention strategies,
but together collaborative empiricism, verbal intervention, and empirical hypothesis-
testing constitute the therapeutic process involved in CR. The following provides an
explanation and illustration of these three central elements of CR.

Collaborative empiricism. A. T. Beck and colleagues (A. T. Beck et al., 1979; A. T.

Beck & Emery, 1985) introduced the term “collaborative empiricism” to describe the
therapeutic relationship adopted in CR. The concept has been refined and elaborated
by subsequent clinical researchers and is now considered a critical element in the
effectiveness of CT or CBT (J. S. Beck, 2011; Kuyken, Padesky, & Dudley, 2009;
Tee & Kazantzis, 2011). In essence, collaborative empiricism involves the client and
therapist sharing their respective expertise in order to describe, explain, and help
resolve the client’s problems. In recognizing their respective contributions to the
therapeutic enterprise, the therapist as an expert in the human change process, and
the client as having the lived experience of the problem, work together on formulating
treatment goals, setting the session agenda, and negotiating homework assignments.
Therapist and client share equal responsibility for the direction of therapy, in which
the therapist frequently seeks feedback and ensures understanding from the client.
A strong therapeutic alliance and client engagement in the therapy process is a
necessary but not sufficient feature of effective CR. To achieve a collaborative atmo-
sphere, the therapist (a) educates the client on the CT model to establish an agreed
rationale for achieving change, (b) involves the client in identifying and prioritizing
treatment goals, (c) collaborates on setting the session agenda, (d) asks questions
and requests client feedback throughout the session, and (e) negotiates homework
 Cognitive Restructuring 5

assignments. This strong emphasis on mutual responsibility and joint involvement

in the therapeutic process ensures that CR does not become dictatorial, with the
therapist imposing ideas and direction on the client. An authoritarian, overly didactic,
and uncompromising therapist style will quickly undermine the effectiveness of CR.
Empiricism is another central feature of the therapeutic process in CR. The thera-
pist encourages the client to take an investigative, questioning approach to long-held
beliefs and attitudes. Throughout treatment, an emphasis is placed on observa-
tion, experiential evaluation, and learning (Kuyken et al., 2009). The therapist uses
Socratic questioning of the client’s past personal experiences to evaluate the validity of
maladaptive beliefs and to introduce the possibility of a more adaptive alternative per-
spective. In addition, experientially based exercises are formulated that can empirically
verify the veracity of the alternative belief and challenge the validity of maladaptive
schemas. The cognitive therapist frequently encourages the client to “test this with
your experience,” or “collect some evidence and see what can be learned.” Through-
out each session the therapist places a strong emphasis on empiricism to achieve
schematic change. Tee and Kazantzis (2011) argue that effective collaborative empiri-
cism will encourage clients more readily to attribute behavioral change to their own
efforts rather than external forces or the skills of the therapist. This self-determined
attribution should result in better and more persistent treatment outcomes.
The importance of collaborative empiricism is especially acute when a therapeutic
impasse arises. This can often happen in the treatment of the anxiety disorders,
for example. Most clients seeking CBT for anxiety desire immediate relief from
their heightened subjective anxiety. For them the goal of treatment is quite clear;
the elimination of anxious feelings. However, CBT for anxiety involves exposure to
anxious situations, intentional elevation of subjective anxiety, and a greater acceptance
or tolerance of anxiety. In this case the client’s and therapist’s treatment objectives may
collide. A strong emphasis on collaborative empiricism will be critical for overcoming
these differences by helping the client identify and evaluate schemas that might
threaten the effectiveness of CR (D. A. Clark, in press).

Verbal interventions. Over the years cognitive behavioral researchers and practitioners
have proposed a number of verbal intervention strategies that can be used by therapists
directly to modify maladaptive schematic content. These strategies, which in many
respects are the essence of CR, are summarized in Table 2.1.
The first four strategies are the most common verbal interventions used in CR, first
introduced by A. T. Beck et al. (1979; A. T. Beck & Emery, 1985) in the original
CT treatment manuals and then later refined and elaborated by other cognitive
therapists (e.g., J. S. Beck, 2011; D. A. Clark & Beck, 2010, 2012; Dobson &
Dobson, 2009; Greenberger & Padesky, 1995; Wells, 1997; Wright & McCray,
2012). Evidence gathering, cost/benefit analysis, identifying cognitive errors, and
generating alternative explanations are such an integral part of CR that implementing
these verbal interventions is what most therapists think of as cognitive restructuring.
They are robust and versatile interventions that can be used in most clinical disorders.
Since these strategies are well described in the sources cited, I will confine my
comments to a few general observations.
6 General Strategies

Table 2.1 Verbal Intervention Strategies Employed in Cognitive Restructuring

Intervention strategy Description

1. Evidence Obtaining schema-congruent and -incongruent evidence from

gathering the client’s past and current experience that enables a more
balanced evaluation of schematic content.
2. Consequential Examining the immediate and long-term costs and benefits of
analysis continued acceptance of the maladaptive belief.
3. Cognitive bias Training clients in greater awareness of the cognitive biases
identification that operate when processing schema-relevant information
(e.g., dichotomous thinking, catastrophizing, mind reading,
magnification/minimization, etc.).
4. Generate Formulating a more adaptive conceptualization of the self or
alternative some aspect of personal experience that more accurately
represents external contingencies and that enhances the
client’s functional adaptation.
5. Normalization Reconceptualizing unwanted thoughts, feelings, and behavior
as deviations of normal human experience in order to
encourage greater acceptance and confidence in dealing with
schema-related subjective experience.
6. Decatastrophizing Developing a hypothetical account of a worst-case scenario,
evaluating its realistic and probable effects on quality of life,
and formulating a coping plan to deal with the catastrophe.
7. Problem solving Specifying a real-life problem, delineating the pros and cons of
various responses to the problem, selecting a course of
action, and evaluating the outcome.
8. Imaginal exposure Guiding the client in repeatedly and systematically generating
a schema-related unwanted intrusive thought, image, or
emotion in order to enhance client self-efficacy in dealing
with unacceptable emotions.
9. Distancing Teaching clients to take a “third party” or observer stance to
their unwanted thoughts and emotions; to react to their
subjective experience as if it belonged to another person.
10. Reframing or Focusing on current experience as a moment in time and
perspective situating it within a longer lifespan time frame or the totality
taking of one’s life experience.
11. Reattribution Identifying the external or situational causes of the client’s
difficulties in order to address exaggerated internal
attributions and self-blame.
12. Positivity Refocusing the client on positive, adaptive personal coping
reorientation experiences that provide schema-incongruent information.

In order to utilize any of these verbal interventions, clients must be willing to engage
in an evaluative process. That is, they must be willing at least to consider the possibility
that their maladaptive schematic thinking might be inaccurate, counterproductive, and
unrealistic. Of course, clients will be considerably invested in retaining their schematic
view of themselves and current circumstances, but there has to be a willingness at
 Cognitive Restructuring 7

least to consider alternative perspectives. Clients who insist that their maladaptive
beliefs are immutable facts will not be amenable to CR. Second, the therapist always
begins by inviting clients simply to examine and evaluate their thoughts and beliefs in
the light of empirical evidence, that is, their own personal experience. The therapist
refrains from cajoling, debating, or trying to convince the client of a more adaptive
alternative belief instead of clinging to the maladaptive schematic perspective. Rather,
clients are encouraged to generate an alternative view that provides the best fit with
“objective” external experience and would be associated with an improvement in
their emotional functioning. Third, effective CR will ensure an equal emphasis on
questioning the veracity of the maladaptive beliefs and evaluating the relevance of
a more adaptive alternative viewpoint. The objective of CR is to raise doubts in
the client’s mind about long-held maladaptive beliefs (e.g., “People will notice I’m
anxious and think there is something wrong with me”) and to consider the accuracy
and utility of an alternative perspective (e.g., “People might notice I’m a little anxious
but consider it unimportant”).
The remaining verbal interventions in Table 2.1 are more specific to particular
clinical disorders or client situations. Normalization, for example, is used frequently
in CR for anxiety in which clients are taught to view their distress as an extreme variant
of normal emotion rather than as a distinct and disconnected experience. A client with
health anxiety, for example, could be asked to describe other nonhealth situations in
which he or she felt anxious and yet coped with the emotion very well (e.g., a job
interview). The client could then be encouraged to think of his or her high anxiety
associated with an unexpected physical pain in the same way that he or she thought
of heightened anxiety during the job interview. In other words, the health anxiety
experience is normalized rather than being considered a unique human experience.
Likewise, distancing encourages the client to consider his or her thoughts and
beliefs from the perspective of another person, a third-party observer, such as a friend
or work colleague. The therapist can ask the client to talk about his or her thoughts
“as if they were the product of someone else’s mind.” For example, a cognitive
therapist might say to a client, “Imagine for a moment that your conviction, ‘I’ll be
alone and miserable the rest of my life’, is a belief expressed by a close friend. What
would you think about her perspective on life? What would you say to her as an
alternative way to view being single?” The goal of distancing is to teach the client to
take a more external, observer orientation to disturbing thoughts and beliefs.
Reframing or perspective taking encourages clients to consider their emotional
experience as a single moment in time and to view their current emotional state from
a longer time perspective. This not only helps clients to “live in the moment” rather
than the past or future, as emphasized in mindfulness cognitive therapy, but to view
the present as one moment in a longer lifespan continuum. For example, a client
with panic disorder who becomes completely immersed in his or her heightened
anxiety while in a supermarket is encouraged to view this experience as one instance
of hundreds of experiences that comprise a typical week. A person with social phobia
is asked to consider his or her current speech anxiety and fear of negative evaluation in
terms of the long-term consequences of this single anxious event, say, 10 years later.
Reattribution is an important verbal intervention for clients with excessive self-
blame and guilt, or what Abramson, Metalsky, and Alloy (1989) call hopelessness
8 General Strategies

depression. These individuals exhibit a negative inferential style in which they tend to
make global, stable, and negative self-referent attributions for the cause of distressing
life events. Findings from the Cognitive Vulnerability to Depression (CVD) Project
indicate that a negative inferential style and endorsement of dysfunctional beliefs
confers vulnerability to depression onset (Alloy, Abramson, Safford, & Gibb, 2006).
Given its prominence as a cognitive vulnerability factor, it is important that the
cognitive therapist helps clients become aware of their biased inferential style and
teaches them how to shift their focus onto external circumstances that may have
contributed to the negative life experience. A responsibility pie chart can be used to
teach the client how to distribute responsibility for a bad outcome among several causes
rather than narrowly attributing all blame to the self (see Greenberger & Padesky,
1995). Reattribution is an important verbal intervention in CT for depression and
was first described by A. T. Beck et al. (1979) in the depression treatment manual.
The final verbal strategy listed in Table 2.1 is positivity reorientation. This is a term
that refers to teaching clients more deeply to encode positive, adaptive experiences and
information that indicates the client is able to cope with strong unwanted feelings. In
most cases more positive, schema-incongruent information is not well processed and
so an important goal of CR is to teach clients intentionally and effortfully to select,
encode, and retrieve positive experiences. This therapeutic work is critical for reversing
the heightened sense of personal vulnerability and helplessness that is commonly seen
in the emotional disorders. A person with generalized anxiety disorder (GAD), for
example, would be taught to process past experiences when his or her worries did
not come true or when he or she successfully coped with a negative experience. The
later sessions in any trial of CBT should shift from a focus on refuting maladaptive
schemas to the processing of a positive orientation to self, world, and future. This will
strengthen the resourcefulness of clients and prepare them for treatment termination.

Empirical hypothesis-testing. CT has always taken a strong behavioral view from its
very inception and so empirical hypothesis-testing is a critical component of CR.
A. T. Beck et al. (1979) described the use of activity scheduling, mastery and pleasure
techniques, grade task assignment, behavioral rehearsal, assertiveness training, and
role playing in CT for depression. The use of these therapeutic strategies has been well
explained in the original treatment manual and numerous subsequent descriptions
of CT (e.g., J. S. Beck, 2011; Dobson & Dobson, 2009; Fennell, Bennett-Levy, &
Westbrook, 2004; Leahy, 2010; Wright & McCray, 2012). For the anxiety disorders,
behavioral experiments mainly take the form of systematic, graded exposure to
fear triggers along with prevention of escape, avoidance and safety, or compulsive
responses (A. T. Beck & Emery, 1985; D. A. Clark & Beck, 2010). Behavioral
interventions in CR for personality disorders often involve observations about the
real-life effects of long-held and exaggerated beliefs about the self or others, which
may be supplemented with experiential techniques such as reliving childhood events
and imagery (A. T. Beck, Freeman, Davis, & Associates, 2004). CR for psychosis again
involves setting up behavioral experiments that test the accuracy of clients’ erroneous
interpretations of reality and help them adopt more effective coping responses to
hallucinations, delusions, and thought disorder (A. T. Beck, Rector, Stolar, & Grant,
2009; Kingdon & Turkington, 2005).
 Cognitive Restructuring 9

Empirical hypothesis-testing can be defined as “planned experiential activities,

based on experimentation or observation, which are undertaken by patients in or
between cognitive therapy sessions” (Bennett-Levy et al., 2004, p. 8). The authors
note that behavioral experiments are derived from the cognitive case formulation and
are designed to test the validity of disorder-related schematic beliefs and contribute to
the construction of more adaptive schemas. The critical difference between traditional
behavior therapy and CT lies in the purpose of the behavioral intervention. In
standard behavior therapy the focus remains on behavior change, whereas CT utilizes
behavioral experiences as a means to achieve schematic restructuring. For this reason,
behavioral experimentation or empirical hypothesis-testing is a key element of CR.
When using behavioral experimentation in CR, there are seven steps that the ther-
apist follows in order to achieve schematic change (D. A. Clark & Beck, 2010; Rouf,
Fennell, Westbrook, Cooper, & Bennett-Levy, 2004). First, a rationale or purpose of
the behavioral experiment must be discussed with the client. The experiment will be
derived from the case formulation and is introduced as a way of testing a maladaptive
belief that contributes to the persistence of the disorder. For example, a student
with pathological worry may believe that worry about “failing an exam” is helpful
because it strengthens her motivation for studying. A behavioral experiment would
be introduced as a means of testing out the positive and negative consequences of
exam worry. The second step involves a clear statement of the maladaptive belief
and its alternative. In our case example, the therapist would record the maladaptive
belief as “worrying about my exams is actually helpful because I’ll study more” and
an alternative belief as “worrying about my exams is more detrimental than good
because it distracts me from studying.”
In the third step the therapist and client collaborate in designing the experiment.
It is important that clients feel invested in devising the experiment. Noncompliance
is likely higher when clients do not understand the rationale for the experiment or do
not feel responsible for its design and implementation. In the current experiment, the
client and therapist decided that the best way to test out the utility of the “exam worry
belief” was to pick two midterm exam courses. For one she would purposefully worry
about her performance for at least one hour per day, and for the other course she let
her worries come and go with the intention that less time would be spent worrying.
Specific details about the time, place, and responses associated with the exercise were
elaborated and recorded for the client’s benefit.
The fourth step involves a clear statement of the experimental hypothesis. In the
present example the client was to record study hours associated with both courses and
to rate her level of motivation to study. If worry facilitated study behavior, the client
would record more study time for the “worry course,” whereas if worry interfered
with study, the client would record more study time for the “nonworry course.”
In the fifth step, the client conducts the experiment, usually as a between-session
homework assignment, and records the outcome. It is important that the therapist
write out details of where, when, and how to carry out the experiment so there
is no misunderstanding on what outcome constitutes evidence for or against the
maladaptive belief. It is often helpful to have clients predict beforehand the outcome
they expect from the behavioral activity. In addition, it is important that a written
10 General Strategies

record of the outcome is made so the therapist is able to review the outcome at the
next therapy session.
The sixth step involves consolidation of the results of the empirical hypothesis-
testing experiment at the subsequent session. The therapist explores with clients their
thoughts and feelings while conducting the experiment, and whether their experience
confirms the maladaptive belief or its alternative. In the present example the client
discovered that the more she worried about her course the less time she spent studying
that evening. On the other hand, letting go of her worries resulted in less worry time
and, surprisingly, more time spent studying the course material. The therapist was
able to use this experience to challenge the client’s belief that “worry motivates me
to study more.”
The final phase is to summarize the findings from the experiment and to draw out
the broader implications. It is important to emphasize how a maladaptive schema
can be modified in light of the findings from the behavioral experiment and how
schematic change will lead to treatment goals and ultimately symptom reduction. As
well, the outcome of a behavioral experiment should lead to further planning for the
next empirical hypothesis-testing experiment (Rouf et al., 2004). In this way each
behavioral experiment plays an important role in moving the client toward schematic
change and achieving significant symptom improvement.

Empirical Evidence for Cognitive Restructuring

Over the years there has been considerable interest in empirically testing the effective-
ness of CR in achieving symptom improvement. Many of these studies have attempted
to contrast “purely” behavioral interventions with “purely” cognitive interventions.
Unfortunately such comparisons are misleading because it can be difficult to ensure
external validity of the treatment conditions (Rodebaugh, Holaway, & Heimberg,
2004) and, as previously discussed, behavioral experiments are a key component of
CR. Stripping CR of its behavioral elements would be tantamount to testing the
effectiveness of fear hierarchies with some proxy to actual hierarchy exposure in real
life. Nevertheless, it is reasonable to ask whether an intervention that emphasizes
schematic change (i.e., CR) is more or less effective than an intervention that omits
reference to schemas (i.e., behavioral activation or exposure alone).
There are two types of psychotherapy process studies that bear on the effectiveness
of CR. The first is component analysis in which CR is compared with a non-
CR intervention. This design represented some of the earliest dismantling studies
that examined the incremental contribution of CR to symptom reduction. The
second is mediation analysis which examines whether cognitive or schema change
precedes symptom reduction. If CR is an effective intervention, one would expect that
schematic change should be a key mechanism in symptom improvement. Most studies
on cognitive mediation have examined changes across baseline, posttreatment, and
follow-up intervals, although a few studies have conducted a more refined analysis of
session-by-session changes in cognitions and symptoms. Another question addressed
by mediation research is whether cognitive change is specific to cognitive interventions
 Cognitive Restructuring 11

such as CR, or whether it is also evident in noncognitive treatments such as exposure

alone or pharmacotherapy.

Component Analysis
One of the earliest component studies compared behavioral activation (BA), automatic
thought modification (AT), and full CT in 152 individuals with major depression
randomly assigned to 12–20 sessions of treatment (Jacobson, Dobson, Truax, Addis,
& Koerner, 1996). CT was the only condition to focus specifically on identification
and modification of core beliefs, whereas BA primarily focused on behavioral change.
Analysis of outcome measures at posttreatment and 6-month follow-up revealed
no significant differences between treatment conditions. Moreover, none of the
treatments had a significant differential effect on specific cognitive or behavioral change
variables. That is, CT did not produce significantly more change in depressogenic
schemas nor did BA result in a significantly greater increase in mastery or pleasure
activities. The authors concluded that BA alone was equally effective to the full CT
treatment protocol. Given equivalence across treatment conditions, Jacobson and
colleagues questioned whether verbal interventions (i.e., CR) were necessary in the
treatment of depression and whether schematic change was as critical to depressive
symptom remission as proposed by Beck’s model.
A subsequent 2-year follow-up revealed that all three treatment conditions were
equally effective in preventing depressive relapse (Gortner, Gollan, Dobson, &
Jacobson, 1998). Again the authors concluded that their findings raised questions
about the validity of the cognitive model and more specifically the clinical utility
of verbal interventions such as CR. In other words, it would appear that schematic
change is not necessary for long-term depressive symptom remission and prevention
of relapse. However, a significant limitation is the one-sided evaluation of the additive
effects of CR without also testing the additive effects of BA. In other words, the
finding indicated that CR may not add significantly beyond the therapeutic benefits
of BA, but we do not know whether BA would have incremental benefits beyond a
“purely” cognitive intervention. It is possible that the treatments are equally effica-
cious and their combination confers no added benefit. Nevertheless, the results do
suggest that one therapy (i.e., BA) is just as effective as another therapy (i.e., CT),
and the findings call into question the necessity of CR in the treatment of depression.
A more recent randomized controlled trial (RCT) based on the Jacobson studies
compared an expanded version of BA to standard CT, paroxetine alone, and an
8-week pill placebo condition in 241 adults with major depression (Dimidjian et al.,
2006). Cognitive interventions were excluded from the BA condition but the CT
condition presented the full range of CT interventions including CR and behavioral
activity scheduling. At posttreatment all three active treatments were equally effective
for depression in the mild to moderate range of severity, but BA and medication were
both significantly more effective in treating those with severe major depression than
was CT. However, a 2-year follow-up revealed that CT may have a more enduring
effect than BA, and both treatments were at least as efficacious over the long term as
maintaining individuals on antidepressant medication (Dobson et al., 2008).
12 General Strategies

What then can be concluded about the role of CR in the treatment of depression?
The dismantling studies have shown that CR is effective in the treatment of depression
but it is clearly not necessary for achieving immediate symptom improvement.
However, there is more recent evidence that CR might contribute to improved
endurance of depressive remission. Thus in terms of depression, CR is effective
but not superior to other “noncognitive” interventions, and it appears not to be
a necessary treatment component for effective psychotherapy of the acute phase of
major depression.
Several studies have compared the effectiveness of cognitive interventions and
exposure in the treatment of anxiety disorders. In studies of panic disorder, CR
alone can lead to a significant reduction in panic symptoms (Bouchard et al., 1996;
Margraf & Schneider, 1991; see Gould, Otto, & Pollack, 1995), although exposure
alone appears to be as effective as exposure plus CR (Bouchard et al., 1996; Öst,
Thulin, & Ramnerö, 2004; van den Hout, Arntz, & Hoekstra, 1994). However for
social anxiety, CR may play a more critical therapeutic role. In their RCT for social
anxiety, D. M. Clark et al. (2006) found that CT was more effective than exposure plus
applied relaxation at posttreatment and 3-month and 6-month follow-up. In an earlier
study, Mattick and Peters (1988) found that therapist-assisted exposure plus CR was
more effective than therapist-assisted exposure alone, although this finding was not
replicated in a later study (Feske & Chambless, 1995). Hofmann (2004) randomly
assigned 90 individuals with social anxiety to group CBT, exposure without cognitive
restructuring, or a wait list control. Although both active treatments produced similar
symptom improvement at posttreatment, only the CBT group exhibited continued
symptom improvement after treatment termination. Thus CR, with its focus on
the identification and modification of maladaptive beliefs, may be a key treatment
ingredient for social anxiety disorder.
Numerous studies have compared exposure and response prevention (ERP) with
a combination of ERP and CR in the treatment of obsessive-compulsive disorder
(OCD). Like other anxiety disorders, a CBT approach to treatment of obsessions and
compulsions that includes a strong CR component does lead to significant immediate
and long-term symptom reduction (e.g., Freeston et al., 1997; McLean et al., 2001;
van Oppen et al., 1995; Whittal, Robichaud, Thordarson, & McLean, 2008; Whittal,
Thordarson, & McLean, 2005). Furthermore, it is apparent that CR alone can have a
significant treatment effect even in the absence of systematic, intensive ERP (Cottraux
et al., 2001; Whittal et al., 2005; Wilson & Chambless, 2005). Although some
studies have found CBT equivalent to ERP (Cottraux et al., 2001; Whittal et al.,
2005), others reported that intensive ERP alone is more effective than CBT (McLean
et al., 2001) or that adding CR to ERP did not significantly improve treatment
outcome (O’Connor et al., 2005). Moreover, Whittal, Woody, McLean, Rachman,
and Robichaud (2010) found that CBT and stress management were equally effective
in treating individuals who experienced obsessions without overt compulsions. This
finding has led to the conclusion that cognitive strategies alone are less effective than
ERP alone and that adding CR to ERP does not boost the effectiveness of treatment
for OCD (Abramowitz, Taylor, & McKay, 2005).
Component analysis of CR, per se, has not been conducted with GAD. However,
outcome studies comparing CBT with applied relaxation or pharmacotherapy alone
 Cognitive Restructuring 13

have concluded that CBT has equivalent or superior treatment effectiveness (see
Fisher, 2006; Mitte, 2005). In posttraumatic stress disorder (PTSD) there has
been considerable research on whether CR adds any treatment effectiveness beyond
prolonged trauma exposure. Several meta-analyses have concluded that individual
trauma-focused CBT that includes exposure to an individual’s memory of the trauma
and its personal meaning is an effective treatment for PTSD (e.g., Bisson & Andrew,
2009; Seidler & Wagner, 2006; see also discussion by Ehlers et al., 2010). However,
there is considerable controversy over whether CR of trauma-related thoughts and
beliefs adds any therapeutic effectiveness over prolonged imaginal exposure to the
trauma memory. In their systematic review, Ponniah and Hollon (2009) concluded
that trauma-focused CBT that included exposure and/or CR was an efficacious
treatment for PTSD. However, other researchers have concluded that cognitive
interventions may be unnecessary in the treatment of anxiety disorders including
PTSD (Longmore & Worrell, 2007).
Recently, Hassija and Gray (2010) conducted a thorough review of component
studies comparing CR and prolonged exposure in PTSD. These researchers found
sufficient evidence that CR is an effective intervention for PTSD and that the
effects are generally comparable to prolonged exposure. Moreover, CR may produce
more enduring effects than does imaginal exposure alone (Tarrier & Sommerfield,
2004) and may differentially affect associated features of PTSD such as detachment,
catastrophic cognitions, and guilt (Hassija & Gray, 2010). Outcome and dismantling
studies of cognitive processing therapy (CPT), which involves intense CR of beliefs
and negative cognitions, indicate that the therapy is as effective as prolonged exposure
in the immediate and longer term (Resick, Nishith, Weaver, Astin, & Feuer, 2002;
Resick, Williams, Suvak, Monson, & Gradus, 2012). In addition, CPT may have
some superiority over trauma-focused exposure alone in treatment of chronic PTSD
in military samples (Alvarez et al., 2011). Recent CPT dismantling studies indicate
that CR may be the more potent component of the treatment package (Resick et al.,
2008; Stein, Dickstein, Schuster, Litz, & Resick, 2012). At this point the most
parsimonious conclusion is that the CR component of CPT and prolonged exposure
produce similar changes in PTSD so that the average person with PTSD can benefit
from either treatment (Stein et al., 2012).
Before concluding this review of component studies, it is worth considering the
most recent meta-analysis on the efficacy of exposure and CT in treatment of anxiety
disorders. Ougrin (2011) identified 20 RCTs that directly compared CT and exposure
alone. Studies of CT versus CT plus exposure, or the reverse, were excluded. Analysis
revealed equivalent short- and long-term effect sizes for PTSD, OCD, and panic
disorder. However, there was a statistically significant difference in effect size favoring
CT for immediate and long-term outcomes for social anxiety disorder.
In summary, the component studies clearly indicate that CR is an effective treatment
intervention for anxiety and depression, and in some cases may convey a distinct ther-
apeutic advantage. This is very different from the conclusion reached by Longmore
and Worrell (2007) in their review of CBT component analysis studies for anxiety and
depression, in which they stated that “for a range of clinical problems, specifically cog-
nitive interventions do not produce superior outcomes to the behavioral components
of CBT” (p. 180). The failure of cognitive interventions to add significant therapeutic
14 General Strategies

value beyond exposure or behavioral activation alone was a significant factor in leading
the authors to question whether challenging negative thoughts was necessary in CBT.
The present review considers this a misguided conclusion, although it is true that the
general finding of equivalence of cognitive and behavioral interventions provides little
practical guidance for the clinician who must decide how much emphasis should be
placed on CR when treating an individual client with anxiety or depression.

Mediation Analysis
Cognitive mediation is a fundamental hallmark of CT and CBT (D. A. Clark et al.,
1999; Garratt, Ingram, Rand, & Sawalani, 2007; Maxwell & Tappolet, 2012).
It is the assertion that symptom improvement and recovery from a disorder is
the result of change in underlying maladaptive thoughts and beliefs, and biased
information processing. It is change in the functioning of the cognitive apparatus
that mediates symptom amelioration. Although CT acknowledges that modification
in physical processes, emotions, behavior, and experiences can result in cognitive
change, it is assumed that CR provides a more direct means to modify the faulty
information processing apparatus. Thus, there are two fundamental questions in
cognitive mediation. Is schematic change a significant causal mechanism of symptom
improvement, and is CR unique in its ability to produce change in schematic
content (Garrett et al., 2007; Hofmann, 2008)? I turn now to the initial question of
mechanisms of therapeutic change.
Longmore and Worrell (2007) reviewed a select number of early CBT treatment
process studies and concluded that there is limited evidence that cognitive variables
mediate therapeutic change in CBT. Hofmann (2008), however, was critical of the
Longmore and Worrell (2007) discussion of cognitive mediation, noting that several
recent CBT process studies that employed more rigorous data analytic procedures in
support of cognitive mediation were missing from their review. Interestingly Garrett
et al. (2007) arrived at a different conclusion in their review of cognitive mediation
in treatment of depression. They stated that in CT, change in cognition does predict
changes in depressive symptoms, although it appears that studies are divided on
whether cognitive change is specific to CT or also evident in other psychosocial
treatments or even pharmacotherapy.
There have been several rigorous tests of cognitive mediation in CBT for the
anxiety disorders. Hofmann (2004) found that group CBT, and exposure alone,
produced equivalent improvements in social anxiety disorder at posttreatment, but
at 6-month follow-up only CBT was associated with continued symptom reduction.
Using linear regression analyses, he demonstrated that change in the estimated
social cost associated with 20 hypothetical negative social events predicted pre-post
difference scores in self-reported social anxiety symptoms, especially for the CBT
group at 6-month follow-up. Smits, Rosenfield, Telch, and McDonald (2006) found
evidence of cognitive mediation for exposure-based treatment of social anxiety using
growth modeling analysis and a cross-lagged panel design. Change in probability
judgmental bias predicted later self-rated fear during exposure, although the reverse
relationship was also found and judgments of cost bias did not predict fear.
 Cognitive Restructuring 15

Based on an RCT comparing CBT and pharmacotherapy for panic disorder,

Hofmann et al. (2007) used multilevel modeling to show that change in catastrophic
cognitions was a significant mediator of change in panic symptoms for those receiving
CBT but not for participants in the imipramine alone condition. A recent study
of one session exposure versus CBT-based exposure for spider phobia revealed that
change in maladaptive cognitions mediated posttreatment and follow-up reductions
in self-report phobic symptoms (Raes, Koster, Loeys, & De Raedt, 2011). Finally, a
systematic review of CBT studies of anxiety disorders concluded that change in threat
reappraisal has a causal effect on reduction in anxious symptoms, although it was not
possible to support the stronger position that threat reappraisal is responsible for the
efficacy of CBT (Smits, Julian, Rosenfield, & Powers, 2012).
Several studies have examined session-by-session change in cognitions and symp-
toms in order to investigate temporal precedence. Tang and DeRubeis (1999) found
that CT sessions involving sudden gains (i.e., large depressive symptom reduction
during a single between-session interval) were associated with cognitive changes in
the previous session. A subsequent reanalysis of the Jacobson et al. (1996) data set
again confirmed that significantly more cognitive change occurred in the pregain than
control sessions (Tang, DeRubeis, Beberman, & Pham, 2005). However, another
study using multivariate hierarchical linear modeling of session-by-session changes
in Beck Depression Inventory symptoms found similar trajectories of change for
cognitive and vegetative symptoms for depressed outpatients randomly assigned to
CT or pharmacotherapy (Bhar et al., 2008).
In a stringent test of cognitive mediation in CBT for obsessions, Woody, Whittal,
and McLean (2011) found that maladaptive appraisals of the primary obsession
significantly accounted for improvement in obsessive symptoms. Although this finding
supported the cognitive mediation hypothesis, a session-by-session analysis using
latent change modeling revealed that prior obsession severity led to subsequent
change in appraisals for both CBT and stress management treatment conditions. In
this study, then, symptom change had temporal precedence over cognitive change.
However, a multivariate time series analysis of session-by-session data for CR versus
exposure treatment for panic disorder indicated that changes in dysfunctional beliefs
and self-efficacy preceded change in panic apprehension (Bouchard et al., 2007).
Overall the research on temporal precedence presents a mixed picture, with some
studies showing cognitive change is a cause of symptom change, others cognitive
change is a consequence of symptom change, and still others a co-occurring change
with bidirectional effects.
Before concluding this review on cognitive mediation, it is worth considering
several lines of research that demonstrated that a specific focus on cognitive change
does have an impact on symptom remission. For example, Segal and colleagues found
that depressed participants treated with CT were less cognitively reactive during sad
mood induction at posttreatment than those treated with medication alone, and
this in turn predicted probability of relapse (Segal, Gemar, & Williams, 1999; Segal
et al., 2006). Furthermore, a study of CT plus medication versus medication alone
for major depression found that both treatments produced a significant reduction
in depressive symptoms and negative cognitions, but only the CT plus medication
group evidenced increased organization of positive schema content and reduced
16 General Strategies

interconnectedness for negative schema content (Dozois et al., 2009). The specific
type of automatic thought targeted during group CBT for social anxiety also appears
to influence treatment outcome (Hope, Burns, Hayes, Herbert, & Warner, 2010).
Finally, patients’ competence in acquiring CR skills in CT predicted lower 1-year
relapse in one study (Strunk, DeRubeis, Chiu, & Alvarez, 2007), although the
evidence is mixed on whether therapist adherence to or competence in the CT
protocol is significantly related to outcome (Strunk, Brotman, DeRubeis, & Hollon,
2010; Webb, DeRubeis, & Barber, 2010). Overall, then, considerable progress has
been made in understanding the mechanisms of change in CBT. It is clear that the
quality of the cognitive intervention, its focus, and the degree of subsequent cognitive
change does have a significant impact on treatment outcome.

Concluding Remarks

CR is a multifaceted therapeutic intervention that seeks symptom reduction by

modifying the maladaptive schematic content considered crucial in the etiology and
maintenance of psychological disorders. Since its first conceptualization by A. T. Beck
and colleagues in the 1970s (A. T. Beck et al., 1979), considerable progress has been
made in elaborating, refining, and applying CR to a variety of psychiatric disorders.
Psychotherapy process research has indicated that CR is an effective intervention for
anxiety and depression, and that CR’s most significant contribution might be in
conferring more enduring treatment effects or mediating change in specific disorder
symptoms. However, it is also clear that CR is at best equivalent to, and at worst
less effective than, “noncognitive” interventions such as exposure or behavioral
activation, at least in terms of short-term symptom reduction. Although there is
substantial evidence in support of cognitive mediation in symptom improvement, the
direction of causality is still a matter of debate and it is evident that cognitive change
is not specific to CR.
There are several issues that remain unresolved about the effectiveness and mech-
anism of change in CR. At the schematic level, the effects of CR remain relatively
unknown. Does CR alter existing maladaptive schema content or does it introduce
more adaptive schemas that compete with or inhibit activation of disorder-related
schemas? There have been no dismantling studies of CR itself to indicate the rel-
ative importance of collaborative empiricism, verbal interventions, and empirical
hypothesis-testing to determine the effectiveness of the intervention. Most of the
component and mediation research has relied on symptom measures taken at limited
time intervals throughout treatment (i.e., baseline, posttreatment, follow-up). What
is needed are more session-by-session studies that use specific cognitive and symp-
tom measures employing multilevel modeling techniques to chart the trajectories of
cognitive and symptom change. It is also unclear which clinical, client, and therapist
variables might moderate the effectiveness of CR, and we are only just beginning to
learn the role that therapist competence and client acquisition of CT skills might play
in the effectiveness of CR. Unfortunately the treatment process research has not yet
matured to the point where it can provide guidelines to clinicians on when to use
CR, when to combine it with other interventions, or when to refrain from its use.
 Cognitive Restructuring 17

Until then, clinicians can consider CR an effective intervention that should hold a
prominent place in their treatment armamentarium.

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