Cognitive Schemas in Therapy
How patients think about their world and their important beliefs and assumptions about people,
events, and the environment constitute cognitive schemas. There are two basic types of cognitive
schemas: positive (adaptive) and negative (maladaptive). What can be an adaptive schema in one
situation may be maladaptive in another.
In describing schemas, Beck and Weishaar (1989) note that schemas develop from personal
experience and interaction with others. Some of the schemas are associated with cognitive
vulnerability or a predisposition to psychological distress. For example, patients who are depressed
may have negative schemas such as “I can’t do anything right,” “I won’t amount to anything,” and
“Other people are much more adept than I.” In this way, cognitive vulnerability can be seen in
distorted or negative schemas. Schemas can be viewed across dimensions other than positive-
negative. Active (versus inactive) schemas refer to schemas occurring in everyday events; inactive
schemas are triggered by special events (Freeman & Diefenbeck, 2005). Compelling (versus non
compelling) schemas are those that were learned when young and are reinforced by family members
and society. Changeable (versus unchangeable) schemas are ones that are not too difficult to change.
Religious schemas tend to be relatively unchangeable and quite compelling. In his book Prisoners of
Hate, Beck (1999) writes about the strength of religious beliefs that support genocide. Active inactive,
compelling-non compelling, and changeable-unchangeable are useful dimensions for therapists to
attend to as clients present concerns. Noticing changes in affect can also be useful. When a patient
presents a negative schema, the therapist may note a cognitive shift. For each psychological disorder,
particular cognitive distortions are likely to be present. By diagnosing the disorder, the therapist can
understand how the client integrates data and acts in accordance with the data. Thus, an anxious
client may perceive a threat while driving home and take a prescribed route that may include
alternates in case traffic jams or accidents are seen ahead. By observing the client describing this
situation, the therapist may perceive an affective shift that indicates that the client has made a
cognitive shift. Signals of such a shift may be facial or bodily expressions of emotion or stress. When
such an event takes place in therapy, the cognitive schema may be emotional or “hot.” In such a case,
the therapist is likely to follow up the “hot” cognition with a question such as “What were you thinking
just now?” Working with and evoking active hot cognitions in a session can be very helpful in dealing
with negative cognitive schemas.
In further describing schemas, Clark, Beck, and Alford (1999) list five types of schemas: cognitive-
conceptual, affective, physiological, behavioral, and motivational. Cognitive-conceptual schemas
provide a way for storing, interpreting, and making meaning of our world. Core beliefs are cognitive-
conceptual schemas. Affective schemas include both positive and negative feelings. Physiological
schemas are those that include perceptions of physical functions, such as a panic reaction that could
include hyperventilating. Behavioral schemas are actions that are taken, such as running away when
scared. Motivational schemas are related to behavioral schemas in that they often initiate an action.
Examples of motivational schemas include the desire to avoid pain, to eat, to study, and to play. These
schemas can be adaptive or maladaptive.
If they occur frequently, such cognitive distortions can lead to psychological distress or disorders.
Making inferences and drawing conclusions from a behavior are important parts of human
functioning. Individuals must monitor what they do and assess the likelihood of outcomes to make
plans about their social lives, romantic lives, and careers. When cognitive distortions are frequent,
individuals can no longer do this successfully and may experience depression, anxiety, or other
disturbances. Cognitive therapists look for cognitive distortions and help their patients understand
their mistakes and make changes in their thinking
Assessment in Cognitive Therapy:
Careful attention is paid to assessment of client problems and cognitions, both at the beginning of
therapy and throughout the entire process, so that the therapist may clearly conceptualize and
diagnose the client’s problems. As assessment proceeds, it focuses not only on the client’s specific
thoughts, feelings, and behaviors but also on the effectiveness of therapeutic techniques as they affect
these thoughts, feelings, and behaviors. Specific strategies for assessment have been devised for many
different psychological disorders, such as anxiety and depression. Cognitive therapists use assessment
techniques, including client interviews, self-monitoring, thought sampling, the assessment of beliefs
and assumptions, and self-report questionnaires.
Interviews: In the initial evaluation, the cognitive therapist may wish to get an overview of a variety
of topics while at the same time creating a good working relationship with the client. The topics
covered are similar to those assessed by many other therapists and include the presenting problem,
a developmental history (including family, school, career, and social relationships), past traumatic
experiences, medical and psychiatric history, and client goals. Therapists may use previously
developed structured interviews (Beck et al., 2004) or non-structured interviews. Freeman et al.
(1990) emphasize the importance of getting detailed reports of events. They caution against asking
biased questions such as “Didn’t you want to go to work?” and suggest instead “What happened when
you did not get to work?” In assessing thoughts, therapists may need to train their clients to
differentiate between thoughts and feelings and to report observations rather than make inferences
about the observations. Accuracy of recall is encouraged (although clients are not expected to
remember all details) and is preferred to guesses about past events. Sometimes in vivo interviews and
observations may be of particular help. For example, if a client suffers from agoraphobia, the therapist
may meet the client at home and walk outside with the client, making observations and assessments
in the interviewing process. Keeping notes of patients’ experiences, emotions, and behaviors is very
helpful. Judith Beck (1995) has developed a Cognitive Conceptualization Diagram to organize patient
data. The therapist starts at the bottom half of the diagram, taking each situation one at a time.
Self-monitoring: Another method used to assess client thoughts, emotions, and behaviors outside the
therapist’s office is self-monitoring. Basically, clients keep a record of events, feelings, and/or
thoughts. This could be done in a diary, on an audiotape, or by filling out a questionnaire. One of the
most common methods is the Dysfunctional Thought Record (DTR). Sometimes called a thought sheet,
the DTR has one column in which the client describes the situation, a second in which the client rates
and identifies an emotion, and a third to record her automatic thoughts. Clients may practice using
the DTR in therapy so that they get used to recording automatic thoughts and rating the intensity of
feelings. Use of the DTR provides material for discussion in the next session and an opportunity for
clients to learn about their automatic thoughts.
Thought sampling: Another method for obtaining information about cognitions is thought sampling.
Having a tone sound at a random interval at home and then recording thoughts is one way to get a
sample of cognitive patterns. Clients may then record their thoughts in a tape recorder or notebook.
Scales and questionnaires. In addition to these techniques, previously developed self-report
questionnaires or rating scales can be used to assess irrational beliefs, self-statements, or cognitive
distortions (Whisman, 2008). Structured questionnaires have been developed for specific purposes,
such as the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Scale
for Suicide Ideation (Beck, Kovacs, & Weissman, 1979), the Dysfunctional Attitude Scale (Weissman,
1979), and the Schema Questionnaire (Young & Brown, 1999). Questionnaires such as these are
usually brief and can be administered at various points in therapy to monitor progress.
When gathering data from clients, especially raw data that include automatic thoughts, it is often
helpful for the therapist to try to infer themes or cognitive schemas represented by the cognitions. As
data are reported from session to session, different cognitive schemas, or insights into them, may
develop. Schemas can be seen as hypotheses that the client and counselor are continually testing.
Progress can be assessed as patients complete homework, fill out questionnaires, and report
automatic thoughts. With progress should come a decrease in the number of cognitive distortions,
increased challenges to automatic thoughts, and a decrease in negative feelings and behavior.
The Therapeutic Relationship: Beck’s view of the client–therapist relationship is that it is
collaborative. The therapist brings an expertise about cognitions, behaviors, and feelings to guide the
client in determining goals for therapy and means for reaching these goals. The clients’ contributions
to therapy are the raw data for change (thoughts and feelings). They participate in the selection of
goals and share responsibility for change. The assessment process is a continually evolving one. As
new data are gathered, the therapist and client may develop new strategies. In some ways, the
therapeutic process can be seen as a joint scientific exploration in which both therapist and client test
new assumptions. In this process, the therapist may use listening skills that focus on the client’s
feelings, somewhat similar to the approach of Carl Rogers, to further understand the client’s concerns
and to develop the relationship. However, the client also takes responsibility for progress by
completing assigned homework outside of the office. Although the cognitive therapist is open to the
feedback, suggestions, and concerns of the client, the process of therapy is specific and goal oriented.
The Therapeutic Process:
More so than many other theories of therapy, cognitive therapy is structured in its approach. The
initial session or sessions deal with assessment of the problem, development of a collaborative
relationship, and case conceptualization. As therapy progresses, a guided discovery approach is used
to help clients learn about their inaccurate thinking. Other important aspects of the therapeutic
process are methods to identify automatic thoughts and the assignment of homework, which is done
throughout therapy. As clients reach their goals, termination is planned, and clients work on how they
will use what they have learned when therapy has stopped. As therapeutic work progresses, clients
move from developing insight into their beliefs to moving toward change. Particularly with difficult
and complex problems, insight into the development of negative cognitive schemas is important.
Guided discovery:
Sometimes called Socratic dialogue, guided discovery helps clients change maladaptive beliefs and
assumptions. The therapist guides the client in discovering new ways of thinking and behaving by
asking a series of questions that make use of existing information to challenge beliefs.
[Client:] I’ve been afraid that when I report to my new job on Monday, people will think I can’t do the
work.
[Therapist:] What does that tell you about the assumptions that you are making?
[Client:] Like I’m mind reading, like I know in advance what’s going to happen.
[Therapist:] And what assumptions are you making?
[Client:] That I know what my new colleagues will think of me.
The three-question technique:
A specific form of the Socratic method, the three question technique consists of a series of three
questions designed to help clients revise negative thinking. Each question presents a way of inquiring
further into negative beliefs and bringing about more objective thinking.
1. What is the evidence for the belief?
2. How else can you interpret the situation?
3. If it is true, what are the implications?
A brief example of this technique shows how it is an extension of the Socratic method and how it can
help individuals change their beliefs. Liese (1993) gives an example of a physician using the three-
question technique with a patient with AIDS.
Therapist.: John, you told me a few minutes ago that some people will scorn you when they learn
about your illness. (reflection) What is your evidence for this belief?
John: I don’t have any evidence. I just feel that way.
Therapist.: You “just feel that way.” (reflection) How else could you look at the situation?
John: I guess my real friends wouldn’t abandon me.
Therapist.: If some people did, in fact, abandon you, what would the implications be?
John: I guess it would be tolerable, as long as my real friends didn’t abandon me.
Specifying automatic thoughts: An important early intervention is to ask the client to discuss and to
record negative thoughts. Specifying thoughts using the Dysfunctional Thought Record and bringing
them into the next session can be helpful for work in future sessions.
Homework: Much work in cognitive therapy takes place between sessions so that skills can be applied
to real-life settings, not just the office. Specific assignments are given to help the client collect data,
test cognitive and behavior changes, and work on material developed in previous sessions. If the client
does not complete the homework, this fact can be useful in examining problems in the relationship
between client and therapist or dysfunctional beliefs about doing homework assignments. Generally,
homework assignments are discussed and new ones developed in each session.
Session format: Although therapists may have their own format that they adapt for different client
problems, there are certain topics to be dealt with in the therapy session. The therapist checks on the
client’s mood and how he is feeling. Usually, the therapist and client agree on an agenda for the
therapy session based, in part, on a review of events of the past week and on pressing problems that
may have emerged. Also, the therapist asks for feedback about the previous session and concerns or
problems that the client may have about issues that have occurred since the last meeting. The
therapist and client review homework and collaborate to see how the client could get more out of it.
Usually, the major focus of the session is on the concerns the client raised at the beginning of the
therapy hour. Having dealt with specific items, new homework is assigned relevant to the client’s chief
concerns. Feedback from the client about the session is an important element of the collaborative
relationship between therapist and client.
Termination: As early as the first session, termination may be planned. Throughout treatment,
therapists encourage patients to monitor their thoughts or behaviors, report them, and measure
progress toward their goals. In the termination phase, the therapist and client discuss how the client
can do this without the therapist. Essentially, clients become their own therapists. Just as clients may
have had difficulties in accomplishing tasks and may have relapsed into old thought patterns or
behaviors, they work on how to deal with similar issues and events after therapy has ended.
Commonly, the frequency of therapy sessions tapers off, and client and therapist may meet every 2
weeks or once a month.
Therapeutic Techniques:
A wide variety of cognitive techniques are used in helping clients achieve their goals. Some of the
techniques focus on eliciting and challenging automatic thoughts, others on maladaptive assumptions
or ineffective cognitive schemas. The general approach in cognitive therapy is not to interpret
automatic thoughts or irrational beliefs, but to examine them through either experimentation or
logical analysis. An example of an experiment would be to ask a client who feels that no one will pay
attention to her to initiate a conversation with two acquaintances and observe how they attend or fail
to attend to her. An example of questioning a client’s logic would be, when the client says “I can never
do anything right,” to ask “Have you done anything right today?” Cognitive therapists also use
techniques to help clients with feelings and behaviors.
The following section explains eight common strategies for helping clients change unhelpful thought
patterns.
Understanding idiosyncratic meaning: Different words can have different meanings for people,
depending on their automatic thoughts and cognitive schemas. Often it is not enough for therapists
to assume that they know what the client means by certain words. For example, depressed people are
often likely to use vague words such as upset, loser, depressed, or suicidal. Questioning the client
helps both therapist and client to understand the client’s thinking process.
[Client:] I’m a real loser. Everything I do shows that I’m a real loser.
[Therapist:] You say that you’re a loser. What does it mean to be a loser?
[Client:] To never get what you want, to lose at everything.
[Therapist:] What is it that you lose at?
[Client:] Well, I don’t exactly lose at very much.
[Therapist:] Then perhaps you can tell me what you do lose at, because I’m having difficulty
understanding how you are a loser.
Challenging absolutes: Clients often present their distress through making extreme statements such
as “Everyone at work is smarter than I am.” Such statements use words like everyone, always, never,
no one, and all the time. Often it is helpful for the therapist to question or challenge the absolute
statement so that the client can present it more accurately.
Reattribution: Clients may attribute responsibility for situations or events to themselves when they
have little responsibility for the event. By placing blame on themselves, clients can feel more guilty or
depressed. Using the technique of reattribution, therapists help clients fairly distribute responsibility
for an event.
Labelling of distortions: There are several cognitive distortions such as all-or nothing thinking,
overgeneralization, and selective abstraction etc. Labeling such distortions can be helpful to clients in
categorizing automatic thoughts that interfere with their reasoning. For example, a client who believes
that her mother always criticizes her might be asked to question whether this is a distortion and
whether she is “overgeneralizing” about her mother’s behavior.
Decatastrophizing: Clients may be very afraid of an outcome that is unlikely to happen. A technique
that often works with this fear is the “what-if” technique. It is particularly appropriate when clients
overreact to a possible outcome.
[Client:] If I don’t make dean’s list this semester, things will be over for me. I’ll be a mess; I’ll never get
into law school.
[Therapist:] And if you don’t make dean’s list, what would happen?
[Client:] Well, it would be terrible, I don’t know what I would do.
[Therapist:] Well, what would happen if you didn’t make dean’s list?
[Client:] I guess it would depend on what my grades would be. There’s a big difference between getting
all B’s and not making dean’s list and getting all C’s.
[Therapist:] And if you got all B’s?
[Client:] I guess it wouldn’t be so bad, I could do better the next semester.
[Therapist:] And if you got all C’s?
[Client:] That’s really not likely, I’m doing much better in my classes. It might hurt my chances for law
school, but I might be able to recover
Challenging all-or-nothing thinking: Sometimes clients describe things as all or nothing or as all black
or all white. In the previous example, the client is not only catastrophizing about grades but also
dichotomizing the idea of making or not making the dean’s list. Rather than accept the idea of dean’s
list versus not dean’s list, the therapist uses a process called scaling, which turns a dichotomy into a
continuum. Thus, grades are seen as varying in degree; the client will respond differently to the
possibility of getting a 3.0 rather than a 3.25 than to the possibility of dean’s list or not dean’s list.
Listing advantages and disadvantages: Sometimes it is helpful for patients to write down the
advantages and disadvantages of their particular beliefs or behaviors. For example, a student can write
down the advantages of maintaining the belief “I must make dean’s list” and the disadvantages of
such a belief. This approach is somewhat similar to scaling, as listing the advantages and disadvantages
of a belief helps individuals move away from an all-or-none position.
Cognitive rehearsal: Use of imagination in dealing with upcoming events can be helpful. A woman
might have an image of talking to her boss, asking for a raise, and then being told, “How dare you even
talk to me about this subject?” This destructive image can be replaced through cognitive rehearsal.
The woman can imagine herself talking to her boss and having a successful interview in which the boss
listens to her request. The cognitive rehearsal can be done so that the woman presents her request in
an appropriate way, with the boss not granting the request in one instance and the boss granting the
request in another. The therapist asks her to imagine the interview with the boss and then asks the
patient questions about the imagined interview.
Other useful cognitive strategies follow a similar pattern. They question the client’s cognitive schemas
and automatic thoughts. In addition to cognitive techniques, cognitive therapists may use behavioral
techniques such as activity scheduling, behavioral rehearsal, social-skills training, bibliotherapy,
assertiveness training, and relaxation training. In the practice of psychotherapy, many of these
techniques are used at different times in the therapeutic process to bring about change in cognitions,
feelings, and behavior.