Cognitive Restructuring Before Versus After Exposure: The Effect on Expectancy and Outcome in Individuals with Claustrophobia

Several strategies have been proposed for optimizing learning during exposure therapy. One strategy, expectancy violation, is thought to facilitate learning by maximizing the discrepancy between expected and actual outcomes of exposure. In the inhibitory learning model, Craske et al. (2014) suggest that engaging in cognitive restructuring (CR) prior to exposure will prematurely reduce expectancy (i.e., how much one believes a feared outcome will occur) and mitigate outcomes. Instead, they recommend reserving CR for after exposure to consolidate learning. To the best of my knowledge, this assumption has not been tested. The goal of this study was to examine whether CR before exposure prematurely reduces expectancy and mitigates outcomes. Participants (N = 93) endorsing all DSM-5 criteria or all DSM-5 criteria except clinically significant distress or impairment for specific phobia (enclosed places) attended an intervention bookended by pretreatment and posttreatment assessments, and a 1-month follow-up assessment. Participants were randomized to one of two interventions (1) the CR Before condition: 15 minutes of CR before exposure or (2) the CR After condition: 15 minutes of CR after exposure. A 15-minute filler task of self-report questionnaires was used as a no-treatment comparison: the CR Before condition completed the filler task after exposure and the CR After condition completed the filler task before exposure. Participants rated their expectancy (e.g., “I might suffocate,” “I might become trapped”) from 0% to 100% before and after engaging in either CR or the filler task before exposure. Next, participants engaged in six 5- minute tailored exposure trials using a claustrophobic chamber. The Claustrophobia Questionnaire (Radomsky et al., 2001), a Behavioural Approach Test, and the Claustrophobia General Cognitions Questionnaire (Febrarro & Clum, 1995) were used to measure treatment outcomes. It was hypothesized that the CR Before condition would experience greater expectancy reduction than the CR After condition before exposure, and therefore less improvement in claustrophobia outcomes at posttreatment and follow-up than the CR After condition. Results demonstrated that the CR Before condition had greater expectancy reduction than the CR After condition. However, both groups experienced similar and large significant improvement at posttreatment with gains achieved at follow-up. Implications are discussed.