Qu'est-ce qui t'appartient?

Recently I told one of my clients that his feeling of being manipulated by his partner didn’t mean that his partner was being manipulative. Within the same week, my sister informed me that my irritation with her didn’t mean that she was doing or saying anything irritating.

The assumption that your emotions accurately reflect reality is a cognitive distortion referred to as emotional reasoning. Examples include assumptions like “Because I dislike her, she must be a jerk” or “Because I feel intimidated by him, he must be trying to intimidate me.” Emotional reasoning is a backwards and often unhelpful method of interpretation; in interpersonal situations, it usually involves assigning responsibility for your emotions to the other person.

One of the best tools for disengaging from emotional reasoning is something I learned from doing therapy in French: the phrase “Qu’est-ce qui t’appartient?" which translates literally to what belongs to you. The idea is to consider the roles that your mood, history, and experience could be playing in the situation.

Keeping this concept in mind, my client and explored other possible explanations for his feeling of being manipulated (e.g., he has a hard time saying no; his previous partner was manipulative) and for his partner’s behaviour (e.g., she wanted to please him; she was trying to help). We concluded that his feeling of being manipulated was generated by his own history and context, rather than by anything that his partner did. In my own case, I was able to identify that my irritation was borne of my own fatigue that day and lingering hurt over a comment someone else had made the day before. Similarly to my client's situation, my emotional reaction had nothing to do with my sister.

When due to his history and experiences, my client feels manipulated by his partner who isn’t doing anything particularly manipulative, ca l’appartient.  When due to my history or context, I get irritated with my sister who isn’t doing anything inherently irritating, ca m’appartient. When, for example, due to your history and experiences, you experience recurrent jealousy in a relationship where there is no objective cause for jealousy, ca t’appartient.

Recognizing that part (or all) of your reaction belongs to you rather than being caused by someone else is a great first step in not being a jerk to others and in avoiding unhelpful automatic responses. 

The next time you’re upset, ask yourself qu’est-ce qui t’appartient? What happens?

Pattern Projection

Mental health tip: Experiences can make you feel the same way without being related.

When we go through a string of negative experiences (e.g., socially, professionally, romantically), our tendency is to review them as a group and search for patterns. This can be a worthwhile exercise: identifying patterns helps us establish what went wrong and determine whether or not there's something we could be doing differently. On the flipside, though, identifying a pattern where none exists can be quite unhelpful:

One of my clients has been looking for work for months and becoming progressively discouraged. Last week, after another promising interview failed to result in a job, he concluded that since "this keeps happening," he must be doing something wrong. At first glance, this seemed like a reasonable hypothesis; but when we took the time to explore the evidence for the idea that "this keeps happening," we failed to find a pattern. The most recent position my client interviewed for was filled by an internal candidate. The job before that fell through after the organization didn't received the grant needed to fund the position. Prior to that, my client was offered a part-time contract position that he declined because his daughter has a chronic medical condition and he needs health benefits to cover her medical costs. For the position prior to that, my client was short-listed but the first-choice candidate simply had more years of experience. In short, although none of the leads resulted in a job, there was no pattern.

One of my friends had two painful romantic experiences in the past six months. In the first case, a close friend for whom he harboured romantic feelings admitted that she'd always had a thing for him, too--and then promptly met and fell for another guy. In the second case, my friend ended a promising new relationship after a frank discussion revealed that the woman he was dating doesn't want to have children. These back-to-back experiences left my friend feeling pretty discouraged; he concluded that "this keeps happening" and that therefore there must be something wrong with him. Thinking of my client and his job search, I encouraged my friend to consider the possibility that he was projecting a pattern onto a patternless pair of experiences. He thought it over and acknowledged that the first situation was attributable to bad timing and the second to long-term incompatibility. That is, even though both relationships ended, there was no pattern.

How does realizing there's no pattern help? Finding patterns where none exist generally involves distorted thinking, including overgeneralization ("this always happens"), personalizing ("it's happening because of my own personal flaws and has nothing to do with external factors"), disqualifying the positive (e.g., my client ignoring the fact that he was offered a contract position; my friend dismissing the heartening facts that both women returned his feelings). Distorted thoughts make us feel bad, whereas identifying and reappraising our distortions alleviates the pain. 

Why do we project patterns onto patternless experiences? My theory is that we assume that experiences that make us feel the same way are related. My client felt discouraged and rejected each time a position didn't work out. My friend felt lonely and hopeless both times the relationship ended. But the respective HR departments made completely independent decisions not to hire my client--based, it turned out, on entirely different rationales. They weren't related. The two women my friend dated didn't know each other and didn't know of each other, and the relationships ended for entirely different reasons. They weren't related.

Both my client and my friend felt less discouraged once they stopped projecting a nonexistent pattern onto their experiences. The next time you're looking for a pattern in a string of negative outcomes, consider the possibility that there is no pattern in the experiences, only in the way you feel about them.

Does it help?

Worst-Case Scenario

What's the best strategy for coping with anxiety generated by hypothetical scenarios and "what if" questions (What if I hit 'reply all?' What if I made a mistake at work? What if I offended my friend?) Should we reassure ourselves that the scenario didn't or won't happen (we didn't hit reply all, we didn't make a mistake or offend anyone), or should we imagine the worst-case scenario?

You'd think that imagining the worst-case scenario would make us feel worse but counterintuitively, following anxiety-provoking "what if" thoughts to their conclusion can sometimes provide greater relief.

How does this work? The key principle is this: avoidance maintains anxiety. When we reassure ourselves that our stressful or scary thoughts probably won't come true, we're essentially avoiding the possibility--pushing it away and dismissing it. Avoidance is often effective in the short term, but the stressful what ifs return in full force after a few minutes, leaving us thinking "Okay I know I probably didn't hit reply all...but what if I did?" The possibility is still there so the anxiety remains.

When this happens, it can help to consider what would happen in the what ifs came true. Examples:

1) After some hemming and hawing about whether or not to make the trip, I booked an expensive airplane ticket to attend an engagement celebration in another city. As soon as I pressed 'purchase' on the airline website, my mind raced to "What if it's not that weekend after all? What if they change the date?" I tried to reassure myself that the party date was unlikely to change, but the anxiety remained. What worked was asking myself what if it were changed--then what? Answer: I'd be stuck with an expensive plane ticket I couldn't use and I'd be out $500.

2) I received an email from a supervisor concerning a decision I'd made about a project we're working on together. Before even reading the message, my mind reacted: "What if she thinks I made a bad decision?" Instead of reassuring myself that my supervisor probably doesn't care that much, I asked myself what if she did disagree--then what? Answer: My supervisor would be unhappy with one thing that I did.

3) I was running late and arrived only minutes before teaching a class, without time to review my notes as I usually do. My mind leapt to: "What if I'm unprepared and the class doesn't go well?" When it didn't work to reassure myself that not reviewing my notes wouldn't affect my teaching, I switched strategies, asking myself what if the class doesn't go well--then what? Answer: One of the classes in the eight-week course would be inferior to the rest and students might be dissatisfied with the one class.

In each of these situations, exploring the worst-case scenario was more effective than reassurance in alleviating my anxiety. Why?

a) Knowing the worst-case scenario puts an end to the what ifs. The answer is clear.

b) Knowing the worst-case scenario allowed me to figure out how to deal with it, and how to not make the same mistake in the future. I determined that if the party date changed, I'd try to sell my ticket online but that next time I'll double-confirm the date before booking. I realized that my supervisor disagreeing with one decision isn't the end of the world, but that next time I'll check with her first. I concluded that sub-par teaching wasn't something I was willing to risk, and that it was worth it to start class a few minutes late in order to review my notes.

Considering the worst-case scenario might not alleviate anxiety in every situation but next time reassurance isn't helping, try it out and see what happens!

R.E.S.P.E.C.T.

Lately I've been feeling impressed by the courage of my patients and my friends.

Once a month at the clinic where I work, two members of the team conduct a psychological evaluation with a new patient, while a group of medical residents and psych interns observes. Each time, I'm struck by the courage of the patient who sits before the group and describes in detail the manifestations and origin of the presenting mental health problem, the distress or impairment it causes, current and past relationships, and goals for treatment. How brave is that!

I was similarly struck a few weeks ago when a colleague told me that her patient with panic disorder willingly ran up and down the stairs inside the clinic, trying to expose himself to the terrifying breathlessness that triggers his panic attacks. I feel the same respect when a patient with chronic health anxiety successfully writes, records, and listens to an exposure scenario describing himself dying of cancer, or when a painfully shy patient reports that she successfully completed her plan to initiate a conversation with one of the other parents in her son's class.

It's not just my patients who are impressive: my friends are, too. A few months ago, one of my friends was diagnosed with schizoaffective disorder, a difficult-to-diagnose mix of depression, mania, and psychosis that neatly explains symptoms he's been experiencing for years. Following the diagnosis, he took his mental health into his own hands--seeking out a support group and tirelessly navigating the overwhelming bureaucracy of the health care system until he found a doctor who understood the diagnosis, prescribed medication appropriately, and addressed his concerns about side effects. Another friend recently began psychotherapy to deal with a procrastination problem that has plagued her for years. A third friend called me up for a referral for a couples therapist so that he and his partner could address some issues they were unable to resolve on their own.

My friends' and patients' initiative touches and impresses me. There's still a stigma attached to mental health care and there are still people who believe that seeing a psychologist or psychiatrist or taking medication is a sign of weakness. I'm pretty sure that acknowledging a problem and seeking help demonstrates the precise opposite.

Think about it.

A Recipe for Depression

It's pretty much fact that people who are clinically depressed demonstrate distorted thinking. Their reactions to negative events are skewed and they're more likely to make attribution errors--that is, to assign distorted meanings and causation to the things that happen to them.

Three specific attribution errors have been demonstrated to be typical in people who are depressed; my non-scientific guess is that they also show up in non-depressed people and contribute to feeling bad.

1) Internal versus external. People who are depressed blame themselves when things go wrong. In contrast, people who aren't depressed are more likely to attribute negative events to external factors like bad luck, chance, or others' actions. For example, a depressed person who doesn't receive a call back after a job interview assumes she made a gaffe during the interview or didn't prepare well enough. A non-depressed person is more likely to acknowledge that another candidate may have had more experience, or that the position could have been given to an internal applicant. A depressed person who gets hit by a car blames himself for not being more careful, even though the driver was running a red light; if his child gets bullied at school, he blames himself for poor parenting even though the bullies are targeting other kids too.   

2) Global versus specific: Non-depressed people typically view negative events as having only isolated or limited significance. In contrast, depressed people are more likely to conclude that a negative event has far-reaching or global implications. For example, a depressed person whose relationship didn't work out generalizes to other areas of his life and concludes that he has failed in every area; a non-depressed person is upset about the end of the relationship but can still acknowledge areas of his life where things are going well. A depressed person misses the bus in the morning and concludes that her whole day is shot; a non-depressed person acknowledges that the morning started poorly but figures that everything will be fine once she arrives at work.

3) Fixed versus changeable: Whereas non-depressed people often adopt a 'this too shall pass' attitude toward negative events or situations, people who are depressed view the same problems or situations as unlikely to change or improve. A depressed person feels lonely and believes she'll always be lonely; a non-depressed person acknowledges that she's going through a period of feeling alone but that it won't always be this way. A depressed person whose washer and dryer break in the same month that his cat gets sick and his transmission dies can't imagine a future wherein such things aren't happening to him; a non-depressed person knows that he's just having an unusually bad month. A depressed person who fails her exam because of poor study habits wonders if she should just give up on school altogether; a non-depressed person figures she can probably get help and learn new study habits.

In depressed people, attribution errors are problematic because they promote hopelessness and maintain depression. In non-depressed people, attribution errors just make us feel bad unnecessarily. In both cases, the first step is to realize that we're falling for these errors in thinking. The next time you're feeling down about some negative event, ask yourself if you're making an attribution error. If you think you might be, ask yourself: Is it really my fault? Am I overgeneralizing? What can I do about it?

NB: For other good questions to help you out of negative thought patterns, see here.

Enough is Enough

How's it going with your New Year's resolutions? If you're on track, good job! If you're less on track, read on:

Sometimes we're reluctant to take a baby step toward change or toward meeting a goal because the step seems too small. For example, say you resolved to quit smoking or to develop a regular meditation practice. And you decided to start by cutting back by two cigarettes per day or by meditating for five minutes every morning. Although these objectives are minor, you may find yourself not meeting them--because they feel almost too minor. 

Part of my job as a cognitive-behavioural therapist is to help people identify the thoughts that prevent them from moving forward. One thought that shows up repeatedly is "It's not enough." For example, a patient's goal might be to introduce regular exercise into his routine in order to counter anxiety and improve physical health. If his usual day involves no exercise at all, we'd probably plan to start with something like five minutes of walking every evening. My patient might express enthusiasm about the plan--but then end up going out walking once or twice, and then quitting. When asked what happened, he might reply that five minutes just didn't seem like enough. Similarly, severely depressed patients sometimes resist the validated strategy of planning small pleasurable activities, because it seems like calling a friend, taking a bubble bath, or going to the movies just isn't enough to counter depression.

The scourge of "enough" is not limited to the clinical setting. It comes up for me regarding writing. More than once, I've set the goal of writing for fifteen minutes every day, only to abandon it because it doesn't seem like enough. Similarly, I have a friend who has already abandoned her New Year's resolution to address her credit card debt with weekly payments of $15--because $15 is just not enough.

Here are a couple tips that might help when you're set to abandon your goals because your small steps seem inconsequential:
 
a) "Enough" is arbitrary. Why is cutting back by two cigarettes per day insufficient? Would three be enough? Four? Where credit card debt is concerned, would $20 per week be acceptable or would it have to be $25 to meet the enough threshold? Who decides? Recognizing that our thresholds for enough are arbitrary and idiosyncratic can help us adjust our expectations and commit to small steps. 

b) "Not enough" is how you get to "enough." Even if five minutes per day of walking isn't enough to immediately reduce my patient's anxiety or improve his physical health, it's a step toward enough. How will he get to twenty minutes per day if he doesn't start with five? Similarly, meditating five minutes per day may not seem like enough, but it's a step toward it. Recognizing that not enough is practically a required stop on the way to enough can help us persevere with small goals.

If the concept of enough is getting in your way, hopefully these tips will help you get back on track with your New Year's resolutions. Keep me posted!

At Your Service

If I had a friend who began every sentence with an apology, I might eventually point it out and ask her to knock it off. If a colleague told the same anecdote three times over the course of one lunch hour, I might tell him to quit repeating himself, or else intervene and change the subject.

But what if these things happened with my patients? What's the difference between conversations with friends and conversations with patients?

The difference is that with patients, everything I say or do should be in the service of the patient. With the friend and colleague in the examples above, I'd speak up to save myself from boredom and crankiness; with patients, my personal feelings are expressed if and only to the extent that expressing them would be helpful to the patient.

Example: Say I had a self-effacing patient who was driving me crazy by beginning every sentence with an apology. By the end of a session, I might want to snap "Quit apologizing!" but that would be a mistake. A better intervention would be to gently say something like "I've noticed that you frequently begin your sentences with an apology." Whereas the former comment expresses personal irritation, the latter is a simple and therapeutically relevant observation; the latter comment also allows for follow-up questions such as "Is apologizing something you also do with other people?" "How do you think your habit impacts your conversations?" and "How might you perceive someone who apologized all the time?" If later the patient and I were hypothesizing about how other people might perceive his constant apologizing, I could ask him for ideas (e.g. "People might think I have low confidence; they might think I'm being fake"), and then maybe add something like "Some people might find it endearing; others might find it frustrating." But my personal impatience would not be relevant.

Second example: Recently, I recently expressed frustration with a friend who kept repeating herself. She was struggling with the decision to move her elderly mother into residential care; despite my validation of the struggle and the decision, my friend continued to repeat just how much she loved and respected her mother, what a good parent her mother had been, etc. Finally I lost my patience and exclaimed "I get it, already--you love your mom!" This wasn't very helpful for my friend; a more helpful response would have been something like "Yes, you've mentioned that a few times. It must be really important for you to make that point clear."

With a patient, this kind of neutral comment is even more important, and often elicits useful information such as "I didn't know if you heard me the first time I said it because you just nodded but didn't say anything" or "I guess I feel guilty, like I'm just getting rid of my mom now that she's become a nuisance, or worried you'll think I'm a bad daughter" or "Really? I already said that?" With patients, these answers can prompt valuable conversations about validation, guilt, and social skills, respectively.

In therapy, comments like "Quit apologizing!" and "I get it!" are not appropriate because they imply a responsibility of the patient toward the therapist (e.g., to not be boring, to not waste my time), and because they express therapist feelings in a way that isn't relevant or helpful. But are there occasions when a therapist should express her true feelings? The answer is yes, but the same rule applies: only in the service of the patient.

Example: A depressed patient tells me he's bad at communicating and I respond that I've noticed that he's actually quite forthcoming and articulate in our sessions.

Example: A panic disorder patient tells me that he felt silly jogging on the spot in my office to try to induce panic symptoms for an exposure exercise, and I tell him that I was just thinking how brave he was to engage in an exercise designed to bring on symptoms that terrify him.

Example: A socially anxious patient reaches over in the middle of our session to pluck a stray hair off the arm of my sweater and then immediately asks, "Was that weird? Should I not have done that?" and I respond that her act didn't seem out of the realm of normal social behaviour, but that the timing was surprising and the gesture had taken me a bit off guard.

In each of these example, my comment is authentic and is designed to validate, bolster, and/or reflect reality to patients whose perspective may be unhelpfully distorted.

Don't Believe the Hype

Although most of us would agree that worry, anxiety, and depression are unpleasant, these experiences are sometimes associated with positive beliefs. This is problematic because such positive beliefs make these mental health scourges resistant to change.

Example: Generalized Anxiety Disorder (GAD) is a disorder characterized by chronic worry and subsequent anxiety and physiological symptoms (e.g., muscle tension, headaches). People with GAD habitually create worry chains of worst-case scenarios, often starting with "what if" (e.g., My boss asked to see me, what if I made some kind of serious mistake, what if I get fired, how will we pay our bills? or My head hurts, what if it's something serious, what if it's fatal, who will take care of my kids?).

Although most GAD patients say they're sick of worrying and wish they could stop, it's well established that most people with this disorder have positive beliefs about worry. Among other things, they believe that worrying offers protection from feared outcomes (e.g., if I worry about my son being in a car crash, it's less likely to happen), that worrying is a positive personality trait (e.g., I'm the family worrier, it's how I show my love), or that worrying shelters them from potential future negative emotions (e.g., if I worry about losing my job, it won't hurt as much if I actually do).

Positive beliefs about unpleasant psychological symptoms aren't limited to GAD. A depressed patient told me that during her childhood, she and her siblings and their divorced parents scoffed at happy-seeming nuclear families, assuming that the happy families were either faking or stupid or both.  As an adult, my patient still believed that being happy was synonymous with being phony and dumb and that being depressed meant that she was smart and authentic. I had a patient with an eating disorder who believed that her bulimia made her dramatic and interesting. Whenever she attended a social function involving food, she would refer to her "serious eating issues," generating instant curiosity and solicitousness. She believed that recovering from her eating disorder would make her boring and pedestrian. Finally, I used to believe that anxiety made me productive. I spent years resisting mindfulness and other enormously helpful relaxation techniques, believing that I'd never accomplish anything if I weren't anxious.

In such cases, the best strategy is not to simply tell people that their beliefs are wrong, but to get them to test the beliefs. My depressed patient took inventory of the people she knew who seemed happy. She found that many of them were both intelligent and genuine, demonstrating that her belief wasn't altogether accurate. My GAD patient practiced not worrying when his son made the five-hour drive to visit; he noticed that not only did his son arrive safely, but he enjoyed their visit more because he wasn't a worried wreck by the time his son arrived. My bulimic patient made a list of people she found interesting and noticed that none of them had eating disorders--and that two of her friends who also suffered from eating issues hadn't made the list. She also made a list of the qualities that she admired in herself, and identified a number of interesting and enviable traits that weren't related to her eating issues. For myself, I took a closer look at whether or not I was actually more productive when I was feeling anxious. I noticed that while anxiety occasionally propelled me into action, it more often drove me to produce unrealistic to-do lists that raised my stress level and stifled productivity. I also observed that on days when I was more relaxed, I was happily productive.

It's counterintuitive that we want to hold on to being anxious, worried, eating disordered, and depressed, and it can be frustrating for friends, family members, and therapists who want to help us make change. In such cases, exploring beliefs about symptoms helps. Worked for me!

Psychoeducation

Psychoeducation is a core feature of cognitive-behavioural therapy--and any good therapy. The term refers to information that a therapist provides a patient about the patient's symptoms or disorder, about the therapy model, and about how treatment will proceed, among other things. A lot of psychoeducation occurs in the first few therapy sessions, but psychoeducation also involves explaining new concepts and providing a rationale for in-session exercises or homework assignments over the entire course of therapy.

As a therapist, I sometimes forget the importance of psychoeducation. Particularly when I feel an urgency about helping a given patient, I make the mistake of cutting short the education part to try to jump ahead to a more "active" treatment phase. To avoid this error, I have to remind myself that good psychoeducation is part of the treatment: patients consistently demonstrate great interest in the information provided, express relief to learn that their symptoms are normal, and show greater commitment to therapy following psychoeducation. In fact, often when therapy doesn't seem to be having the intended effect, it's because I went too quickly and failed to psychoeducate sufficiently.

I had an experience today that reminded me just how powerful psychoeducation can be: I have a patient who suffers from obsessive compulsive disorder (OCD), an anxiety disorder characterized by intrusive thoughts and by repeated compulsive actions designed to eliminate the anxiety generated by the thoughts. During our session, we were discussing the nature of OCD and I emphasized the fact that intrusive thoughts* (e.g., I could jump in front of this bus; what if I had sex with my best friend's partner; my hands could be contaminated from that weird meat at lunch; I could drop the baby off the balcony) are normal and common, and that most almost everyone--OCD or not--experiences them. My patient was so happy and relieved to hear this that he kissed my cheeks when he left my office--not our usual way of saying goodbye!

My patient's reaction reminded me that psychoeducation is an important part of my job. Here are some examples of information that can make a big difference for patients:

• For patients with panic attacks: It's normal to think you're going crazy or to think you're having a heart attack during a panic attack. In fact, both are listed as panic symptoms in the DSM.
• For patients who feel guilty about being depressed: It's normal to feel guilty when you're depressed. In fact, guilt is one of the DSM criteria for diagnosing depression.
• For patients who fear their depression is making them stupid: Poor memory and difficulty concentrating are listed as DSM diagnostic criteria for depression.
• For patients with generalized anxiety: Worry and anxiety are maintained by intolerance of uncertainty.
• For depressed or anxious patients: Depression and anxiety can be maintained by beliefs about depression and anxiety (e.g., anxiety makes me productive; only stupid people are happy).
• For patients with insomnia: Many cases of insomnia can be cured through simple sleep hygiene (e.g., always going to bed at the same time; not eating, drinking, or exercising right before bed; eliminating noise and light in the bedroom).
• For mindfulness meditation clients: Meditating doesn't mean clearing your mind of all thoughts. Practicing mindfulness doesn't mean you'll be Zen all the time.
• And my favourite, for everyone: Thoughts aren't facts. Not everything you think is true. 

The examples listed above are everyday facts for cognitive-behavioural therapists, but gifts for patients. It's like when your dentist explains to you that exposed roots are common and are often caused by overzealous brushing; when your lawyer informs you that you need your neighbour's consent to build a fence on your shared property line; or when my athletic therapist told me that imbalances in muscle strength can produce knee pain. The gift is information that produces understanding and/or relief and/or a direction for moving forward (e.g., get a soft-bristled toothbrush; set up a meeting with your neighbour; stop exercising late at night; consider ways of increasing your tolerance for uncertainty). 

* NB: Everyone has intrusive thoughts, i.e., thoughts that seem to come out of nowhere and are inconsistent with our real feelings and values (e.g., we don't really want to jump in front of a bus or have sex with our best friend's partner). The difference is that someone who doesn't have OCD treats the intrusive cognition as an annoying but passing thought and lets it go, whereas someone with OCD perceives the thought as both realistic and dangerous, and needs to perform a compulsive behaviour to alleviate the anxiety generated by the thought.

Anecdote: Parallel Therapy Universe

In September, I explained how psychologists are just like other professional that you might consult--with a specific set of skills, knowledge, and training. Today I had an experience that demonstrated the remarkable similarities between two very different types of therapy:

Before work this morning, I had an appointment with an athletic therapist. I told her my problem: "One of my knees hurts when I run." After asking some questions to understand the background and history of the problem, she maneuvered my legs around, testing muscles and ligaments to determine a diagnosis. Then she educated me: "Sometimes when you have surgery on one knee, that leg never fully regains equal strength; over time, the discrepancy between the two legs forces the muscles and ligaments to compensate--pulling in weird directions and resulting in pain." Next, she guided me through a few exercises that will strengthen the weaker leg. Once she was sure I understood how to do them, she prescribed a few for homework and made sure I wrote them down. She took notes during our session and put them in my file.

After my athletic therapy appointment, I went to work and met with my first patient of the day, a socially anxious man in his late twenties. He told me his problem: "I have to give a toast at a friend's wedding this weekend and I'm so anxious about it I can barely breathe." After asking some questions to fully understand the situation, I asked him to write down some of the thoughts and feelings that come up when he imagines giving the toast. His thoughts included "I'll go blank and won't be able to give the toast," "The other guests will laugh at me," and "If that happens, I'll be humiliated and devastated." Then I educated him: "Often people who are anxious both overestimate the likelihood of a feared event and underestimate their ability to cope with it."

Next, I guided him through an exercise that involved rating the probability of each thought: Given his ample preparation and the notes he planned to bring to the wedding, he rated the probability of forgetting his toast at only 15%. Given that most of the guests were friends of his, he rated the probability that they would laugh at him at only 10%. Given that he had experienced embarrassment during public speaking in the past--but allowing that humiliation and devastation were probably exaggerated predictions--he rated the probability of humiliation and devastation if he forgot his toast at 60%. Together we did the math (15% x 10% x 60% = .009% chance of his feared outcome occurring) and explored the impact of calculating the probabilities on his anxiety. Once I was sure that my patient understood how to apply this strategy, I assigned the use of probabilities in other anxiety-provoking situations as homework for next week. I took notes during our session and put them in his file. 

There you have it! Regardless of type, it seems that therapy involves explaining the problem, testing and diagnosis, education, introduction of a new skill or exercise, practicing the skill/exercise, and homework.

Confirmation Bias

Confirmation bias refers to our tendency to seek and favour information that confirms our pre-existing ideas, and to interpret ambiguous information as supportive of our beliefs. That is, we pay attention to and believe information that confirms what we already think, while ignoring contradictory information. So for example, if I believe that the city where I live has the best restaurants in the world, I'll notice and remember every delicious meal I eat in my city--ignoring any poor customer service or bad food experiences, and forgetting about delicacies consumed in other cities.

How does confirmation bias manifest in clinical psychology practice?

We all have automatic thoughts and core beliefs about ourselves, others, and the world. Some of our problematic thoughts and beliefs aren't quite accurate and, reinforced by confirmation bias, they can be quite resistant to change. Consider one of my patients--an undergraduate student who was depressed after a longterm relationship ended. She was very lonely after the break-up, and frequently had the thought that everyone in the world but her was in a relationship. This recurring thought meant that every time she attended a social event, she was hyper-aware of couples and failed to notice people who had arrived alone or with friends. In our sessions, my patient repeatedly compared herself to her two best friends, both of whom were in relationships, ignoring that her sister and her roommate were both single.

As her depression deepened, my patient's recurrent thought was reinforced by confirmation bias and consolidated into a biased belief: if she was the only single person in her peer group, she must be unlovable. The belief that she was unlovable was in turn reinforced by confirmation bias: when her friends organized a huge surprise birthday celebration, she reported they were just looking for an excuse to party. When her lab partner asked her out, she assumed it was only because he wanted to copy her notes.  Her confirmation bias prevented her from taking in any information that contradicted her belief that she was unlovable, maintaining both the belief and the depression. 

You don't have to be clinically depressed to experience the effects of confirmation bias. Think about the last time you woke up in a bad mood. You probably paid a lot of attention to the guy whose massive backpack took up an extra seat on the subway, or to the fact that the elevator at work was out of service again. You probably failed to notice the gorgeous weather, or the delicious lunch your loving partner packed you. Why? Because these things didn't fit in with your preconceived idea that day that the world was a lousy place.  

How can we challenge confirmation bias?

The trick is to realize when we're in the grip of confirmation bias, to identify the bias, and to be willing to test it. Example: I have a patient who has a high-powered job and young kids, but her life is more difficult than it needs to be because she believes that fundamentally, other people are incompetent. Not only does this belief create interpersonal conflict, but it means that she can never delegate responsibility for any task or chore to her colleagues, her husband, or her kids because they're liable to do it wrong.

After a bit of psychoeducation about CBT, and some work on cognitive distortions, she agreed to test her belief. Armed with the scientific hypothesis "Others are incompetent," she set out to complete the following assignment: for one week, record evidence that supported or contradicted her belief. Evidence that supported the belief included "My husband put my daughter's diaper on backwards" and "The construction on my street that was supposed to be completed two months ago still isn't done." Contradictory evidence included "The tech support guy at work fixed my printer," "The airline actually served me the gluten-free meal I ordered," and "My son did his homework while I was away."

Faced with clear evidence that others are not always incompetent, my patient was forced to reconsider her belief. She modified "Others are incompetent" to "Other people can be incompetent sometimes, but often get it right." My patient's new faith in her husband, children, and colleagues smoothed relationships and allowed her to delegate tasks, leaving her a bit of time to relax.

Challenging confirmation bias is tricky and requires an open mind. If there's a thought or belief that's making you depressed or anxious ("I never do anything right"), creating relationship problems  ("No one could ever really love me"), or generating stress ("Asking for help implies weakness"), try looking around for information you might be ignoring, and for possible reinterpretations of the information you've been using to justify your belief! 

NB: Sneaky confirmation bias occurs on sites like Facebook that use algorithms to feed us information. Example: If in following the US election, you clicked on and "liked" all your Obama-supporting friends' statuses and ignored all your Romney-supporting friends' posts, your Facebook news feed narrowed, showing you more news from your Democrat friends and fewer posts from your Republican friends. Through the Obama supporters' posted statuses and articles, you learned more about why the Democrats were the better party, and received little information that challenged this perspective--maintaining and strengthening your bias.

Lens Lesson

Everybody sees life through the lens of his or her own history. Try as we might, it's almost impossible to view any person, event, or situation completely objectively, without the impact of our experience and memories. Sometimes it's more obvious than others; for example, when someone cringes every time her boss says "Can I speak with you privately for a minute?" it's not hard to figure out that she's carrying the memory of another boss that said the same thing right before he fired her.

Sometimes it's more subtle though. You might not realize that your exaggerated fear of gaining a few pounds developed the time your ex offhandedly mentioned that your jeans looked tight, right before the relationship ended. Similarly, it might not be obvious that your resistance to buying birthday and Christmas presents is the result of the time you gave what you thought was an exceptionally perfect gift, only to receive a devastatingly indifferent response. Such experiences become the lens through which you see weight-related or gift-related situations, and seeing through the lens influences how you behave (e.g., obsessing over the scale, refusing to buy gifts).

Lenses are often composed of thoughts: "I'm not good at choosing gifts." "Gaining weight is unacceptable." "I could get fired at any time." One of my jobs as a cognitive-behavioural therapist is to help clients become aware of their "lens thoughts" and develop alternative thoughts that help them act differently and feel better. I tell clients that when they they feel down, anxious, or otherwise unhappy about a given situation or event, they can ask themselves the following questions:

a) What was I thinking?
b) Is it a lens thought? 
c) What might someone else think in this situation?

Example:  I have a client who was bullied mercilessly in high school and now feels extremely anxious in social situations. When someone so much as glances sideways at her, she instantly interprets the look as one of disrespect, dislike, and scorn. The impact of her social anxiety is that she feels sad and isolated, never attending a work party and avoiding situations like parent/teacher night at her daughter's school. When she received an email invitation to her cousin's baby shower, her immediate thought was "Everyone will make fun of how I look;" she felt shame and dread, and quickly discarded the email. Going over the example using the three questions above, my client was able to identify the thought as a lens thought; she acknowledged that another person who received a baby shower invitation might think something like "Oh great, a party! Hmmm, what will I wear? " This allowed her to label her upsetting thought as a relic from high school, and to focus on choosing an outfit she liked.

Recognizing lens thoughts and putting someone else in your shoes can help you adjust your perspective and change your behaviour.  The next time an event or situation is bringing you down, try the lens lesson!

When Panic Attacks

We use the term "panic" all the time, saying we panicked at our job interview, or had a panic attack when our child wandered into the street, but what do psychologists mean when they talk about panic attacks or panic disorder?

Panic isn't the nervousness you feel the morning of your presentation at work, the stress you feel when you're running late for an appointment, or the anxiety you feel when your partner is mad at you. A panic attack is a sudden surge of overwhelming anxiety and fear, accompanied by a flood of physiological symptoms; it develops abruptly and usually lasts no more than fifteen minutes. It may be triggered by something specific (e.g., public speaking, enclosed spaces, a stressful thought), or may come out of the blue.

The DSM defines a panic attack as a discrete period of intense fear, in which at least four of the following symptoms develop abruptly and reach a peak within ten minutes:

Physiological symptoms: palpitations, pounding heart, or increased heart rate; sweating; trembling or shaking; shortness of breath or a feeling of smothering; a feeling of choking; chest pain or discomfort; nausea; feeling dizzy, lightheaded, or faint; chills or hot flushes; and numbness or tingling, often in the extremities. Psychological symptoms: fear of dying, losing control, or going crazy; and derealization or depersonalization, i.e., feeling unreal, disembodied, or detached from your surroundings.

What does a panic attack feel like?

It feels like terror in your belly, an elephant sitting on your chest, and going crazy. Your heart feels like it's pounding out of your chest, the room seems to be closing in, and you can't breathe. Many people experiencing panic are convinced they're having a heart attack--in fact, over 40% of individuals who show up the emergency room with chest pain are actually suffering from a panic attack. On top of the discomfort of the physiological symptoms of panic, the feeling of derealization can make panic lonely and confusing because what's happening in your mind doesn't match what's happening in the external world; it's hard to understand why other people seem to be calmly and happily going about their business when, for you, the world seems to be ending.

A panic attack is not a DSM diagnosis, but panic disorder is. Panic disorder is diagnosed when recurrent panic attacks result in persistent concern about further attacks, worry about the consequences or implications of the attacks, or significant change in behaviour for fear of future attacks (e.g., refusing to give presentations at work, declining social invitations). At worst, individuals with panic disorder develop agoraphobia--the fear of being out in public, or in a place where they could panic--and begin to avoid crowded public spaces, or avoid leaving the home at all.

A panic attack can happen in the context of panic disorder, depression, or another psychological problem, or can simply be an isolated incident during a stressful period or situation. During a panic attack, it's not important to try to figure out what happened or what's wrong; instead, just focus on breathing slowly and trying to calm down. It can help to realize that you're having a panic attack and to remember that thinking you're going crazy and thinking you're having a heart attack are symptoms of panic. If you experience recurrent panic attacks, it may be time to see your doctor or consult a psychologist. Panic is eminently treatable and responds well to cognitive-behavioural therapy (CBT), among other treatments.

There's an App for That

Cognitive-behavioural psychologists encourage clients to not believe everything they think. One way to apply this suggestion is to imagine your mind as an email inbox and some of your thoughts as spam. In the same way that you don't take seriously every email informing you that you've just won £20,000,000, maybe you don't need to take seriously every thought that runs through your mind.

When you believe everything you think and react to your thoughts as though they were facts, you're experiencing what psychologists call cognitive fusion. Say I have a tough session with a client and I have the thought "I'm a bad therapist." If my heart sinks and a knot of shame forms in my belly, I'm fused with my thought--that is, I'm reacting as if the thought were a fact, rather than a mere string of words my mind created. What's problematic about fusion is that we can get so wrapped up in a fused thought that we fail to notice or incorporate any information that disconfirms it. For example, say a depressed client were fused with the thought "Life is hell." Cognitive fusion would maintain his grey-coloured glasses and prevent him from noticing anything pleasant about the world around him.

Cognitive defusion is used in psychotherapy to help clients unhook from painful and stressful thoughts. A lot of defusion techniques involve using mindfulness to see thoughts and emotions as transient external events, observing them in the same way you would observe a bus drive by or a pen fall to the floor. You might picture your thoughts like leaves on a stream, each one just floating into and then out of consciousness, or you might add the words I'm having the thought that to the beginning of your sentence, so that instead of saying to yourself "I'm an idiot," you would say "I'm having the thought that I'm an idiot." In so doing, you acknowledge that your thought is just a thought, not a fact.

Other defusion methods include saying the fused thought out loud over and over until it loses meaning, saying it in a silly voice, and singing it. I went to a conference a couple weeks ago where I attended a workshop on cognitive defusion techniques; the presenter showed us an iPhone application called Songify that he uses to help his clients defuse from thoughts. The app records you speaking, analyzes your speech, organizes it into a chorus and verses, and maps it to your choice of melody, adjusting your pitch and syncing your words with the beat. He played us a demo of a client saying "I'm a loser." It was impossible not to laugh at the electronic but melodic "I'm a loser" song and it really made the words seem like just words. Apparently the client felt the same way.

I tried Songify recently with colleague, testing some of the thoughts we sometimes find ourselves fused with. It worked! Not only did we have a good laugh, but hearing our thoughts sung out loud to a melody gave us some distance from them, letting us see them for exactly what they are--mind spam, rather than literal truths.

Rain Check

Earlier this summer, I took a six-week workshop about dealing with emotions using (among other things) mindfulness and CBT strategies. Of the things I learned in the workshop, my favourite was that the word emotion comes from a Latin root that means to move through or to move out.

I love this! It reminds me that emotions are transient in nature, and that the way out is through (that is, that experiencing tough emotions makes them dissipate much more quickly than does avoiding them). But what's the best way to move through (and therefore, beyond) painful feelings?

There's an acronym that can be used to deal mindfully with uncomfortable emotions: RAIN. It's often taught in Buddhist meditation circles, but you definitely don't have to be Buddhist or even into Buddhism to use it. All you need is to be willing to try it, even when it's hard.

R is for Recognition, the first step to mindfulness in the midst of powerful or painful emotion. Recognition means that you take a second to acknowledge and label the emotion, asking yourself what exactly you're feeling and naming it (e.g., fear, guilt, anxiety, shame). Identifying and labeling emotions forces you to step outside the swirly vortex of feelings, at least briefly. It normalizes emotions and reduces their power.

A is for Acceptance, which means deciding that whatever you're feeling is okay. Give yourself permission to experience any emotion under the sun. You don't have to like the emotion or be happy that you feel that way, but you also don't need to judge yourself for it (creating secondary emotions). When you have a feeling that you find hard to accept (e.g., rage at a loved one), it can help to think of the emotion as your own secret. No one can see how you feel inside; you get to decide whether or not to act on it or express it, and if you don't, no one will ever know how you felt. The idea of your emotions as secret can help you accept them, whatever they are.

I is for Investigation. One way to be mindful with your emotions is to stop trying to think about what they might mean or how you can get rid of them and to instead explore how they feel in your body. In the investigation step, you adopt an attitude of curiosity about how the emotion manifests itself physically, what it feels like inside you. Ask yourself how you know you're feeling a particular emotion: what tells you that you're disappointed, anxious, or scared? Is your face cold, are your limbs prickly, or your belly made of lead? All emotions have some kind of physical manifestation and bringing your attention to it forces you out of your head, away from avoidance, and into the present experience.

N is for Non-identification. This means remembering that the definition of emotion involves movement, and adopting a "this too shall pass" attitude. It means creating some space around the emotion, rather than being one with it. Think of it as a visitor who dropped by. You can open the door and let it in, and acknowledge that it's present. You can even sit in in the living room and serve it tea, but you don't have to identify with it or get tangled up in it. The emotion isn't who or what you are.

The next time you feel your emotions taking over, try letting it RAIN!

Believe Me

Behaviour doesn't persist for no reason. Any habit or way of being that you repeat or maintain even though it causes problems for you is probably being reinforced, often through underlying beliefs. This holds true for both everyday habits and chronic mental health problems.

Everyday Habits

Say you're someone who is always late. Your lateness frustrates others and means that you're often stressed out and rushed. You always tell yourself to try harder to be on time and promise to do better next time, but you're still always late. Why? Examine your beliefs: what do you really think about promptness? You might realize that you believe that people who are on time must be less busy and are therefore less important. Alternatively, you might realize that you believe that being late (e.g., for a work meeting) makes you look good--like you're working so hard you couldn't tear yourself away from your desk.

Say you just moved to a new city and you're always tired because you stay up late every night emailing or chatting online with friends from your old city. Every day when you're falling asleep at your desk in the afternoon, you promise to get to bed early, but every night, you go online to catch up with your friends. What beliefs are preventing you from getting into bed at a decent hour? Maybe you believe something like "Out of sight, out of mind," and are scared your old friends will forget about you if you don't talk every night.

Finally, say you're someone who is constantly in conflict with your partner, who unfailingly answers the question "How's it going with your boyfriend/girlfriend?" with a litany of crises and dramas. You may purport to envy a friend who always replies "Pretty good, nothing to report" to the same question, but look at your beliefs: do you secretly believe that your perpetual drama makes you seem intriguing? Alternatively, do you believe that if you don't create conflict and "keep things interesting," your partner will get bored and leave you?

Chronic Mental Health Problems

Individuals who suffer from Generalized Anxiety Disorder--a disorder characterized by chronic and excessive worry--have beliefs about worry that make it hard for them to stop. They believe that worrying (e.g., about their children) demonstrates love and support, that worry helps control outcomes (e.g., if I worry about my plane crashing, it makes it less likely to happen), that worrying in advance can prevent negative emotions if the worry comes true (e.g., if I worry that my partner will leave me, it will hurt less if it happens).

People with other chronic mental health problems also have beliefs about the usefulness of their condition. I had a client whose belief about her chronic anxiety made her reluctant to change: although being anxious most of the time decreased her quality of life, she believed that if she reduced the anxiety that fueled her spotless home, compulsive list-making, and hyper-organization, she would no longer be productive or efficient. She believed that if she weren't anxious, she'd never get anything done.

People with chronic depression may also develop beliefs about the advantages of certain aspects of their condition. An individual whose depression is such that she goes through life spotting flaws and seeing the world through a negative filter may fear that if she becomes less depressed, she'll lose her ability to think critically and spot potential pitfalls, decreasing her effectiveness at work. Similarly, someone who believes that his depressive tendency toward moody contemplation or rumination is the foundation of his artistic career may fear that working on his depression will make him less creative.

People may also have beliefs about happiness that make them reluctant to embrace or strive toward happiness: they may believe that happiness is boring, that it's shallow or ignorant, or that it's selfish.

Try identifying and testing the beliefs that motivate your habits and behaviour. If it turns out that your belief isn't true (e.g., your partner is actually considering leaving you because of all the conflict and drama), you may find it easier to change your behaviour. If your belief turns out be true (e.g., your old friendships fade when you go to bed early instead of chatting online), you can still use that information to change your behaviour (e.g., chat with your friends on your lunch break instead; accept that friendships change and seek friends in your new city).

Unidentified underlying beliefs make problem habits resistant to change. Identified beliefs provide insight and a springboard for change.

Ask Yourself This

Whenever I reread the list of cognitive distortions, I re-notice how they pepper my everyday thoughts. If you've started noticing your own distorted automatic thoughts, you may be wondering what you're supposed to do once you've identified them.

Here are three questions that will help you evaluate and alter your thoughts. NB: the point isn't to change our thoughts to think positively; rather, the point is to think realistically because realistic thoughts create helpful emotions and promote behaviour change.

1) What is the evidence for and against this thought? This exercise requires you to play devil's advocate with yourself, using objective facts. Say you're overtired and you lose your temper and yell at your daughter for knocking over her cup of milk. Your automatic thought might be "I'm a bad parent." Your supporting evidence might include things like you were so tired that you didn't read to her before bed even once this week, and you didn't put any vegetables in her lunch today. But if you look for evidence that contradicts your thought, you'll remember things like that you stood in line for two hours last weekend to register her in a good summer camp, and that your daughter's teacher recently told you that she seems overall happy and well adjusted. Considering the evidence will allow you to adjust your thought from "I'm a bad parent" to "I'm short-tempered when I'm tired but I'm a good parent in general."

Another example: You're having lunch alone at a cafe, feeling lonely. Looking out the window, everyone who walks by seems to be with family or friends and you automatically think "I'm the only person who's alone." That all the passersby are in groups supports your thought, but if you look for evidence against the thought, you might notice that there are four other people in the cafe who are reading or working alone. This direct and concrete contradictory evidence will help you adjust your thought from "I'm the only person who's alone" to "I'd rather be with a friend or partner right now, but I'm not the only one who's alone."

2) Is there an alternative explanation? This one is especially good for automatic thoughts about others' behaviour. If you're talking to someone you just met at a social event and he keeps looking away during the conversation, your automatic thought might be "I'm boring and socially awkward." But if you try to generate alternative explanations for his behaviour, you might come up with "He's keeping an eye out for a friend who hasn't arrived yet" or "He's shy and socially awkward." Second example: You don't get the grant you applied for and you automatically think "My application sucked." Generating alternative explanations, you'll come up with possibilities like "There were more applicants than usual this year" and "The funding body had a smaller budget his year." 

Final example: After your interview on Monday, your potential employer says she'll call by Thursday at the latest. By Thursday she hasn't called and you automatically think, "I didn't get the job." Alternative explanations for her behaviour include "She hasn't decided yet" and "Something  came up and she didn't have a chance to call." It doesn't mean you did get the job, but it allows you to change your thought from "I didn't get the job" to the more realistic "I don't know yet if I got the job."

3) And if it were true--is it that bad? If all the evidence supports your negative thought and you can't find alternative explanations, maybe it's true. If so, ask yourself: Is it that bad? The answer to this question works in two ways. First, it can help you realize that even if your automatic thought reflects reality, it's not the end of the world. For me, it's been the most useful for the thought that someone is upset with me. I'm prone to friendship paranoia (my own coined term, not a DSM diagnosis!) and have been known to interpret the slightest lack of warmth as a sign that my friendship is at risk. Recently, though, I've learned to consider that even if a friend is irritated or angry with me, it's not the end of the world. It's uncomfortable, but it's also normal, and most relationships can withstand a bit of conflict. Realizing this helps me calm down enough to apologize if necessary and otherwise, to let it go.

The second way that "and if it were true--is it that bad?" works is that when the answer is yes, it is that bad, it can motivate you to change. If all evidence indicates that your grant application did suck, you are the only person who is alone, or that you are socially boring or awkward--and these things bother you--maybe you'll get someone to edit your next grant application, try speed dating, or work on your social skills. This is the behavioural part of cognitive-behavioural therapy, where you actually change the way you behave (in turn changing your thoughts and emotions).

Up next: shorter blog posts.

Don't Believe Everything You Think

News Flash: Just because you think something doesn't mean it's true.

A lot of our thoughts are distorted or irrational and directly promote depression, anxiety, and anger, among other mental health scourges. Cognitive-behavioural therapists use the non-exhaustive list below to point out the things and ways we think that are unrealistic, distorted, and just plain false.

1) All-or-nothing thinking: You see things in black and white, as all good or all bad. You say things like "Everything sucks," and "That was a complete waste of time." The hallmarks of all-or-nothing thinking are words like complete, total, everything, and everyone.

2) Overgeneralization: You see a single negative event as part of a never-ending pattern of defeat. If you don't get a call back after your job interview, you think "I always screw up." If you plan a barbeque and it rains, you think "Nothing ever works out for me." Words like always and never figure prominently.

3) Labeling: This is an extreme form of overgeneralization. Instead of naming your own or someone else's specific behaviour, you attach a global negative label. Rather than say " I lost my temper and yelled at my son," you say "I'm a bad parent." Instead of saying, "My boss gave me an unfair evaluation, you say "My boss is an asshole."

4) Negative filter: You pick out negative details and dwell on them exclusively, not letting in any positive information. You focus on the one rainy day in the sunny week or the one snag in a project or relationship that is otherwise going quite well, darkening your overall perception until you see the whole world through a lens of negativity.

5) Disqualifying the positive: You reject positive experiences by insisting that they're trivial or somehow don't count, maintaining a negative perspective that's incongruent with reality. You say things like "I only got the job because no one else applied," and "Sure I finally completed my PhD--but most of my friends finished school a decade ago!"

6) Mind Reading: Without sufficient evidence, you arbitrarily conclude that someone is reacting negatively to you. You think things like, "Now that she knows I'm single, she thinks I'm a loser, "and "He didn't come over and say hi right away; he's wishing he hadn't invited me."

7) Fortune Telling: You predict failure and negative outcomes. You anticipate that things will turn out badly and are convinced that your prediction is already an established fact. You think things like "There's no way I'll win that competition," and "I'll never meet someone I'll love as much as I loved my ex."

8) Catastrophizing: You believe that what happened or might happen will be so awful and unbearable that you won't be able to stand it. In this case, it's not that you misperceive what happened or might happen--it's that you exaggerate the consequences and minimize your ability to deal with it. You believe things like "If he broke up with me, I'd fall apart," and "There's no way I can handle moving again this year."

9) Emotional reasoning: This one is neatly captured by "I feel it, therefore it must be true." You assume that your negative emotions are a reflection of reality and think things like, "Because I feel intimidated by him, he must be smarter than me," and "Because I'm scared of flying, it must be dangerous."

10) Should statements: You have rigid standards or expectations and you use them to judge yourself, others, and the world. You think things like "It shouldn't be this hard for me to stick to my diet," "I should have been able to handle that on my own," and "These people should treat me with more respect."

11) Personalizing: You assume total responsibility for negative events and arbitrarily conclude that they are your fault or reflect your inadequacy. You think things like, "If I were a better therapist, my client would do her homework," and "If I were a better mother, my daughter would have more friends."

Cognitive-behavioural therapists love this list and use any excuse to whip it out. It's been given to me by countless professors, supervisors, and workshop leaders, and by more than one therapist. I've in turn given it to my own friends and clients.

Next up: what to do once you've identified your distortions.

What is CBT?

We often say things like "I don't know why I feel anxious," or "All of a sudden, I felt so mad... out of nowhere!" or "I don't know why I acted the way I did." Here's a question: what were you thinking at the time?

Cognitive-behavioural therapy (CBT) is a psychotherapy approach that emphasizes the role of automatic thoughts in feelings and behaviour, and suggests that our feelings and behaviour aren't caused by people, situations, and events, but are instead caused by our thoughts about people, situations, and events.

Example: say your parents call three different times in one evening. How do you feel? If you think, "They're always trying to run my life," you might feel irritated or indignant and avoid returning their calls; if you think, "They love me and are excited for my upcoming trip home," you might feel warm and fuzzy and call them back the next morning; if you think "They're trying to reach me because something bad happened," you might feel worried and call them back that night even if it's late.

Another example: your work colleague walks by in the hall and doesn't say hi. If you think, "He thinks he's awesome now that he got that promotion," you might feel insulted and gossip about it with your office mate; if you think, "He's probably distracted; I heard his daughter's sick," you might feel sympathetic and send a quick email to ask how he's doing; if you think, "He's still mad about that mistake I made last week," you might feel anxious and avoid running into him again. In each of these cases, your reaction isn't the direct consequence of the event, but is the consequence of your thoughts and your interpretation of the event.

CBT is based on three principles: thoughts affect behaviour; thoughts can be monitored and altered; and changing thoughts can change behaviour. Learning the CBT lesson that emotions and behaviour don't come out of nowhere can help people who experience a lot of upsetting emotions or who are unhappy with certain elements of their behaviour gain some control over their feelings and actions. Cognitive-behavioural therapists first teach clients that a lot of distress is created by distorted or unhelpful thoughts, and then help clients adjust their thinking by teaching them to evaluate the validity of their thoughts and generate possible alternative thoughts.

CBT has proven to be an effective treatment for a variety of anxiety, mood, sleep, personality, substance use, and eating disorders, as well as for problems like chronic pain, stress, anger, and relationship issues. As a CBT student, client, and therapist, I'm here to tell you that it works. I believe in it and I recommend it.

Up next: examples of specific CBT concepts and interventions.

Just Don't Think About It

Last time, I described exposure therapy and how it can be used to successfully treat most common fears and phobias. But what if what you fear and avoid isn’t dogs, flying, or heights? What if you’re scared of and avoid your thoughts?

Some people get overwhelmed by worries—What if I can’t pay my rent next month? What if this lump is breast cancer? What if I marry the wrong person and one day get divorced?—and cope by pushing them out of their heads. Cognitive avoidance is the equivalent of putting your hands over your ears and singing “LA LA LALALA!” in order to not hear your scary thoughts. It’s things like distracting yourself with another activity, thinking about something pleasant instead, and avoiding places, people and situations that remind you of your worries.

The problem with cognitive avoidance is that it doesn’t work. Distracting yourself from worries provides short-term relief, but a) the relief you feel when you successfully avoid your thought reinforces the idea that the thought is scary and that you can’t deal with it, and b) thought suppression doesn’t work and your worry will come back. In the same way that crossing the street every time a dog approaches maintains and reinforces a dog phobia, avoidance of worries prolongs and reinforces worry.

The cure for cognitive avoidance is cognitive exposure. Cognitive exposure rests on the principle of habituation, that is, that with enough exposure to a feared stimulus, anxiety always fades naturally. In this case, the feared stimulus is your worry. Cognitive exposure requires you to choose one of your worries and compose a short text describing the worst-case scenario. You have to include all the thoughts and images that you associate with the worry, especially the most disturbing ones; you have to describe the situation in the present, as if it were happening right now, leaving out any reassurances or distractions. In other words, write out your worst nightmare in the simplest, scariest way. 

The exposure part is to interact with the scenario by listening to a recording of yourself reading it out loud. You have to close your eyes, vividly imagine yourself in the situation, and allow your anxiety to mount. Prolonged and repeated exposure (e.g., 45 minutes every day for a week) to your scenario will decrease your anxiety to the point that you’ll eventually be able to hold the worry in your mind without becoming overwhelmed or having to distract yourself.

NB: Cognitive exposure is primarily indicated to help with hypothetical worries (e.g., What if I get divorced one day?) whereas real and current worries (e.g., What if this lump is cancerous?) are managed through problem solving. However, I think that cognitive exposure can be used for both types of concerns. It’s true that if you have a lump (real and current problem), you need to see a doctor; however, if you’re too anxious to even think about the lump, let alone make an appointment, cognitive exposure can help you calm your fear enough to be able to begin the problem solving process.