What is cognitive reframing?

Cognitive restructuring, also called cognitive reframing, is a psychotherapeutic strategy focusing on the identification and substitution of unhealthy and maladaptive automatic thoughts and beliefs with healthy logically and empirically sound ones as a way to resolve psychiatric symptoms.¹ Through collaborative psychological treatment, patients are taught to use this strategy to combat intrusive negative thoughts, also called automatic thoughts. Cognitive restructuring was originally created in the context of the treatment of depression, but it can be used in addressing a variety of mental health conditions, including panic disorders, anxiety disorders, depression, phobias, obsessive-compulsive disorder, body dysmorphic disorder, post-traumatic stress disorder, and psychotic disorders.^1-5 

Cognitive restructuring has grown and evolved from treatment guidelines published in 1979 and 1985 that emphasized thought self-monitoring as an intervention for cognitive change.^6,7 The technique was inspired by the cognitive theory of depression which posits that emotional disturbances and the behaviors that result from them are often the result of maladaptive thoughts. 

Cognitive restructuring uses both verbal and behavioral methods involving the following elements: identification of dysfunctional or negative automatic thoughts, identification of the cognitive distortions underlying those thoughts, rational disputing of the thoughts, and developing a rational rebuttal to the thoughts.^1,2,8 Both when interviewing patients and when walking patients through a rational dispute of the automatic thoughts, mental health professionals may use Socratic questioning, which can help patients reconsider their maladaptive thoughts through open-ended questions.^1,9

Cognitive restructuring trains patients to change their thought process to acknowledge that their thoughts are not indisputable facts but rather hypotheses that can challenged and tested.¹⁰ It provides patients with the tools to examine their emotions, thoughts, and behaviors, analyzing them for unproductive or unsubstantiated negativity, and rationally rethinking their initial interpretation.

While traditionally understood to be a core technique of cognitive behavioral therapy, cognitive restructuring is often used in other modalities of psychotherapy as well.¹ A study conducted in Spain of 272 psychologists showed that over 80% used cognitive restructuring as treatment in over 50% of therapy cases.¹¹ There is also increasing evidence that cognitive restructuring can be employed in the context of mobile health interventions that use mobile phone applications to deliver trainings to participants.¹²

Multiple studies have shown the effectiveness of cognitive restructuring. A 2021 meta-analysis of 45 studies (n=3,382) examined the effectiveness of cognitive restructuring compared to behavioral activation (defined as increasing positive interactions between a person and their environment) in the treatment of depression in adults.¹³ Both interventions were more effective than care as usual, with cognitive restructuring rated 81.5% effective, behavioral activation 80.8% effective, and care as usual 25.3% effective.

A 2022 randomized control trial (n=37) compared the effects of cognitive restructuring to imagery rescripting, a technique in which images associated with aversive experiences are mentally changed from distressing to benign.¹⁴ Participants were diagnosed with clinical depression and also reported intrusive thoughts or imagery. Both methods significantly reduced the effect of intrusive thoughts as assessed by a customized interview designed for the study (scored 0-100, with higher scores indicating thoughts that were more frequent, distressing, uncontrolled, or interfered more with daily activities). Cognitive restructuring lowered mean scores by 34.47 points (p<0.001), and imagery rescripting lowered mean scores by 40.66 points (p<0.001). Both methods also reduced depressive symptoms as assessed by the Beck Depression Inventory II (BDI-II; scored 0-21 with higher scores indicating more severe symptoms) by 9.12 points (p=0.001) and 15.27 points (p<0.001), respectively. 

A 2012 trial examined the effectiveness of cognitive restructuring or systematic desensitization in addressing acute anxiety surrounding test-taking in 50 high school seniors and recent graduates taking university entrance exams.¹⁵ Both methods were effective in reducing depressive symptoms as assessed by the BDI, anxiety symptoms as assessed by the Beck Anxiety Inventory (BAI; scored 0-21 with higher scores indicating more severe anxiety symptoms), and general psychiatric symptoms as assessed by the Symptom Check List (SCL-90; scored 0-360 with higher scores indicating more severe symptoms). For cognitive restructuring and systemic desensitization, BDI scores decreased by 6.62 points and 6.58 points, BAI scores decreased by 9.34 and 11.3 points, and SCL-90 scores decreased by 35.33 and 39.66, respectively (p≤0.001).

Cognitive restructuring may not be effective for all patients. A 2021 cross-sectional study (n=49) found that those who have more difficulty switching between executive functions also have more difficulty with cognitive restructuring.¹⁶ It is important to personalize treatment approaches to the needs of individual patients.

References

1. Clark DA. Cognitive Restructuring. The Wiley Handbook of Cognitive Behavioral Therapy. 2013:1-22.
2. Reddy YCJ, Sudhir PM, Manjula M, Arumugham SS, Narayanaswamy JC. Clinical Practice Guidelines for Cognitive-Behavioral Therapies in Anxiety Disorders and Obsessive-Compulsive and Related Disorders. Indian J Psychiatry. Jan 2020;62(Suppl 2):S230-s250. doi:10.4103/psychiatry.IndianJPsychiatry_773_19
3. Avasthi A, Sahoo S, Grover S. Clinical Practice Guidelines for Cognitive Behavioral Therapy for Psychotic Disorders. Indian J Psychiatry. Jan 2020;62(Suppl 2):S251-s262. doi:10.4103/psychiatry.IndianJPsychiatry_774_19
4. Courtois CA, Sonis J, Brown LS, et al. Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. American Psychological Association; 2017.
5. Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1(Suppl 1):S1. doi:10.1186/1471-244x-14-s1-s1
6. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. Guilford Press; 1979.
7. Beck AT, Emery G, Greenberg RL. Anxiety disorders and phobias: A cognitive perspective. Basic Books; 1985.
8. Hope DA, Burns JA, Hayes SA, Herbert JD, Warner MD. Automatic Thoughts and Cognitive Restructuring in Cognitive Behavioral Group Therapy for Social Anxiety Disorder. Cognitive Therapy and Research. Feb 2010;34(1):1-12. doi:10.1007/s10608-007-9147-9
9. Pardo-Cebrián R, Calero-Elvira A, Guerrero-Escagedo MC, López-Gómez A. What works in the Socratic debate? An analysis of verbal behaviour interaction during cognitive restructuring. Behav Cogn Psychother. Sep 2021;49(5):513-525. doi:10.1017/s1352465820000880
10. Marquart AL, Overholser JC, Peak NJ. Mood regulation beliefs in depressed psychiatric inpatients: Examining affect, behavior, cognitive, and social strategies. Int J Psychiatry Clin Pract. 2009;13(4):265-72. doi:10.3109/13651500902898331
11. Pardo Cebrián R, Calero Elvira A. Applying cognitive restructuring in therapy: The clinical reality in Spain. Psychother Res. Feb 2019;29(2):198-212. doi:10.1080/10503307.2017.1341655
12. Morello K, Schäfer SK, Kunzler AM, Priesterroth LS, Tüscher O, Kubiak T. Cognitive reappraisal in mHealth interventions to foster mental health in adults: a systematic review and meta-analysis. Front Digit Health. 2023;5:1253390. doi:10.3389/fdgth.2023.1253390
13. Ciharova M, Furukawa TA, Efthimiou O, et al. Cognitive restructuring, behavioral activation and cognitive-behavioral therapy in the treatment of adult depression: A network meta-analysis. J Consult Clin Psychol. Jun 2021;89(6):563-574. doi:10.1037/ccp0000654
14. Ma OYT, Lo BCY. Is it magic? An exploratory randomized controlled trial comparing imagery rescripting and cognitive restructuring in the treatment of depression. J Behav Ther Exp Psychiatry. Jun 2022;75:101721. doi:10.1016/j.jbtep.2021.101721
15. Başpınar Can P, Dereboy C, Eskin M. [Comparison of the effectiveness of cognitive restructuring and systematic desensitization in reducing high-stakes test anxiety]. Turk Psikiyatri Derg. Spring 2012;23(1):9-17. Yüksek Riskli Sınav Kaygısının Azaltılmasında Sistematik Duyarsızlaştırma ile Bilişsel Yeniden Yapılandırmanın Etkililiğinin Karşılaştırılması.
16. Holder LJ, Prasad A, Han J, Torok M, Wong QJJ. Shifting as a key executive function underlying cognitive restructuring for individuals with elevated social anxiety. Psychol Psychother. Jun 2021;94(2):217-230. doi:10.1111/papt.12301