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The previous blog articulated how to find your “emotional sweet spot”, which is the mental space between being aware of and attuned to your feelings and at the same time regulating them in an adaptive way. This blog focuses on another aspect of your mental system, what many folks in psychotherapy call your “cognitive system”, but what I refer to as the “justification system”. This system is the portion of your mind that processes information verbally and puts into narrative form what is happening and why. Here I give a little background of the cognitive approach to mental health and then examine key aspects via a recent clinical encounter.
The cognitive approach caught fire in the 1980s, such that by the mid1990s it was the most frequently taught psychotherapy orientation in university settings. Aaron T. Beck is considered by many as the father of the cognitive approach, and I was fortunate in that I worked with him for four years at UPENN. The main insight from the cognitive approach is that one’s (verbal) expectations and interpretations of situations play a central and causal role both in how one feels and what one does. If we break this insight down to the fundamentals of the cognitive approach, we can make the following claims: (a) interpretations of situations are DIFFERENT than the empirical facts of one’s situation; (b) people’s feelings and actions largely stem from their interpretations and expectations; (c) if someone has chronically maladaptive ways of feeling or acting, it is likely that there are maladaptive patterns interpretations feeding them; and (d) the cognitive approach is an effective way to help folks become aware of these interpretations and expectations and adjust them to be more adaptive (i.e., more accurate and helpful), and this in turn reduces problematic feelings and actions and generally leads to more adaptive lifestyles.
Let me start with a simple example that I often use to give a flavor for the cognitive approach. Imagine that you are sleeping alone in an apartment late at night when you are jolted awake by a loud noise, something that sounded like a thud coming from inside the house. Most imagine that, upon hearing that noise, they would have the thought, “There might be an intruder in my house”. That thought then results in a host of feelings (e.g., fear, anger) and impulses toward action (e.g., hide in the bedroom, go cautiously explore, grab a gun, call 911, etc.). Now imagine that you decide to explore the apartment and, upon entering the kitchen, your dog sitting there next to an overturned trashcan. I then ask clients, “What would you NOW think, feel, and do?” The usual response is something like, “Well, I guess I would feel relieved and a bit silly. I would clean it up and go to bed.” After I help them be very clear about how their interpretations are influencing their feelings, I then ask, “But do you now know for a fact that there is no intruder in the house?” At that point they look at me a bit funny and say, “Well, no, I guess not. But I assumed that the loud noise was the trashcan being knocked over by the dog, right?” I proceed to help them see, via the example, how interpretations and expectations of various situations are in driving emotions and actions. The exact same loud noise might yield feelings of deep fear or relief and relaxation depending on whether it was interpreted as “There is an intruder in my house” or “My dog knocked over the trashcan, so there is no intruder”. Note that at the level of empirical fact, the only known empirical facts were that there was a loud noise and that the dog was sitting near the trashcan. The other elements were interpretations of empirical data.
I use this example to help folks get clear about the distinction between empirical facts and interpretations, and to help them see how strong interpretations can be in driving emotional reactions. It is not a bad thing that interpretations drive feelings and behavior—indeed, it is absolutely necessary to make interpretations all the time. But the connection between feelings, actions and “cognitions” it is something we should be aware of. In our minds, all these things tend to blend together. However, they are conceptually separate and it is a good and important skill to be able to mindfully separate them. This is especially true if we are in the habit of making extreme, rigid negative interpretations, because these kinds of interpretations can play a key role in depressive and anxious spirals. A recent clinical encounter makes this clear.
I was working with a college student—call her Jessica—who was prone to “emotional breakdowns” under stress. It was the end of the semester and she called me in a panic. “I am freaking out,” she told me. “I have no idea what I am doing in chemistry. The final is today. I am going to fail. My parents are going to kill me. I can’t function. What am I going to do?” Sobbing followed.
As noted above, the cognitive approach teaches folks to separate the known, empirical facts from one’s interpretations and expectations. Applying this to Jessica, we can ask, “What were the facts of Jessica’s situation?” The basic fact was that she did not understand several relevant concepts in chemistry and that her final was that day. That was the situation. But that was not really what Jessica was responding to emotionally. What was causing her to panic was the way she was interpreting and narrating her situation. She inferred that her difficulty understanding chemistry concepts meant that she would fail the final. And then, if she failed the final, she would fail the course. From that, she then came to believe that she would be “killed” by her parents. This image was horrible and intolerable because she believed that she would then be a failure as a person because she would have greatly disappointed the people that she loves. In other words, Jessica was in a panic because she had made a string of interpretations that led to a catastrophic expectation for the future.
Jessica was fortunate that I had some free time, and I encouraged her to come on in for a special session. We spent two hours together, in which she was taught in the moment how to understand and gain insight into the vicious cycle of panic, how to identify her pattern of catastrophic thinking and how to replace those extremely negative interpretations with more realistic narratives about her situation.
The first thing I did to help Jessica was to identify how she wanted to be. That is, what was her valued state of being, given her capacities and situation? The current situation was that she was not understanding chemistry, that she was three hours away from taking her final and was fearful that if she failed chemistry bad things would happen. I basically narrated for Jessica two options. Option one was that we could focus on the worse possible outcome, blame her and the school for the unfairness of it all, and crawl up into a little ball, and weep like a baby. Option two was that we can see the difficult situation for what it was currently, understand what it might (or might not) mean for the future, and try to adapt to it in a way that minimized bad outcomes and taught her how to cope more effectively with stress.
Framed with the option, Jessica said, “Obviously, I want option 2. But I don’t know how!”
To which I replied, “Exactly. You don’t know how. So we will teach you. Come on down to the office and let’s get to work. Whatever your final grade is in chemistry, we can turn this into a growth experience because you don’t know how to cope with stressful life events without decompensating. But it is one of the most important things to learn living life as an adult.”
So Jessica came on down to my office, and I told her that we would start by doing what she would normally do. I had her bring in her chemistry book and so I told her to go ahead and proceed to study the part she wanted to learn about. She opened the book to the page, and within 30 seconds tears were running down her face. “I don’t know this. I missed two classes when I went home, remember? And besides, he sucks as an instructor. I barely understand it when I am there. I don’t know what I am doing. I am definitely going to fail this course.”
“See what happened, there?” I ask. “Looking at chemistry problems you don’t know gets you into a catastrophic narrative. Remember what I have taught you about thinking about your thinking. When you find yourself in a narrative like this, what are you supposed to ask yourself?”
Taking a deep breath she replied, “I am supposed to ask myself, ‘Is my thought accurate?’ and ‘Is it helpful?’.”
“So,” I say, “Is thinking that you are guaranteed to fail this course an accurate statement?”
“Well, I think so!” Then she chuckles through her tears, knowing what I would say. “I guess I don’t know for a fact I will fail. And, you are right, it does not help me to think I am going to fail. It only makes me panic.”
“Actually, it is appropriate for you to be concerned that it might happen, because it might. There is a grain of possible truth here. But focusing on it now and claiming it is certainly going to happen is neither fully accurate nor helpful. Given your situation, what would be most helpful?”
“I don’t know.” A pause. “I guess, based on what you’ve said, I need to focus on doing what I can to take the test with the best mindset I can and then try to cope with whatever happens.”
“Exactly. So, what can we do to get you into a better mindset.”
“I have no clue.”
“Well, is your final cumulative?”
“Yes.”
“Did you understand any of it?”
“Well the stuff on covalent bonding was pretty straight forward. I also did well on that stuff on entropy and thermodynamics.”
“Teach me some of that stuff.” So, for the next 15 minutes she reviews stuff she knows. Her mood shifts.
“What are you thinking and feeling now?” I ask.
“I don’t know, I guess I feel a little better. I know some of this stuff pretty well and it will be on the final.”
“Do they ever curve the grades?” I ask.
“Yes, they curve the grades.”
“Listen, I have no idea what you are going to get on your chem final or for your final grade. But what I do know is that focusing on what you don’t know and catastrophizing future outcomes makes you miserable and puts you in no position to take the exam in an effective way. Remember what we talked about in earlier sessions regarding arousal and performance. Extreme anxiety is horrible for effective performance. Keep that in mind. Ok, let’s look at another section.” Jessica turns to a different chapter that is difficult for her. Again the tears begin to flow.
“Ok,” I ask. “What are the tears about?”
“My being smart is one of my good features. Looking at this tells me I am not smart. If that is true, then what do I have? Nothing!"
“Here again, notice how you frame your interpretations. Whereas before the negative focus was on your future and disapproval from your parents, now you are focusing on something fundamental about your character. Let’s test out this conclusion you have reached, namely that if someone can’t understand this section of your book, they are not fundamentally smart. Here, pass me the book.”
She hands it too me and I stare at the complicated chemical formula on the page. “I have no idea what this means. I guess I am an idiot, then.”
“No, of course, not” she says.
“But why not?”
“Because you are a professor of psychology.”
“But you’re a student who has blown off several classes for lots of different reasons and stopped paying attention to developing your chem skills. No one can learn this stuff who doesn’t try to learn it. As we both know, for a host of reasons you have not really been focused on your studies the last two months. The point here, Jessica, is that you are engaging in what I call a ‘character assassination’, which is that because you are in a less than ideal spot, you see yourself as fundamentally bad or unworthy in some way. A different and I believe more adaptive frame is that the situation is not ideal and we will learn from it. But that doesn’t mean you are fundamentally worthless or incompetent.”
“I know that at one level. But that just makes me feel like a loser. Why am I this way? Why can I just think like a normal person?”
“Good question and it is important for you to understand why you came to be this way. It is also important to note that many people who start learning how to possibly cope better have the thought that they are a loser because they did not figure this out on their own. But once again, we can ask which interpretation is more adaptive: One is that ‘I am a loser because I am not the best at coping with stress,’ and another is ‘Hey, I have the potential to learn a new way of being that will help me out’.
“The basic principle, here, Jessica, is that because of your unique learning history, you build justification narratives for what is happening that tend to be pessimistic, catastrophizing, and self-blaming. There are lots of reasons for this. It keeps you somewhat submissive in conflict, it often drives you to perfection in ways that are associated with past success, and it has become a bit of a habit. But regardless of why you have learned to be this way, now the key point is that when you think this way, you feel like shit and when you feel like shit, your thoughts shift more toward thinking this way, so it is a cycle. The main issue that I want to help you see is that your narrator is a key part of your mental health. I want to help you see its connections between your feelings and your actions and how they are all interrelated. I want to help you see how those interrelations get you in maladaptive spaces. Through awareness of your thoughts, acceptance of where you are and who you are, and the idea of what is a realistically adaptive way of being that will move you toward your goals in the future, we can learn new pathways of dealing with stress.”
Jessica and I spent the next few hours together, practicing distraction (i.e., going for a walk), mindful acceptance of her thoughts and feelings in the moment, replacing extreme negative interpretations with more helpful ones, and going over the most adaptive game plan for the test (i.e., focus on the questions she knew, emphasize the thought that she can tolerate whatever the outcome might be, and stay with the test for as long as she can tolerate it, and hand it in before she decompensates into a full blown panic). Just before the test, she described herself as being in a “pretty good” mindset.
Jessica later returned to my office just to let me know she stayed fairly regulated during the exam. She felt like she probably failed it, but at least she was doing ok. The next day she wrote to tell me that she told her parents she probably failed chemistry, but actually was doing ok with it because she was training herself on how to cope. She said her parents were surprisingly cool with it.
A week later she wrote and told me she “somehow” ended up with a C in the course and was having a great summer. To which I wrote her the note: “I guess you did not ‘know’ you were going to fail after all. :o).”
