CHAPTER 21

Cognitive Reappraisal

Amy Wenzel, PhD, ABPP

University of Pennsylvania School of Medicine

Definitions and Background

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 descrip-
tion of techniques for delivering cognitive restructuring. However, this chapter
Process-Based CBT

also demonstrates the way in which foci on defusion and present-moment aware-
ness 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 inaccu-
rate, exaggerated, or simply unhelpful even if accurate) and either (a) take strate-
gic 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 cog-
nitive reappraisal approach that is often used by cognitive behavioral therapists.

326
 Cognitive Reappr aisal

Implementation
Cognitive restructuring typically occurs in three steps: the identification, evalua-
tion, and modification of automatic thoughts or underlying beliefs. The following
sections provide guidance for implementing each of these steps.

Identifying Maladaptive Thinking

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 identi-
fied 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 dif-
ficult for many clients. Most people have not practiced slowing down their think-
ing 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 behav-
ioral 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 condi-
tional rules and assumptions, core beliefs). There are many ways to identify

327
Process-Based CBT

underlying beliefs. Clients can identify themes inherent in the automatic thoughts
that they have shaped over the course of treatment. Therapists can use the down-
ward 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 under-
lies their automatic thoughts.

Evaluating Maladaptive Thinking

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 alto-
gether 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

328
 Cognitive Reappr aisal

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 question-
ing 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 explana-
tions 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

329
Process-Based CBT

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 correspond-
ing 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 outlin-
ing 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 orien-
tation, 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 ques-
tions 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 disappoint-
ing life circumstances, their rumination is exacerbating their emotional stress and
keeping them stuck in a struggle against those circumstances. Clinicians can then

330
 Cognitive Reappr aisal

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 environ-
ments, 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” situa-
tion, such that the results of the experiment either provide evidence that the cli-
ent’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 reap-
praisal 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 sup-
ports 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 experi-
ences that are inconsistent with the maladaptive belief that has been activated,
even if they are currently experiencing many problems. Cognitive behavioral ther-
apists 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 modifi-
cation techniques.)

331
Process-Based CBT

Modifying Maladaptive Thinking

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, ratio-
nal responses, adaptive responses, or balanced responses. I prefer the term “bal-
anced 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 sui-
cidal crisis, need a response that is relatively direct and easy to remember.

332
 Cognitive Reappr aisal

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 per-
spective 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 every-
one 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.

Tools
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.

Thought Record
A thought record is a sheet of paper on which clients work through the cogni-
tive 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 experi-
ences. As they acquire skill in identifying their thoughts, they switch to a

333
Process-Based CBT

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.

Coping Card
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.

Technology
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.

Summary
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,

334
 Cognitive Reappr aisal

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 likeli-
hood 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 develop-
ing (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 reap-
praisal 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 toler-
ance, 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 avoid-
ance 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 reap-
praisal 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 therapeu-
tic 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

335
Process-Based CBT

by self-compassion is associated with greater reductions in depression than cogni-

tive reappraisal alone (Diedrich, Hofmann, Cuijpers, & Berking, 2016). As cogni-
tive 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.

References
Abramowitz, J. S., & Arch, J. J. (2013). Strategies for improving long-term outcomes in cognitive
behavioral therapy for obsessive-compulsive disorder: Insights from learning theory. Cogni-
tive and Behavioral Practice, 21(1), 20–31.
Beck, A. T., Grant, P. M., Huh, G. A., Perivoliotis, D., & Chang, N. A. (2013). Dysfunctional
attitudes and expectancies in deficit syndrome schizophrenia. Schizophrenia Bulletin, 39(1),
43–51.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New
York: Guilford Press.
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York: Guilford
Press.
Burns, D. D. (1980). Feeling good: The new mood therapy. New York: Signet.
Burns, D. D., & Spangler, D. L. (2001). Do changes in dysfunctional attitudes mediate changes in
depression and anxiety in cognitive behavioral therapy? Behavior Therapy, 32(2), 337–369.
DeRubeis, R. J., Evans, M. D., Hollon, S. D., Garvey, M. J., Grove, W. M., & Tuason, V. B. (1990).
How does cognitive therapy work? Cognitive change and symptom change in cognitive
therapy and pharmacotherapy for depression. Journal of Consulting and Clinical Psychology,
58(6), 862– 869.
Diedrich, A., Hofmann, S. G., Cuijpers, P., & Berking, M. (2016). Self-compassion enhances the
efficacy of explicit cognitive reappraisal as an emotion regulation strategy in individuals with
major depressive disorder. Behaviour Research and Therapy, 82, 1–10.

336
 Cognitive Reappr aisal

Dobson, K. S., & Dozois, D. J. A. (2010). Historical and philosophical bases of the cognitive-
behavioral therapies. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd
ed., pp. 3–38). New York: Guilford Press.
Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of
General Psychology, 2(3), 271–299.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The
process and practice of mindful change (2nd ed.). New York: Guilford Press.
Hayes-Skelton, S. A., Calloway, A., Roemer, L., & Orsillo, S. M. (2015). Decentering as a poten-
tial common mechanism across two therapies for generalized anxiety disorder. Journal of
Consulting and Clinical Psychology, 83(2), 395– 404.
Hayes-Skelton, S., & Graham, J. (2013). Decentering as a common link among mindfulness,
cognitive reappraisal, and social anxiety. Behavioural and Cognitive Psychotherapy, 41(3), 317–
328.
Hofmann, S. G. (2004). Cognitive mediation of treatment change in social phobia. Journal of
Consulting and Clinical Psychology, 72(3), 393–399.
Hofmann, S. G., Meuret, A. E., Rosenfield, D., Suvak, M. K., Barlow, D. H., Gorman, J. M., et al.
(2007). Preliminary evidence for cognitive mediation during cognitive-behavioral therapy of
panic disorder. Journal of Consulting and Clinical Psychology, 75(3), 374–379.
Hsieh, M. Y., Ponsford, J., Wong, D., Schönberger, M., McKay, A., & Haines, K. (2012). A cogni-
tive behaviour therapy (CBT) programme for anxiety following moderate-severe traumatic
brain injury (TBI): Two case studies. Brain Injury, 26(2), 126–138.
Kendall, P. C., & Hedtke, K. A. (2006). Cognitive-behavioral therapy for anxious children: Therapist
manual (3rd ed.). Ardmore, PA: Workbook Publishing.
Persons, J. B., Davidson, J., & Tompkins, M. A. (2001). Essential components of cognitive-behavior
therapy for depression. Washington, DC: American Psychological Association.
Smits, J. A. J., Julian, K., Rosenfield, D., & Powers, M. B. (2012). Threat reappraisal as a mediator
of symptom change in cognitive-behavioral treatment of anxiety disorders: A systematic
review. Journal of Consulting and Clinical Psychology, 80(4), 624– 635.
Stice, E., Rohde, P., Seeley, J. R., & Gau, J. M. (2010). Testing mediators of intervention effects in
randomized controlled trials: An evaluation of three depression prevention programs. Journal
of Consulting and Clinical Psychology, 78(2), 273–280.
Wenzel, A. (2012). Modification of core beliefs in cognitive therapy. In I. R. de Oliveira (Ed.),
Standard and innovative strategies in cognitive behavior therapy (pp. 17–34). Rijeka, Croatia:
Intech. Available online at http://www.intechopen.com/books/standard-and-innovative
-strategies-in-cognitive-behavior-therapy/modification-of-core-beliefs-in-cognitive-therapy.

337