Cognitive Restructuring

Abstract

Cognitive restructuring is the core change method of cognitive behavioral therapy, itself a form of behavior therapy: the systematic process of identifying, examining, and revising the maladaptive thoughts and beliefs that sustain emotional distress. Developed from Aaron Beck's cognitive therapy and Albert Ellis's rational emotive behavior therapy, it treats not events but their appraisal as the proximal cause of feeling, and uses guided questioning, evidence-weighing, and behavioral tests to loosen distorted cognition rather than argue it away. This article sets out the cognitive model behind the method, the catalogue of distortions it targets, the thought-record and Socratic procedures through which it is delivered, and a meta-analytic evidence base that made it among psychotherapy's most tested techniques, alongside a dismantling critique questioning whether challenging thoughts is what does the work.

Keywords: cognitive restructuring, automatic thoughts, cognitive distortions, cognitive behavioral therapy

Cognitive restructuring is the set of procedures by which a therapist and client identify the thoughts and beliefs that accompany distress, test those thoughts against evidence and logic, and construct more accurate and useful alternatives. It is the operational heart of cognitive therapy: where the theory holds that appraisal drives emotion, restructuring is the technique that changes the appraisal (Beck, 1976). The method is deliberately empirical rather than persuasive, treating a distressing thought not as a fact to be accepted or a falsehood to be argued down but as a hypothesis to be examined, so that the client learns a portable skill for evaluating their own cognition rather than adopting the therapist's conclusions (Beck et al., 1979).

What Cognitive Restructuring Is

Cognitive restructuring is a therapeutic method, not a theory or a disorder, and MeSH classifies it under cognitive behavioral therapy, a branch of behavior therapy. It names the family of techniques through which cognitive and cognitive behavioral therapies act on their central claim: that psychological distress is maintained less by events than by the habitual, often inaccurate ways a person interprets them (Beck, 1970). Restructuring is the working end of that claim — the concrete procedures a clinician uses to bring interpretations into view and change them.

The method has a characteristic sequence. A client first learns to notice the automatic thoughts that arise in distressing situations — rapid, unbidden appraisals that usually pass unexamined. Those thoughts are then examined: the client and therapist gather evidence for and against them, identify the recurring distortions they contain, and weigh them against alternatives. Finally a more balanced appraisal is constructed and, crucially, tested in behavior, so that the new thought is not merely spoken but lived out and confirmed against experience (Beck et al., 1979). The aim is not positive thinking but accurate thinking: a distorted thought is replaced with a more evidence-consistent one, which may be more hopeful or, at times, simply more precise.

What distinguishes restructuring from ordinary reassurance or advice is its stance. The therapist does not tell the client that a fear is groundless; the two investigate together whether the evidence supports it, a stance Beck termed collaborative empiricism (Beck, 1976). The client is treated as a partner testing their own beliefs, and the therapist's questions are designed to open inquiry rather than to win an argument. This is why the technique is taught as a durable skill: its object is to leave the client able to run the procedure on new thoughts long after therapy ends (Beck, 2005).

The Cognitive Model

Cognitive restructuring is motivated by the cognitive model of emotion, the proposal that events do not cause feelings directly but are filtered through appraisal. Between a situation and an emotional response falls an interpretation — an automatic thought — and it is the content of that interpretation, not the raw event, that determines the emotion's quality and intensity (Beck, 1963). Two people meeting the same setback feel differently because they appraise it differently; one reads a declined invitation as a scheduling accident, another as proof of rejection, and their emotions follow their readings rather than the event they share.

The model is layered. At the surface sit automatic thoughts, the moment-to-moment appraisals that restructuring first targets. Beneath them lie intermediate beliefs — the rules, attitudes, and assumptions ('If I am not perfect, I have failed') that generate automatic thoughts across situations. Deeper still are core beliefs or schemas, global convictions about the self, others, and the world ('I am unlovable') that are laid down early and organize the layers above them (Beck et al., 1979). Restructuring usually begins at the accessible surface and works downward, because a single core belief may be reached most reliably through the many automatic thoughts it produces.

The model carries a clinical implication that defines the whole approach. Because the emotion follows the appraisal, distress can be reduced without altering the situation, simply by correcting an appraisal that misreads it. This is what makes the target of therapy the thought rather than the circumstance, and it is why the same technique generalizes across disorders whose triggering situations differ widely, from the catastrophic misreading of bodily sensations in panic to the self-critical appraisals of depression (Clark, 1986).

Cognitive Distortions

The thoughts restructuring targets are not random errors but fall into recurring patterns Beck called cognitive distortions: systematic biases in appraisal that reliably skew interpretation in a negative direction (Beck, 1963). Naming them serves a practical purpose. A client who can label a thought as catastrophizing or as all-or-nothing thinking has already gained distance from it, converting an experienced truth into an instance of a known error and making it easier to examine rather than obey.

The catalogue is now standard in the field. All-or-nothing thinking casts experience into two absolute categories with no middle ground; overgeneralization reads a single event as a never-ending pattern; catastrophizing treats the worst outcome as the likely one; mind reading assumes knowledge of others' negative judgments; and emotional reasoning takes a feeling as evidence for the fact it seems to signal ('I feel worthless, so I am'). Each distortion is a shortcut that once served economy of thought but that, running unchecked, manufactures distress from ambiguous material.

The catalogue also travelled from Beck's work into everyday clinical language and self-help, where it is the most widely recognized part of the whole approach. That popularity carries a risk restructuring is careful to avoid: labelling a thought a distortion is the start of examining it, not a verdict that ends inquiry, and a thought that names a real problem must be acted on rather than relabelled away (Beck et al., 1979).

The Method in Practice

The signature instrument of restructuring is the thought record, a structured worksheet that externalizes the cognitive model column by column. In its full form the client logs the situation, the automatic thought and how strongly it is believed, the emotion and its intensity, the evidence for and against the thought, a balanced alternative appraisal, and a re-rating of belief and emotion after the exercise (Beck et al., 1979). The record turns an overwhelming internal experience into a manipulable object on the page, and its before-and-after ratings make the effect of examination visible to the client in numbers they generated themselves.

The questioning that drives the record is Socratic. Rather than asserting that a thought is wrong, the therapist asks the questions that let the client discover its weaknesses: what is the evidence for and against this thought, is there an alternative explanation, what the client would tell a friend who thought this, and what is the worst, best, and most realistic outcome. This style, refined by Padesky into the method of guided discovery, keeps the conclusions the client's own, which is what makes them stick (Beck, 2005). Where a belief cannot be settled by discussion alone, restructuring turns to the behavioral experiment: a real-world test in which the client acts against the prediction their thought makes and observes the outcome, so that a fear of visible trembling, say, is checked by deliberately drawing attention and recording whether the feared consequence occurs (Clark, 1986).

Restructuring is rarely used alone. In practice it is one component of a package that also includes behavioral activation, exposure, and skills training, and the relative contribution of the cognitive component to the whole is an open and contested question taken up below (Longmore & Worrell, 2007). Its cognitive relatives, meanwhile, extended the same logic in different directions: Ellis's rational emotive behavior therapy disputed irrational beliefs more directly and forcefully, and Meichenbaum's cognitive-behavior modification recast restructuring as the training of adaptive inner speech and coping self-statements (Meichenbaum, 1977).

Two Roots: Beck and Ellis

Cognitive restructuring has two independent origins that converged into a shared technique. The earlier was Albert Ellis's rational emotive therapy, set out at the start of the 1960s, which held that emotional disturbance arises from irrational beliefs a person imposes on events and that therapy should actively dispute those beliefs (Ellis, 1962). Ellis's framework is often taught through its ABC structure — an Activating event, a Belief about it, and the emotional Consequence that follows from the belief rather than the event — which gave clinicians a simple, portable schema for locating the appraisal that restructuring targets.

The second root was Aaron Beck's cognitive therapy, developed independently from his research on depression. Beck's early studies found that depressed patients showed a systematic negative bias in the content of their thinking — about themselves, their world, and their future — rather than the hostility turned inward that theory then predicted (Beck, 1963). From that observation he built a therapy that identified and tested these distorted cognitions, and he explicitly framed it in relation to the behavior therapy of the day, sharing its empiricism while adding an account of the thinking that mediated behavior (Beck, 1970). Beck's approach, more collaborative and empirical in tone than Ellis's disputational style, became the dominant model and supplied the manualized procedures — the thought record, the graded testing of beliefs — that standardized the technique (Beck et al., 1979).

The two traditions differ in emphasis more than substance. Ellis pressed harder and faster on the irrationality of beliefs; Beck moved more slowly through collaborative examination of evidence. But both located the cause of disturbance in appraisal rather than event, both made the modification of belief the engine of change, and both bequeathed to modern cognitive behavioral therapy the conviction that a thought can be treated as a testable claim. It is that shared conviction, not either founder's particular style, that the term cognitive restructuring now denotes (Beck, 2005).

The Evidence Base

Cognitive therapy was, from early on, unusually willing to submit itself to trial, and the accumulated evidence is substantial. An early meta-analysis of cognitive therapy for depression found it more effective than waiting-list and no-treatment controls and at least as effective as pharmacotherapy, establishing the approach as an evidence-supported treatment rather than a school of thought (Dobson, 1989). Later quantitative reviews extended the finding across disorders: a meta-analysis of cognitive behavioral therapy for anxiety confirmed medium-to-large effects against control conditions (Hofmann & Smits, 2008), and a broad review of meta-analyses concluded that the strongest support was for anxiety disorders, somatic problems, and depression, with the cognitive component central throughout (Hofmann et al., 2012).

Comprehensive updates have kept the verdict favorable while sharpening it. A meta-analytic update covering depression and anxiety found cognitive behavioral therapy clearly more effective than control conditions, with effects that were smaller than early trials suggested once study quality and publication bias were taken into account (Cuijpers et al., 2016). The most comprehensive synthesis for depression, pooling more than four hundred trials, confirmed a robust effect against controls and rough parity with pharmacotherapy, while noting that the advantage over other structured psychotherapies is modest (Cuijpers et al., 2023). Taken together these reviews are the basis for the frequent claim that cognitive behavioral therapy is the current gold-standard psychotherapy, a status resting on the sheer volume and consistency of its trial evidence rather than on a demonstrated superiority to every alternative (David et al., 2018).

The harder question is not whether the package works but whether cognitive restructuring specifically is what makes it work. A influential dismantling review examined component studies that added or removed the cognitive-restructuring element and found little evidence that directly challenging thoughts improved outcomes beyond the behavioral components it accompanies, raising the possibility that restructuring's benefit operates through behavioral change or nonspecific factors rather than through belief modification as such (Longmore & Worrell, 2007). The critique did not show restructuring to be inert, and process research since has continued to test how cognitive and behavioral change relate, but it reframed a technique long assumed to be the active ingredient as a hypothesis still in need of mechanistic proof (Kazantzis et al., 2018).

Cognitive Restructuring in Motion

The three demonstrations below make the method manipulable. The first runs a thought record, showing how weighing evidence for and against a hot thought revises both the belief in it and the emotion that tracks it. The second is a distortion identifier, presenting automatic thoughts to be sorted into the distortion categories that restructuring names. The third makes the evidence base concrete, translating a meta-analytic effect size into the share of untreated patients the average treated patient exceeds, and showing how that figure shrinks as the comparison condition is made more demanding.

Thought record: testing a hot thought

Hot thought: “I will fail the exam.”

Supporting weight 5, opposing weight 10. The revised belief is the share of total weight that supports the thought, 5/(5+10), and the emotion is scaled by the same factor the belief moved. Conviction is meant to follow the evidence, and the feeling to follow the conviction.

The thought-record demonstration puts the core procedure under the reader's hand. Setting an initial strength of belief in a hot thought and then toggling items of evidence for and against it computes a revised, evidence-weighted belief and the reduced emotion that follows it. It makes visible the mechanism the whole method assumes: that conviction is meant to move with evidence, and that the emotion is expected to fall in step with the belief rather than being addressed directly.

Spot the cognitive distortion

“If I do not get an A, the whole course was a failure.”

Score 0 of 0 answered. Naming the pattern is itself the first restructuring step: it converts an experienced truth into a recognizable, and therefore examinable, error.

The distortion demonstration exercises the labelling skill. Each automatic thought presented is an instance of one distortion, and sorting it into the right category — all-or-nothing thinking, overgeneralization, catastrophizing, mind reading, or emotional reasoning — rehearses the move that gives a client distance from a thought. It shows that naming the pattern is itself a restructuring step, converting an experienced truth into a recognizable and therefore examinable error.

Effect size by comparison condition

Cognitive therapy vs untreated control: illustrative d = 0.85, so the average treated patient does better than 80.2% of the comparison group.

The therapy is identical across the three buttons; only the comparison changes. Against an inactive control the effect looks large; against another active treatment it shrinks toward the 50% mark that means no difference, which is why an effect size is uninterpretable until its comparator is named.

The efficacy demonstration makes the evidence base tangible and its interpretation cautious. Choosing the comparison condition cognitive therapy is tested against — an untreated control, pharmacotherapy, or another active psychotherapy — sets a standardized effect size and converts it into the percentage of control patients the average treated patient outperforms. It shows both why the therapy is called effective and why the size of that claim depends entirely on what it is measured against.

Worked Example

Begin with the thought record the first demonstration builds. A client holds the hot thought 'I will fail the exam' and rates their belief in it at 85 out of 100. Restructuring gathers evidence and weights each item by how strongly it bears on the thought. Two items support it — 'I did badly on one quiz' (weight 3) and 'I feel unprepared' (weight 2), a supporting total of 5. Four items count against it — 'I passed every prior exam' (weight 4), 'I have completed the readings' (weight 3), 'the quiz was ungraded practice' (weight 2), and 'feeling unprepared is not the same as being unprepared' (weight 1), an opposing total of 10. Model the evidence-weighted belief as the share of total weight that supports the thought: 5 / (5 + 10) = 0.333, or a revised belief of 33 out of 100. The belief has fallen from 85 to 33.

The emotion is assumed to track the belief rather than to be worked on directly, so the anxiety, rated 80 before the exercise, is scaled by the same factor the belief moved: 80 × (33 / 85) = 31. The record thus turns an 85-strength conviction and an 80-intensity anxiety into a 33 and a 31, and it does so with numbers the client produced, which is the point — the reduction is demonstrated, not asserted. (The weights here are chosen to show the arithmetic, not to prescribe how any real evidence should be scored.)

Now the evidence base. A standardized effect size (Cohen's d) can be read as U3, the fraction of control-group patients the average treated patient exceeds, where U3 is the standard normal cumulative distribution evaluated at d. Against an untreated control an illustrative d = 0.85 gives U3 = 0.802, so the average treated patient does better than about 80% of untreated controls — a large, headline effect. Against pharmacotherapy an illustrative d = 0.20 gives U3 = 0.579, about 58%. Against another active psychotherapy an illustrative d = 0.05 gives U3 = 0.520, about 52%, barely above the coin-flip value of 50% that marks no difference at all. The therapy has not changed across the three rows; only the comparator has, which is why an effect size for cognitive restructuring is uninterpretable until the condition it was measured against is named (Cuijpers et al., 2023).

Discussion

Cognitive restructuring occupies a peculiar dual status: it is at once the most recognizable technique in modern psychotherapy and a method whose specific mechanism remains under active dispute. Its reach is hard to overstate. The cognitive model it operationalizes reorganized clinical psychology around the premise that appraisal mediates emotion, its catalogue of distortions entered ordinary language, and the thought record became one of the most widely taught clinical tools in the world (Beck, 2005). Much of what a non-specialist means by 'therapy' is, in effect, some descendant of the procedures Beck and Ellis formalized.

That prominence sits alongside a genuine and unresolved question about how restructuring works. The efficacy of the packages it belongs to is not seriously in doubt — the trial base is among the largest in psychotherapy and consistently favorable (Hofmann et al., 2012). But efficacy of a package is not evidence for the mechanism of a component, and the dismantling literature that isolated the cognitive element found its unique contribution harder to demonstrate than the model's popularity would suggest (Longmore & Worrell, 2007). The honest reading is that restructuring is part of treatments that reliably help, that it plausibly contributes, and that the field has not yet cleanly shown that changing beliefs by challenging them is what produces the change.

The wider significance for cognitive psychology lies in the method's core assumption made testable. By treating a thought as a hypothesis with evidence for and against it, restructuring imports the logic of experiment into private mental life, and its research program has in turn had to submit that logic to experiment — asking not just whether appraisals can be changed but whether changing them is the lever it was assumed to be. Whether the answer ultimately vindicates the belief-change account or relocates the active ingredient elsewhere, the discipline of putting the question to trial is itself part of what cognitive restructuring contributed (Kazantzis et al., 2018).

Current Directions

The most active line of current work is process research: the effort to specify which mechanisms actually carry the change in cognitive behavioral therapy rather than assuming the named technique is responsible. Reviews of the meta-analytic literature on mediators and moderators have begun to map how cognitive and behavioral changes relate over the course of treatment, treating the mechanism of restructuring as an empirical question to be settled by mediation designs rather than by theoretical assertion (Kazantzis et al., 2018). This program is the direct descendant of the dismantling critique, converting its challenge into a research agenda.

A second direction is the consolidation and cautious qualification of the evidence base. Comprehensive syntheses have moved from establishing that cognitive behavioral therapy works to estimating how large its effect really is once bias is controlled, and to clarifying where it does and does not outperform alternatives — a maturing of the field from advocacy toward measurement (Cuijpers et al., 2016); (Cuijpers et al., 2023). The recurring finding that effects are real but smaller than early trials implied, and that superiority over other active treatments is modest, has tempered the gold-standard framing without overturning it (David et al., 2018).

A third strand concerns delivery. The same cognitive-restructuring procedures have been packaged into internet-delivered and guided self-help formats that reproduce the thought record and Socratic questioning without a therapist in the room, widening access while raising fresh questions about how much of the method's effect survives when its collaborative, in-session character is automated. Across all three strands the common movement is from asking whether restructuring helps toward specifying, measuring, and testing the process through which it is supposed to help (Hofmann et al., 2012).

Common Misconceptions

Cognitive restructuring is positive thinking.

It aims at accurate thinking, not optimistic thinking. The goal is to bring an appraisal into line with the evidence, which sometimes means a more hopeful thought and sometimes simply a more precise one; a distortion is corrected, not painted over (Beck et al., 1979).

It means arguing clients out of their thoughts.

The stance is collaborative empiricism, not persuasion. Therapist and client investigate a thought together as a testable claim, using Socratic questions and behavioral tests so the client reaches their own conclusions rather than adopting the therapist's (Beck, 1976).

Every negative thought is a distortion to be replaced.

Some negative thoughts are accurate and signal real problems that require action, not relabelling. Naming a thought as a possible distortion begins the examination; the evidence decides whether it holds, and a well-founded thought survives the test (Beck, 1963).

Because the therapy works, challenging thoughts must be what works.

The efficacy of cognitive behavioral therapy as a package does not by itself establish that the cognitive-restructuring component is the active ingredient; dismantling studies have found its unique contribution difficult to isolate from the behavioral elements it accompanies (Longmore & Worrell, 2007).

Glossary

ABC model.

Ellis's schema in which an Activating event is followed by a Belief about it and then an emotional Consequence, locating the cause of the feeling in the belief rather than the event.

Automatic thought.

A rapid, unbidden appraisal that arises in a situation and usually passes unexamined; the surface-level cognition that restructuring first targets.

Behavioral experiment.

A planned real-world test in which a client acts against the prediction a thought makes and records the outcome, used to check a belief that discussion alone cannot settle.

Cognitive distortion.

A systematic bias in appraisal, such as catastrophizing or all-or-nothing thinking, that reliably skews interpretation in a negative direction.

Cognitive model.

The proposal that emotion is caused not by an event directly but by the appraisal that mediates it, so that changing the appraisal changes the emotion.

Cognitive restructuring.

The set of procedures for identifying, evaluating, and revising maladaptive thoughts and beliefs; the central change method of cognitive behavioral therapy.

Collaborative empiricism.

The therapeutic stance in which client and therapist jointly investigate the client's thoughts as testable hypotheses rather than the therapist asserting their falsity.

Core belief.

A global, deeply held conviction about the self, others, or the world, laid down early and organizing the intermediate beliefs and automatic thoughts above it; also called a schema.

Dismantling study.

A trial design that adds or removes a single treatment component to test its specific contribution, used to ask whether cognitive restructuring adds to the behavioral elements it accompanies.

Guided discovery.

A questioning style, refined by Padesky, that leads a client to examine and revise their own beliefs through open Socratic inquiry rather than through direct correction.

Hot thought.

The automatic thought most strongly tied to the peak emotion in a situation, singled out on a thought record as the one most worth testing.

Intermediate belief.

A rule, attitude, or assumption sitting between core beliefs and automatic thoughts that generates the latter across many situations.

Rational emotive behavior therapy.

Ellis's cognitive therapy, which locates disturbance in irrational beliefs and disputes them directly; one of the two roots of cognitive restructuring.

Schema.

An organized core belief structure through which experience is filtered; the deepest layer of the cognitive model and the ultimate target of sustained restructuring.

Socratic questioning.

The method of asking open questions that lead a client to examine the evidence for a thought and reach their own revised conclusion, central to how restructuring is delivered.

Thought record.

A structured worksheet that logs a situation, automatic thought, emotion, evidence for and against, a balanced alternative, and re-rated belief and emotion; the signature instrument of restructuring.

Key Researchers

Aaron T. Beck. University of Pennsylvania psychiatrist who founded cognitive therapy; his 1963 analysis of the systematic negative bias in depressive thinking and his collaborative-empirical method of testing automatic thoughts are the direct origin of cognitive restructuring. Wikipedia - Wikidata

Judith S. Beck. President of the Beck Institute and author of the standard cognitive behavioral therapy training text, who codified the case-conceptualization and thought-record procedures through which restructuring is taught and practiced. Wikipedia - Wikidata - Faculty page

David M. Clark. University of Oxford clinical psychologist whose cognitive models of panic and social anxiety turned restructuring into disorder-specific reappraisal of catastrophic misinterpretation, and who architected England's IAPT programme. Google Scholar - Wikipedia - Wikidata - Faculty page

Albert Ellis. Clinical psychologist who founded rational emotive behavior therapy, the direct disputation of irrational beliefs that is the other root of cognitive restructuring and predates Beck's cognitive therapy. Wikipedia - Wikidata

Stefan G. Hofmann. Alexander von Humboldt Professor at Philipps-University Marburg whose meta-analyses of meta-analyses supply much of the quantitative evidence base for cognitive behavioral therapy and for restructuring's efficacy across disorders. ORCID - Wikipedia - Wikidata - Google Scholar

Donald Meichenbaum. University of Waterloo psychologist whose cognitive-behavior modification and self-instructional training extended restructuring to inner speech and coping self-statements. Wikipedia - Wikidata - Faculty page

Christine A. Padesky. Clinical psychologist and co-author of Mind Over Mood who developed the multi-column thought record and the Socratic guided-discovery style now standard in teaching cognitive restructuring. ORCID - Wikipedia - Wikidata - Faculty page

Frequently Asked Questions

What is cognitive restructuring?
It is the core technique of cognitive behavioral therapy: a set of procedures for identifying the maladaptive thoughts and beliefs that maintain distress, testing them against evidence, and revising them into more accurate and useful appraisals (Beck, 1976).

How is cognitive restructuring different from cognitive behavioral therapy?
Cognitive behavioral therapy is the whole treatment package; cognitive restructuring is the specific cognitive component within it that works on thoughts, alongside behavioral elements such as activation and exposure (Longmore & Worrell, 2007).

What is a thought record?
It is a structured worksheet that logs a situation, the automatic thought and its strength, the emotion and its intensity, the evidence for and against the thought, a balanced alternative, and a re-rating of belief and emotion; it is the signature instrument of the method (Beck et al., 1979).

What are cognitive distortions?
They are systematic biases in appraisal, such as catastrophizing, overgeneralization, and all-or-nothing thinking, that reliably skew interpretation negatively; naming them helps a client gain distance from a thought and examine it (Beck, 1963).

Who invented cognitive restructuring?
It has two roots: Albert Ellis's rational emotive therapy, which disputed irrational beliefs, and Aaron Beck's cognitive therapy, which identified and tested cognitive distortions; Beck's collaborative, empirical version supplied the standard procedures (Ellis, 1962).

Does cognitive restructuring actually work?
The cognitive behavioral packages it belongs to are among the best-supported psychotherapies, effective against control conditions across many disorders, though whether challenging thoughts specifically is the active ingredient remains contested (Hofmann et al., 2012).

Is cognitive restructuring the same as positive thinking?
No. Its aim is accurate thinking, not optimistic thinking: an appraisal is brought into line with the evidence, which may yield a more hopeful thought or simply a more precise one, and an accurate negative thought is acted on rather than replaced (Beck et al., 1979).

What conditions is cognitive restructuring used for?
Because it targets appraisal rather than any single situation, it is applied across depression, anxiety disorders, panic, and many other presentations, with the strongest meta-analytic support in anxiety and depression (Hofmann & Smits, 2008).

References