dear friend

Its completely dependent to the subjects and their traits. e.g : in  aging varied from childhood. please let me  know how I can help you?

Regards

Is this not to be expected.

Was there any ongoing reeinforcement? .Did you examine the factors which have have changed since the first treatment? There are many possible inhibitors and promoters of effectiveness such as self-confidence.. And what of outside circumstances (like coping with institutionalization or physical disablement) drastically changing?  How long did you expect CR to be effective? Did you consider it permanent?

Did you read the following?:

Clark, D. A. 2013. Cognitive Restructuring. The Wiley Handbook of Cognitive Behavioral Therapy. Part One:2:1–22.

Beck's cognitive therapy (CT) has made a substantial contribution to current evidence-based cognitive behavioral therapy (CBT) for a variety of psychiatric disorders, 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 apparatus, 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 alternatives, 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 interventions as cognitive restructuring until the publication of his second treatment manual for anxiety disorders (A. T. Beck & Emery, 1985). Since then, various descriptions of 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.

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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 processing 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, demonstrates 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 fluctuating pattern of shifting schematic processing that is influenced by circumstances and even mood state, with symptom improvement associated with an eventual dominance 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 conducting 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 maladaptive 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 propositional 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 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, accessibility, 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 strengthening 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 atmosphere, 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 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 therapist encourages the client to take an investigative, questioning approach to long-held beliefs and attitudes. Throughout treatment, an emphasis is placed on observation, 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 perspective. 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.” Throughout each session the therapist places a strong emphasis on empiricism to achieve schematic change. Tee and Kazantzis (2011) argue that effective collaborative empiricism 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 1.

Table 1. Verbal Intervention Strategies Employed in Cognitive Restructuring

Intervention strategy

Description

1. Evidence gathering Obtaining schema-congruent and -incongruent evidence from the client's past and current experience that enables a more balanced evaluation of schematic content.

2. Consequential analysis Examining the immediate and long-term costs and benefits of continued acceptance of the maladaptive belief.

3. Cognitive bias identification Training clients in greater awareness of the cognitive biases that operate when processing schema-relevant information (e.g., dichotomous thinking, catastrophizing, mind reading, magnification/minimization, etc.).

4. Generate alternative Formulating a more adaptive conceptualization of the self or 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 perspective taking Focusing on current experience as a moment in time and situating it within a longer lifespan time frame or the totality 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 reorientation Refocusing the client on positive, adaptive personal coping experiences that provide schema-incongruent information.

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.

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 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 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 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 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).

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 therapist 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 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.

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Empirical Evidence for Cognitive Restructuring

Over the years there has been considerable interest in empirically testing the effectiveness 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 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 efficacious 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).

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 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 therapeutic 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 cognitive interventions do not produce superior outcomes to the behavioral components of CBT” (p. 180). The failure of cognitive interventions to add significant therapeutic 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.

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, ).

Several studies have examined session-by-session change in cognitions and symptoms 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 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.

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

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Thank you for your input. That was a very thoughtful and well articulated response. I am actually specifically asking about cognitive remediation therapy, not cognitive restructuring or cognitive behavioral therapy.