Introduction to Cognitive Restructuring

The Cognitive Behavioral Model, also known as the Cognitive Behavioral Therapy (CBT)
model, is a theoretical framework that underpins the principles and techniques used in CBT.
It provides a comprehensive understanding of how thoughts, emotions, behaviors, and
physiological responses are interconnected and influence each other. The model identifies
cognitive distortions as erroneous or biased ways of thinking that lead to negative emotions
and maladaptive behaviors. For example, all-or-nothing thinking, overgeneralization,
catastrophizing, mind reading, and personalization.

The model helps therapists and clients identify and address dysfunctional patterns of thinking
and behavior that contribute to psychological distress. When people engage in negative
thinking about their lives, it is logical that they experience aversive emotional reactions, such
as depression, anxiety, guilt, or anger. Cognitive behavioral therapy (CBT) form of
psychological treatment has been demonstrated to be effective for a range of problems
including depression, anxiety disorders, alcohol and drug use problems, marital problems,
eating disorders, and severe mental illness.

People who seek out psychotherapy often experience challenging problems in their lives, and
their aversive emotional reactions are understandable. However, it is just as often the case
that these people limit their focus on the negative aspects of their problems or exaggerate the
importance of those negative aspects, which in turn exacerbates their emotional distress and
can interfere with problem solving.

Cognitive restructuring is not the same thing as positive thinking because positive thinking
has the potential to be just as inaccurate as negative thinking. Instead, clients are told that
cognitive restructuring helps them to acknowledge all of the information that affects their life
problems and to recognize that some of those pieces might not be as negative as they are
concluding. In other words, cognitive restructuring encourages balanced thinking.

Cognitive restructuring, or the process by which cognitive behavioral therapists help clients
to identify aspects of their thinking that have the potential to be overly negative or limited in
scope, systematically. Cognitive restructuring can help clients to derive accurate, helpful, and
balanced situational interpretations and meanings.
Firstly, it is important for the therapist to establish a sound rationale for the intervention so
that clients can see the powerful role that their cognition plays in their emotional distress, as
well as the powerful role that the modification of cognition can play in recovery from
emotional distress.

Many cognitive behavioral therapists find it useful to illustrate these principles with examples
from clients’ lives and have some pre-prepared examples that illustrate the role that cognition
plays in emotional reactivity. The client gives their automatic responses to such scenarios
which is later confronted by the therapist.

Various ways of Cognitive Restructuring in CBT approach.

Fig 1.1

Example illustrating a hypothetical situation used in cognitive restructuring

Identifying Automatic thoughts

The first step in cognitive restructuring is to help clients to recognize and put words to their
automatic thoughts. Although it is easy to view this step as self-evident, more often than not,
clients need to develop skill to identify the most relevant automatic thoughts that account for
most of their emotional distress. Some clients experience automatic thoughts as images,
rather than as words that run through their minds. Cognitive behavioral therapists must be
mindful that automatic thoughts might not be experienced as statements that clients explicitly
say to themselves. Some clients who have difficulty identifying their thoughts can be asked
about the meaning that the situation holds for them or about them. Such clients might
recognize that they are viewing the situation through a negative “filter” that might not be
stated overtly in their minds but that nevertheless colors the manner in which they are
interpreting the situation. That filter then serves as the automatic thought to be subjected to
cognitive restructuring.

Initially, the therapist observes and reflects on the client’s negative thoughts ("I'm a failure")
and their effect on her self-esteem and ability to handle their self-image effectively. The
therapist introduces the concept of cognitive restructuring by proposing a strategy to help the
client catch themself when they start to engage in negative thinking and replace these
thoughts with more balanced and realistic ones. This involves challenging their negative self-
assessment and encouraging them to consider alternative interpretations of situations.

When cognitive behavioral therapists use time in the therapy session to teach clients to
identify automatic thoughts, it is often logical to continue to track automatic thoughts
between sessions as homework. Although, in principle, this exercise can be completed by
clients in their head, by paying attention to their thoughts, we strongly encourage some type
of record of the clients’ automatic thoughts. The take-home message for clients is that
although they may face challenging situations in their lives, it is the way that they perceive
and the meanings that they attach to these situations that are especially important to address
in therapy. The idea is to remember the meaning that they make out of situations that they
face in their lives, rather than the situations themselves, are associated with the emotional
reactions that they experience.

A standard tool that clients can use to record automatic thoughts is a thought record,
historically known as the Dysfunctional Thought Record. The thought record is a structured
template in which clients record their automatic thoughts when they notice an increase in
emotional distress.
Fig 1.2

Template for Dysfunctional Thought Record

Socratic Questioning

Once clients become adept at identifying automatic thoughts linked to their emotional
distress, they embark on evaluating the accuracy and usefulness of these thoughts. The
cognitive behavioral therapist utilizes Socratic questioning—a methodical and guided
approach—to prompt critical thinking regarding the automatic thoughts and to enable clients
to independently arrive at conclusions regarding their accuracy and utility. Initially, the
therapist employs Socratic questions to assist clients in learning how to respond to these
inquiries and to encourage them to reach varied conclusions concerning their life
circumstances. Over time, cognitive behavioral therapists anticipate that clients will develop
the ability to apply these questions autonomously without therapist guidance. This process of
posing and addressing Socratic questions is termed guided discovery.

Evidence-based questions form a crucial part of this process, aiding clients in thoroughly
assessing the accuracy of their thinking by examining the evidence that supports their
automatic thoughts and contrasting it with evidence that contradicts their automatic thoughts
(J.S. Beck, 2011). The key task is to shift from sweeping generalizations to specific instances,
which allows clients to accumulate a rich data set as the basis for conclusions about the
accuracy of their thinking. Cognitive behavioral therapists are alert for “evidence” that is not
truly factual.

Socratic questioning can be applied beyond the classroom and is valuable for individuals to
analyze their own thoughts. For instance, if someone notices they are feeling anxious, they
could ask themselves:

 What specific concern is causing my anxiety?

 What do I believe will occur because of this concern?
 How would I handle the situation if my feared outcome materializes?
 Why does this particular outcome matter to me?
 What triggered this anxious thought?
 Is there an alternative explanation or a more likely outcome?

Through this self-inquiry, individuals might realize that their initial worry is improbable or
that even if it were to happen, they would be capable of managing it.

Alterative Explanation Questions

An attribution refers to the explanation individuals give for situations or challenges they
encounter. For instance, if someone experiences a setback at work, they might attribute it to
their lack of skills (a maladaptive self-attribution), or if a person faces rejection in a
relationship, they might attribute it to the other person's lack of understanding (a maladaptive
other-attribution).

Questions aimed at exploring alternative explanations can assist clients in recognizing that
various factors contribute to any given situation, and that attributing blame solely to oneself
or others is often oversimplified. This process helps clients reduce self-blame, self-criticism,
and resentment towards others or circumstances.

For instance, consider a situation where someone's business proposal is rejected. They might
initially attribute the rejection to their incompetence (a maladaptive self-attribution).
However, through exploring alternative explanations, they might realize that factors such as
market conditions, competition, or timing also played a role in the rejection. This broader
perspective can help soften self-criticism and promote a more balanced understanding of the
situation.

Decatastrophizing questions

Cognitive behavioral therapists frequently encounter clients who engage in a cognitive

distortion known as catastrophizing. This involves an exaggerated estimation of the
likelihood of a worst-case scenario occurring and assigning an excessively high cost to that
scenario. The individual then believes with certainty that the worst-case scenario will happen,
that it will have devastating consequences, and that they won't be able to cope or recover
from it. Evidence-based questions are commonly used to help these clients gain perspective
on their concerns. However, an alternative approach involves using decatastrophizing
questions. In this technique, therapists ask clients to realistically estimate the likelihood of a
worst-case scenario occurring, consider the actual severity of the outcome if it were to
happen, and explore how they would cope in such a situation.

Consider this dialogue with Maria, who struggles with the automatic thought that she will fail
an upcoming exam:

Therapist: Maria, let's talk about your concerns regarding the upcoming exam. What are your
thoughts about it?

Maria: I'm convinced that I'll fail the exam. It's going to be a disaster.

Therapist: Let's break that down. What do you think is the realistic likelihood of you failing
the exam?

Maria: Well, maybe there's a chance, but I feel like it's almost certain.

Therapist: What if we consider a more balanced perspective? What would realistically

happen if you didn't perform as well as you hoped?

Maria: I might not get the grade I wanted, but it wouldn't be the end of the world.

Therapist: That's a valid point. How do you think you would cope if you didn't achieve the
grade you desired?
Maria: I would be disappointed, but I know I could learn from it and improve in the future.

In this example, the therapist uses decatastrophizing questions to help Maria reconsider the
severity of the potential outcome and explore her coping abilities. This approach encourages
a more balanced and realistic assessment of the situation, which can reduce anxiety and
improve problem-solving skills.

Distancing Questions

While decatastrophizing questions are beneficial in helping clients recognize the low
likelihood of worst-case scenarios, it's crucial for them to acknowledge that absolute safety,
acceptance, and ideal outcomes cannot always be guaranteed. Therefore, it's essential to assist
clients in understanding their coping abilities to manage adversity or disappointment and to
diminish the significance of these worst-case scenarios.

As previously mentioned, clients may struggle to apply logical reasoning skills when
overwhelmed by emotional distress. Distancing questions aid clients in applying Socratic
questioning to scenarios that are less personally meaningful than their own, helping them
realize their tendency to judge themselves more harshly than they would others. Cognitive
behavioral therapists then prompt clients to explain the gap between the standards they hold
for themselves versus others. Additionally, they pair distancing questions with impact
questions, encouraging clients to consider the consequences of maintaining unrealistic
standards or a pessimistic thinking style. Clients often recognize the detrimental impact of
such unhelpful thinking patterns on their goals.

In certain situations, cognitive behavioral therapists may encounter clients facing challenging
problems with accurate and balanced thinking given the circumstances. In such cases, there's
no need to push for a change in thinking. Instead, therapists employ problem-solving
questions to guide clients in exploring coping strategies or solutions for the specific problem
they're facing.For instance, if a client is facing a chronic health condition and is realistically
acknowledging the challenges it presents, the therapist might focus on problem-solving
questions to help the client navigate daily life, manage symptoms effectively, and maintain a
positive outlook despite the difficulties.
Balanced thought

When an assessment reveals that a client's thinking is inaccurate, exaggerated, or unhelpful,

cognitive behavioral therapists assist them in transforming their automatic thoughts into
balanced thoughts. Balanced thoughts amalgamate all conclusions drawn from the evaluation
questions into a coherent response to the initial automatic thought. To be effective during
emotional distress, balanced thoughts must be convincing. Clients often find that simply
dismissing the original automatic thought with brief statements like "Just get over it" or
"Everything will be okay" lacks believability in overwhelming moments. Thus, balanced
thoughts typically span at least a few sentences and acknowledge the factual basis of the
original thought while integrating evidence contradicting the automatic thought, alternative
explanations for the circumstances, or steps the client plans to take to address the issue

After crafting their balanced thought, clients are asked to reevaluate the intensity of their
emotional distress using the same scale used for their original automatic thought. This step is
crucial as it provides objective confirmation that the cognitive restructuring process has
successfully reduced the emotional distress intensity. A general guideline is to ensure that the
balanced thought correlates with no more than mild emotional distress, such as a rating of 3
on a 0-to-10 scale. If clients assign a higher emotional distress level to their balanced thought,
therapists help them identify any associated automatic thoughts that may still apply despite
the balanced thought's content.

For example, if a client's automatic thought is "I'm worthless because I made a mistake at
work," a balanced thought might be, "While I made a mistake, it doesn't define my worth as a
person. I have skills and qualities that are valuable, and I will learn from this experience to
improve in the future." After crafting this balanced thought, the client would rate their
emotional distress intensity to gauge the effectiveness of the cognitive restructuring process.

Conclusion

Cognitive restructuring is a fundamental aspect of cognitive behavioral therapy (CBT) that

aims to help clients identify and modify their automatic thoughts, which often contribute to
emotional distress and maladaptive behaviors. The cognitive behavioral model provides a
framework for understanding how thoughts, emotions, behaviors, and physiological
responses are interconnected. By addressing cognitive distortions and promoting balanced
thinking, therapists assist clients in developing more accurate, helpful, and adaptive
interpretations of their experiences. Various techniques within cognitive restructuring, such as
Socratic questioning, exploring alternative explanations, decatastrophizing questions,
distancing questions, and crafting balanced thoughts, offer effective strategies for challenging
negative thought patterns and promoting psychological well-being. These techniques
empower clients to evaluate the accuracy and utility of their thoughts, recognize the role of
cognition in emotional distress, and develop coping skills to manage adversity and
disappointment.

Through guided discovery and homework assignments like thought records, clients learn to
apply cognitive restructuring techniques independently, leading to lasting improvements in
their cognitive and emotional functioning. Overall, cognitive restructuring plays a vital role in
helping clients cultivate resilience, enhance problem-solving abilities, and foster positive
changes in their lives within the framework of CBT.

References

The Wiley Handbook of Cognitive Behavioral Therapy, First Edition. Edited by Stefan G.
Hofmann. Volume I edited by David Dozois. 2014 John Wiley & Sons, Ltd.
Published 2014 by John Wiley & Sons, Ltd. DOI: 10.1002/9781118528563.wbcbt02

Wenzel, A., Dobson, K. S., & Hays, P. A. (2016). Cognitive Behavioral Therapy Techniques
and Strategies (1st ed.). American Psychological Association. DOI:
http://dx.doi.org/10.1037/14936-000