Clmzcal Psvchologyi Rrznew, Vol 4, pp. 35-76. 1984 0272-7358/84 $3.00 + .

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COGNITIVEFACTORS IN CLINICAL
RESEARCHANDPRACTICE

Steven D. Ho/Ion and Margaret R. Kriss

University of Minnesota

ABSTRACT. Recent advances in delaneating basic cognative and social cognative processes
may hold great promise for furthering our understanding of important clinical zssues, in
particular theories of psychopathology, theories of therapeutacchange, and theories of clinical
anference. In this article, the role of knowledge structures (includang schemata), processing
heuristics, biases, and products are explored with particular emphases on their potential role
in the clinical change process. Therapies whachare explicitly metacognitive in nature are seen
as frequently, but not invariably, most closely approximating the active intervention compo-
nents most likely to produce alterations an amportantmechanisms mediating change. Sugges-
tions for refanements an both clanical practace and clinical research are offered.

There has been a recent resurgence of interest in the role played by cognitive
factors and information processing in psychopathology and the clinical change
process. Reviving a tradition begun by Meehl’s (1954) classic work on the fallibility
of clinical prediction and the separate pursuit of lay inference processes by Heider
(1958), this work has suggested that common failings in inference generation may
both color the clinical judgment process and have real implications for the etiology
and treatment of psychopathology. Recent volumes by Kahneman, Slavic, and
Tversky (1982) and Nisbett and Ross (1980) have highlighted the increasingly
sophisticated conceptual and methodological advances made, respectively, in the
basic cognitive and social cognitive literatures (see also Harvey, 1984, this issue).
In this article, we focus on the role of cognitive products, structures, and pro-
cesses in the clinical change process. In general, most clinical research efforts have
not kept pace with these recent breakthroughs in understanding lay inference.
Nonetheless, powerful change procedures have been developed, at least some of
which are explicitly metacognitive in nature (i.e., focusing on the nature and process
of cognition as the explicit subject of discussion, as well as the implicit object of
change efforts, Brown 1978; Flavell, 1979). We attempt to evaluate the role of such
cognitive phenomena in the treatment process. Finally, we examine the occurrence

Preparation of this article was supported in part by a grant from the National Institute of
Mental Health (ROI -MH33209) to the Department of Psychology, University of Minnesota.
Reprint requests may be sent to Steven D. Hollon, Department of Psychology, University
of Minnesota, 75 East River Road, Minneapolis, Minnesota, 55455.
35
36 Steven D. Hollon and ~~largaret R. Krm

of fallible inference generation in the clinical judgment task, long studied with
regard to diagnosis, with regard to its impact on both diagnosis and treatment.

COGNITIVE STRUCTURES,PRODUCTS, AND PROCESSES

In parallel with the advent of cognitive-behavioral interventions, many researchers

and clinicians have developed an interest in understanding the basic cognitive
factors that operate in both normal and patient populations. Some researchers have
borrowed concepts from cognitive, social or experimental psychology while others
have developed new concepts to explain how individuals function cognitively. Along
with a broadened understanding of cognitive functioning has arisen a confusing
terminology regarding human cognition. Such confusion is most likely due to the
various approaches taken to understand this domain.
In surveying the various terms and concepts that have been discussed in the
literature, we think that a division of cognitive factors into three types, namely
structures, processes, and products (or events) may prove to be particularly useful
conceptually (see Hollon & Bemis, 1981; Hollon 8c Garber, in press; Piaget, 1954;
Turk Jc Speers, 1983). Basic to all three is the notion of cognitive content, infor-
mation present in some fashion, whether readily accessible or not, in the central
nervous system. We will attempt to categorize the various terms and concepts in
the literature regarding cognition into this framework while being careful to retain
the important and unique qualities of each concept. While cognitive structures,
products, and processes will each be discussed as separate construct domains, it is
apparent that these three domains are part of an openly dynamic and reciprocal
system in which each influences and is influenced by the others.

A. Knowledge Structures

Knowledge structures are organizational entities that contain all of an individual’s

knowledge at any given moment about himself/herself and the world. These struc-
tures are assumed to be fairly stable organizers of cognitions (Nisbett & Ross, 1980;
Turk & Speers, 1983). The two key aspects of cognitive structures are that: (1)
they are made up of content, and (2) they are stored in an organzed fashion.
According to Turk and Speers, schemata are the cognitive structures of the human
mind. Cognitive schemata (singular:schema) have been proposed by many theorists
(Markus, 1977; Neisser, 1976; Turk 8c Speers, 1983;). While it has been noted that
there is no generally agreed upon definition of the schema concept (Alba & Hasher,
1983; Brewer & Treyens, 198 1; Kihlstrom & Nasby, 198 1; Taylor & Cracker, 198 l),
our purpose here is to offer a general understanding of the basic agreed upon
notions of schemata.
Schemata have been assumed to be basic theories that contain our knowledge
of how environmental stimuli are organized and structured (Hollon & Garber, in
press). Schemata contain specific information about situations (e.g., “yesterday it
rained”) as well as more general information in the form of rules (e.g., “it seems
to rain a lot more in the spring, when it is cloudy, and when I have planned
something pleasant to do outdoors”) or in the form of prototypic information (e.g.,
“all cats have ears, say meow, like to eat mice”, etc.) (Turk 8c Speers, 1983). Schemata
are presumably constructed from information received and processed by the in-
dividual in the past (Thorndyke & Hayes-Roth, 1979). A schema is strengthened
when similar information is repeatedly processed and thereby stored in the same
 Clznicul Cognition 37

schema (Markus, 1977). A schema may be altered when information received from
the environment is discrepant with a certain category of coded schematic infor-
mation. A schema that is frequently used, however, can become very difficult to
alter as a great deal of information consistent with the basic theme of a given
schema accumulates.
In addition to being a storage mechanism for old information, schemata also
play an active role in processing new information. Schemata help determine which
information will be attended to and which ignored, how much importance to attach
to stimuli, and how to structure information (Hastie, 1981; Markus, 1977; Neisser,
1976; Turk & Speers, 1983). The important aspect is that knowledge structures
make information processing more economical and coherent. The individual need
not rely solely on the information present in the environment or attend fully to all
of the information in the stimulus, since “default” values are apparently provided
by the activated schema (Thomdyke & Hayes-Roth, 1979). A commonly used phrase
to describe the result of schema-based information processing is that the individual
“goes beyond the information given” (Markus, 1977; Turk & Speers, 1983).
As the concept of schema has become further developed, researchers have begun
to categorize knowledge structures according to the type of information they seek
to organize. Markus (1977) has elaborated and presented empirical evidence in
support of a self-schema which functions as an active organizer of self-referent
information. Bandura (1977) has posited a related concept of self-efficacy, which
is the belief that one can successfully achieve a certain desirable outcome. According
to Turk and Speers (1983), this concept likely represents a component of a self-
schema. Beck (1967, 1976) has proposed that depressives have a negative self-
schema that serves to maintain their negative view of themselves, their worlds, and
their futures.
Another type of knowledge structure that has received study is the person pro-
totype (Cantor, 1981a; Cantor & Mischel, 1977, 1979a, 1979b) or personae (Nisbett
& Ross, 1980). Such a prototype contains information regarding a certain type of
person, such as a “conservative” or a “wheeler-dealer”, and may well play an im-
portant role in the perserverance of stereotypes and biases. Cantor and colleagues
(Cantor 1981b; Cantor, Mischel, & Schwartz, 1982) have extended the prototype
concept to situation perception, mapping a taxonomy of both consensual and idio-
syncratic perceived situations. Organized knowledge regarding behavioral routines
has been referred to as “scripts” (Abelson, 1976, 1981; Schank & Abelson, 1977).
Minksy (1975) has described “frames”, schemata that contain knowledge about the
structure of familiar events. All of these structures appear to function by virtue of
storing cues and prompts facilitating “matches” between impinging information
and internally-stored representations (Tversky, 1977). When a match is made,
meanings are given, connections made, and information inferred from internal
stores which go beyond that immediately present in the triggering stimulus. Various
authors (e.g., Landau & Goldfried, 1981; Schank 8c Abelson, 1977; Taylor & Cracker,
1981) have attempted to define and classify the several types of knowledge struc-
tures.
Individual differences clearly exist with regard to the specific content and or-
ganization of knowledge structures. For example, Markus (1977) has identified a
group of “dependence-independence” aschematics, individuals who lack any strongly
developed self-schema with regard to that particular aspect of personality. In the
psychopathology literature, Davis and Unruh (198 1) have presented evidence that
newly depressed individuals lack the stable, negative self-schemata found in indi-
38 Steven D. Hollon and ‘Margaret R. Kriss

viduals who have been depressed for longer periods of time. The implication is
that individuals may acquire schematic organizations over time as a function of
experience. Clearly, variations in content are critical. One individual mav have a
knowledge structure organized around one particular type of information or di-
mension for which other individuals are largely aschematic (Derry & Kuiper, 198 1;
Kihlstrom & Nasby, 198 1; Kuiper & Derry, 1980).
Nisbett and Ross (1980) distinguish between two different forms of knowledge
structure; theories (or beliefs) and schemata. Theories are different from schemata
in that the former are propositional in nature. Propositions refer to cognitions that
involve representations of two or more concepts and the perceived relationships
between them. (For example: Dogs make good pets.; Mary is a pretty woman.).
Schemata, on the other hand, are viewed by Nisbett and Ross as more “generic
knowledge” that is organized in more of a “laundry list” manner than in the form
of propositions. (For example: a tree has leaves, branches, trunk, stands in dust,
needs water, etc.). They include frames, person, prototypes, and scripts in the
category of schemata.
Knowledge structures appear to play a role in both information search and in
determining behaviors which create their own consequences. The first phenome-
non, referred to as “confirmatory bias” (Snyder, 1981; Snyder & Cantor, 1979:
Snyder 8c Swann, 1978a), involves information search which is biased in a fashion
tending to confirm the searcher’s initial preconception. In these studies, subjects
typically pursued tests of hypotheses such as whether someone was an “introvert”
by asking loaded questions such as “Do you ever like to just be by yourseh?”
Closely related is the phenomenon labelled “self-fulfilling prophecy” (Darley &
Fazio, 1980; Merton, 1948; Snyder & Swann, 1978a). The essence of the phenom-
enon is that the individual acts in a manner consistent with his or her a priori
notions, thereby altering the world in a manner making external reality more nearly
match those preconceptions. A colleague at the University of Washington, Neil
Jacobson, provided a nice example based upon work with a moderately depressed
young male adult on heterosexual dating skills. Dr. Jacobson’s client reported being
turned down on a date as evidence of his (the client’s) essential undesirability. When
asked by Dr. Jacobson to describe precisely how he had phrased his invitation, the
young man thought for a moment then replied, “I just said to her, ‘I know you
probably wouldn’t want to go out with someone like me, but I still thought I’d see
if you’d like to go.“’ It was hardly an invitation likely to stimulate someone else’s
interest, but it did directly express the client’s own estimation of the likelihood of
acceptance. The young woman politely turned him down.
Confirmatory bias and self-fulfilling prophecy differ in that the former influ-
ences only the information perceived, not the actual course of events, while the
latter has an actual impact on the course of external events. Both tend to be
conservatizing tendencies with regard to existing beliefs and knowledge structures.
That is, both tend to maintain or increase the individual’s belief in his or her
existing preconceptions.
Overall, knowledge structures, in their various formats, appear to organize ex-
isting information in ways which provide stability over time and the abstraction of
communalities across situations. They permit the emergence of meaning and a
certain economy of effort, but they do so in a manner which permits systematic
distortions and biases to develop. In general, these biases operate in a conservatizing
fashion.
 Clznd Cogrutwn 39

B. Cognitive Products

Cognitive products are similar to cognitive structures in that both are made up of
informational content. Whereas cognitive structures are the raw data stored in the
central nervous system, cognitive products are the results or output of information
processing (see Guidano & Liotti, 1983; Hollon & Garber, in press; or Turk &
Speers, 1983). Cognitive products are largely accessible to the individual, whereas
the content of knowledge structures can often only be inferred (Nisbett & Wilson,
1977). Linguists have referred to this distinction as the difference between surface
and deep structures (Arnkoff & Glass, 1982; Chomsky, 1957; Hollon 8c Bemis,
1981; Lindsay & Norman, 1977). Surface structures represent what is said (overt
verbalization) or thought (covert self-statement) by the individual, while deep struc-
tures represent the meaning system that underlies the statement. It is an important
concept that an individual’s statement can have several different meanings and that
a meaning can be expressed in many different statements (Thorndyke & Hayes-
Roth, 1979).
Cognitive products may be viewed as signs or hints of the nature of one’s knowl-
edge structures, processes, and their systematic interrelationships. Clearly cognitive
products are only the “tip of the iceberg” in relation to all of one’s knowledge about
the world. Systematic study of individuals’ cognitive products, however, is certainly
a useful endeavor, as it will likely lead to some reasonable generalizations about
the nature of deeper knowledge structures and cognitive processes.
Researchers have referred to cognitive products by such terms as self-statements
(Meichenbaum, 1977), automatic thoughts (Beck, 1970; Hollon SC Kendall, 1980),
or beliefs (Arnkoff & Glass, 1982; Ellis, 1962). These terms are largely overlapping
synonyms for the same entities, although some subtle differences in meaning exist.
Cognitive products can be differentiated, however, by their content. Hollon and
Bemis (198 1) have suggested a taxonomy of cognitive inferences, which includes
causal attributions, characteristic ascriptions, and expectations, to name three of
the more important categories. These three types of cognitive contents overlap
with the three domains seen by Ross (1977) as representing the main foci of study
for attribution theory. Causal attributions refer to inferences regarding the causes
of events, including behaviors. Characteristic ascrzptions refer to inferences regarding
a particular characteristic of an object, situation, or person. For example, one might
attribute or ascribe the characteristic of “sweetness” to a particular food or person.
Historically, interest within social psychology in the causal attribution process has
grown out of a recognition that many lay observers generated stable interpersonal
“trait” ascriptions to account for the behaviors of others. Expectations refer to in-
ferences about the outcomes of actions or about future events.
Another way of analyzing cognitive products is in terms of adaptiveness (Arnkoff
& Glass, 1982). For example, Ellis (1962) distinguishes between irrational and
rational cognitive products. Beck (1976) refers to adaptive and maladapnve thoughts,
and Meichenbaum (1977) discriminates task-adaptive from task-maladaptive self-
statements.
Whereas these other researchers were most interested in distinguishing cognitive
products of the emotionally disturbed from normals, cognitive and social psycho-
logical researchers have focused more on the accuracy of cognitive products. Ross
(1977) suggests that for each type of inference made by an individual, it is theo-
retically possible to specify what constitutes an accurate or normative inference
under states of less than total certainty or unavailability of information. A normative
40 Steven D. Hollon and Margaret R. Krzss

inference is one that is based on a logical synthesis of all of the information available
to the organism. Cognitive and social psychologists (Kahneman et al., 1982, and
Nisbett Ross 1980, respectively), have documented many examples of inaccurate
or nonnormative’ inferences drawn by nonpathological groups of individuals.

C. Cognitive Processes

Cognitive processes have been posited to explain how deep structures get translated
into surface structures or how knowledge structures lead to cognitive products
(Kihlstrom & Nasby, 1981; Nisbett & Ross, 1977). In essence, these processes are
the transformational rules for turning input into judgements. Furthermore, these
cognitive processes have been implicated as being responsible for the ephemeral
inaccuracies or maladaptations of cognitive products and the rigid unchanging
quality of certain cognitive structures.
Cognitive processes can be thought of as being analogous to computer software.
In this analogy, these processes determine how incoming information is perceived,
encoded, stored, combined, and altered with respect to information and structures
already in the system, and how that existing information is retrieved and those
existing structures are engaged, disengaged, or altered (Hollon & Garber, in press;
Kihlstrom & Nasby 1981).
As noted in the preceding discussion of cognitive structures, schemata play a
role in the processing of information (Alba 8c Hasher, 1983; Thorndyke & Hayes-
Roth, 1979). There is a very close relationship between schemata and the operating
processes in that schemata provide the context for processing. Two important
principles, assimilation and accommodation (Piaget, 1952, 1954), describe the re-
ciprocal relationship between information and structure mediated by these pro-
cesses. When an individual is presented with novel environmental information that
is discrepant with an existing schema, one of two outcomes may occur. On the one
hand, the stimulus may be altered or assimilated such that it becomes consistent
with the preexisting schema. Conversely, the schema itself may be modified so as
to accommodate the discrepant information (Nisbett & Ross, 1980). The processes
assimilation and accommodation can only function when given certain information
in a particular structure (i.e., a schema) as a framework. Most of the literature in
cognitive psychology seems to suggest that the process of assimilation occurs more
frequently than accommodation (Nisbett 8c ROSS, 1980; Ross, 1977). Assimilation
is particularly likely to lead to inaccurate on nonnormative cognitive products, since
incoming information is likely to be selectively processed in a fashion which favors
consistency with internal beliefs over fidelity to external realities.
As Tversky and Kahneman (1974) point out. such processing does not invariably
produce inaccurracy. Under normal conditions, existing knowledge structures may

1 Throughout this article, we have adopted the apparent convention m the cogmtlve and
social cognitive literature of defining “normative” prescrzptzvel!. That IS, thmking is normative
if it conforms to what are perceived to be sound logical principles. In so doing, we recognize
that we are explicitlv eschewmg a statistical definition of “normativeness.” Thus, according
to convention, thinking can be nonnormative if it does not adhere to our current standards
of appropriate inference generatlon, even if it is the way most people think most of the
time. We are not wholly comfortable with this convenuon, but an explication of the sources
of our discomfort would take us far afield from the purposes of this article.
frequently provide highly accurate guides to external realities. Further, such pro-
cessing clearly permits greater efficiency in information processing. Occasional
inaccuracies may well represent the price paid for having a system capable of
structuring and storing the fruits of prior experience.
Hollon and Garber (in press) have speculated that an outcome besides assimi-
lation or accommodation may take place when individuals encounter information
discrepant with their schemata. They such stimuli might lead to deac-
suggest that
tivating the currently operating schema and activating a schema that is more con-
sistent with the incoming stimuli. This latter schema may have been dormant for
periods ranging from minutes to vears. Perhaps the clearest example of this phe-
nomenon occurs when moving from one situation (e.g., driving a car) to another
(e.g., entering a restaurant), in which each situation elicits a different behavioral
“script”. Similarly, any clinician who has ever been asked for professional advice
at a social event has experienced the “switch” from a “party-goer” to a “professonal”
self-schema. The situational or state-dependency nature of schematic activation
strikes us as being a research issue of particular importance.
Why does assimilation occur more frequently, and why does it lead to nonnor-
mative inferences or cognitive products? Tversky and Kahneman’s (1974) work on
human judgment under uncertainty has provided some answers to these important
questions. These researchers suggest that under conditions of uncertainty (which
hold in many noncontrived situations outside of the laboratory), individuals use
heuristics2 or shortcuts as ways to process information and thereby make judgments.
Heuristics are information-processing strategies which reduce complex judgmental
tasks to a set of simpler operations. These strategies appear to be innate, automatic
processes operating without an act of volition and, presumably, outside of conscious
awareness. Tversky and Kahneman describe three types of heuristics commonly
used; availability, representativeness, and anchoring with adjustment.
The availability heuristic is a useful shortcut for making judgments about fre-
quency or probabilities of certain events. Judgments are made on the basis of how
quickly or easily similar instances of the event are remembered, rather than on the
base rates of the event (Tversky & Kahneman, 1973). For example, an individual
may more readily recall a single vivid instance (e.g., a particular car that was a
“lemon”) than more normatively valid base-rate information (i.e., all the other cars
of that type that performed ably). Any number of stimulus factors could influence
the availability of information; that is, its ease of retrieval from memory, including
its vividness or concreteness (Borgida & Nisbett, 1977), its importance or meaning
(Alba 8c Hasher, 1983), or the “frame-of-reference” of the perceiver (Taylor &
Fiske, 1975, 1978). In addition, the state of the individual at the time of retrieval
may similarly alter the availability of information for retrieval. Clearly, this is basic
for schema theories of memory (Alba & Hasher, 1983; Taylor & Cracker 1981;

? As with the term “normative”, we will, in this article, accept what appears to be the prevailing
convention in the basic cognitive and social cognitive literature concerning the definition of
the term “heuristics.” In those literatures, the term heuristic appears to be used to refer to
shortcut strutegtes for generating influences which ignore or overlook at least some available
information. In a broader sense, the term more typically refers to any strategy or tool serving
to further investigation or to facilitate judgment. The connotation that heuristics are short-
cut strategies which promote efficiency at the expense of accuracy develops only from the
particular heuristics most often studied in the “fallible scientist” literature. It is not implicit
in the basic nature of heuristics themselves.
12 Steven D. Hollon and ‘Margaret R. Krus

Thorndyke 8c Hayes-Roth, 1979). Quite possibly, affective states may themselves

increase the availability of specific types of information (Kihlstrom & Nasby, 1981).
A recent study by Clark and Teasdale (1982) illustrated this phenomenon. In that
study, depressed patients evidencing diurnal mood variations were found to be far
more likely to spontaneously recall negative experiences during times of the day
when their moods were negative than at other times.
The second heuristic, representativeness, refers to the process of makingjudgments
regarding stimuli based on knowledge of a more familiar stimulus category to which
the original stimulus appears similar (Kahneman & Tversky, 1972). Nisbett and
Ross (1980) have suggested that traditional psychodynamic theories may have too
readily assumed that observed negative consequences must, perforce, have been
the products of underlying (i.e., unconscious) negative motivations. Under the
representativeness heuristics, “bad outcomes” most readily suggest “bad intentions”.
The third heuristic, anchoring wzth adjustment refers to the failure of individuals
to revise (or adjust) their beliefs (anchors) after being given disconfirming evidence.
In a classic study on the clinical judgment process, Temerlin (1968) had various
groups of clinicians and nonclinicians listen to an audiotaped interview with a
trained actor carefully portraying a happy, healthy, well-adjusted interviewee. Tem-
erlin manipulated his judges’ preconceptions by having a respected professional
confederate indicate either that the man was interesting because “although he looks
neurotic, he&is really quite psychotic” or that the interviewee was a “healthy indi-
vidual”. Diagnostic judgments, clinical inferences, and even recollections of clinical
observations were clearly biased in the directions of these induced preconceptions.
According to’Tversky and Kahneman (1974), while these heuristics may occa-
sionally produce normative or accurate inferences, the more frequent outcome is
to produce nonnormative or inaccurate cognitive products. Such inaccuracies are
the consequences of the fact that many other pieces of relevant information, such
as base rate or correlational data, are ignored. Further, biases in information pro-
cessing, including the tendency to overlook regression to the mean, failure to
recognize the inadequacy of sample size, and the pernicious influence of illusory
correlations, appear to contribute to this penchant for nonnormative processing.
Let us return now to the question regarding why assimilation occurs quite fre-
quently and leads to inaccuracies. Heuristics are actually based on the principle of
assimilation. Information stored and organized in the nervous system is used by
human beings as a shortcut to guide and affect their perception of the environment.
We, as human beings, cannot possibly conduct the complex information processing
strategies necessary to constantly draw normative inferences. As a result, our species
has come to use heuristics as shortcuts in our processing of the environment. It so
happens that our heuristics generally work by the process of assimilation.
We have become intrigued by the prospect that the distortions in information
processing attributed to psychopathological populations (e.g., Beck, 1967, 1976;
Ellis, 1962) may prove, in some cases, to be ubiquitous heuristics found in all human
beings (Evans & Hollon, in press). Such “distortions” as “all-or-none thinking”, in
which continuous information is processed in dichotomous terms, or “selective
abstraction”, in which only some aspects of a stimulus array are attended to, may
reflect more universal processes that are noticeable only when two individuals differ
in the content of their respective schemata. This possibility, we believe, clearly
merits investigation.
Recently, researchers in cognitive psychology have distinguished between two
types of information processing, automatzc versus deliberate (or controlled) (Keele.
1973; Neely, 1977; Posner & Snyder, 1975; Schneider & Shiffrin, 1977; Shiffrin
& Schneider, 1977). According to Schneider and Shiffrin, automatic processing
requires less energy by the individual and typically occurs without the individual’s
awareness. Deliberate processing, on the other hand, requires a larger amount of
energy and requires the individual’s conscious attention.
It is likely that automatic processing relies to a large extent on heuristically-
based judgments closely tied to currently operating schemata, and is more likely
to output nonnormative cognitive products. Deliberate processing, on the other
hand, is likely to rely less on heuristics and may require more time and energy,
while producing more nearly normative inferences. This process is more likely, in
turn, to lead to changes or accommodations in schemata (Hollon & Garber, in
press). While individuals in general are clearly less cognizant of cognitive processes
than cognitive products (Nisbett & Wilson, 1977), it is not always the case that
processes need remain outside one’s awareness. As will be discussed in the section
to follow, many psychotherapies, particularly those which are explicitly metacog-
nitive, appear to have been somewhat successful in bringing cognitive processes
into their client’s awareness.
It is important to keep in mind that all of the cognitive factors discussed in this
section, including the operations of knowledge structures and heuristic processes,
even those leading to biased inferences, may well operate in normal, as well as in
psychopathological populations. For years, clinical researchers have focused on the
aberrant cognitive processes of psychopathological groups such as depressives and
anxiety disordered individuals. The extensive research by cognitive and social psy-
chologists that has been discussed in this section highlights the extremely important
fact that all individuals may be said to engage in aberrant styles of cognitive pro-
cessing. In fact, since so much of the research has been conducted with normal
populations, it is not all together clear how many of these processes actually gen-
eralize to specific psychopathological populations. Clearly, research needs to be
directed to this issue.
The importance of these ubiquitous cognitive factors as mechanisms of change
in psychotherapy will now be discussed. The ramifications of aberrant information
processing by normals for our theories about mechanisms of change in psycho-
therapy will also be discussed.

COGNITION IN THE CLINICAL CHANGE PROCESS

A. A Model of the Change Process

We begin our discussion of the role of cognitive phenomena in therapy by consid-

ering a basic model of the clinical change process. This model, adapted from our
earlier theoretical work (Hollon, DeRubeis, & Evans, Note 1, Note 2) is presented
in Figure 1. The basic distinction lies between aspects of the treatment manipulation
and various client processes. At the far right are “clinical outcomes,” defined here
as any phenomena meriting clinical attention. Outcomes are essentially client var-
iables considered to be important in their own right.
“Mechanisms” are defined as client processes mediating change in those clinical
outcome processes of interest. Mechanism variables can be likened to a “toothed
cog” interfacing with treatment manipulations on the one hand, and outcomes on
the other. Inducing changes in these mechanisms, presumably as a function of
treatment, in turn induces changes in the outcome variables. Rosen and Proctor
 44 Steven D. Hollon and Margaret R. Krzss

TREATMENT MANIPULATION CLIENT PROCESSES

(Descriptive/Differential) Clinical
Components Outcome
#?\
I’ ’
y ’ f
Active _b Mechanisms
Components of Change

)c,
\ 44 4
\
\ / \
\ \
* / \
\
\
‘N Prognostic \
Indices i
\
\~11111__111111W.
-----1--111~1~~11111~~~~~~~~~~~~~~~~~~
\
EXTRA THERAPY FACTORS

Psychosocial
Stressors

FIGURE 1. A model for the clinical change process.

(1981) have proposed a similar distinction, using the term “instrumental outcomes”
to refer to causal mediators. Since mechanisms are seen as causal mediators, we
have drawn our figure to represent a causal relationship, adopting the convention
of using straight arrows with a single head to indicate the existence and direction
of causal relationships.
The mechanisms themselves are seen as being impacted by at least two domains
of phenomena: (1) “extra therapy factors” (i.e., psychosocial stressors), and, (2)
“active components” of the treatment manipulation. The extra therapy factors are
defined as those events occurring in the client’s life independent of treatment. We
recognize that, in actuality, treatment-induced changes may impact on those outside
events in a reciprocal fashion (Bandura, 1978b), but that is beyond the scope of
our present discussion.
The “active components” of treatment represent that subset of the larger set of
therapist activities contributing to the change process. These components are doubt-
less some combination of treatment manipulation (“descriptive/differential com-
ponents”) and the characteristics of the particular therapist(s) involved. Schaffer
(1982) has recently distinguished between the type of activity, the quality with which
it is delivered, and the interpersonal style in which it is embedded. For our purposes,
active components can derive from any aspect of the treatment manipulation: the
theoretically-prescribed activities that define specific modalities, nonspecific pro-
cesses common across multiple types of therapies, or idiosyncratic aspects unique
to a given therapist.
“Prognostic indices” represent individual difference variables that define the
background context variables for subsequent change. Traditionally, we have em-
phasized demographic factors (e.g., age, sex, socioeconomic status) or diagnostic
status (e.g., schizophrenia, affective disorder, anxiety disorders, etc.). As we will
see, cognitive structures and processes have been, as yet, relatively unexplored as
prognostic indicators, especially with regard to differential treatment selection and
component modification. This is an area in which, we think, real clinically-relevant
progress can be made.
For our current purposes, we will be concerned with those active components most
heavily involved in producing change in potential cognitive mechanzsms, given the
range of cognitive prognostic zndices. We can label the first issue the “active com-
ponents (mechanisms) question”; i.e., what aspects of the various types of therapy
actually produce changes in purported cognitive mechanisms of change? In essence,
we would be asking how one changes (or, at least, compensates for) cognitive
products, knowledge structures. and processes. We can label the second issue the
“mediating mechanisms (outcomes) question”; i.e., do changes in the purported
cognitive mechanisms really covary with and, more critically, mediate changes in
important clinical outcome phenomena? The astute reader will note that what we
have done is to divide the domain of process research into two parts, the compo-
nents of the manipulation producing change and the client mechanisms mediating
change. What we will not formally address is the traditional outcome issue; i.e.,
what treatments produce maximal change in outcomes, or the related process issue,
which treatment components are actually active in producing change in outcomes.
This latter question, which can be labelled the “active components (outcomes)
question,” may largely follow from the first two, but will ultimately prove to be the
most theoretically interesting way of pursuing treatment outcome issues. We leave
it unaddressed in the sections that follow, but fully recognize its ultimate impor-
tance. Finally, we address the role of pretreatment individual differences in cog-
nition as predictors of change and as differential treatment selection indicators.
These questions we label the “prognostic indices” and the “differential treatment
selection indices” questions. We turn to a discussion of each conceptual domain
from the perspective of basic cognitive and social cognitive phenomena.

B. Active Treatment Components

In this section, we discuss the desirability of adapting clinical interventions with an

eye toward the question of cognitive structures and processes. In essence, we at-
tempt to identify those treatment components most effective in mobilizing pur-
ported cognitive mechanisms of change.
Treatments can be more or less explicitly metacognitive in nature. As defined by
Flavell (1979), metacognitive knowledge “consists primarily of knowledge or beliefs
about what factors or variables act and interact in what ways to affect the course
and outcome of cognitive enterprise” (p. 907). Probably no approaches to treatment
are more explicitly metacognitive than are some of the recently articulated cog-
nitive-behavioral therapies (Beck, Rush, Shaw, & Emery, 1979; Ellis, 1962; Foreyt
& Rathjen, 1978; Goldfried, 1979; Goldfried & Davison, 1976; Kendall & Hollon,
1979; Mahoney, 1977a; Meichenbaum, 1977). With many, but by no means all,
populations, the focus of treatment is on changing cognitive products (and, per-
haps, structures and processes) by means of explicit careful attention to their ra-
tionality, validity, or functionality.
It is by no means clear that explicitly metacognitive therapies either produce
changes in cognitive phenomena or, if they do, that it is their metacognitive com-
ponents which are, in fact, the causally active mechanisms producing change. Con-
versely, there is no reason why a therapy must be explicitly metacognitive in order
to produce change in cognitive phenomena. For example, Bandura (1977) has
argued that enactive exposure, a largely behavioral component, is the most effective
46 Steven D. Hollon and Margaret R. Krm

single procedure for producing change in self-efficacy expectations. Similarly, there

is reason to believe that traditional dynamic-eclectic therapies may effect profound
changes in how an individual thinks about himself or herself and his or her place
in the world (Wachtel, 1981), even if those therapists couch their explanations in
other than cognitive terms. While it initially seems reasonable to assume that ex-
plicitly metacognitive components should produce maximal cognitive change, we
recognize that that is, in fact, an empirical question which has really yet to be tested.
We need to exercise caution in this regard lest we fall prey to the representativeness
heuristic, inferring a relationship based on the perceived similarity of purported
cause and consequence.
The basic dilemma is this: The main thrust of the cognitive and social cognition
research would seem to suggest that beliefs, once adopted and organized into
structures and processes, the latter presumably universal and quite possibly innate,
are extremely difficult to change. These processes appear to make it unlikely that
naturally occurring “corrective experiences” will occur, or, if they occur, that they
will have an impact. Hence, the inertia in the system appears to mitigate against
change. There are at least four reasons for this conclusion.
First, most people appear to be poor natural observers of relationships between
events in the real world (Jennings, Amabile, & Ross, 1982; Smedslund, 1963). Aside
from instances of near perfect co-occurrence, most human beings are remarkably
poor covariation detectors. What they are good at doing is inferring covariation in
the presence of theory or belief. Even the simple occurrence/nonoccurrence of
events may be misperceived, to the extent that those events are inconsistent with
schema-driven expectations. This recognition that natural observers are frequently
more “theoq-driven” than “data-driven” should come as no surprise to most scientists,
accustomed as they are to developing methodologies designed to offset just such
observational biases. Thus, people may fail to benefit from potential corrective ex-
periences if they are unprepared to recognize the significance, or even the occur-
rence, of those events.
Second, there is good evidence to support the long-held clinical contention that
people engage in acts which contribute to creating the environments and events
which they expect to exist and, in the case of distressed populations; from which
they then suffer (Darley & Fazio, 1980; Merton, 1948; Snyder & Swann, 1978a).
Paranoids, who fear that others are plotting against them, frequently elicit plots in
their environment (if only on the part of loved ones to get them professional help),
while depressives frequently act in ways that lead to interpersonal loss and a failure
to achieve gratification (Coyne, 1976a, 1976b; Seligman, 1975). This “self-fulfilling
prophecy” works to assure that people frequently have hard evidence in support
of their beliefs by the time they reach the clinician.
Third, there is evidence suggesting the existence of “confirmatory biases” (Roth-
bart, Evans, & Fulero, 1979; Snyder, 1981; Snyder & Cantor, 1979; Snyder &
Swann, 197813). That is, left to their own devices, when people set out to formally
test their hypotheses, they tend to do so using methods unwittingly biased in favor
of producing evidence confirming those existing beliefs. According to Wason (1960),
most individuals test beliefs by looking for and counting instances which are con-
firmatory (i.e., “if X, then Y”), rather than noting the occurrence of potentially
disconfirming instances (e.g., “What are the relative frequencies of X without Y,
Y without X, and neither X or Y?“). In ambiguous instances, people appear to be
far more critical of the quality of the methods used to collect information contrary
to their existing beliefs (Lord, Ross, & Lepper, 1979).
 Finally, the typical lay scientist appears to be more conservative with regard to
discarding a belief than he or she is in its formation (Nisbett & Ross, 1980). Not
only do beliefs appear to survive the discreditation of their initial evidential base
(Ross, Lepper, & Hubbard. 1975). but they appear particularly likely to do so if
people generate an explanatory svstem for that belief prior to evidential discon-
firmation (Anderson, Lepper. & Ross. 1980; Ross, Lepper, Strack, & Steinmetz.
1977). Given that human beings appear to evidence a proclivity for generating
causal explanations, even in the face of minimal information (Tversky 8c Kahne-
man, 1978, 1980), such enhancing schematic enlargement appears likely in most
instances.
All of these phenomena can be explained without invoking motivational expla-
nations (Nisbett & Ross, 1980). Tha‘i is not to say that people don’t ever maintain
their beliefs because they are motivated to do so (i.e., because it serves some purpose
over and above the desire to maintain an accurate internal representation of ex-
ternal reality, e.g., the protection of self-esteem, the procurement of external re-
ward, or as a safeguard against acting upon unacceptible impulses.) The controversy
between cognitive-based and motivational theories of human behavior is an old
and honorable one (see Jones, 1973; Nisbett & Ross, 1980; Zajonc, 1980); one
which we will make no pretense of resolving. What is evident is that a plausible
explanation (albeit one which may ultimately prove to be inaccurate) for each of
these various phenomena can be generated based solely on a “passionless” infor-
mation-processing model. While one of the basic tenets of dynamic-eclectic theory
has long been that motivations can be inferred from the observation of conse-
quences (e.g., the academic underachiever must be motivated to fail; the depressive
must be motivated to suffer), a cognitive model suggests that expectation alone, in
the absence of any unconscious dynamic conflict, may prove sufficient to produce
a wide range of consequences. We would not argue that motivational factors do
not play a role in this process at some points. They clearly do. But we are by no
means convinced that they must play a role at all points.
A cognitive model would argue that undesirable inferences may, at times, be
the consequence of errors in judgment while seeking reasonable goals in a tolerant
environment (see, for example, Beck, 1970; Mahoney, 1977a; or Abramson, Se-
ligman, & Teasdale, 1978). As Nisbett and Ross (1980) observe, to insist on the
primacy of motivational explanations for such an event requires the belief in the
omnipotence of the organism as a causal agent (i.e., events only occur if some agent
wills them to happen, in the service of some motive). Such an explanatory system,
maintained to the exclusion of the recognition of “honest” error, is both primitive
in its logic and unparsimonious in its account.
Two other points need to be addressed; that of the relatively greater stability of
early learning (a “primacy” effect) and that of the asymmetry in the processes
governing acquisition versus modification in cognitive learning. In the first instance,
it appears, in part for the reasons cited above, that beliefs and prejudices acquired
earlier in life are less malleable on the basis of subsequent experience than might
be expected on normative grounds. One need not posit the existence of unconscious
defense mechanisms to account for the intransigence of early learning (although
such mechanisms might exist). Simple cognitive explanations are sufficient and,
perhaps, more parsimonious (Nisbett & Ross, 1980).
In the second instance, it is clearly the case that different mechanisms mediate
the acquisition of cognitive beliefs and structures than mediate their modification
and dismantlement. When Jenkins waggishly titled his classic article “Remember
48 Steven D. Hollon and Margaret R. Kms

that old theory of memory? Well, forget it!” (Jenkins, 1974), he was counseling a
course of action largely outside of voluntary control. Current opinion now holds
that either perception or retrieval, or both, are largely constructive processes (Bart-
lett, 1932; Loftus & Loftus, 1980; Neisser, 1967, 1976). When we acquire, we are
largely adding cues and prompts representing the relevant information which can
be accessed in multiple ways and which are organized into multiple meaning sys-
tems. Retrieval involves the reconstruction of that information from those cues, a
process heavily influenced by factors operating in the larger environmental context
in which retrieval occurs. When we modify, it is unlikely that the whole of those
multiple meaning systems are changed as well. When we forget, it is not clear
whether it is that the basic information is degraded and lost, or that the cues for
retrieval are misplaced.
All of these processes conspire to maintain existing beliefs and knowledge struc-
tures. How then, since change clearly does occur, does change come about? Ross
(1977) has suggested that there are at least three ways in which existing beliefs are
changed. These are; (1) through the “brute” force of raw evidence, (2) by replacing
an existing explanatory system with a whole new system, in its extreme case a form
of wholesale conversion often relying more on “passionate” persuasion with mo-
tivational overtones than on appeals to evidence and reason, and, (3) by providing
insight into the processes which govern thinking and belief maintenance.
Elsewhere (Hollon & Garber, in press), we have attempted to analyze the various
components of Beck’s cognitive therapy (CB) with respect to Ross’ three principles.
In general, it is apparent that CB makes explicit use of each; encouraging clients
to test the validity of their beliefs by virtue of both reviewing available evidence
and conducting prospective “experiments” to gather new evidence, generating
alternative explanations to existing systems adhered to by clients (usually as a
prelude to a subsequent round of evidence gathering and belief system testing),
and highlighting the operation of distortions and biases in information processing.
This last component frequently feeds into the first, since the “available” evidence
is frequently biased due to the operation of observational and self-fulfilling proph-
ecy biases, and since efforts at prospective hypothesis testing are frequently un-
dermined by confirmatory biases.
Ellis’ rational-emotive therapy (RET) (Ellis, 1962, 1970), also an explicitly me-
tacognitive approach, appears to rely more heavily on Ross’ second principle; that
of replacing one philosophic viewpoint with another. The emphasis appears to be
more on rational persuasion, contrasting existing irrational beliefs with a more
“reasonable” set, than for CB. In essence, RET appears to emphasize a rational,
didactic, hypothetico-deductive approach as its active change component, while CB
appears to emphasize an empirically-referenced, evidential, hypothesis-testing ap-
proach as its specific active component. Both utilize behavioral components. RET
conceptualizes this utilization as a means of practicing living in a manner consistent
with the more rational beliefs acquired during conversations with the therapist.
CB, meanwhile, tends to utilize behavioral components as the “experimental” pro-
cedures in its hypothesis testing process.
Other cognitive-behavioral approaches may or may not be explicitly metacog-
nitive in nature. Self-instructional training (Kendall & Finch, 1979; Meichenbaum,
1977), which typically seeks to build in functional mediating cognitions where
cognitive deficits exist, can, but need not be, explicitly metacognitive. Especially
when used with children. it is quite possible for the therapist to interact with the
child in a manner designed to teach the overt verbalization of coping strategies
 Clrnzcal CognzlLon 49

which the therapist hopes will eventually become covert cognitive processes without
formally conveying information to the child about his or her own cognitive pro-
cesses. This approach has traditionally relied heavily on repel&on as a key mecha-
nism of acquisition (Vygotsky, 1962). In effect, overt behavioral modeling followed
by encouragement to and reinforcement for imitation is utilized to add to the
client’s covert associative network. Repetition alone may or may not lead to incre-
ments in belief of some body of information, but it clearly increases the probability
of its encoding and subsequent retrieval. We have increasingly come to rely on a
variant of this component in our efforts at cognitive restructuring within CB. When
going through the various steps in cognitive evaluation; e.g., testing the evidence,
generating alternative explanations, or commenting on the process, we try to be
explicit about what we are doing, preferably labeling the component with a brief,
easily remembered title.
Stres.+znnoculution training (Meichenbaum, 1977; Novaco, 1979), in which clients
are explicitly presented with analogue situations which are typically difficult for
them to handle, is typically metacognitive in its presentation, but again need not
be. In effect, it is possible to consider zn viuo exposure as the nonmetacognitive
component of stress-innoculation training. Self-control therapy (Kanfer, 1971; Rehm,
1977) may be structured so as to incorporate metacognitive aspects, but also need
not be. Finally, problem-solving approaches (e.g., D’Zurilla & Goldfried, 197 1) and
copingskills approaches (Goldfried, 1979, 1980b), while targeted, in part, at cognitive
change, may or may not be explicitly metacognitive in nature.
Goldfried and Robins (1982, 1983) have presented a set of comprehensive clinical
guidelines regarding specific active treatment components in the light of the op-
eration of cognitive products, knowledge structures, and processes. In keeping with
Goldfried’s (1980a) views on rapprochement, these guidelines are presumed to
hold across all forms of psychosocial interventions. These guidelines include: (1)
encouraging new behaviors (which presumes that prior behaviors were maladap-
tive, either by omission or commission), (2) facilitating the discrimination between
past and future functioning (which recognizes that existing schemata may mitigate
against the recognition of successful change), (3) assisting the retrieval of past
successful experiences (which is predicated on the realization that schematic pro-
cesses may bias retrieval processes), (4) encouraging clients to adopt an objective,
rather than a subjective perspective (which notes that systematic differences exist
between the inferences people draw regarding others as opposed to those they
draw regarding themselves, Garber & Hollon, 1980), and (5) aligning clients’ ex-
pectancies, anticipatory feelings, behaviors, objective consequences, and subsequent
self-evaluations (which starts from Lang’s 1980 observation that the various func-
tional systems don’t always change in concert). The authors provide specific ex-
amples of actual therapeutic procedures designed to affect each of these various
areas.
As discussed earlier, the notion that therapies designed for one purpose may
work in wholly different ways than originally presumed is not new (see, for example,
Dollard & Miller’s 1950 treatise examining dynamic therapy from a behavior per-
spective, or Breger & McGaugh’s 1965 reinterpretation of behavior therapy from
a cognitive perspective). Wachtel (198 1) has examined psychoanalytically-oriented
psychotherapy from the perspective of knowledge structures and information pro-
cessing. According to Wachtel, the therapist’s main task is to change the client’s
distorted view of the therapist, presumably altering the client’s underlying schema
regarding important significant others. The emphasis placed on encouraging the
50 Steven D. Hollon and .blargaret R. K~LSS

development of the transference phenomenon is thus explained from a schematic

perspective. This approach’s emphasis on the development of insight is reinter-
preted as an effort to make the client aware of the schemata he or she possesses
and to provide corrective experiences leading to their modification. It is this sche-
matic representation which is “transferred” onto the therapist, with the subsequent
in-session interactions providing the bulk of the opportunity for corrective expe-
riences (i.e., “working through”).
Humanistic approaches can also be interpreted from a social cognitive perspec-
tive (Goldfried & Robins, 1983). Rice (1974) and Wexler (1974) have suggested
that client-centered therapy may actually function by virtue of realigning infor-
mation processing and changing idiosyncratic meaning systems. Rice has pointed
particularly to the role of strong affective states in blocking accurate information
processing. For Wexler, an empathetic response involves a more adequate repre-
sentation of the client’s own meaning system than the client himself or herself is
able to articulate.
Even such diverse approaches as structural family therapy (Haley & Hoffman,
1967; Minuchin, 1974) or strategic communication approaches (Watzlawick, Weak-
land, 8c Fisch, 1974) may operate, in part, through cognitive change procedures.
The component of “reframing”, in which existing struggles, interactions, patterns
of behavior, etc., are relabeled by the therapist in terms facilitating change, appears
to be a prime example. By virtue of renaming the process, the therapist often
succeeds in leading his or her clients to perceive the situation differently, with
changes in behaviors following.
The distinction between metacognitive and nonmetacognitive processes strikes
us as being quite important. In some systems, there are strong assumptions which,
if correct, would argue against too great a reliance on explicit, metacognitive treat-
ment components. If classic analytic assumptions regarding the operation of un-
conscious intrapsychic defense mechanisms (Alexander 8c French, 1946; Freud,
1953 -64; Wolberg, 1967) or neo-Freudian assumptions regarding the operation
of unconscious esteem-protective mechanisms (Sullivan, 1953) are accurate, then
the more explicit the therapist is in communicating what he or she is about, the
more active those resistances will be and the less the change that will be accom-
plished, at least initially. Similarly, in structured family therapy, where the existing
system is seen as actively resisting change, probably through some combination of
inter- and intra-individual processes, explicit treatment components, much less
explicit metacognitive approaches, would also probably be expected to mobilize
active opposition to change. Whereas a cognitive model would posit only inertia in
the system, with “passionless” biases and information-processing failings slowing
the process of change, many therapeutic systems posit the existence of formal
mechanisms which will actively,oppose change. To the extent that active mecha-
nisms of resistance exist, explicitly metacognitive components are likely to be par-
ticularly ineffective. To the extent that the processes blocking change are passive
in nature, then the more explicitly metacognitive the approach, the better. We
suspect that this issue will become increasingly important as a topic in clinical
research and practice over the next decade.
Assuming that metacognitive components at least merit discussion, what are some
of the actual steps that can be taken to offset the biasing influences of existing
knowledge structures and processing heuristics ? In presenting the following guide-
lines, we are relying largely on extrapolations from the cognitive and social cognitive
literatures, which have, we recognize, largely involved the drsrrzptm of phenomena
 Clinlcnl Cogn’lro?l 51

in normal populations, not the correction of biases in those normal populations, much
less the correction of biases in ~s~rhopatholo~~ral populations (see Einhorn, 1982;
Fischhoff, 1982; Kahneman 8c Tverskv. 1979: Nisbett. Krantz, Jepson, & Fong,
1982; Nisbett & Ross, 1980, for exceptions to this rule). We also draw heavily on
our own unvalidated clinical experiences and the recent spate of articles and chap-
ters seeking to combine the above sources to accomplish what we are about to
attempt (Beach, Abramson, & Levine, 198 1; Evans & Hollon, in press; Goldfried
& Robins, 1982, 1983; Turk & Salovey, in press-a; Turk & Speers, 1983). Makin,g
no claims for the temporal or logical order in which they are presented, the sug-
gested components are as follows:
1. Systematic self-monitoring: One way to partially offset biased observation and
information retrieval is to train the client in systematic self-monitoring skills (Cim-
inero, Nelson, & Lipinski. 1977; Hollon & Kendall, 1981; Kanfer. 1970; Kazdin,
1974; McFall, 1977: Mahoney, 1977b; Nelson, 1977). These procedures can be
more or less formal, but they should be structured so as to offset probable biasing
processes. If, as suggested by the basic cognitive and social cognitive literature,
people are more likely to be “theory-driven” than “data-driven” when monitoring
events (Jennings et al., 1982; Smedslund, 1963). careful instruction in observational
skills should prove useful. Ongoing behavioral observation systems, which can
readily be expanded to include external events, affects, and cognitions, have been
found to be more robust with regard to inferential errors than are unsystematic
judgments (Kent, O’Leary, Diament, & Dietz, 1974; Weiss & Brown, cited in Nisbett
& Ross, 1980). Further, temporal factors appear to play a role, with the delayed,
retrospective monitoring systems apparently more susceptible to distortion than
more nearly contiguous observation (Evans & Hollon, Note 3). As Alba and Hasher
(1983) have pointed out, schematic biasing processes may have their predominant
effect on retrieval from memory rather than the initial processing of information
for encoding and storage. Ongoing archiving at or near the occurrence of an event
should facilitate accurate retrieval later. In general, our clinical experience has been
that the more nearly descriptive, immediate, and structured the monitoring system
(as opposed to inferential, delayed, and unstructured), the freer it is from bias.
Such systems present a second, closely related, advantage. They provide a stable
archive for subsequent hypothesis-testing. Since memorial retrieval represents a
prime locus for both schematic and situational context bias (Alba & Hasher, 1983;
Hastie, 1981; Loftus & Loftus, 1980; Thorndyke & Hayes-Roth, 1979), frequent
reference to this ongoing archive can help forestall such biasing. The therapist
himself or herself often plays this role during the session, pointing out past instances
of successful encounters or adaptive actions (Goldfried & Robins, 1983), but our
experience has been that recourse to client-generated material is usually more
compelling than the therapist’s verbalized recollection.
2. Multiple-observation mode: The bulk of the cognitive and social cognitive lit-
erature has been built on single-observation instances; i.e., instances in which in-
dividuals are asked to generate an inference based on a single instigating cue. While
the failings of the intuitive scientist have been amply documented in these single-
observational contexts (Kahneman et al., 1982; Nisbett & Ross, 1980), earlier work
by Kelley (1967, 1972a. 1972b, 1973, 1980) has suggested that people, at times,
generate quite reasonable inferences following rather normative processes. Rusbult
and Medlin (1982) have demonstrated that allowing subjects to sample multiple
trials in a “stockmarket” simulation before asking them to generate causal inferences
led to normative attributions of causality (in keeping with Kelley’s 1973 “covaria-
5.2 Steven D. Hollon and hlargaret R. Krzss

tion” principle). Inferences regarding causality in the single-observation case evi-

denced the classic attributional asymmetry for normals in which positive outcomes
were attributed internally while negative outcomes were attributed to external
factors (Jones & Davis, 1965; Jones 8c Nisbett, 1972; Miller, 1978; Miller & Ross,
1975).
Rusbult and Medlin argued that the biasing influences of schematic knowledge
structures and heuristic information processing are most potent in situations of
greatest uncertainty. When encouraged to suspend judgment until multiple-ob-
servations were acquired, subjects drew inferences more nearly consistent with
normative conclusions and in a manner more nearly consistent with Kelley’s in-
tuitive scientist than Nisbett and Ross’ fallible scientist. Therapeutic procedures
which counsel caution in inference-generation and encourage the observation of
multiple outcomes (trials) in a given situation may work to forestall theory-driven
biases.
3. Memorial reconbuctaon of detail: In a recent review, Alba and Hasher (1983)
observed that while many aspects of schema theory do appear to be supported by
the available literature, “more is stored in memory than any version of a schema-
based selective encoding mechanism can account for” (p. 222). They suggest that
omissions and inaccuracies may as often be attributable to the failure of retrieval
as to any systematic distortion at the time of encoding. In short, the client may
possess fairly rich and accurate information about earlier events, but have systematic
and predictable difficulties retrieving that information. In part, this interpretation
is based on the observation that schematic distortions are far more prevalent in
recall than in recognition tasks.
Clinically, the aforementioned utilization of self-monitored records clearly rep-
resents one means of capitalizing on this distinction. But what of situations for
which no a priori records exist ? Our experience has been that thP Gestaltian tech-
nique that asks the client to first describe the original scene, providing as many of
the actual physical cues and characteristics as possible, may facilitate more accurate
subsequent recall. In effect, we encourage the client to first provide meaning-
irrelevant context before providing meaning-relevant detail in an effort to offset
theory-driven recollection. The actual clinical utility of this procedure has, so far
as we know, not been formally tested.
4. Formal prediction generatzon and recording: Fischhoff and colleagues (Fischhoff,
1975, 1977; Fischoff & Beyth, 1975) have described what they refer to as “hindsight
bias”, a tendency for people to misrecall their earlier predictions when confronted
with subsequent disconfirmatory evidence. Closely related is Wood’s (1978) “knew-
it-all-along” effect, in which subjects tend to overestimate the quality of their original
knowledge about facts after they have been provided with relevant subsequent
information. Both processes probably contribute to what Sherman (1980) has la-
beled the “self-erasing nature” of errors of prediction. The net effect of either
process is to leave people less surprised subjectively by new information than they
ought to be, which obscures the failings and foibles of earlier inference processes
(Einhorn & Hogarth, 1978). For example, most clinicians have had the frustrating
experience of working for weeks with a client to bring them to the point where
they could actually engage in some previously avoided or unattempted activity,
only to find that the client minimized their eventual performance by observing
that they “knew all along that they could do it” or that “they never really believed
the task was all that difficult”. What makes this process so frustrating is that there
typically appears to be little generalization to tasks as yet unattempted; those
tasks continue to be seen as too threatening or too demanding to be attempted.
The problem, of course, is that clients are unlikely to correct for systematic biases
in inference generation if they fail to recognize that errors have been made. Fisch-
hoff (1982) has proposed a set of procedures for “debiasing” consisting largely of
education regarding these processes (Ross’s third change principle: Ross, 1977).
Similarly, Wood (1978) has shown that such biases can be largely offset if subjects
are encouraged to memorize their prior knowledge states at the time predictions
are made.
Clinically, we have developed a strong preference for eliciting and amplifying
a prior-r predictions from clients prior to engagement in specific activities or events.
Preferably, these predictions are written down. After subsequent information is
acquired, clients are invited to compare their subsequent predictions to their prior
expectations. The whole process is approached not as a demonstration of the
existence of bias, but as an experiment to see if “bias” notions actually apply to the
specific client. This codificatioh of prior states of knowledge, followed bv compar-
isons to actual subsequent information, preferrably repeated over multiple occa-
sions, strikes us as a particularlv powerful way of ensuring that, “corrective
experiences” really produce systematic alterations in existing knowledge structures
and reduce the confidence clients have in the accuracy of their a priori predictions.
It also provides a nice device for identifying systematic tendencies (e.g., a tendency
to overestimate threat by anxious neurotics, a tendency to underestimate one’s own
capacities and the likelihood of gratification by depressives, a tendency to under-
estimate the probability of negative outcomes by manics or punishment and re-
sponse cost by psychopaths). As has typically been the case, we know of no formal
testing of this proposition with clinical populations.
5. Perspective change as a mearu of tapping or developing alternate knowledge sets: One
of Goldfried and Robins’ ( 1983) five change components, alternating objective and
subjective perspectives, has held great appeal for us, both clinically and as a research
paradigm. While Goldfried and Robins have quite reasonably emphasized en-
couraging the client to switch from viewing situations from a subjective to an
objective perspective (based on the earlier actor-observer literature, Jones & Davis,
1965; Jones & Nisbett, 1972; subsequently reinterpreted by Taylor & Fiske, 1975,
1978; Taylor & Koivumaki, 1976. as reflecting systematic differences in the avail-
ability and salience of information about events), we suspect that such a manipu-
lation is just one of a set of larger perspective changing procedures. In addition
to clients being able to provide different sets of inferences for “people in general”
than they do for themselves (e.g.. Garber & Hollon, 1980; Regan & Totten, 1975).
we have found our depressed clients quite frequently able to generate quite rea-
sonable and detailed plans of action when asked “What would you have done before
you got depressed?” when, only moments earlier, they appeared unable to for-
mulate any coherent plan of action. While we would not deny that many clients
have real skills deficits which require the acquisition of specific behavior or cognitive
capacities, we have frequently been impressed by our clients capacity to demonstrate
knowledge (or performance capacity) if encouraged to change perspectives. This
observation may represent what Abelson (198 1) has referred to as a “failure to
activate” a relevant knowledge structure concerning possible courses of action (i.e.,
a “script”). Presumably, such an “activation” failure can occur for any of the types
of knowledge representations.
6. “ConfirmatoT bias”: As noted earlier, “confirmatory biases” appear to manifest
themselves through both largely cognitive (i.e., distorted memorial retrieval) and
 partly behavioral (i.e.. blased information search methodologies) mechanisms
(Rothbart et al., 1979; Snyder, 1981: Snvder 8~ Cantor, 19i9: Snyder & Sl\.ann.
1978b). As described by Goldfried and Robin5 (1983). the therapist ma! ha1.e to
play a major role in offsetting memorial mechanisms III the session b\ reminding
the client of schema-inconsistent events which the client has pre\iously reported.
Archival self-monitoring records can, of course, play a role as Iveil.
More critically. therapists can work lvith these clients’ information-search pro-
cedures on an a prioti basis, utilizing role playing and covert imaginal rehearsal.
For example, in a demonstration tape with a client named “Mia.” *Aaron Beck asked
the client to role play how she might ask her husband about the reason he had
been “working late” on a regular basis. The client, who feared her husband was
having an affair, responded: “‘John why don’t >ou come home ,mymore?” Beck
was able to suggest that she rephrase her prompt, deleting the “\\rhydon’t you,”
which he thought conveyed an implied accusation. Similarlv. in working \;ith a
depressed male client, one of the current authors (SDH) negotiated that the client
would obtain feedback from his wife regarding how his depression was affecting
her. When asked to roleplay how he would actually word his inquiry, the client
responded as follows: “I know this has been an awful time for you. What have
been the worst aspects?” Since the task was intended to acquire unbiased infor-
mation, such a query could hardly be considered even-handed. Xfter some dis-
cussion and additional practice, the client was able to pursue the Issue with his wife
in a less biased fashion.
We have consistently been struck by how similar the metacognitive therapy
process can be to the process of training a bright and able graduate student to
become a scientist. While the qualitv of the working relationship can be quite
helpful, there is an explicit body of conceptual and methodological skills that you
want both client and student to come to be able to appreciate and apply. The steps
that we have found useful in coping with “confirmatory hia5” in our clients strike
us as being particularly similar to those \ve have fo~cnd easeful in training (and being
trained by) our students.
7. “False co~m~m~~~KLS”:Ross and colleagues (Nisbett 8~ Rob5. 1980; Ross, 1977;
Ross, Greene, 8c House, 19i7) have described cl tendency for mo5t people to assume
that others share their perceptions and opinions. This tendenc\. labeled the “false
consensus bias”, strikes us as one process leading clients to underemphasize the
potential causal role of idiosyncratic beliefs on subsequent feel111~5 ,tnd actions and
to fail to recognize the distinction bet\veen beliefs and f‘1ct.s.
Clinically, \ve have irequently found it useful to h,~\,echents unobtrusi\,el\ poll
other people about their viekvs. One of OLLI.colle.lguea. Da\ e C:o,tt5. recentI\, treated
a depressed female client ivho Lva5 con\ incetl that no tle\lrable man should e\ er
want to marry her because, having undergone a total h~sterectomv for medical
reasons in her mid-twenties. she could ne\‘er ha\~ children. She regarded her
attitude as being near universal. expressing her con\ Ictlon th,lt .~lmost ant male
would share her prejudice. Lt’hen pressed b! her therapist. she ‘igreed to conduct
a discrete poll of various males at her place of viork. u ~tl~hold~r~gthe information
that this was a situation she herself shared. Presenting the i.s.sue ‘1s a theme from
a daytime television serial. she found that nine of the ten nl;Je.s she polled specif-
ically disagreed with her belief, almost all stating that the\ \\ould ima~me themselves
to be far more concerned about :he qualit! of the relation.sh~p th,m the fertility of
their potential spouse.
8. Inuclequatr ~~ilouur~r /c)r sod W/P: Rosh and colleagues (Slsbt’tt &CRoss. 1980:
Ross. .Im;ll~ilr. & Sleiulliet/. I!)Ti) Ii;tw div u4wd <I trticlellc\ for ptfopie lo fail to
take into ;KCOUI~~ MKLII role coII~1I~dIII1~ \j 11cIl tli-;I\\ ing iiitt’r~x3-soi~;d inferences.
‘I‘his reiitlenc\ Ill~lillf~St~ Ir~rlf‘I~oth iI1 rstl-;t-~Il~l~~l~)\ ;llltl \Ilthin wSsi0n interacrions.
\,I’e h;~\,eno yood gui(lel111~3 trri-e otlirr 111x11 ~tiuc;ition ,Ihout it\ otcun~enc‘e (Ko4s’s
third cii;~ngr prinr~ipl~). l)tlrrw4wcl II\ ~uili~dr~ ti-0111 lliv c lirnr’s o\\ ii experience
(e.g.. “do \ 011 1wllt?lll~tT ho\\ 5IlI‘cY \‘01ll p;rl-ents ser111rd of thelllsel\ es ‘llld bon

unsur? \ou f’wl of‘ \ourwl1 ‘IS d p;IIwilJ”~. .\I lIillt3. \\ c ha\ e e~lcouI-~~ged chents
to attempt to solicir the pri\ ;ire 1wr4pecti\.t’ 01 percei\ rtl “po\~erful” orhers (e.g..
emplovers. profeswr4. parw~s. ;iu1hori~\ figures. etc.).
BY far the most a\2ilable relationship 10 explore is that bet\Veen client and
therapls:. \Z’e frequentI\ tr\ to ,tr1 .tilgc for thr chriit to tahe an active. participarorl
role in skills application mi(1 ~~~-ol~leiii-sol~i~~g in therap\. Fol- example. \vhen making
notes or lists of thing5 to renit7i~lw- or activities to carr\ out. 1j.e routineh start the
process. then pass papet- and pen o\‘eI- to tile client. .After one or t\\‘osuch expe-
riences. the client tvpicall\ initir;te\ the recording prowss on subsequent occasions.
M’hen examining the \alitlit\ of belief’s or attempting to generate solutions to
problems, \ce prefer to promp’ the client to take the lead in such aspects (bvithout,
ho\ve\Ter. being reluctant to prcnride our o\\.ninput if‘. after a moment or two. the
client encounters difficult\ lI1 50 doing). \I’hen. as frequentI>, happens, the client
engages in an in\,idious self-c-ompal-ist,n \\.lth the therapist or others, we have
typicall\ already generated e\.idence regarding the client’s successful mastery of
various’ skills.
Finall\,. one of the advantages (among \farious disadvantages). of group therap!
is that clients themselves are often quite skilled at applving therapeutic procedures
to others’ problems. e\‘en when those problems are quite similar to ones they believe
themselves powerless to solve on their own behalf (Hollon & Evans, 1983; Ho!lon
8c Shaw. 1979). The observation that one has successfully engaged in a given skill
can be helpful in offsetting denigrating self-other comparisons derived from an
inadequate allowance for social role.
9. Self-fulfillmg- prophrc_~: This phenomenon, producing as it does belief-
confll-ming data as a consequence of schemata-relevant behaviors (Darle\ & Fazio.
1980). strikes us as the most troublesome of all the problems confrdnting the
therapist in producing change. In one respect. it is the exception lvhich proves the
rule: in our experience. clients are particularly likely to have confidence in beliefs
lvhich are buttressed bv experiential data. The problem, therapeuticall!, is that
the! fail to recognize how their beliefs ma\‘ have shaped actions ieading to outcomes
and. as a consequence, ma\ be reluctant to alter behaviors in the face of their
perception of realit!.
Clinicall!. we find ourselves relving on several coordinated strategies. First, we
tr\ to generate alternative explanations for existing data in an effort to introduce
uncertaint! regarding the interpretation of those events. an example of Ross’ sec-
ond principle. Tvpicall\,. this in\-elves an explicit depiction of the self-fulfilling
prophet\ phenomenon, an instance of Ross’s third change principle. Second, as
noted earlier. I\-e train clients in some t\pe of structured observational svstem,
eliciting and recording their schema-related predictions, and verbalize the predic-
tion(s) that would follow from the one or more alternative models just postulated.
M’e next have OUT clients consider ho\\. the relative validities of the two models
could best be tested. Generally. such an enterprise l\,ould have to include the client’s
behaving in an atypical fashion as a means of testing their existing hypothesis. As
might have been predicted b\. \Vason ( 1960). our experience has been that most
56 Steven D. Hollon and *MargaretR. Krlss

clients initially assume that the continued observation of events following repeated
instantations of their existing behavior pattern constitutes a sufficient test. We find
that clients frequently need both assistance in conceptualizing appropriate behav-
ioral modifications and reassurance before attempting to execute those altered
responses. Finally, we typically find it useful to discuss, after the fact, the processes
involved and the implications of the outcomes. In a metacognitive approach, be-
havioral change in specific instances is as much a means to an end as an end in
itself.
10. Hzstorical reconstructzon: Despite our primary identification with a relatively
ahistorical approach to therapy, we are aware that many therapies rely heavily on
this particular treatment component (e.g., Adler, 1927: Alexander & French, 1946;
Freud, 1953-64; Sullivan, 1953; Wachtel, 1981; Wolberg, 1967). We have never
been opposed to historical reconstruction, which we regard as a useful vehicle for
pursuing Ross’ second change strategy; i.e., the reinterpretation of earlier “facts”
as a prelude to the replacing one point of view with another. We have frequently
seen our clients benefit from coming to understand (or at least generate a plausible,
nonmotivational explanation for) how they acquired their earlier self-schemata.
For example, one of our clients came to view his derogatory self-schema as the
outgrowth of a series of competitive interactions with a younger brother for their
father’s approval, a competition actively encouraged by the father to facilitate the
family-operated mail order business (Hollon & Beck, 1979). The client had already
largely dispelled the notion that he was “characterologically lazy and immoral”,
which he had believed entering therapy, through an ongoing program of hypothesis
testing. With “insight”, the client came to believe that that earlier schema was a
reasonable, if inaccurate, self-perception to have abstracted from his environment
as a child.
Our preference is to utilize historical reconstruction as a means of sohdif?ring
cognitive change, not producing it, but that preference is strategic only. Whether
the therapist utilizes insight-generating historical reconstruction to produce change
(the traditional approach), or the generation of current change to produce insight.
which is subsequently buttressed by historical reconstruction, the procedure itself
may have a useful role to play in therapy.
Overall, we have attempted to suggest a number of discrete manipulation com-
ponents which we think may prove to be active components in the clinical cognitive
change process. As noted, few have been explicitly tested in any formal sense,
independent of larger treatment packages. Our suggestions are largely based on
a concatenation of extrapolations from the basic cognitive and social cognitive
literatures and unstructured clinical experience.
We can address the issue of what types of changes in cognitive mechanisms we
anticipate. In the section to follow, we examine whether changes are most likely at
the level of product, structure, or process.

C. Cognitive Change Mechanisms in Psychotherapy

I. Mechanisms as a Conceptual Domain. The proper identification of cognitive

mechanisms is important for
treatment of psychopathology.
within the client for clinical
optimal clinical interventions
if it were shown that change
the further advancement of our knowledge of the
Once we know what actwe changes need to occur
improvement to take place, we can then devise the
for a given client or type of disorder. For example,
in certain schemata were necessarv for a depressed
state to subside, then a treatment directed at altering such schemata might be used.
It is important to note that the mechanisms of change (i.e., the mediators of
clinical improvement) may be different from the mechanisms producing pathology,
that is, the mechanisms that moved the client from normality to psychopathology.
For example, Hollon and Garber (1980) suggest that certain negatively biased causal
attributions may lead to the onset of depression, whereas change in expectations
are more likely to lead to the alleviation of depression. This concept is important
as a strict reliance on theories of etiology of psychopathology may not always be
the most fruitful source from which to develop theories of change. In other words,
theoreticians of the psychotherapy change process need to be ready not only to
draw on existing etiological models, but to develop unique models of the change
process.
Research on cognitive change mechanisms should not be confused with treat-
ment outcome research. The former task need not rely on one particular treatment.
What is important in mechanism research is to demonstrate a correlation between
change in the mechanism and clinical improvement, regardless of the clinical in-
tervention used. For example, Bandura and colleagues (Bandura, 1977; Bandura,
Adams, & Beyer, 1977) have suggested that a cognitive mechanism, self efficacy,
is responsible for clinical improvement in many different behavioral treatments.
On the other hand, treatment outcome research is concerned with whether the
presence of a certain treatment (as opposed to other treatments) or component of
treatment is differentially related to clinical improvement. Recent therapy outcome
research (e.g., Hollon, Weimer, & Tuason, Note 4; Zeiss, Lewinsohn, & Munoz,
1979) has gone one step further, however, and addressed the following questions:
(1) Why do treatments work, i.e., what mechanisms of change within the client
were affected by the treatment? and, (2) Did the treatment affect the mechanism
of change originally targeted by the originators of the intervention? As can be
observed by the questions being addressed, our understanding of the efficacy of
therapy and active mechanisms of change will be advanced in a reciprocal fashion.
In order to address these two questions, cognitive assessment strategies must be
incorporated into the research protocol (Kendall & Korgeski, 1979). Such proce-
dures are especially important when separate treatments, each proposing to influ-
ence different active mechanisms, are compared. For example, suppose that a
cognitive restructuring procedure and a relaxation approach are compared in the
therapy of test anxiety. It will be important to document via cognitive assessment
whether the former treatment is effecting a change of beliefs in the client (a cog-
nitive change mechanism), and that the latter therapy is primarily effecting change
via reducing physiological arousal. Furthermore, it is important to determine whether
the physiological mechanism associated with the latter therapy is also affected to
some degree in the former therapy, and vice versa. Finally, it is important to
determine what additional mechanisms are being affected in the two treatments
(Kriss, Note 5).

2. Possible Cognitive Mechanisms in Psychotherapy. Our discussion of cognitive

mechanisms will be organized according to whether the mechanism is a cognitive
product, structure, or process. As will become clear in the discussions to follow,
this distinction is not always a clearcut one. For example, change in products
probably reflects an underlying change in the process and structure of cognitions.
An effort will be made to point out the interrelationships between relevant cognitive
phenomena. Throughout this section, we will discuss some representative studies
 that have empirically tested the existence of cognitive mechanisms. Our purpose
is not to present an exhaustive review of such studies. Rather. our goal is to use
representative studies to point out important methodological and conceptual issues
implicit in the study of cognitive change mechanisms.
a. Cognztzz~ Product ,Wrc/~anzsm.c: One mechanism that has received consldernble
attention is the occurrence or I~~I~~~~~uwwP of specific cognitive products (Hollon &
Bemis, 1981). Several researchers have suggested that it is much more important
for a client to decrease or stop negative self-statements than it is to increase positi\ e
self-statements (Kendall, Williams. Pechacek. Graham. Shisslak. ,% Herzof. 1979:
Schwartz & Gottman, 19i6; Zeiss et al., 19i9).
Others have suggested that an increase in the output of positive self-statements
is what is most related to clinical improvement (e.g.. Hamberger & Lohr. 1980:
Rehm, 1977). An interesting finding was reported in a case studv of a cognitive
restructuring therapy for anger control bv Hamberger and Lohr (1980). The\
noted an initial increase in their patient’s negative self-statements follolved bv a
reduction of negative self-statements and an increase in positive self-statements.
This finding is consistent with the suggestion (Kendall & Korgeski. 1979) that an
initial effect of therapy is to make subjects aware of then- negative self-statements
and hence increase the frequencv with which they verbalize them.
It is important to be specific when discussing the concept of self-statements.
Such self-statements can be classified in a general ivay as being positive or negative
in content or they can be described more specificall) m terms of their function
(Arnkoff & Glass, 1982). Functionallv, self-statements might be discussed in terms
of task specific self instructions (Meichenbaum, 197;) or as serling as adaptive or
maladaptive coping self-statements (Arnkoff ti C;la~. 1982; Sleichenbaum, 1977).
. Arnkoff and Glass (1982) suggest that the content of a patient’s self-statement
may be less related to their subsequent emotional state than IS ivhether that covert
verbalization is followed by coping self-statements. For example. the presence of
the negative thought, “I am starting to feel very ;IIIX~OU” might lead a test-anxious
patient to many other debilitating self-statements, or it might signal to the pa-
tient that he/she should start emitting adaptive or task specific self-statements.
The important cognitive mechanism being suggested here is the sequence of self-
statements from negative to more adaptive. It should he noted that the sequence
of cognitive products is quite closelv related to 011e’~ cognitive .structures. as the
mrunzng of a particular self-statement (I.e.. the k~/oi~~i~~rl,~~ that this thought is part
of- one’s coping schema or failure schema) is pro\ iclect b\ schem,~ta. Lnfortunatel\
there is not anv specific empirical evidence tel,ltiii g change in sequence of selt-
statements to clinical improvement. C:learlv. it 1s ;i research .irea \vorth\ of stud!.
Research has focusetl. however. on the eitect of incre,ismg subjects’ adapti\ e or
coping statements, with contrxlictor~ results. For e~nlple. (;logoiver. Fremou\v.
and McCroskev ( 197X) provided e\itlrnce th,tt ‘in 111cre;l~ in task relevant coping
statements (i.e. prepatorv. coping. in5tructiollJ. ,~iltl ~lt-i~\.~rci self-statements)
was related to behavioral and aelt-reportect imI)ro\,enlent ot speech anGet\. Somr-
what different results were found hv Kini ( l!MO) u~ho compared t\\o tapes of
cognitive-behavioral interver:tions t’or hell)in g stuclrnts &~pt to their .icadeniic
major department and improve their xatlennic p~rtc~rmance. ii.hilr subjects in the
tLv0 interventions differed in their ~~ro~iuction of ,lctapti\c self-4t,itenients. the t\vo
groups did not differ on oiitcoiiiv Iiltxiyure4 ot .ic,~tlcilllc pcrtoriii~~nce. ‘IIlls stud\
sLi,qgests that tl1ei.e niu\t be other cognili~ iiitx h,1iilst115 tli,lr ‘1i.c’Iiiipc)rt;int t.or this
client popul,~tiori.
 Two major tre;~lnl~llt o~llc‘o~ur stuclws hve attempted to identif’v the active
n~echani~m~ in \ ariou\ trc,ltment\ toi- tlepression. In a further analvsis of data
collected in the Ku\Ii. l{rcL. Lo\acs , autl Hollon ( 1977) comparison of’ cognitive
therap\ and iniipr;inliiic l~Ii,II~liiacotliei-;ll)\. Rush. Heck. Kovacs. M’eissenhurger,
and Hollon (19X2) found greater change in pessimism. as measured by the Hope-
lessness Scale (Beck. \\‘eiasm,~n. Lester, & ‘l‘rexler. 197-l) in clients receiving cog-
nitive therapv. The diffri cilct‘ irl magn~tudr betlveen the groups. hoivever, M’;ZSnot
large and \vas found at midtl-~;ltrnc-nt onl\~. Such data do not necessarily indicate
that change in pessimism is an (IC//~Wcogniti\,e mechanisms as there was no evidence
presented to suggest that a decrease in pvss~mism \vas positively correlated with
change in depresalon
Zeiss et al., (19iY) attempretl to identifj specific cognitive. behavioral. and
interpersonal change inechanisms that might be differentiallv affected by three
specific treatments. cogniti\,e-behavioral therapy. behavior therapy, and interper-
sonal therapy for the treatment of depression. Results failed to find such differ-
ences. as all three treatment\ demonstrated equivalent change on all mechanism
measpres. The authors concluded from this stud\ that a nonspecific mechanism
was implicated in reccn~er~ from depression. As noted hv Hollon and Evans (in
press-a). holvever. rhe absrncr of dif‘ferential component checks and the utilization
of unvalidated mechanism measures precluded ruling out rival plausible alterna-
tives. Furthermore, it might be that differential mechanisms were associated with
different treatments. hut that such mechanisms were not among those assessed.
h. Copztzrv Stnrctrrrcll .\l~chcr,,/sms: M’hile cognitive products appear to he good
candidates for cognitive change mechanisms, such products represent only one
line (i.e., an end link) in the causal chain that accounts for change in psychotherapy.
As outlined in part one. structures and processes account for a large amount of
the variance in cognitive products and are likely to he early links in the causal
cognitive mechanism chain. The important relationship between self-reported cog-
nitive products and structure and processes is well stated by Glass and Arnkoff
(1982). who note that. “even though reports of self-statements mav not ever he
total11 veridical. people are telling us something meaningful about themselves that
reflects differences in more ‘deep’ cognitive structures. schemata, or processes.”
The structural mechanism that has perhaps received the most attention is Ban-
dura’s (19iS) theory of- self-efficacv. Bandura differentiates between two different
tvpes of expectancies: outcome expectancies and efficacy expectancies. Outcome
expectancies are beliefs concerning lvhether a certain behavior will lead to a desired
outcome (e.g.. “If I study for three hours. then there is a good chance that I will
pass rn! exam”). Efficacy expectancies are beliefs of one’s capability to produce the
required behavior (e.g.. *‘There is very little chance that I will he able to study for
three hours tonight”). Bandura proposes that the important change mechanism in
behavioral and cognitive-heha\ioral interventions (in fact. any treatment) is an
increase in self-efficacy. Change in self-efficacy can he measured in terms of mag-
nitude. strength, or generality. .4s discussed in an earlier section, self-efficacy might
best he conceptualized as a ‘\.pe of self-schema (Turk & Speers, 1983) with the
specific expectations generated from it being considered cognitive products.
Bandura and his colleagues (Bandura X: .4dams, 197’7; Bandura, et al., 1977)
have provided some empirical eiridence that change in self-efficacy expectancies
for snake phobics wxs greater in a treatment lchich instructed clients to practice
nelz- behaviors. as opposed to a treatment that used therapist modeling alone as a
means of effecting desired behavior change. Furthermore. these t\vo studies dem-
60 Steven D. Hollon and .Margaret R. Krzss

onstrated a positive correlation between client reported self-efficacy and perfor-

mance on various snake approach tasks. Self-efficacy expectancies were found to
be far superior predictors of approach performance than were measures of past
behavior.
There has been considerable criticism of the self-efficacy concept (Goldfried,
1982). A major criticism has been that self-efficacy expectancies are not causal
mediators of change, but are rather epiphenomenal byproducts of behavior change
(Borkovec, 1978; Eysenck, 1978; Lang, 1978). Bandura (1978a) replied to such
criticisms by pointing out that expectancies are better predictors of post-therapy
performance than is knowledge of whether or not a client is exposed to certain
fearful stimuli.
Another structural mechanism that has received attention is Ellis’ notion of
irrational beliefs (Ellis, 1962). To Ellis, a person’s philosophical view of the world,
evidenced by the set of beliefs or values that one holds, plays a major role in one’s
emotional well-being. Ellis suggests that the negative self-statements that individuals
emit are a result of their holding certain irrational beliefs. We have chosen to
categorize such irrational beliefs as being organized in schema-like structures. Ex-
amples of Ellis’ irrational beliefs include the notions that “I must be perfect”, “I
must be loved”, or “I must not be frustrated”.
Several therapy outcome studies examining cognitive-behavioral interventions
have assessed change in such irrational beliefs. Most researchers have used the
Irrational Beliefs Test developed by Jones (1969) to assess such cognitive structures.
Support for irrational beliefs as a cognitive structural change mechanism was pro-
vided by Kantor and Goldfried (1979) in a study comparing cognitive restructuring,
self-control desensitization, and combined restructuring-densensitization for the
treatment of interpersonal anxiety. The important finding with regard to cognitive
mechanisms is that only subjects in the cognitive restructuring and combined groups
reduced their irrational belief scores as compared to controls. Conflicting evidence
was found by Alden, Safran, and Weidman (1978) who compared a cognitive-
behavioral treatment to skill training in the treatment of unassertive clients. Whereas
both treatments produced significantly more improvement than a control group,
clients in the behavioral treatment demonstrated greater reduction in endorsement
of irrational beliefs.
While at least some of the studies discussed in this section have demonstrated
positive correlations between change in a mechanism and clinical improvement,
these researchers have not explained from a structural viewpoint exactly how or
why the schemata have changed. As Hollon and Garber have suggested (Hollon
& Garber, in press), change leading to clinical improvement may occur (or appear
to occur) when individuals simply switch from one operating schema to another
(differential deactivation/reactivation), as opposed to actually change (accomoda-
tion) in the content of a currently operating schema. Hollon and Garber suggest
that the former phenomenon may be advantageous for immediate or short-term
symptom relief, but that such “troublesome” schemata are likely to be retriggered
when exposed to certain stressful experiences. Such a phenomenon might prove
analogous to the dynamic concept of “flight into health.” The latter approach, in
which individuals are encouraged to “stay with” their troublesome schema in order
to disconfirm its content (i.e., accommodation), may delay short-term symptom
relief, but may be more effective in reducing the likelihood of relapse.
Our clinical impression has been that when a formerly depressed client relapses,
that client appears to evidence a depressotypic schema every bit as powerful and
coherent as when that client first arrived for treatment. While treatment frequently
progresses more rapidly than during the initial episode, this may well have as much
to do with the prior acquisition of a therapeutic “script” as with the prior modi-
fication of the presumed pathogenic cognitive knowledge structure.
Another way in which schemata might change is for certain schemata to weaken
or disappear. In line with Markus’ (1977) finding of aschematic individuals (for
certain types of information), it may be that certain treatments make clients a-
schematic for certain troublesome material. The outcome of this may be that in-
dividuals will be unable to use shortcut heuristics (a cognitive process), and instead
will need to rely on a more thorough and normatively based information processing
strategy. Individuals might vary on how long they remain aschematic; some might
be aschematic while in the midst of treatment only, while others might remain
aschematic for long periods of time. While there is no research to date on the
aschematic concept as a mechanism of change in therapy, Davis and Unruh (198 1)
found support for the notion as a possible mechanism of pathology. These inves-
tigators presented cross-sectional data in support of the notion that some short-
term depressives are aschematic for self-referent information.
Several research questions come to mind from this discussion: Do treatments
differ in how schemata are structurally altered? Which method of structural change
is best for immediate symptom relief or for protection from relapse? Are there
client (or therapist) by method-of-structural-change interactions? Answers to these
questions will significantly advance our knowledge of cognitive change mechanisms.
c. Cognitive Process Mechanisms: According to cognitive and social psychological
literature on human information processing, people may differ more in terms of
their cognitive structures and products than they do in their processing styles (Evans
& Hollon, in press; Hollon & Garber, in press; Kahneman et al., 1982; Nisbett &
Ross, 1980). In other words, both psychopathological groups and nonclinical groups
of individuals may demonstrate somewhat similar heuristic-based processing strat-
egies, yet may differ markedly in terms of the content of their schemata and their
self-statements. What may cause clinical groups a problem is that the interaction
of certain potentially universal heuristics with “problematical” schemata (e.g., sche-
mata containing excessively negative information or excessively fearful stimuli)
produce problematical cognitive products (e.g., negative and critical self-statements,
phobic or paranoid thoughts). Nonclinical groups on the other hand, are less likely
to experience problematical cognitive products because they base their heuristic
processing on more neutral or positive schemata.
Examples of the differential outcomes of heuristic based information processing
may prove helpful. Roth and Rehm (1980) found that depressives’ tendency to
underestimate the quality of their current performance is based in part on their
assumption that they typically have done poorly on such tasks in the past. This
mode of processing IS an example of the adjustment and anchoring heuristic dis-
cussed previously (Tversky 8c Kahneman, 1974). The depressives’ starting point
will be quite low due to the information in their self-schemata; therefore the uni-
versal process of insufficient adjustment will result in an underestimate of the
depressives’ true performance. In contrast, a nondepressed subject’s anchor might
be quite high due to more positively coded self-schemata and hence their insuf-
ficient adjustment of the starting point may result in an overestimate of their
performance. This latter phenomenon is similar to the “self-serving bias” of non-
depressives discussed by Alloy and Abramson (1979). It may be then that heuristics
serve to produce biased cognitive products for all individuals, with the nature of
 the bias determined by cognitive structures. These biased cognitive products clearly
differ in how detrimental they are to an individual’s we]!-being.
Assuming for a moment that this proposed state of affair-s 1s true, lvhat then
would be the mechanism of change responsible for producing clinical improve-
ment? One might suggest that change in cognitive structures or schemata is im-
portant. Various ways in which such structures might change lvere discussed in the
previous section. An alternative hypothesis is that change in one’s processing style
is an important change mechanism.
Hollon and colleagues (Evans & Hollon, in press; Hollon & C&her, in press)
have suggested that the major change mechanism in depressives who have received
cognitive therapy (Beck et al., 1979) is that they relv less on shortcut heuristics and
learn to engage more frequently in normative strategies of processing. This latter
style of processing clearly is a more exhaustive. comprehensive, and time consuming
one, but it may well produce less maladaptively biased judgments. As a result of
this strategy, individuals relv less on their schema-based information and more on
the information avai!able in the environment.
In achieving a more normative processing style, we are not suggesting that
individuals will never draw inaccurate inferences. Instead, we hypothesize that
individuals will question such potentially inaccurate inferences drawn from reliance
on heuristics in order to check their validity by scanning the environment for
relevant information. This mechanism then contains two parts, a questioning phase
and an “examining-the-evidence-via-the-environment” phase.
The result of those normative based information processes for an individual
may be to alter schematic and cognitive products. Perhaps an individual can return
to his or her high degree of reliance on heuristics once the necessary changes (e.g.,
negative to positive; fearful to nonfearful content) have been made in schemata.
The reason for this is that heuristic-based information processing may only cause
individuals difficulty when the content of the schemata are of a certain type. The
time period needed for such structural change to take place is not currently known.
Knowledge of such a time period may have relevance for understanding and
preventing the process of relapse. For example, an individual may start feeling
better as soon as his or her cognitive products are altered, even though the schemata
are not fully changed. The client may choose to terminate therapv and/or revert
back to heuristic-based information processing at this time. Since permanent changes
in schemata have not been made at this point, however, the client may be predis-
posed to relapse especially if faced with a stressful experience.
The notions of automatic versus deliberate information processing and meta-
cognition can also be viewed from this perspective. One question that needs ad-
dressing is whether clients can turn their cleliberate. normative processing strategy
into an automatic one. Do successfully treated clients remain deliberate in their
normative processing of information. automatlc yet still normative, or automatic
and nonnormative in their interaction with the environment? How important is
metacognition to maintenance of clinical improvement? Do treated clients always
have to be more aware of how their thinking affects then- frelings or is metacog-
nition less necessary once schematic changes have been made. i Kesearchers in this
area are encouraged to pursue these questions.
In summary, more work clearly neecls to be done in an effort to determine what,
if any. cognitive mechanisms mediate the change process. ‘I-his work fan. \ve think,
profit from being grounded in more powerful theories reg:arding the nature of
coy>ition. \~e;~surement effort\ \vhich include. but go beyond, simple cognitive
I)]-(ducts asse4bmc‘nts ma\ \+cll prove particularly worthwhde.

D. Cognitive Predictors of Change

There has beeli little work. as Let. on the role of- cognitive knowledge structures,
products. or processes as predictors of‘differential outcome or treatment response.
Since the \t.hole ef’fort to extend these processes to the clinical endeavor is so new,
this is hard]! surprising. While the icientification of purely prognostic indices is a
relari\-el\ simple matter. requiring only a longitudinal design, the identification of
dit‘ferential treatinent response indicators is far more difficult. Such specification
requires all the logical safeguards needed to generate a valid inference regarding
treatment efiicacv, plus accurate specification of the clinical predictors and their
careful assessment.
In general. we suspect that it \cill prove to be the case that it is the specific content
of existing knowledge structures (and their derivative inferential processes), rather
than the mere existence of’ kno\\.ledge structures or heuristic processes that will
ultimarel\ prove most fruitful. In our own ongoing treatment outcome project
(Note 4) ir appears to be the case that attributional styles (as measured by Seligman,
.\bramson. Semmel. & van Baever’s 19’79 i\ttributional Styles Questionnaire), may
predict relapse following treatment for those patients not protected by continuation
medication. although this Impression is based solely on preliminary data and may
change b\ the time the full sample has been collected. If it holds, this indication
\\ould appear to be consistent with our earlier formulation (Hollon & Garber, 1980),
i$vhich postulated that attributional processes would be more directly implicated
icith etiolog\- or relapse than \vith treatment response.
Keller (l&3) has provided evidence that variations in dysfunctional attitudes,
as measured by Weissman and Beck’s Dysfunctional Attitude Scale (DAS [Weissman
& Beck. Note 61). predicted response to a cognitive-behavioral approach in de-
pressed clients. However, high levels of endorsements of such attitudes predicted
nonresponse. a finding which Keller found difficult to understand. Given that his
design held treatment constant while allowing individual differences to vary, it is
not at all clear what can be made from these findings. In general, it is likely that
such designs will confound topological with dimensional indicants. On the one
hand. we might well be surprised if clients without difficulties in cognitive domains
\vere as responsive to metacognitive interventions as clients with such difficulties.
Hence, low scores. if indicative of a distinct noncognitive subtype. might be expected
to be predicti1.e of nonresponsi\.eness. On the other hand, if low scores simply
reflect minimal levels of cognitive “pathogen,” one would expect greater response
to a “fixed” dose of treatment.
DiLoreto (19’71) has provided what is perhaps the classic example of a largely
personalogic indicator of differential treatment efficacy. In that study, subjects
suffering from interpersonal anxiety were assigned to either RET, systematic de-
sensitization. or other treatments or controls. Classification of subjects into intro-
verts or extroverts on the basis of personality tests predicted differential treatment
response. Jvith introverts doing better in RET and extroverts doing better in sys-
tematic desensitization.
Two potentially interesting distinctions will. we think, merit exploration. As
described earlier, clients’ existing capacity for metacognitive thinking may deter-
64 Steven D. Hollon and .Llargaret R Krus

mine the facility with which they can modify existing inference processes. Secondly,
the extent to which clients are swayed by empirical, as opposed to nonempirical,
informational appeals may determine optimal treatment components. Our expe-
rience has been that some clients more readily appreciate empirical procedures
than others. For these clients, an emphasis on systematic self-monitoring, hypothesis
testing, and experimentation appears to be most efficient. For other clients, evi-
dential approaches appear to be dull and uncompelling. These clients appear more
intrigued by the phenomenological experience, emphasizing intuition and feeling
over experimentation and reason. Our experience has been that those latter clients
are more efficiently helped by global, holistic treatment components; e.g., role
playing, fixed-role therapy, etc.
Overall, we have little to say at this early date about cognitive structures or
processes as predictors of response. Some early indications of content-product
prediction and differential treatment indication are already evident, but scant and,
to date, unreplicated. This clearly is an area that deserves exploration.

THE CLINICIAN IN THE EQUATION

A. Matching Clients and Clinicians

Little has been said up to this point of the importance of the therapist’s cognitive
tendencies in the outcome process. Given the importance of patients’ cognitive
change mechanisms in the treatment process and our knowledge of errors and
biases in the inference process for nonclinical populations, it seems plausible that
the therapists’ cognitive attributes may play a contributory role in treatment out-
come. One way in which therapists’ cognitions may be studied is to examine whether
matching therapist/client dyads on relevant cognitive variables will affect treatment
outcome.
In a comprehensive review of patient/therapist matching studies, Parloff, Was-
kow, and Wolfe (1978) reviewed five studies that address matching on cognitive
variables. We borrow heavily from their review in this section. Lau (1970) dem-
onstrated that “neurotic” patients who were initially more similar to their medical
student therapists on a measure of conceptual differentiation had a better outcome
than patients who differed from their therapists on this variable. Similarly, Mc-
Lachlan (1972) found in his study of groups treated for alcoholism that patients
who were initially similar to their therapists on a measure of cognitive complexity
showed more improvement on patient reported improvement ratings. Further-
more, such improvement remained at a one-year follow-up (McLachlan, 1974).
Edwards and Edgerly ( 1970) demonstrated that outcome of brief counseling was
positively related to discordance of therapist/patient cognitive style, when groups
were assessed on the evaluative dimension of the semantic differential. Landfield
(197 1) demonstrated that initial therapist/patient cognitive discordance on personal
schemata (as measured by the Role Construct Repertory Test) was positively related
to more successful outcomes as compared to outcome from concordant dyads.
Landfield found that successful outcomes were also characterized by clients’ sche-
mata becoming more similar in content to the therapists’ schemata.
In summary, three studies supported concordance and two studies indicated
discordance of cognitive style for successful therapist/patient dyads. While at first
glance the research cited seems contradictory, our understanding of cognitive pro-
cesses, content, and knowledge structures may serve to explain these seemingly
incongruous results. The Carr (1970) and McLachlan (1972; 1974) studies appear
to have focused on cognitive processes whereas the Edwards and Edgerly (1970)
and Landfield (197 1) studies have focused on matching dyads according to their
knowledge structures. Similarity in processing style may be an important ingredient
for therapeutic success because such styles may make joint problem solving easier.
Parloff et al. (1978) suggested that such similarity facilitates understanding between
the dyad and allows the participants to problem solve at similar levels of complexity.
In contrast, dissimilarity in knowledge structures seems important in order to
effect cognitive change in the patient. Such dissimilarity may make it easier for the
therapist to suggest alternative views (e.g., not see life as hopeless as the depressed
patient does) and exposes the client to get a different perspective on his or her
experiences.
The relationship between therapist/patient matching on cognitive styles and
treatment success has received some early support. As our understanding of the
relevant cognitive mechanisms in the treatment process increases, we will be in a
better position to address this important matching question.

B. Judgments Under Clinical Uncertainty: Clinicians’ Cognitive Products, Structures,

and Processes

It was Paul Meehl who, in his classic monograph Clinical Versus Statistical Prediction
(1954), most powerfully asserted that the judgments of clinicians were no more
immune to biases in information processing than the judgments of lay persons.
After discussing the various steps involved in arriving at diagnostic judgments
through normative processes, Meehl stated “. . . I think that many clinicians are
unaware of the extent to which their daily decision-making behavior departs from
such a model not by being qualitatively different but mainly by being less explicit
and, therefore, less exact” (Meehl, 1960, p. 20). Meehl went on to argue that the
exploration of cognitive errors made by either lay persons or clinicians is in the
best tradition of the discipline, stating that “. . . if there is anything that justifies our
existence.. .it is that we think scientifically about human behaviors and that we
come from a long tradition, going way back to the very origins of experimental
psychology in the study of human error, of being critical of ourselves as cognitive
organisms and of applying quantitative methods to the outcomes of our cognitive
activity” (Meehl, 1960, pp. 26-27).
Despite this earlier recognition of the role of nonnormative inference processes
in clinical decision-making, there has been surprisingly little subsequent research
in this domain. With the exceptions of the Chapmans’ classic demonstration of the
role of “illusory correlations” in psychodiagnostics (Chapman, 1967; Chapman &
Chapman, 1967, 1969), Temerlin’s demonstration of the effects of preconceptions
on patient perceptions (Temerlin, 1968), Guaron and Dickinson’s (1966) demon-
stration of clinicians “lack of awareness” regarding their own judgment processes,
and work purporting to demonstrate the superiority of behavioral assessment over
clinical judgment (e.g., Kent et al., 1974), the bulk of the work examining inferential
errors in clinical judgment processes has been conducted by nonclinicians (e.g.,
Langer & Abelson, 1974; Rosenhan, 1973, 1975). To say that these efforts have
had little impact on clinical research and practice would be an understatement. If
anything, these studies have been met with active hostility by many clinicians.
This state of affairs may well be in the process of changing. Just as recent work
in basic cognitive and social cognition has stimulated a renertrd Interest in the role
of knowledge structures and heuristic processes m ps)chopatholog:\ and rherapv.
so too has that work stimulated a renelved inreresr in the lagaries of clinical in-
ference. There is a rough justice to this reinvigoration, since Kahneman. Slo\,ic.
and Tversky acknowledge Meehl’s seminal work on clinicai inference as being one
of the primary influences in their own work (see “preface”, E;dhnem,ui‘ et al. 1 lCr82). .
Although we are aware of only a few instances of recent empirical lvork in this
domain of clinical inquiry (see Arkes & Harkness, 1980; hrkes. ~l’ortmann. Sav-ille.
8c Harkness, in press; Cantor Smith, French, & Mezzich. 1980: HorowlItz. Post.
French, Wallis, & Siegelman, 1981: Schwartz. Gorrv, Iiassiner, & Essig. 1973).
several recent reviews have nicelv summarized the issues suggested b\ the basic
cognitive, social cognitive, and clinical inference literatures (Xrkes. 198 1; Turk ,Y:
Salovey, in press-b; Wiggins, 1981).
For our current purpose, we will be prlmarilv concerned rvlth the Impact of such
clinical judgments on the treatment process. It is quite clear that clinicians. much
like the typical layperson, form knowledge structures lvhich help organize mfor-
mation and facilitate subsequent judgments. These processes are clearl) central to
the whole diagnostic process and doubtless play a role in the selection and imple-
mentation of appropriate treatments, but they can have a darker side as !\.ell.
Once formed, clinical judgments appear to be markedl) resistant to change.
Meehl (1960) noted that clinicians’ Q-sorts of clients’ phenotypic personality traits
stabilized after two-to-four sessions, differing little from similar sorts based on
months of therapy contacts. Such stability could, of course, represent valid per-
ceptions rather than only partly accurate person-perceptlon prototypes. Rubin and
Shontz (1960) found that clinicians were remarkably tenacious in adhering to di-
agnostic impressions once they were formed, often domg so in the face of contra-
dictory subsequent information. This conservation of perception in the face of
subsequent disconflrmatory information is directlv parallel to that found In la\
inference (Ross, 1977; Nisbett &Z Ross. 1980). To the extent that the inferences
generated are accurate, such processes probablv facilitate the clinical change pro-
cess. To the extent that they are inaccurate, thee ma\ actuall\ work against the
provision of change. There are at least two ways in \vhich such biasing processes
mav operate:
1. Co?l/zr~~~torv 6zasrs (Rothbart et al.. 1979: Snider. I9SO: Sn\der ,Y: C.antor.
1979; Snyder 8c.Swann, 19781~) rnaL come into pla\, III an\ Illlt’ractlon betr\.een
client and clinician involving interactive information exchallge. .In arlec dote from
our own therapy experience demonstrates the role \uch processes can plan. In our
treatment outcome study (Hollon et al.. Note 4) our stud\ d~a~no~r~cians 5vere
utilizing the semi-structured Schedule for the Affectl\e l>icorders and Schlzo-
phrenia-Lifetime \‘ersion (Spltzer. Endicott. ti RobIns. i!);S, to iclentltv ;L hotno-
genous sample of primary depressives. Despite our rxfllance on d senii-structllrect

interview with specific prompts to gu~cle inqulr), our Inter\ieL\ monitoring unto\ -
ered several instances in which our clinGam+ would inclulre .ibouT \\ mptoms that.
if present. might have led them to exclude a potential sublecr tram the stud\ I~\
asking questions such as. “You’te never heard voices, have \,ou?“. ~l‘he t’ssence 01
confirmatory bias is that the clinician pursues information In A manner \\,hlch
influences the nature of the information received.
In therapv, such Information search strategies m‘lv le,~ve onv \\~holI\ <it thy mewi
of original stereotvpes ;md impression. One of the (u1-rent a111 hors (SH I 1~14had
 the experience of‘ \\ orking \\‘ith a passive, dependent female client of apparentlv
onl\ amperage intelligence for months before learning that the woman’s favorite
social contact (prior to becoming depressed) had been her involvement in MENSA.
.I t-e\% of earlier therap tapes clearly indicated that the author/therapist had
sought information ,ibout rhe chent’s interests and clhrlztic~ which was consistent
\Z.lth and ser\ ccl to mamtaln his initlal misconceptions. Therapists need to he careful
to request information 111\$‘a~ that could ~~J/wo~~P their developing working hy-
potheses, both in terms of \vhat the\ ask their clients in sessions and in terms of
the outside of therapv experiments thev encourage their clients to attempt.
2. sq-f 11 if 2I1IPZ~
a)!)‘/1
70I IMPS(Darley & Fazio, 1980: Merton. 1948) involve instances
in \chich ini;ially unfounded expectations lead to behaviors which produce con-
sequences taken as confirmator\ of the original expectations. The clinician who
regards a client as too dependent to function without active clinical direction may,
bv vigorous+ providing that direction, induce dependency in the client, thus con-
firming the original judgment. Similarly. assuming that a client could not handle
some observation by the therapist, or could not execute some activity outside of
therap!, may lead the therapist to refrain from acting and, ultimately, deprive both
client and therapist of “corrective feedback” regarding the client’s capacities.
In one area, we think there have been ample indications of the operation of
self-fulfilling prophecies. That is the operation of expectations for change on clin-
ical outcome. It has been clearly demonstrated that perceptions of clinical efficacy
influence clinical response (Frank, 1973: Kazdin & Wilcoxin, 1976; Wilkins, 1979).
Further, there can be little doubt that clinicians’ prognostic judgments influence
their selection of treatment modalities. We have been consistently chagrined when,
at lvorkshops, clinicians \vho ask “what types of patients does treatment ‘X’ work
for?” are quite content when the question is responded to by statements of the type
“females tend to do better than males”, or “endogenous depressives do better than
nonendogenous depressives”. Such statements are typically based on designs in
which treatment tvpe is held constant while individual differences are allowed to
vary. Such a design is ideal for deciding what individuals to select to enhance the
prestige of an institution or therap), but it is a wholly inadequate basis for selecting
a treatment for a given individual.
Overall, it is clear that clinical inference deserves exploration. While it is by no
means certain that clinicians are “fallible scientists”, it is likely that that is the case.
Turk and Salovev (in press-b) and Arkes (1981) both provide explicit discussions
of “debiasing” procedures for enhancing the accuracy of clinical inference, drawing
heavily upon speculations about such procedures from the nonclinical literature
(Einhorn, 1982; Fischhoff. 1982: Rahneman 8c Tversky, 1979; Nisbett et al., 1982:
Nisbett & Ross, 1980). In general, the strategies parallel those already described
for “debiasing” clients. Reliance is placed on explicit record-keeping of judgments,
followed bv careful attention to their subsequent confirmation-disconfirmation,
attention to inference-processes. and the intentional generation and testing of al-
ternative models. .4s yet. we have not seen any instance of efforts to improve clinical
inference bv virtue of utilizing such strategies.
There is one final area which we think holds great promise. It should, we think,
prove possible to examine clinicians’ knowledge structures concerning therapeutic
procedures using a “scriptual analvsis” (,4belson, 1976, 1981). In essence, it should
prove possible to assess clinicians’ knowledge structures regarding response se-
quences in clinical activities (either diagnostic or-therapeutic). Recent clinical the-
68 Steven D. Hollon and ,Margaret R. Krus

orists have emphasized the role of “cognitive maps” or “paradigms” in guiding the
clinical process (e.g., Beck et al., 1979; Mahoney, 1977a). It should prove possible
to explicate individual clinicians’ internal scripts regarding the clinical process.

SUMMARY

Throughout this paper, we have attempted to evaluate the relevance of recent

advances in the basic cognitive and social cognitive literatures for clinical theory
and practice. We clearly think the relevance is massive: we suspect that these lit-
eratures will provide the same type of underpinning for cognitive therapies that
the basic animal learning literature did for behavior therapy. The distinction be-
tween products, structures, and processes appears to be important, with distinctions
just beginning to be mapped out. Specific treatment components appear to have
different loci of action; some more explicitly metacognitive than others. Whether
these more explicitly metacognitive components produce greater cognitive change,
and, if so, whether that change translates into greater clinical change, remains to
be determined. Mechanism and prognostic work is clearly in its infancy, but con-
ceptual and operational strategies are currently being articulated that should fa-
cilitate such research.
Similarly, we can foresee real promise in efforts to pursue the investigation of
cognitive processes in clinical inference. Such processes are clearly indicated in
clinical perception and treatment efforts. Whether these processes facilitate or
disrupt the clinical task and, if the latter, whether they can be modified, also remains
to be explored.
We find ourselves quite excited by the prospect of such research. While there
is no guarantee that such efforts will be rewarded, we suspect that they will. A
thorough integration of cognitive and social cognitive principles into clinical think-
ing strikes us as the source of the next major breakthrough in clinical theory.

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