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Hi, again –

Here is the next article from the book “Freedom From Agoraphobia.” It gives you the essence of Cognitive Therapy. This form of therapy, originally developed by Aaron Beck, M.D. for the treatment of depression, continues to be proven effective for more and more problems. It is currently even having success in treating Schizophrenia! Also, there have been many studies showing it to be at least equally effective as medications and with longer lasting benefits and no side effects. One of the original applications of Cognitive Therapy was in treating anxiety disorders such a Panic Disorder. It has been increasingly refined over the years and is now a mainstay of their treatment. I know you will find a great deal of use in its insights.

Since I am an M.D., I cannot express my point of view without being concerned about liability. So please note this disclaimer before reading further: Any medical information in this article is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Mark Eisenstadt, M.D.

Article Ten

Cognitive Therapy Or “As a man thinketh in his heart, so is he.” Proverbs 23:7

Anything that can cause an outpouring of adrenaline will give you a pounding heart, rapid breathing, rubbery knees, butterflies in the stomach and all the rest of it. And lots of things cause an outpouring of adrenaline: 1. Falling in love and seeing your loved one crossing the room towards you. 2. Becoming angry. 3. Watching an exciting movie or sports event. 4. Even laughing hard.

As you begin to consider this, you will likely find there are times when you really do not know whether you are feeling fear or anger or love or amusement. After all, any injection of adrenaline will cause all the panic symptoms. And what is your usual response to feeling your heart pounding, your breathing becoming rapid and shallow, butterflies in your stomach and rubbery knees? You probably conclude that something terrible is happening. But, for example, unless you have correctly deduced that your boyfriend is actually an axe-murderer in disguise, what is really going on may be love!

The point to notice is that your physical feelings give rise to certain thoughts. And these thoughts may be correct (e.g. “I love him.”) or incorrect (e.g. “I’m about to die.”)

The reverse is also true: thinking certain things can cause those same physical sensations. Obviously. Just remember the old horror movie scenario that goes like this: It’s a dark, foggy night. The light of the single, dim street lamp casts a human-like shadow on the wall. It is holding what appears to be some blunt object by its side. It grows larger and larger while steps are heard approaching. The camera flashes on the terrified face of our heroine. The shadow has meanwhile become enormous. She is about to scream. But then the person causing the shadow walks into the circle of light. It is a small child carrying her teddy bear by one leg. And we give a great sigh of relief. Moral: what we thought caused what we felt.

So the principle is:

Thoughts and feelings can cause bodily responses and bodily responses can cause thoughts and feelings.

Furthermore, it’s really easy to get into a vicious cycle with this. You have the thought: “I do not think I can go to the women’s discussion group tonight because I might have a panic attack.” Next, you check out your feelings to see if that feels correct. And sure enough, you can picture it being hot and noisy and you can already feel some twinges of knots in your stomach. Noticing these, you think to yourself: “Yup, I’m already feeling anxious just thinking about it. In fact, it’s beginning to feel like I’m going to have a panic attack right now.” Next, you check out this thought by focusing more on your body to see if your heart is beginning to feel funny, too. And thinking about that feeling, you begin to feel it as well. So this gives you the thought: “Oh God, here it comes!” And that thought gives you more panic feelings. And the feelings give you more thoughts. And away you go.

So what’s a poor girl (or guy) to do? Cognitive Therapy to the rescue!!

Cognitive Therapy has repeatedly been proven highly effective for Agoraphobia as well as a host of other conditions. It is based upon the principle that your thoughts control your feelings. So by changing your thoughts, you can change your feelings. And what’s the main kind of problematic thinking in Agoraphobia? (Everyone hopefully knows this by now -) Catastrophic Thinking!!

So Cognitive Therapy for Agoraphobia works largely by undoing Catastrophic Thinking. And there are lots of ways to do this.

Thought Stopping

One of the simplest and earliest techniques of Cognitive Therapy was called “Thought Stopping”. And it means just what it says.

First, pay attention to your thoughts. As soon as you catch yourself doing some Catastrophic Thinking, stop it. The main way to stop thinking about something is to think about something else. One commonly-used alternative thought is created by visualizing a red Stop sign like you see on the road and, in your mind, yell the word: “STOP!!” If you are alone, you could even yell out loud. Simple though this is, if you diligently do it for a couple of days, you will find that you quickly develop the habit of replacing your Catastrophic Thinking with the “Stop” visualization/ verbalization. And I don’t need to tell you what happens in your body when you stop your Catastrophic Thinking.

Focusing

Another thought-replacing technique is called “focusing”. In this, you first pay attention to your thoughts. As soon as you catch yourself doing Catastrophic Thinking, you focus your attention on something else. Anything else. Planning what you’d like to do on your next vacation is fine. Picking out a name for your son’s coming baby would be good. Trying to remember your mother’s recipe for that great cheesecake would work. Anything on which you can plant your thoughts will do the trick.

This works well with feelings, too. In fact, it is one of my favorite techniques to use during a panic attack.

O.K., your heart’s pounding, you feel short of breath, you think you are going to pass out and so on. Now tell me how many ceiling tiles there are in each row. No, you do not have to pay attention to your breathing. That won’t help anything. And it’s not more important than the number of ceiling tiles. In fact, the number of ceiling tiles is the single most important thing in your life, right now. COUNT THEM!! OUT LOUD!! NOW!!

Focusing on repetitive sensations in the immediate environment seems to be especially helpful. Also, engaging more than one of the five senses is useful – especially touch. Feeling the texture of the seat of the chair on which you are sitting or the pressure of the chair against your back are two examples. Counting is another good focus. So counting the number of different types of surfaces you can touch from where you are standing is often done. Or counting red cars per mile as you go down the road. And so on.

I recall going through the tunnel to the airport in Boston as a field trip with a couple of agoraphobics. The traffic through the tunnel was slow and one person panicked. I steered with my left hand and held hers with my right. (You drive on the right in Boston.) Together, we pounded our held hands against the seat, focusing on counting how many times we could hit it between each of the lights on the tunnel wall. Bang – one thousand one. Bang – one thousand two. Bang – one thousand three. And so on until we reached the next light when we started over. This also had the virtue of measuring the number of seconds it took to get from one light to another so we got some feeling of making progress while we were at it.

And here’s the ultimate focusing method: Focus on one of your panic symptoms and try to make it worse! Yep, your eyes do not deceive you. And I know this seems like the last thing in the world you would want to do. But it is actually the most powerful thing you can do during a panic attack, amazing as it seems. If you have never done this, you will be surprised at what happens - the symptom gets better!

For example, you are busy trying to get your heart to slow down and I’m telling you to try to speed it up. Scary thought, huh? But you will find that you not only can’t speed it up by focusing on it and trying to will it to go faster, it‘ll slow down. Same thing with any panic symptom that is not under voluntary control. (Breathing is under voluntary control and, of course, you can breathe faster if you try.) But this works with trying to make your knees more rubbery, collecting more butterflies in your stomach and even sweating more.

There are two things to remember when doing this. First, we are talking about trying to directly make the symptom increase. Not indirectly. By now, we all know that you can indirectly make any symptom worse. That’s what Catastrophic Thinking was invented for. Want to make your heart go faster? Easy. Do not focus directly on your heart. Instead, think about what everyone will say when you have a panic attack and faint at Aunt Victoria’s family reunion next month. Your heart will respond quite well. And you can run the rate up even more by worrying that you are having a heart attack right now.

So that’s not the technique. The technique is paying attention directly to how your heart is feeling now as it pounds away and try to mentally push it to pound more.

The second thing to remember when doing this is to focus - do not jump around. If you are working with the knots in your stomach, stick with trying to make them more knotted. Do not go from your stomach, to your heart, to feeling dizzy, back to your stomach, to feeling sweaty and so on. That’s another technique for freaking yourself out which you have already perfected. It does not need more practice.

Cognitive Mistakes

More recent Cognitive Therapy has focused on what can be called “Cognitive Mistakes”. (Se especially the works of David Burns, M.D. such as his book “Feeling Good.”) Cognitive Mistakes (or “distortions” as Dr. Burns calls them) are errors in thinking. Everybody makes them. One example is Black-and-White thinking. Perfectionists do this a lot. If you weren’t the life of the party, you conclude that you have the social charm of a slug. Or, if the job isn’t perfect, to the perfectionist, it’s a mess. (By the way, Cheri Huber makes the point that so-called perfectionists are really “imperfectionists” since they are so focused on the 5% that’s imperfect instead of the 95% that’s fine. Good point, no?)

You can see that the conclusions being drawn by the Black-and-White thinker are just, plain untrue. They’re mistakes. And they can sometimes be quite serious mistakes. For example, deciding that one is a social write-off could and has resulted in people never meeting or dating others, never getting married, never having a family and instead, sentencing themselves to lives of loneliness and regret.

Another Cognitive Mistake is called “Overgeneralization.” This is a great one for creating agoraphobic avoidance patterns. It consists of mistakenly concluding that because something has occurred in one or two instances, it will occur in all instances. (Do you see already where this is going?): Because you had one or two panic attacks in the supermarket, you have mistakenly concluded that you will always have panic attacks in the supermarket. The actual fact may be that you had the panic attacks because of some trap going on in your life that is already resolved. But your overgeneralization not only causes you to avoid supermarkets, but it is also a self-fulfilling prophecy. Namely, your expectation of a panic attack at the supermarket creates lots of Anticipatory Anxiety when you try to go there. This, of course, escalates as you approach it. And by the time you enter the door, voila! – Your conclusion was right – you have a panic attack. (Q.E.D. – Quite Easily Done.)

So that ancient person who wrote down Proverbs was right – the way you think it will be for you is the way it will be for you. James Allen, who lived from1864 to 1912, wrote an interesting little book on this point with the title: “As A Man Thinketh”. It remains so inspiring to people that they have placed the whole book on the Internet for free. He is quoted as saying: “All that a man achieves and all that he fails to achieve is the direct result of his own thoughts.” And this gives us a way out because we can change our thinking. That is the essence of Cognitive Therapy – identifying Cognitive Mistakes and correcting them.

What do you do? Simple (but very effective).

1. Pay attention to what you are thinking.
2. Identify the Cognitive Mistake (mistaken thought).
3. Correct it.

Our self-proclaimed social cripple would solve her problem by (repeatedly): 1. Noticing that she is taking the fact that she was not the most popular person at the party to mean that she is completely socially unattractive, 2. Remembering: “Aha. This is Black-and-White thinking” and 3. Telling herself something like: “Just because I’m not the most popular does not mean I’m not likeable at all. Actually, there were lots of people at the party who were much less a part of things than I was. And I don’t feel that they had no right to be there so why should I feel that I can’t go to parties? Actually, there was that kinda cute guy who looked lost and didn’t talk to hardly anybody. Maybe if I see him again, I’ll just ask someone to introduce us…”

What to do about Overgeneralization?

1. Pay attention to what you are thinking.
2. Identify the Cognitive Mistake.
3. Correct it.

In the case of the supermarket overgeneralization, the process would go like this: You have made the kids’ sandwiches and notice that you are almost out of peanut butter. You instantly think: “Oh, no. Not a trip to the supermarket.” But you have just read this article last night. So you remind yourself: “Aha. Here’s the very problem I just read about. Now, what was the deal about it? Oh, yeah – I’m supposed to pick out the mistake in my thinking and correct it. Yeah – I’m Overgeneralizing from having had trouble with the supermarket before. And the correct way of thinking is that just because I had trouble there before does not mean that I will have trouble there now.”

So armed with the thoughts that: 1. This is a new day, 2. That you have made many changes since you last had trouble at the supermarket, 3. That you have your Emergency Kit with you (See Article 3) and 4. That this can be an opportunity to practice Systematic Desensitization (See Article 9), you: (This is a quiz. Pick one.)

A. Send your husband out for peanut butter.

B. Tell the kids that jam-only sandwiches are just as good.

C. Decide to spend some time today working towards your own freedom using systematic desensitization. And if you save yourself asking your husband to get the peanut butter, all the better. If not, you are still better off because however much of the shopping trip you desensitize yourself to will last until you next work on it.

Other Cognitive Mistakes (The are my takes on errors described by Cognitive Therapy writers such as Dr. Burns and Aaron Beck, M.D.):

Dwelling In The Dark: You pick out the negative aspect of a situation and pay attention only to it until everything seems to be negative.

Feeling Out Reality: Taking what you feel as an accurate indication of what is going on. We already discussed this regarding your axe-murderer boyfriend: You had the same feelings you would have if he were an axe-murderer, so he must be one.

Rejecting The Light: Like Dwelling In The Dark, you ignore anything positive. Instead, you say, “it doesn’t count”. For example, you dispose of the times you went to a movie and enjoyed yourself by saying that they do not count and you will certainly have a panic attack if you go tonight.

Being Psychic: Knowing things by magic. For example, you know that others are thinking badly of you even though there have been no words or actions to even hint that this is the case. Thus, you could only know they are looking down on you by means of your psychic abilities such as reading peoples’ minds. Predicting negative events in the future with no material or rational basis for your foreknowledge is another psychic ability. You could hang out your “Fortune-teller Is In” sign.

Exaggeration: When both good things and bad things happen, you exaggerate the size of the bad things and minimize the size of the good.

Giving or Taking Blame: You hold yourself responsible for occurrences that were only partly under your control. Or, you give out responsibility to someone else who only had a partial say in the matter. For example, thinking that you wrecked everyone’s having a picnic because you did not want to go even though they chose not to go without you.

Hidden Beliefs

Why do we make such silly errors in thinking? Are we crazy, irrational beings? No. The answer is that we are blinded to what makes good, rational sense by our underlying beliefs.

For example, why exaggerate the bad things and minimize the good? Because we are unconsciously fitting reality to our beliefs about it. Sherlock Holmes repeatedly corrected Dr. Watson for inventing theories as to who committed the crime and then trying to bend and twist all the facts to fit the theories. In the same way, if we have a hidden belief like “Life is a never-ending series of problems,” we automatically focus on the events that confirm the belief and kind of do not even see the events that contradict it. This may make us unhappy, but it achieves something more important to us: we are on solid ground and life is predictable. You know that old saying that we would prefer ten devils that we know to one that we do not? Same thing. We know how the ten devils are going to torment us. But that is preferable to an unknown torment by the stranger devil.

So even though our beliefs (by means of our Cognitive Mistakes) keep us in an unhappy world, it is our unhappy world - the one we know and know how to live with.

Each time you note a Cognitive Mistake in your thinking, you get a clue as to the hidden belief that underlies it. By asking yourself: “Now why did I distort things that way?”, the belief behind the mistake soon emerges. For example: “Now why did I take all the blame for everybody not going on the picnic?” “And why did I exaggerate the effect of my not making a bigger party for my daughter’s birthday?” “ And why did I predict that everyone would dislike it when my mother came to help out while I was sick?” Soon, it gets pretty hard to miss what all these misapprehensions have in common: the belief that you always ruin everybody’s good time.

As you identify your Cognitive Mistakes, keep an eye out for the beliefs that fuel them. Learn what kind of world you are keeping going by means of misperceiving what is really going on. After all, the familiarity is really not worth it. One devil will never torment you as much as ten. And life without the ten is a much nicer place.

So there you have the essence of Cognitive Therapy. In “Freedom From Agoraphobia,” the assignments for this chapter involve identifying your cognitive mistakes and the beliefs behind them. Then, you change the way you think about your life and the world you live in.

Until next month, I wish you continuing progress,

Mark Eisenstadt, M.D.

You can find article 11 Here

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