Facilitating Reappraisal in Anxiety Disorders
It is well known that the central tenet of CBT is the mediational role of cognitive appraisal in the origin and maintenance of psychological disorders. According to Aaron Beck’s theory, a key goal of CBT is to help patients with anxiety disorders change their dysfunctional appraisal of a stimulus in terms of its threatening nature and significance. Patients’ appraisals of a threat are not limited to situations/events (i.e., antecedent focused); they can also include the actual anxiety response (i.e., response focused) and the perceived consequences of the situation and/or the anxiety symptoms (i.e., consequence focused).
Different Kinds of Appraisals
Cognitive and affective neuroscience research and theory suggest that the cognitive appraisal process of a threat does not necessarily involve thoughts or consciousness. In addition, the appraisal process is not a singular operation but rather one that involves at least two types of information processing styles and different brain networks (LeDoux, 2015).
There are different models for what is called the dual process theory, which suggests that the appraisal of a stimulus may occur simultaneously in two different ways as a result of two different kinds of information processes. One process has been called implicit (also termed “implicational” “experiential” or “system 1”), which is automatic, nonconscious, fast, habitual, associative, contextualized, nonverbal, low-effort, usually emotionally laden, non-logical, evolutionarily old, and difficult to change. Explicit appraisalon the other hand (also named “propositional” “rational” or “system 2”) is controlled, slow, verbal, abstract, logical, rule-based, high effort, conscious, evolutionarily more recent, and is easier to change.
Physiologically, these two information processes are based on related but different neural circuits, thereby leading to different ways of learning and remembering. Neither of the processes are reliably predictive or in control of the other. Hence, changes in the explicit aspect of the appraisal process may not generate changes in the implicit one (e.g., “Rationally, I know now that I am safe, but my gut tells me otherwise, and I still don’t feel safe.”)
In sum, the modern formulation of the cognitive mediation hypothesis in CBT is not limited to conscious or preconscious verbal propositions in our mind, but includes all aspects of the dual process of making sense of something.
Implication for Anxiety Disorders Treatment
Beck’s CBT theory posits that, regardless of the nature of the intervention(s) used to treat anxiety disorders, reappraisal is the main mechanism of change in therapy. Only when the intervention modifies the original threatening appraisal of a stimulus and changes it into a new, less threatening or non-threatening one, will the treatment be successful (Clark & Beck, 2010). From a different perspective, Michelle Craske and colleagues’ (2014) inhibitory learning theory suggests that exposure works not by reappraising the old meaning, but by creating new nonthreatening associations (i.e., a new appraisal) that compete with and inhibit the original excitatory threatening memory.
The dual process theory has important implications for clinical practice.
- Explicit and implicit aspects of a maladaptive threat appraisal may require different types of interventions. Explicit aspects are amenable to change by using psychoeducation and forms of rational analysis (e.g., to test the validity and usefulness of a belief through the review of evidence or the correction of faulty reasoning processes), whereas the implicit processes require repeated new corrective experiences in order to develop new associations and habits of attending, appraising and coping.
- Treatment can be more effective when it includes interventions that target both the explicit and implicit aspects of the appraisal processes. For example, since hot cognitions and conditioned fear responses usually do not respond to logical evaluation, treatment frequently includes forms of exposure, behavioral experiments, experiential exercises (e.g., empty chair dialogues, adopting new bodily postures) and skill rehearsal practices to facilitate lasting changes. Consistent with this view, Beck’s theory postulates that an effective treatment includes both the use of intellectual and behavioral/experiential types of interventions (Alford & Beck, 1997).
- A well thought out case conceptualization that includes what each patient needs to learn to reduce his/her maladaptive anxiety and function better in life informs the agenda, and will allow for session time to be spent more on doing rather than just talking about the problems. That is, helping patients to have new corrective experiences (e.g., practicing attending to new stimuli and modifying attention biases, practicing new and more functional appraisal and coping skills, particularly when experiencing hot cognitions, and creating new associations/conditioned responses). Similarly, the regular use of self-help Action Plans between sessions (i.e., homework assignments) provide patients with new implicit and explicit learning experiences in naturalistic settings, which are crucial to reinforce and generalize the gains achieved during the “in-session” part of the therapy.
Alford, B.A. & Beck, A.T. (1997). The Integrative Power of Cognitive Therapy. New York, NY: Guilford.
Clark, D.A. & Beck, A.T (2010). Cognitive Therapy of Anxiety Disorders. New York, NY: Guilford.
Craske, M.G., Treanor, M. Conway, C.C., Zbozinek, T., &Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23.
LeDoux, J. (2015). Anxious. Using the brain to understand and treat fear and anxiety. New York, NY: Viking.