Cognitive Restructuring Before Exposure Therapy or Behavioral Experiments? How the Timing of Expectancy Violation and Magnitude of Expectancy Change Influence Exposure Therapy Outcomes

Johnco, Carly J.
Norberg, Melissa
Wuthrich, Viviana M.
Rapee, Ronald M.

Macquarie University Lifespan Health and Wellbeing Research Centre, Macquarie University
School of Psychological Sciences, Macquarie University

Jasper Smits served as action editor.

No other published, in press, or under review articles have resulted from the current data set.

The authors have no conflicts of interest to disclose. This study was supported by funding from Macquarie University awarded to Carly J. Johnco.

Carly J. Johnco played a lead role in conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, supervision, visualization, writing–original draft, and writing–review and editing. Melissa Norberg played a supporting role in conceptualization, methodology, supervision, and writing–review and editing. Viviana M. Wuthrich played a supporting role in conceptualization, methodology, and writing–review and editing. Ronald M. Rapee played a supporting role in conceptualization, methodology, and writing–review and editing.

Carly J. Johnco, School of Psychological Sciences, Macquarie University [email protected]

Received April 19, 2024

revised January 29, 2025

Accepted February 5, 2025

Open Access funding provided by Macquarie University: This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0; https://creativecommons.org/licenses/by/4.0). This license permits copying and redistributing the work in any medium or format, as well as adapting the material for any purpose, even commercially.

Journal of Consulting and Clinical Psychology 93(5):p 369-381, May 2025. | DOI: 10.1037/ccp0000953

Objective: Inhibitory learning models emphasize the central role of threat expectancy violation during exposure therapy. However, exposure is often implemented alongside cognitive restructuring, which reduces threat expectancies before exposure, reducing the potential for expectancy violation. This study examined whether the timing of expectancy violation (before/during exposure) and magnitude of expectancy change impact the efficacy of exposure therapy. Method: A total of 249 adults (range 18–59 years old, M = 21.19, SD = 6.89) with elevated public speaking anxiety completed an intensive exposure session. Participants were randomly allocated to receive exposure based on (a) behavioral experiments (BE; i.e., maximizing expectancy violation and emphasizing prediction error following exposure); (b) cognitive restructuring before exposure (CR + EXP; i.e., threat expectancies reduced before exposure, thus reducing expectancy violation during exposure tasks); or (c) exposure without explicit processing of threat expectancies or expectancy violation. Change in symptoms was assessed pre–post exposure session and at 1-week follow-up. Results: The BE and CR + EXP groups showed superior anxiety reduction (primary outcome) and threat expectancy change (secondary outcome) compared to exposure without explicit processing of threat expectancies or expectancy violation. There was a nonsignificant small effect size difference in anxiety reduction favoring BE over CR + EXP. There was greater expectancy change in the BE group compared to the CR + EXP group and shorter treatment duration. Greater threat expectancy change during exposure tasks was associated with greater anxiety reduction. Conclusions: Threat expectancy change facilitates anxiety reduction during exposure therapy, and there may be modest advantages to challenging threat expectancies after exposure (BE) compared to before exposure (CR + EXP).