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Cognitive Therapy

In 1976, Philadelphia psychiatrist David Burns, M.D., became the father of a son, David Erik. The birth was normal, but something was clearly wrong with the newborn. His skin looked blue. He had difficulty breathing and he gasped for air. The obstetrician reassured Burns and his wife that David Erik's condition did not appear serious, but he explained that the infant's bloodstream wasn't getting enough oxygen. As a precaution, the obstetrician said he wanted to send David Erik to the intensive care nursery for extra oxygen.

Dr. Burns consented--then suddenly became depressed and panicky. Intensive care meant something was terribly wrong. His baby son wasn't getting enough oxygen. That meant that his brain wasn't getting enough. He could be brain damaged. Burns flashed on a future ruled by the needs of a severely handicapped child. He wondered if he could love such a child, and imagined that people would think the less of him for having a handicapped son.

Feeling himself becoming overwrought, Dr. Burns decided to try the disarmingly simple therapeutic technique his colleague, Aaron Beck, M.D., had pioneered. It involved writing down negative thoughts and then seeing if they were really true or somehow illogical. But the moment the idea occurred to him, Dr. Burns dismissed Beck's program as absurd: It was fine for his patients. They were imagining their problems. His problem was real. Of course, Dr. Burns' patients had often made the identical comment to him, so he told himself what he always told them: Just try it. What do you have to lose?

It didn't take the depressed psychiatrist long to identify his negative thoughts: Intensive care meant the worst. His son was brain damaged. His life would be ruined caring for a handicapped child. And his child's problems would diminish him in others' eyes.

Next, Dr. Burns looked for fact or fallacy in his stated feelings--and found major distortions. The obstetrician had said intensive care was a precaution, that David Erik's condition did not look serious. By assuming the worst, he'd "mentally filtered" the information available to him, seeing only the most dire possibility, when his son was probably fine. Thinking that his son was brain damaged, he'd "jumped to a conclusion" that was unjustified. Even if his son were handicapped, he'd "magnified" the problem by assuming it would ruin his life. Plenty of people live full, rich, rewarding lives despite their children's--or their own--handicaps. Finally, by assuming that others would think the less of him because his son was handicapped, he'd engaged in "over-generalization." On reflection, he realized that his friends would judge him for himself, just as he judged them independent of their children.

This simple exercise immediately calmed Dr. Burns, and improved his mood. Soon after, he learned that David Erik was breathing normally and that his skin had turned a healthy pink. Subsequently, he learned that the boy's brain was fine.

In addition, Dr. Burns, a professor of psychiatry at the University of Pennsylvania Medical Center in Philadelphia, learned that the technique he'd used could benefit not just those with major psychiatric problems, but anyone dealing with emotional negativity. He went on to write Feeling Good: The New Mood Therapy, and The Feeling Good Handbook , pioneering popular guides to cognitive therapy. "Cognitive" refers to thought processes. Cognitive therapy is a powerful self-help technique for dealing with depression and other negative emotions by consciously changing the way we think.

What Causes Negative Feelings?

The cause of negative emotions--depression, anxiety, anger, impatience, frustration, guilt, irritability--is a matter of opinion. To Freudian psychoanalysts, they are the result of repressed feelings that typically date back to childhood relationships with parents. To biological psychiatrists, they stem from chemical imbalances in the brain. To cognitive therapists, they represent distorted thinking. Cognitive therapy is comparatively new to the mental health profession, but it's approach was first espoused more than 2,000 years ago by the Greek philosopher, Epictetus, who said, "People are not disturbed by events themselves, but rather by the views they take of them." Shakespeare put it well in Hamlet: "There is nothing either good or bad, but thinking makes it so."

Some emotional turmoil is clearly the result of problems early in life, for example childhood abuse, and Freudian-style talk therapies can help. "But most people don't have to spend a great deal of time understanding the past to improve how they react to potentially depressing situations in the present," says psychologist Mark Sisti, Ph.D., associate director of the Center for Cognitive Therapy in New York City.

Some mental health problems are caused by chemical imbalances in the brain, and for severe depression, antidepressant medication is clearly the way to go. Antidepressants may also help people with mild to moderate depression, but for these conditions, Dr. Sisti says, "cognitive therapy is also quite effective."

The 10 Forms of Twisted Thinking

Dr. Burns has documented 10 types of distorted thinking. How many of these depressing emotional traps have you fallen into?

All-or-Nothing Thinking. You see things as black or white. If you're not perfect, you're a total failure. You make one mistake at work, and decide you're going to be fired. You get a B on a test, and it's the end of the world. Your husband reprimands you for not checking the oil when you got gas, and you decide he doesn't love you.

"Like many people, I was a perfectionist," Dr. Burns explains. "Either I was terrific, or I was nothing. Either I pleased my boss, spouse, parents, or friends, or else I was good for nothing. It made me terribly anxious, and I spent a good deal of my life ashamed of myself because, of course, I wasn't perfect."

Labeling. An extension of all-or-nothing thinking. You make a mistake, but instead of thinking I made a mistake, you label yourself: I'm a jerk. Your girlfriend breaks up with you, but instead of thinking she doesn't love me, you decide: I'm unlovable.

Dr. Sisti felt himself slipping into labeling during a six-hour professional licensing exam. When he came to a section he found difficult, his first thought was: This is really tough. I must be an idiot. "But then I took a deep breath, and realized that I'd completed other sections that weren't so hard, and that everyone else in the room was probably having as tough a time as I was."

Over-generalization. The tip-offs are the use of the words "always" or "never." You drop something and think: I'm always so clumsy. You make a mistake and think: I'll never get it right.

Mental Filtering. In complicated situations that involve both positive and negative elements, you dwell on the latter. Your mother clearly enjoys the dinner party you throw in her honor, but comments that the cake was a bit dry. You filter out all her positive comments and whip yourself for being such a lousy baker.

"As a perfectionist," says Bruce Zahn, M.A., director of psychology and cognitive therapy at Presbyterian Medical Center in Philadelphia, "I sometimes slip into mental filtering. I usually get good feedback on my job and in my personal relationships, but when people give me minor criticism, I'm apt to think the worst: They don't love me. They're going to fire me. Then I realize, no, this is a minor criticism, and all I have to do is correct it."

Discounting the Positive. The tip-offs here are the phrases: "That doesn't count," "That wasn't good enough," or "Anyone could have done it." You do well on a test, and think: It doesn't count. Your colleagues praise a presentation, and you think: It wasn't good enough. You win a commendation and think: Anyone could have done it.

Jumping to Conclusions. You assume the worst based on no evidence. In "mind-reading," you decide that another person is reacting negatively to you. Two of your coworkers are chatting at the coffee machine at work, but as you approach, they fall silent. Chances are they'd simply finished their conversation, but you assume they've been criticizing you behind your back. In "fortune-telling," you predict the worst possible outcome. A test is difficult, so you decide you failed. The sky is cloudy before you lawn party, so you decide a thunderstorm must be imminent.

Dr. Sisti slipped into fortune-telling recently when he realized he'd lost his automatic teller machine (ATM) bank card: "My blood pressure shot up as I imagined that I'd lose all my money. Then I thought: What's the worst thing that could happen? Someone might use my card. But no one could--not without my personal identification number. But what if I'd left it in the machine? Then someone could withdraw $250. That would have been a loss, but not a terrible one."

Magnification. You exaggerate the importance of problems, shortcomings, and minor annoyances. Your toilet backs up, and you believe you need your entire plumbing system replaced. You forget to close a window before it rains, and imagine that you'll return to a flooded home. A neighbor's dog tramples a few flowers and you decide your garden is ruined.

Emotional Reasoning. You mistake your emotions for reality. I feel nervous about flying, therefore, it must be dangerous. I feel guilty about forgetting my brother's birthday, therefore, I'm a bad person. I feel lonely, therefore, I must not be good company.

"Should" and "Shouldn't" Statements. You play well in the company volleyball tournament, but miss one shot and berate yourself: I should have made that shot. I shouldn't have missed. You eat a donut and think: I shouldn't have done that. I should lose 10 pounds. Other self-demanding tip-offs include: "must," "ought to," and "have to."

Personalizing the Blame. You hold yourself personally responsible for things beyond your control. Your child misbehaves at school and you think: I'm a bad mother.

"Occasionally, I've been late for an appointment because of heavy traffic," Dr. Sisti says, "and I've felt tempted to personalize it, as in: I must be irresponsible. But then I've realized that I'd allowed what should have been enough time, and that the traffic jam is beyond my control. People understand if you get stuck in traffic. It happens to everyone."

Seven Ways to Untwist Your Thinking

"When you feel badly," Dr. Burns explains, "your thinking becomes negative. This is the ABC of emotion: 'A' stands for the Actual event, 'B' for your Beliefs about it, and 'C' for the Consequences you experience because of your beliefs."

Suppose the actual event is a divorce. You might believe many of the charges your ex leveled against you: You're selfish, uncaring, vindictive, and lousy in bed. The consequences of these beliefs might be deep depression. Cognitive therapy tries to change the "B's" so you don't experience the "C."

How can you change your beliefs about the slings and arrows of outrageous fortune? Dr. Burns recommends subjecting any negative belief to the following tests:

What would you say to a friend? "People are generally much harder on themselves than they are on others," Dr. Burns says. Suppose a friend were getting divorced, and felt like a selfish, uncaring, vindictive failure. What would you say? Probably something like: You're not a failure simply because your relationship ended. Many marriages end in divorce, just like many winning teams lose games. It's rough to endure a divorce, and break-ups never bring out the best in people, but I've known you for years, and you're a warm, kind, caring person."

Examine the evidence. Your ex says you're lousy in bed, but are you, really? Until you learned of you ex's unfaithfulness, you had a good sexual relationship. Of course, after your heart was broken, you didn't have any energy for sex, especially with the person who'd rejected and betrayed you. That's not being lousy in bed. That's a normal reaction to your situation.

Experiment. You ex called you selfish for wanting to keep the house, but are you really? If you were truly selfish, you wouldn't give to charity, wouldn't help friends in need, and wouldn't share credit for your group's accomplishments at work. Test your reactions the next time a charitable solicitation arrives, or a friend calls with a problem, or your group's efforts are recognized. If you write a check, offer to lend a hand, or praise a coworker, you're not entirely selfish. You may not be as magnanimous as you'd like to be, but you're not the ogre your ex says you are.

Look for partial successes. Instead of thinking your marriage was a "complete failure," consider how it was successful. You took turns putting each other through school, and now both have much more fulfilling careers than you had when you met. You have two great kids, and the problems that led to your breakup have given you valuable new insights into the kind of person you'll look for in your next relationship.

Take a survey. You ex insists that your refusal to take the kids for an extra day after a holiday weekend proves you're vindictive. You maintain that you're open to rescheduling time with the children, but not when it means allowing your ex to jet off to a luxurious resort with the new lover. You feel justified, but after a screaming argument on the phone, your confidence is shaken. Perhaps you are a vindictive SOB. That's the time to call a few friends and solicit their views. Chances are they'll say you're justified.

Define your terms. You had no idea your ex was having affairs. You were blind. Define "blind." The dictionary says "completely without sight." That wasn't you. You saw that your ex had withdrawn from you, and was spending an enormous amount of time "working late." You weren't blind, just too trusting of someone you had every reason to believe was trustworthy.

Solve the problem. You blew up when you came home early and found your ex, who'd moved out months ago, unexpectedly in your house. Since that ugly scene, you've been thinking that your "terrible temper" has turned you into a "monster." Possibly, but the problem here is that you ex still has keys to your house. Maybe it's time to change the locks.

Seven Steps to Feeling Better

Six steps may not sound like many, but "simplicity is one of cognitive therapy's major strengths," Dr. Sisti explains. It's quick and easy, and once people understand the basic concepts, almost anyone can practice it." Sometimes, though, cognitive therapy's very simplicity puts people off. They say: "It's so simple, it can't possibly work." When that happens, Dr. Sisti points out that they're jumping to a conclusion, and urges them to try the steps and see if the process has value:

Step 1. Get pen and paper. Write everything down. "The act of writing automatically puts some distance between you and your negative thought," Dr. Sisti says. "Jotting things down provides perspective and helps people detect distorted thinking more easily." If you can't put pen to paper, Dr. Sisti recommends saying things out loud.

Step 2. Identify the upsetting event. What's really bothering you? Is it simply the fact that you got a flat tire? Or is it that you soiled your outfit changing it? Or that you knew you needed a new tire, but didn't replace it? Or that the flat made you late for your daughter's soccer game?

Step 3. Identify your negative emotions. You might feel annoyed about the flat, frustrated that replacing it soiled your outfit, angry at yourself for not replacing it in time, and guilty for being late to the soccer game.

Step 4. Identify the negative thoughts that accompany your negative emotions.About failing to replace the tire: I always procrastinate. I never take care of things in time. About soiling the outfit: I'm a slob. I can't go anywhere and look okay. About being late for the game: My daughter will make a scene. She'll think I don't love her. And the other adults there will think I'm a bad parent.

Step 5. Identify distortions and substitute rational responses. About the tire: I don't always procrastinate. I juggle my job and family, and accomplish just about everything that has to get done. I would have replaced that tire in time, but I had to deal with an emergency at work, and the tire just got by me. About the stained outfit: I'm not a slob. I'm usually very careful about my appearance, more so than most people, which is why things like this upset me. About the tardiness: My daughter knows I love her. She knows that if I'm late, whatever detained me was beyond my control. She's unlikely to make a scene, but if she does, the other adults there will comfort her. I've done the same for their kids, and never thought them to be bad parents. No one will think the worse of me.

Step 6. Reconsider your upset. Are you still heading for an emotional tailspin? Probably not. But you still feel annoyed about getting the flat.

Step 7. Plan corrective action. As soon as the game is over, we're getting that tire. That will take the time I'd planned to spend cooking dinner, so I'll pick up some take-out instead.

Count Your Blessings

"A major task of adulthood is to balance striving to do your best while accepting your limits," Dr. Burns says. "Cognitive therapy has helped me accept my limits without feeling ashamed."

"Cognitive therapy is simply a more organized way to implement traditional psychological self-care advice," says New York psychotherapist Alan Elkin, Ph.D. "It boils down to counting your blessings. Most depressing or anxiety-producing events are not inherently awful. What makes them feel distressing is the way we react to them. Counting your blessings forces you to step back, get some perspective, and see challenges in a larger context. The problem with 'count your blessings' is that it's vague. Cognitive therapy is a step-by-step program, and when you feel depressed or stressed by negativity, an organized program helps."
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