Amy Wenzel, PhD, ABPP
University of Pennsylvania School of Medicine
Over 2,000 years ago, the Greek philosopher Aristotle noted, “It is the mark of an educated mind to be able to entertain a thought without accepting it.” In the present day, mental health professionals from all theoretical orientations work with clients whose lives are stymied by negative and judgmental thoughts and beliefs that they regard as absolute truth. To address the needs of such clients, treatment packages in the family of cognitive behavioral therapies (CBTs) have incorporated strategies for recognizing and addressing negative thoughts and beliefs.
Cognitive reappraisal is a strategy in which people reinterpret the meaning of a stimulus in order to alter their emotional response (Gross, 1998). One traditional approach to cognitive reappraisal used in many cognitive behavioral treatment packages is cognitive restructuring, or the guided and systematic process by which clinicians help clients to recognize and, if necessary, modify unhelpful thinking associated with emotional distress. It is a key strategic intervention in Aaron T. Beck’s cognitive therapy approach (e.g., A. T. Beck, Rush, Shaw, & Emery, 1979). In contrast to reinterpreting and changing thinking, cognitive defusion is the ability to distance oneself from one’s thoughts and continue on even in the presence of those thoughts (Hayes, Strosahl, & Wilson, 2012), which allows people to let go of the significance that they attach to their thoughts (see chapter 23 of this volume for further discussion). Regularly using cognitive reappraisal and defusion promotes psychological flexibility, or the ability to live fully in the present moment and engage in valued activity, regardless of the thoughts one may be experiencing. In this chapter, I illustrate cognitive reappraisal through a description of techniques for delivering cognitive restructuring. However, this chapter also demonstrates the way in which foci on defusion and present-moment awareness can be used in conjunction in order to achieve psychological flexibility.
A growing body of research devotes attention to the mechanisms by which cognitive reappraisal achieves desired outcomes in treatment. Perhaps the most central tenet of Beckian CBT is that cognition mediates the association between experiences in life and one’s emotional and behavioral reactions (cf. Dobson & Dozois, 2010). There certainly exist some data to support this notion (Hofmann, 2004; Hofmann et al., 2007). At the same time, there also exists research that does not support this premise, either because (a) the studies did not include the necessary variables and statistical tests to demonstrate mediation unequivocally (cf. Smits, Julian, Rosenfield, & Powers, 2012); (b) the change in symptoms of emotional distress occurred before the change in mediators (e.g., Stice, Rohde, Seeley, & Gau, 2010); (c) the change in problematic cognition simply did not predict outcome (e.g., Burns & Spangler, 2001); or (d) the change in problematic cognition was just as great in a non-CBT condition (e.g., pharmacotherapy) as in CBT (e.g., DeRubeis et al., 1990). More recent research raises the possibility that cognitive reappraisal exerts its effects through the process of decentering, or the ability to recognize that thoughts are simply mental events rather than truths that necessitate a particular course of action (Hayes-Skelton & Graham, 2013).
Cognitive behavioral therapists who use cognitive reappraisal with their clients can target three levels of cognition: (a) thoughts that arise in specific situations (i.e., automatic thoughts); (b) conditional rules and assumptions (i.e., intermediate beliefs) that guide the characteristic way in which people interpret events and respond behaviorally; and (c) core beliefs, or fundamental beliefs that people hold about themselves, others, the world, or the future (cf. J. S. Beck, 2011). Consider the case of Lisa, a client who describes an upsetting situation in which she was not invited to a friend’s baby shower. Her automatic thought might be something like “My friend doesn’t like me.” This automatic thought might be associated with a conditional assumption, like “If someone is truly a friend, then she would invite me to an important social event,” and a core belief, like “I’m undesirable.” Over time, through cognitive reappraisal, clients are able to see that the automatic thoughts they experience in specific situations are reflective of underlying beliefs they hold. Cognitive reappraisal helps clients to slow down their thinking to recognize maladaptive thinking (i.e., thinking that is either inaccurate, exaggerated, or simply unhelpful even if accurate) and either (a) take strategic action to ensure that their thinking is as accurate and as helpful as possible, or (b) recognize that their thinking is simply mental activity that has no bearing on reality and their ability to live their lives in the ways they want. In the next section, I describe the techniques for delivering cognitive restructuring: the cognitive reappraisal approach that is often used by cognitive behavioral therapists.
Cognitive restructuring typically occurs in three steps: the identification, evaluation, and modification of automatic thoughts or underlying beliefs. The following sections provide guidance for implementing each of these steps.
When clinicians notice a distinct negative shift in clients’ affect, they ask, “What was running through your mind just then?” When clients identify a thought, clinicians ask what emotion they were experiencing. These steps serve to further reinforce the association between cognition and emotion, and they also give clients practice in slowing down their thinking enough so they can recognize key thoughts associated with their emotional distress. Once clients have identified one or more emotions, clinicians typically ask them to rate the intensity of the emotions on a 0-to-10 Likert-type scale (e.g., 0 = very low intensity; 10 = the most intense emotional distress imaginable) or using percentages (e.g., 30%, 95%). In some instances, clinicians ask clients to rate (using a similar type of scale) the degree to which they believe the automatic thought. It is important to socialize clients to rating the intensity of their emotions early in the process of cognitive restructuring, as they will use those ratings later to evaluate the degree to which cognitive restructuring has been effective.
Although this exercise appears to be straightforward, in reality it can be difficult for many clients. Most people have not practiced slowing down their thinking to identify key thoughts associated with emotional distress. Thus, the simple act of thoughtfully identifying cognition, in and of itself, has the potential to be therapeutic for three reasons: it (a) reinforces the cognitive model and illustrates the way in which it has continued relevance in clients’ lives, (b) creates awareness of psychological processes that are exacerbating mental health problems, and (c) interrupts the “runaway train” of negative thinking that can happen for some clients. When clients experience difficulty identifying thoughts, cognitive behavioral therapists can ask them what they “guess” they were thinking in light of their emotional reaction, or they can provide a menu of options from which a client can choose. They can also assess for the presence of images rather than thoughts in the form of verbal language, as some clients report having images of terrible future outcomes or upsetting memories from the past.
Over time, clients gain skill in identifying and working with automatic thoughts. At this point, many cognitive behavioral therapists will move toward a focus of working at the level of underlying beliefs (i.e., intermediate-level conditional rules and assumptions, core beliefs). There are many ways to identify underlying beliefs. Clients can identify themes inherent in the automatic thoughts that they have shaped over the course of treatment. Therapists can use the downward arrow technique, in which they repeatedly probe a client about the meaning associated with an automatic thought until the client gets to a meaning that is so fundamental that there is no additional meaning underneath it (Burns, 1980). Recall the earlier example of Lisa, who identified the automatic thought “My friend doesn’t like me” when she realized that she was not invited to her friend’s baby shower. Using the downward arrow technique, her therapist asked her, “What does it mean that you weren’t invited?” Lisa responded, “It means that we were never friends in the first place.” The therapist continued, “What does it mean about you if you were never friends in the first place?” Lisa responded, “It means that I’m more invested in my friends than they are in me.” The therapist continued, “What does that say if you are more invested in your friends than they are in you?” Lisa became tearful, began shaking, and responded with a core belief: “It means that I’m totally undesirable.” When clients demonstrate significant affect in session, such as tearfulness, shaking, aversion of eye contact, and so on, it provides yet another clue that they have identified a powerful belief that underlies their automatic thoughts.
Once clients have recognized the thoughts and beliefs that have the potential to exacerbate emotional distress, they can begin to consider the accuracy and helpfulness of their thinking, as well as the degree to which they are attaching excessive significance to their thinking. Although many clinicians describe this process as “challenging” maladaptive thinking, it is preferable to approach it from a more neutral stance, such that the clinician and client are detectives jointly examining the evidence, or scientists evaluating the data and then drawing a conclusion (i.e., a hypothesis-testing approach). Most clinicians find that with the vast majority of clients, there is a grain of truth in their thinking (if not several grains of truth), so it is important not to presuppose that their thinking is altogether abnormal. Many clinicians prefer to aim for “balanced” thinking, with balance being achieved by acknowledging and tolerating the accuracies of the clients’ thinking and by modifying the inaccuracies (though it should be noted that other clinicians, particularly those who practice from the stance of acceptance-based approaches, use cognitive defusion to intervene in a way that promotes distance from maladaptive thinking, rather than changing the content of the thinking).
There is no one formula that clinicians use to evaluate maladaptive thinking. Rather, clinicians are mindful that they are practicing from a stance of collaborative empiricism, or the joint enterprise between the clinician and client in which they take a scientific approach to examining and drawing conclusions about the client’s thinking and behavior. Rather than telling clients how to think, clinicians use guided discovery, in which they ask guided but open-ended questions (i.e., Socratic questioning) and set up new experiences in order to prompt clients to evaluate their thinking and develop an alternative approach to viewing life circumstances. In the following paragraphs, I describe typical lines of Socratic questioning.
Perhaps the most versatile way to evaluate maladaptive thinking is to ask, “What evidence supports this thought or belief? What evidence is inconsistent with this thought or belief?” Clients who engage in this line of Socratic questioning often find that they are focused exclusively on evidence that supports maladaptive thinking, ignoring a vast array of evidence that is inconsistent with the thought or belief. Once they consider the full spectrum of evidence that is relevant to their thinking, they often see that their original thought or belief is overly pessimistic, self-deprecating, or judgmental. Although many clinicians have great success with this tool, two notes of caution are in order. First, clients sometimes identify evidence that supports their thinking but is not truly factual, or to which they are attaching excessive significance. For example, when Lisa was asked to supply evidence that her friend does not like her, she listed the fact that she was not invited to the baby shower. Although this statement might be factual, she is attaching a negative interpretation to it by equating being invited to a baby shower with being liked by her friend, and then concluding that her friend does not like her. Thus, at times evidence that clients identify might need to be subjected to cognitive restructuring. Second, clinicians who work with clients with obsessive-compulsive disorder are encouraged to use the examination of evidence judiciously (Abramowitz & Arch, 2013), as this tool itself can become a compulsion they use to minimize the anxiety associated with their obsessive automatic thoughts.
When clients experience adversity in life, they often attribute it to a personal shortcoming, which in turn can exacerbate their emotional distress. Reattribution is a cognitive restructuring technique in which clients learn to consider many explanations for why an event occurred, rather than focusing exclusively (and incorrectly) on something being wrong with them or what they did. Clinicians who use this technique pose the Socratic question “Are there any other explanations for this unfortunate situation?” When Lisa’s therapist used reattribution and encouraged her to consider viable explanations for the fact that she was not invited to the baby shower, she acknowledged that her friend has a big family, and often only family is invited to events like this; that it was likely another person, rather than her friend per se, who organized the shower and invited guests; and that she and her friend had recently gone on a lunch date that was filled with warmth and good conversation. Clinicians who use reattribution sometimes draw a pie chart with their clients, allowing them to allocate various explanations for adversity in a graphical format.
All clinicians encounter clients who catastrophize, or worry that horrible things will happen to them or their family members in the future. It has been a tradition in CBT to initiate a line of Socratic questioning in which clinicians ask these clients to identify the worst, the best, and the most realistic outcomes. In many cases, clients see that the most realistic outcome is much more closely aligned with the best outcome than with the worst outcome. However, some clients, particularly those with anxiety disorders, do not experience a corresponding decrease in emotional distress when they use this tool, claiming that the remote possibility of the worst outcome is too difficult for them to tolerate. However, many of these clients respond well to evaluating how they could cope with the worst outcome, perhaps even developing a decatastrophizing plan outlining how they would proceed if the worst outcome were to occur. Although this tool can be helpful in managing anxiety and promoting a problem-solving orientation, it should be noted that it also serves to decrease uncertainty, even when the tolerance of risk and uncertainty might be the very skill that would best serve these clients.
At times, clients are wrapped up in their own internal experience and have difficulty separating logic from emotional distress. To get some distance from the problematic situation, the clinician can pose the Socratic question “What would you tell a friend if he or she were in this situation?” Clients often find that they would tell a friend something different, and much more balanced, than what they are telling themselves, which can prompt them to evaluate why they are treating themselves differently than they would treat others.
It is important for clinicians to recognize that not all automatic thoughts are negative and inaccurate; in some instances, automatic thoughts represent a very real and difficult reality. In these cases, it is contraindicated to ask guided questions to evaluate the accuracy of these thoughts. Clinicians can, nevertheless, encourage clients to evaluate how helpful their thinking is for their mood, for others, for problem solving, and for acceptance. Thus, clinicians might ask Socratic questions like “What is the effect of focusing on this automatic thought?” or “What is the effect of changing your thinking?” or “What are the advantages and disadvantages of focusing on this thought?” Clients who consider the answers to these questions often realize that rather than accepting stressful or disappointing life circumstances, their rumination is exacerbating their emotional stress and keeping them stuck in a struggle against those circumstances. Clinicians can then help these clients adopt a present-moment focus, distancing themselves from their thoughts (i.e., cognitive defusion) and attaching less significance to them in order to achieve psychological flexibility, which allows them to live their lives according to their values even in the presence of upsetting thinking.
Socratic questioning is but one way to facilitate the evaluation of maladaptive thinking. Perhaps the most powerful tool is the behavioral experiment, in which clients test out, prospectively, nonjudgmentally, and usually in their own environments, the accuracy and implications of their maladaptive thinking. Consider Lisa again. If she were to take her thinking about her friend one step further, such that she predicts her friend will reject her if she reaches out to schedule another lunch date, and she accepts that prediction as truth, it is likely that Lisa will not reach out and will begin to withdraw from her friend. A behavioral experiment that she could implement in between sessions would require her to ask her friend to schedule another lunch date and then use that experience to draw a conclusion about the degree to which her thinking was accurate. Because others’ reactions to clients cannot be controlled, there is always the possibility that their prediction will be realized. Thus, cognitive behavioral therapists devise a “win-win” situation, such that the results of the experiment either provide evidence that the client’s thinking was inaccurate or demonstrate that the client can tolerate the distress associated with a negative result.
The techniques described thus far can be used to modify underlying beliefs in addition to situation-specific automatic thoughts. However, there exist some reappraisal strategies geared specifically toward belief modification (J. S. Beck, 2011; Persons, Davidson, & Tompkins, 2001). For example, clients can keep a positive data log, which allows them to accumulate evidence arising in daily life that supports an adaptive belief. Lisa, for example, could keep a running log of instances of friends initiating contact with her. Historical tests of beliefs provide a forum for clients to evaluate the evidence that supports the maladaptive and adaptive beliefs in discrete time periods in their lives. When they embark on a historical test of their beliefs, many clients realize that they have dismissed important life experiences that are inconsistent with the maladaptive belief that has been activated, even if they are currently experiencing many problems. Cognitive behavioral therapists also use experiential role-plays to restructure key early memories that are hypothesized to contribute to the development of a maladaptive belief. For instance, a client might play two roles, such as her current self and herself at the age in which a key negative life event occurred, and her current self would apply cognitive reappraisal tools to help her younger self interpret that life event in a more benign manner. (See chapter 22 for a discussion of additional belief modification techniques.)
If, after evaluating the accuracy and usefulness of their thinking, clients realize that it is problematic, then one option is to move toward modifying it. Modified automatic thoughts are often referred to as alternative responses, rational responses, adaptive responses, or balanced responses. I prefer the term “balanced response” because there are usually both negative and positive aspects to the life circumstances that clients face. Restructuring an automatic thought into a thought that is uniformly positive has the potential to be just as inaccurate as the original automatic thought. Thus, balanced responses must be believable and compelling, accounting for both the positive and negative aspects of a situation. This is why it is erroneous for cognitive restructuring to be equated with positive thinking, as the aim of cognitive reappraisal is to achieve balanced, realistic, and accepting thinking rather than positive thinking, per se.
Clinicians encourage clients to craft balanced responses on the basis of the conclusions that they drew from the guided evaluation. These balanced responses tend to be lengthier than the original automatic thought. The reason for this is that automatic thoughts tend to be quick, evaluative, and judgmental, such as Lisa’s “My friend doesn’t like me.” Balanced responses take into account nuances, as most situations that people face in life are multifaceted. Thus, a balanced response might incorporate the highlights from the evaluation of evidence that does and does not support the automatic thought, from the reattribution exercise, from the decatastrophizing plan, or from an advantages-disadvantages analysis. As Lisa responded to her therapist’s Socratic questioning, she arrived upon the following balanced response:
It is okay to be disappointed that I was not invited to the baby shower, as I’d have liked to share this special moment with my friend. But I know that it is typical for her large family to restrict events like this to family members only. She and I recently had lunch together, and it seemed that we very much enjoyed each other’s company. We even set another lunch date. What is happening here is that my belief of being undesirable has been activated, and the most adaptive course of action is to distance myself from it so that I continue to act as a good friend to her, which is important to me and which increases the likelihood that the two of us will cultivate a close friendship.
Though balanced responses are often relatively long, there are times when clients with certain clinical presentations, such as recurrent panic attacks or suicidal crisis, need a response that is relatively direct and easy to remember.
After constructing a balanced response, clients rerate the intensity of their emotional distress. They compare their ratings of emotional distress associated with the original automatic thought and with the balanced response to determine whether the cognitive restructuring exercise helped them feel better. In most cases, clinicians should not expect the ratings of emotional distress to drop to 0 or 0 percent, as clients are usually facing life circumstances that would be unpleasant or difficult for most people. However, the aim of the exercise is for the ratings to be reduced to a level that clients experience as manageable and that allows them to take skillful action. If after constructing a balanced response clients provided ratings of the degree to which they believed the original automatic thought, after they have completed the cognitive restructuring exercise they should indicate the degree to which they now believe the original automatic thought. From the perspective of cultivating a sense of psychological flexibility, as clients go through this process, they can also practice assuming a present-moment focus, noticing their maladaptive thinking, and taking steps to distance themselves from their thoughts. They can begin to recognize that maladaptive thoughts do not always have to be changed and that they can live a quality life even when they are present.
Similarly, maladaptive beliefs can be modified into more balanced, adaptive beliefs using the interventions described in the previous section. Clinicians encourage clients to craft an adaptive belief that is balanced, compelling, and believable (Wenzel, 2012). Recall Lisa’s core belief, “I’m undesirable.” If she has a history of receiving negative feedback from others, an adaptive belief like “I’m desirable” might not ring true. “I have strengths and weaknesses, just like everyone else,” and “I have much to offer friends, even if I make the occasional mistake,” are examples of more balanced beliefs toward which she can work.
Cognitive reappraisal is often done verbally in the context of conversation between the client and clinician in session. In addition, clinicians often use one or more aids that help clients to organize their work and remember the fruits of their work outside of session. I describe these tools below.
A thought record is a sheet of paper on which clients work through the cognitive restructuring procedure. Clients typically start with a three-column thought record, on which they record a few words about situations that increase their emotional distress, as well as accompanying cognitions and emotional experiences. As they acquire skill in identifying their thoughts, they switch to a five-column thought record, which adds two more columns—one for recording a balanced response and one to rerate the intensity of the emotional experience—to the initial three. Between sessions, clients often keep a thought record in order to work with automatic thoughts that arise in daily life. The idea behind the thought record is that it allows clients to practice the “real-time” application of cognitive restructuring so they can eventually catch and reframe unhelpful cognitions without having to write them down.
A coping card is a reminder of the work done in session that clients can consult outside of session; typically, these reminders are written on a sheet of paper, an index card, or a business card. Coping cards are versatile and tailored to the needs of each client. For example, clients who experience recurrent automatic thoughts can work with their therapist in session to devise a compelling balanced response. Then, on the coping card, they might write the original automatic thought on one side and the balanced response on the other. Other clients prefer reminders of ways to evaluate their automatic thoughts, so they list questions on coping cards, such as “What evidence supports my thinking about this situation?” or “What evidence does not support my thinking about this situation?” Still other clients prefer to list concrete pieces of evidence to counter a recurrent automatic thought.
In the twenty-first century, cognitive behavioral therapists are finding that many clients prefer to record their homework using technology rather than by writing it down on a sheet of paper. Microsoft Word and Excel files allow much flexibility, in that clients can use customized prompts to identify and evaluate their thinking. Other clients record their thoughts on mobile devices to catch and restructure automatic thoughts when they are on the go. Moreover, there exist many applications (i.e., apps) that provide a template for clients to record their cognitive restructuring work using smartphones or tablets. Such apps can be located by searching for “cognitive behavioral therapy” in app stores.
Cognitive reappraisal is indicated for an array of mental health conditions, including (but not limited to) depression, anxiety disorders, obsessive-compulsive and related disorders, trauma- and stressor-related disorders, eating disorders, addictions, and adjustment to medical problems like chronic pain, cancer, and diabetes. It can even be used with clients with psychotic disorders, not necessarily to directly challenge delusional thinking but instead to help them obtain a softer perspective on the defeatist attitudes they hold about themselves and the likelihood of living a quality life (A. T. Beck, Grant, Huh, Perivoliotis, & Chang, 2013). Cognitive reappraisal is also incorporated into many CBT protocols for children with mental health disorders, whose cognitive capability is still developing (e.g., Kendall & Hedtke, 2006), and adults with traumatic brain injury, whose cognitive capabilities have been compromised (Hsieh et al., 2012). However, with these populations, it is usually implemented in a more digestible format (e.g., the development of a single coping statement, the identification and labeling of errors in thinking) than in the more sophisticated way described in this chapter.
Many clients indicate that cognitive reappraisal is a life skill that they wish they had been taught when they were younger, before there was a need to seek out a cognitive behavioral therapist. Evidence of its effectiveness lies in the degree to which clients are able to manage emotional reactivity, engage in effective problem solving, function adaptively, and achieve quality of life as a result of thinking in a more balanced manner. However, it is important to recognize that cognitive reappraisal is not indicated in all cases, and that pushing it when it is not indicated has the potential to interfere with an otherwise effective course of CBT. For example, clients who already view their situation in an accurate and realistic manner are usually helped more by interventions that promote problem solving, distress tolerance, and/or acceptance. Forcing cognitive reappraisal in these instances could be confusing or even invalidating. Moreover, as mentioned previously, some clients use cognitive reappraisal in a way that is compulsive or that reinforces an avoidance or intolerance of negative affect. Failing to recognize that these issues are exacerbated by cognitive reappraisal could increase the probability of recurrence or relapse.
Evidence is mixed, at best, regarding the degree to which cognitive reappraisal specifically affects outcome through the process of reducing the frequency or degree of belief in maladaptive cognition. The recent research of Hayes-Skelton and Graham (2013) raises the possibility that decentering accounts for its positive effect. Interestingly, data reported by Hayes-Skelton and colleagues suggest that decentering may be an important mechanism of change in a number of therapeutic approaches, such as mindfulness, acceptance-based approaches, and even applied relaxation, in addition to cognitive reappraisal (Hayes-Skelton, Calloway, Roemer, & Orsillo, 2015). It will be important for future research to identify ways to enhance cognitive reappraisal’s ability to facilitate decentering. One possibility is by encouraging clients to precede cognitive reappraisal with an acceptance-based technique, as recent research indicates that cognitive reappraisal preceded by self-compassion is associated with greater reductions in depression than cognitive reappraisal alone (Diedrich, Hofmann, Cuijpers, & Berking, 2016). As cognitive behavioral therapists continue to use cognitive reappraisal with their clients, it will be important for them to do so with an eye toward facilitating decentering and increasing psychological flexibility, rather than focusing on simply changing maladaptive thoughts and beliefs.
In closing, clinicians are encouraged to take a scientist-practitioner approach to evaluating the degree to which cognitive reappraisal enhances treatment for any one client by thinking critically about the function that it serves for the client. This means that the clinician gathers observational and quantitative data from individual clients to examine not only the degree to which cognitive reappraisal reduces negative affect and improves functioning, but also the degree to which it has any unexpected, negative effects, such as the reinforcement of unhelpful beliefs about the need for certainty or the need to avoid uncomfortable affect at any cost. When cognitive reappraisal facilitates the approach toward (versus avoidance of) life problems, tolerance of uncertainty and distress, and acceptance, then it can be a powerful tool that enhances quality of life and allows clients to embrace the full array of cognitive and behavioral strategies that clinicians can offer them.
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