CBT podcast

The hour-long radio program on CBT that aired May 6 is now available for listening as a podcast. Host Jeff Frey, MD and I discuss topics such as how CBT works, automatic thoughts, mindfulness, medication vs. talk therapy, and similarities and differences between various types of mental health professionals (licensed clinical social workers, psychologists and psychiatrists). The show is called Your Health Matters, and it airs every Wednesday, 6-7 p.m. Central on KOPN 89.5 fm in Columbia, MO.

Mindfulness and options

Mindfulness has found its way into the work of many cognitive-behavioral therapists, and for good reason. Any practice that has the potential to increase awareness, improve focus and reduce harmful judging deserves our consideration.

Someone practicing mindfulness is noticing their inner experiences (thoughts, feelings, urges and body sensations, for example), without necessarily acting upon them. The practice is designed to enrich whatever one chooses to focus upon, by allowing them to fully participate.

In my last post I wrote about how black-and-white thinking occurs when someone is limited in their ability to see good options for themselves. In her book, Mindfulness, Ellen J. Langer describes how the practice of mindfulness can serve as an antidote to this type of thinking. She writes:

A model of mindful receptivity is the inertial navigation system in modern aircraft. This device is constantly receiving new information, constantly letting the pilot know where the plane is at any particular moment. We have a similar mechanism operating within us as we walk or balance ourselves in other ways. Our minds, however, have a tendency to block out small, inconsistent signals (p. 67).

The inconsistent signals Langer mentions can be any bit of information or alternative point of view that we don't normally consider. Many times, we limit our own options by the way we think, which means only considering the options that come to us readily. Being mindfully aware of all information available allows us to see possibilities that we'd either dismissed or never considered. As Langer points out, the results can be liberating.

Thinking in black and white

An important part of any therapy is helping people make sense of things. As a therapist, if I can help someone figure out what’s really driving their emotions and behaviors, then there’s a chance they can do something about it.

One of the ways that CBT makes sense of things is by helping people identify the thoughts behind their moods. Once you pinpoint the thoughts, then you can start to examine them for accuracy.

I’ve found that many of my clients benefit from a list of thought categories that drive moods. These lists have various names—cognitive distortions, irrational beliefs, thinking errors—none of which I particularly like because of their pejorative nature. They’re simply ways of thinking that everyone engages in from time to time. The important thing is to recognize when your thoughts fit into one of the categories.

In this post, I’d like to look at one of the most common thought categories: black-and-white thinking (a.k.a. all-or-nothing thinking or dichotomous thinking). This happens when you see yourself as having very limited options in a situation, and none of them is good. Further, the options often represent opposite extremes (hence the “all-or-nothing”).

Some examples:

“I’m either a complete success or a total failure.”
“I can either stay in my job forever or quit right now.”
“If I don’t bottle up my anger, then I explode.”

When feelings are running high, it’s easy to lose sight of your options. Depression and anger can narrow your view even further. The CBT way of addressing these kinds of thoughts is to challenge them by asking, “Are these really the only options?” “Is there some middle ground or alternative that I haven’t considered?” Often it’s helpful to see your options as a continuum, with extremes at either end. This can help highlight the possibility that other choices exist somewhere in between.

CBT on the air!

For an hour of radio discussion about CBT, tune in or log on to KOPN 89.5 FM in Columbia, MO, Wednesday, May 6, 6:00-7:00 p.m. Central. I’m scheduled to be the guest on Your Health Matters, a weekly call-in program hosted by Jeff Frey, MD. I’m looking forward to answering all sorts of questions about CBT. The on-air phone number is (573) 443-TALK.

Awareness and automatic thoughts

One of the often-cited benefits of CBT is that it can work quickly. Some people achieve their goals in just a few sessions; for others, the process can take a year or more. Some of the people who report rapid progress tell me it's because they feel more aware--aware of their own thoughts, feelings or even just the "issue" that brought them to therapy.

There are many paths to awareness: meditation, yoga, reading and group therapy are but a few. In CBT, people often start to increase their awareness by noticing their thoughts, or more specifically, their automatic thoughts.

Psychiatrist Aaron Beck coined the term automatic thoughts after noticing something interesting. His patients' moods, such as sadness or nervousness, didn't always match the thoughts that they were expressing to him. He discovered that people often have two streams of thought going at any given time--thoughts they are fully conscious of, and others that happen "automatically," without any real acknowledgement or reflection. People notice the moods that happen as a result of these automatic thoughts, but they don't stop to articulate or question the thoughts themselves.

CBT helps people get into the habit of noticing their automatic thoughts. You can try this the next time you experience a strong emotion, and aren't sure why. Ask yourself, "What was going through my mind when I started to feel this way?" Other questions to try include "What does this situation mean to me?" or "What do I think this says about my life?"

Identifying these thoughts is the first step. In CBT, people also learn how to evaluate their thoughts for accuracy. Of course, some thoughts are 100 percent accurate. But when depression or anxiety is part of the picture, people often focus on the worst or most scary things they can think of. CBT can help broaden the view, helping people see their lives in the most realistic, balanced way possible. They may still feel sadness or worry, but their feelings will be more appropriate to the situation.

And it all starts with awareness.

Anger: The guest that won't leave

Say you’re waiting in your car at a red light. It turns green. You start to go, when another car zips through the intersection, running their red light and nearly taking off your front end. Now you’re angry. How long does it take for you to cool down?

If you take a long time to cool off from anger, you may be doing one of two things: rehearsing or elaborating.

Rehearsing refers to playing out situations in your mind in which you act upon your anger. You tell the person off. You make cutting remarks. You scream. You might even exact revenge in creative ways. None of this actually happens, but it’s all very real inside your head.

What happens to your anger level while you’re imagining these elaborate scenes? Most likely, it’s on the way up. It’s only natural for your anger to intensify, or at least gain staying power, if you’re keeping it around in your thoughts. After all, you’re rehearsing for anger, and we tend to get better at what we rehearse.

Another mental activity that keeps anger around is elaborating. After getting angry at someone you know, have you ever found yourself thinking of every thing you don’t like about that person? Or you might make a mental list of every time they made you mad in the past. The current issue may even be forgotten by the time you’re through. In any case, you’ve just given yourself a lot more reasons to be angry.

Trying to stop rehearsing or elaborating altogether is a lofty goal, but there are ways to cut back. Using ideas from anger management self-help books, working with a therapist, and practicing mindfulness can all make a big difference. Just becoming aware of when you’re engaging in either of these activities can help. And when you’re able to shorten your cool-off time, just think of the extra time and energy you can devote to things that matter more to you than that person who just ran a red light.

From zero to 100 in a heartbeat

The last time you found yourself getting seriously angry, how long did it take? A lot of people say they go from feeling perfectly fine to feeling really angry in about two seconds. Some people even report feeling “blinded” by their anger. They do or say things they later regret.

How is it possible for something so powerful to sneak up on you so quickly? The answer may lie in self-awareness.

Self-awareness is knowing what’s going on in your mind and body at any given moment. When you react to a situation—like that driver who just cut you off on the freeway—changes happen in your body and mind. These are your anger cues. They tell you that unless you do something different quick, you might be headed for trouble.

There are at least four different types of anger cues to look for—body sensations (rapid heartbeat, for example), behaviors (such as slamming objects), emotions (embarrassment, fear, etc.), and thoughts (“Here we go again!”). Everyone’s cues are different. If anger is a problem for you, it’s important to become intimately familiar with your own unique anger cues.

This idea fits well with CBT, which can help people heighten their awareness of their own inner experience. This is often a first step toward managing moods and behaviors. When coupled with mindfulness practice, CBT can be used to foster tolerance of anger cues without necessarily acting on them.

For a lot more information on anger, check out AngerManagementExpert.