As a psychologist, I am particularly interested in the mental aspects of chronic pain. Although pain is experienced as unpleasant physical sensations, your thoughts and attitudes play an essential role in how you respond to your chronic pain condition. For the most part, thoughts and attitudes reflect automatic processes. Specific thoughts about pain and other life problems take the form of implicit automatic assumptions. A pain patient with very negative and pessimistic attitudes assumes that his thoughts accurately reflect the way life really is. Another person with exactly the same chronic pain condition as the pessimist may have very different attitudes and thoughts about his life situation. Cognitive therapy refers to a collection of psychological approaches aimed at helping you become more aware of your underlying automatic thought processes. In particular, cognitive therapy can help you to identify and change overly negative, pessimistic, distorted, and irrational thoughts and ideas that significantly interfere with your ability to cope with pain. These negative thought patterns lead to a warped and erroneous perspective on yourself and others, create unnecessary emotional distress (depression, anger, anxiety), and interfere in your relationships with others.

Cognitive therapy begins with the fact that all of us as human beings have basic values, goals, and assumptions about the world. These basic underlying values, goals and assumptions tend to guide our actions. Values refer to those things in life that we consider most important (e.g., health, family, honesty, hard work, etc.). Goals, which are guided by our values, refer to those things that we want out of life. Examples of some very common general goals held by most people include the following:

• Maintaining your health and avoiding pain and discomfort
• Being successful in your work
• Being liked, accepted, and respected by significant people in your life
• Having financial security along with certain material possessions which will help make you feel comfortable and happy

• All pain and sickness is temporary and goes away with natural healing or proper medical treatment
• If you work hard, your efforts will be rewarded and you will be successful
• People who do good deeds will be rewarded with good fortune and those who are bad will be punished with some type of misfortune. This assumption is often stated as, "People get what they deserve."

Problems and difficulties in life occur whenever your basic goals are interfered with, blocked or thwarted. Problems also arise when events occur which challenge or seem to go contrary to your basic assumptions about the world. Certainly the occurrence of a chronic and disabling pain condition goes contrary to some of your basic goals and challenge the assumption that pain is always temporary.

Returning to the A-B-C-D model mentioned earlier, we can view any situation or event which interferes with your goals or challenges your assumptions as an Adverse situation or event [A]. These adverse events normally lead to some type of negative emotional reaction [C = Consequent emotions] such as annoyance, frustration, anger, worry, fear, sadness or discouragement.

Chronic pain and disability are often associated with a whole host of adverse situations and events. Let's consider one example of a possible adverse event to see how the model works.

Background:

John suffers from chronic low back pain. He has been to many doctors and tried a number of medications, but nothing has seemed to help. He has also been told that it is unlikely that back surgery will be beneficial. As a result of his chronic pain, John can no longer do his former work as a welder. Consequently, he has applied for Social Security disability. It was John's belief that he was fully deserving of these disability benefits. Furthermore, since he had used up much of his savings, he felt that he needed the disability income to pay his bills.

Adverse event [A]

A few months after John completed his application for Social Security Disability, he received a letter in the mail from the Social Security Administration. As he began opening the letter, his heart was pounding in anticipation that he would finally receive some income enabling him to pay his many bills. However, when he actually read letter he learned that his claim had been denied.

Consequent emotional reactions [C]

How do you think John reacted emotionally to this adverse event? Do you think he became angry? If so, how angry did he get? Did he feel merely frustrated and annoyed, or did he go into an absolute rage and start thinking about blowing up the Social Security office? Perhaps what John felt was more like disappointment. If so, how disappointed did he feel? Did he feel sad and discouraged, or did he feel deeply depressed and hopeless to the point that he thought about ending it all? Perhaps John actually felt anxious about how he was going manage financially. If so, how anxious did John feel? Was he just somewhat worried and concerned, or did he feel extremely fearful and panicked about how he was going to survive?

Can you see that there are potentially different emotional reactions that John might have to this adverse event? As we shall see below, it was not so much the adverse event itself which determined John's emotional reactions. Rather, his reactions were determined primarily by his thoughts and beliefs about the situation.

Cognitive therapy is concerned primarily with the "B" part of the A-B-C-D model which refers to Beliefs, attitudes and thoughts. Whenever we encounter difficult, challenging, or stressful (Adverse) events and situations, three aspects of Beliefs can be distinguished.

1. Thoughts about the adverse event itself [A]. What do you think is going on? What does this situation mean to you?

2. Thoughts about what you can do [D] to cope with the adverse event. What are your options and choices? Can you use problem solving and, if so, what are your alternatives? Is this a situation that you can't anything about and so you have no alternative but to learn to accept it.

3. Thoughts about your emotional reactions [C] to these adverse events. What do you think about the way you handled the adverse situation? Was your reaction appropriate and justified, or did you overreact?

Returning to the general model, we can analyze problem situations in the following manner:

A = Adverse situation or event

B = Beliefs (thoughts, perceptions) including

1. Beliefs (thoughts) about the Adverse situation or event (A) itself

2. Beliefs (thoughts) about what you can Do (D) about the adverse situation or event

3. Beliefs (thoughts) about how you reacted to and handled the situation

C = The Consequent emotional reactions to the adverse situation or event

D = What you actually Do to cope with the adverse situation or event

Let's now return to the example described above in which John received a letter from Social Security indicating that his disability claim was denied. The first aspect of thoughts (Beliefs) that we can consider is how John thought about the Adverse situation itself. What thoughts do you suppose might have gone through John's mind as he read the letter? Following are some examples of what John might have thought. See if you can predict what Consequent emotions John might have felt along with each thought.

"This is totally unfair. Those dirty rats at Social Security are always giving disability to other people who are much less deserving than I am."

"This is absolutely terrible. How am I ever going to pay my bills now?"

"Wouldn't you know it. This is just my luck. It seems like nothing ever goes right for me anymore."

"I'll show them they can't mess with me. I'm going to go down to the Social Security office right now and raise some hell."

"I guess I'll just have to file an appeal and hope for the best. Meanwhile, I'm going to have to think of other ways to pay my bills."

"What's the use. I guess there's nothing I can do about it. I'll probably end up being homeless."

In the example above, it is likely that John's initial reaction to the denied disability claim was either disappointment or anger. However, after he thinks about it for a while and imagines the consequences, several different emotional reactions may occur depending on the nature of his thoughts. That is, his anger may intensify, he may become more depressed, he may become more anxious and fearful, or he can revert to a calm problem solving orientation and try to figure out what to do next.

The important point made in Cognitive Therapy is that your emotional reactions [C] to adverse situations [A] are not necessarily a direct response to the situation itself but rather your thoughts [B] about the situation [A], what you can do [D] to cope with it, and your evaluation of how well you reacted to the event. A goal of Cognitive Therapy is to honestly examine your thoughts and beliefs in an effort to determine whether your emotional reactions to adverse effects are more distressing than they really need to be.

Sometimes in cognitive therapy we distinguish between healthy and unhealthy emotional reactions. Since all of us have particular values and goals, it is only natural to feel some degree of distress when these values or goals are blocked or threatened. That is, it is perfectly normal to experience frustration, resentment, sadness, or worry in response to adverse situations and events.

Emotional reactions are typically seen as unhealthy when they are extreme and out of proportion to the actual situation or event. Emotional reactions are also unhealthy when they are self-defeating and cause us more harm than good. Thoughts about events can be classified according to the degree of emotion associated with them. Some have labeled these varying degrees as cool thoughts, warm thoughts, and hot thoughts.

Cool Thoughts

Cool thoughts are usually simple statements of fact, devoid of any particular emotional reaction. Susan can say to herself, "my husband is a smoker." John, in the example above, can say to himself, "I received a letter from Social Security." No particular emotion is suggested by these self-statements.

Warm Thoughts

Warm thoughts are associated with relatively mild or moderate degrees of emotional reaction and are typically associated with what we consider to be preferences. Susan can say to herself, "I really wish my husband didn't smoke." John can say to himself, "I'm really disappointed that Social Security denied my disability claim. I wish they would have approved it."

When situations or events go contrary to your values and preferences, it is normal to experience some degree of emotional distress. You can say to yourself, "I really wish I didn't have this chronic pain condition," or "I really wish my doctor could do something for me so I could get rid of this pain." You have every right to feel unhappy with the fact that you have chronic pain and that doctors can't cure it.

Hot Thoughts

Hot thoughts are associated with much more intense emotions and significant emotional distress (e.g., intense anger, deep depression, feelings of panic). Certainly there are times when it may be appropriate to experience anger, fear, or sadness. Problems occur, however, when people repeatedly experience emotions that are out of proportion to the situation. For example, some drivers experience murderous rage if another driver cuts in front of them on the freeway. What type of hot thoughts might go through a person's mind that would evoke such an extreme reaction? Does the driver who experiences what has been called "road rage" believe (assume) that the other driver cut in front of him deliberately and that this act constitutes an unforgivable personal insult and a major challenge to his integrity as a man? Moreover, does the angry driver believe that because he has been significantly wronged by the other person that he must therefore punish the offending driver?

Hot thoughts are extreme and often represent rigid, dogmatic, and absolute demands. "I absolutely must get my own way," or "I demand that you meet my wishes and desires." Hot thoughts are often expressed as musts, shoulds, needs, ought to's, have to's, etc. The angry driver may say to himself, "if anybody gets in my way, I have to punish them" (even if it means shooting at them). Susan can say to herself, "I just can't stand it when my husband smokes. He absolutely has to quit smoking or I'm going to leave him."

In addition to absolute musts and demands, hot thoughts can also assume the form of "awfulizing" and catastrophizing. A person can say to herself, "this is awful, horrible, or terrible." In the example above, John might say to himself, "It is absolutely terrible that Social Security denied my claim. I just cannot survive unless they give me disability." As a person with chronic pain you might say to yourself, "I can't stand to be in pain like this. If I have to live like this I might as well kill myself." These extreme "hot thoughts" tend to be associated with more extreme and unhealthy emotional reactions. As a result, these hot thoughts usually create much greater emotional distress than is really necessary. In other words, it is not so much the situation itself that makes you upset and miserable, rather it is your thoughts about the situation.

In summary, problems occur when your preferences about the way you would like things to be (warm thoughts) get elevated to absolute demands and musts (hot thoughts). When your preferences are not realized, it is natural to experience frustration, disappointment, sadness, or regret. However, when your demands and musts are not met, you will tend to experience more extreme and potentially self-defeating emotions such as significant anger, depression, or fear.

According to Albert Ellis, one of the early pioneers of a cognitive therapy known as Rational Emotive Behavior Therapy (REBT), hot thoughts about adverse situations are often associated with core irrational beliefs. These core beliefs refer to a person's basic attitudes (philosophy) about oneself, other people, and the world. Core beliefs are labeled "irrational" when they become self-defeating.

Dr. Ellis identified a number common irrational beliefs which are summarized below. Following each irrational belief is a more rational alternative which is stated more in terms of a preference.

1. Irrational Belief: I must have sincere love and approval almost all of the time from all the people in my life that I find significant.

Rational Alternative: I would like to be approved of by others but I do not need such approval. If I decide that their lack of approval (rejection) is not based on any inappropriate behavior on my part, I can find others who I will enjoy being with.

2. Irrational Belief: I must prove myself thoroughly competent, adequate, and achieving in all important respects, otherwise I will be an inadequate and worthless person. In other words, I must always be perfect in all I try to do.

Rational Alternative: I would like to be perfect at this task, but I do not need to be. I'm still successful when I do things less than perfectly. To make mistakes is normal and human. I will be happier if I attempt to achieve at a realistic level rather than a perfect level.

3. Irrational Belief: My life is awful, terrible, horrible, or catastrophic when things do not go my way or the way I would like them to go.

Rational Alternative: If I can't change the situation, it is frustrating, but not dreadful or awful. I can begin to make plans for correcting the situation if I can, or preventing it from occurring again in the future. Or, if the bad situation is completely beyond my control, I can learn to accept and live with it.

4. Irrational Belief: People who commit misdeeds against me are generally bad and I should severely blame them and punish them.

Rational Alternative: When I am wronged, I may feel irritated and hurt, but I don't have to berate that person. I can tell them firmly and directly what they are doing that has negative consequences for me, and I don't have to go so far as to punish them.

5. Irrational Belief: If something seems dangerous or fearsome to me, I must become terribly preoccupied with and upset about it.

Rational Alternative: If I am not as good at it as I would like, I can handle it. It's impossible to prevent a bad event from occurring by worrying about it; instead I can think constructively and use problem solving. In all likelihood the event will not be as bad as I fear.

6. Irrational Belief: Emotional miseries always come from external events and things that people do to me. When bad things do happen, I have little ability to control my feelings or rid myself of depression, anxiety, or hostility.

Rational Alternative: I can choose to stand it when things go wrong if I want to. I have quite a bit of control over how I react to adverse situations.

7. Irrational Belief: My past remains all important and because something once strongly influenced my life, it has to keep determining my feelings and behavior today.

Rational Alternative: Although my past does exercise considerable influence over me, I am not fixed mentally, emotionally, or behaviorally and I can change.

8. Irrational Belief: It is easier to try and avoid facing life's difficulties and self-responsibilities than to undertake more rewarding forms of self-discipline.

Rational Alternative: Even though I get immediate relief when I either avoid a disturbing situation or numb myself with alcohol or drugs, I feel unfulfilled and that is often as frustrating. What I am avoiding will probably not be as awful as I convince myself it is. Avoiding difficult situations or numbing my mind with alcohol or drugs does not ultimately lead to pleasure.

Although living with chronic pain and disability is not easy, it does not have to be catastrophic or devastating. Following are examples of some irrational, self-defeating thoughts (Beliefs) about chronic pain along with more rational alternatives.

1. Irrational Belief: I can't stand being in pain. I have to find a way to completely get rid of this pain or I will be totally miserable.

Rational Alternative: I don't like being in pain, but I can handle it. I'm going to do my best to either distract my mind away from the pain or find ways to better control it.

2. Irrational Belief: There just has to be a medical cure from my chronic pain. If a particular doctor doesn't help me, it means that he or she is either incompetent or simply unwilling to treat me. I must keep searching until I find a doctor who can cure me.

Rational Alternative: I wish there was a medical cure for my chronic pain condition. Perhaps someday in the future one will be found. However, I know that my doctors have done the best they can and that current medical science is limited when it comes to many chronic pain conditions. Therefore, I will do my best to learn to live with my pain condition.

3. Irrational Belief: If I am physically unable to work or do what I used to do because of my chronic pain, I am no good to myself or anybody else.

Rational Alternative: Although I am no longer able to do some physical activities that I used to do, there still is a lot that I can do. Rather than dwelling on the things I can no longer do, I will direct my energies to what I can do or I will try to learn new skills that are within my current physical capabilities.

The four primary goals of cognitive therapy are as follows:

1)  Identify your unrealistic, distorted, self-defeating, and irrational thoughts and beliefs which create more distress and misery than is necessary.

2)  Work at challenging and disputing these irrational thoughts and beliefs.

3)  Develop more healthy beliefs and attitudes, i.e., a more effective and healthy philosophy of living that replaces absolute demands with preferences.

4)  Increase your sense of confidence that you have the ability to successfully manage adverse situations and events. That is, by applying healthy problem solving combined with realistic acceptance, you can get through (cope with) even the most difficult and perplexing situations.

A = Adverse situations and events

B = Beliefs about these adverse situations and events

C = Consequent emotional reactions

D = Disputing your irrational beliefs

E = Effective coping and developing an effective new philosophy

The process of identifying your irrational and distorted beliefs is not easy. Most of these irrational beliefs and distorted thinking patterns take the form of automatic assumptions. They represent ways of thinking that are firmly embedded in your subconscious mind and have been practiced throughout much of your lifetime. They are repeatedly reinforced through a process called "confirmatory bias." This refers to the tendency to only accept information that confirms your pre-existing beliefs. Events which don't match your deeply held beliefs and assumptions are either ignored or forgotten.

For example, William has the distorted belief that people are basically untrustworthy and out to take advantage of him. If questioned about this assumption, William will probably be able to cite lots of evidence where people have let him down in the past. However, William also tends to completely ignore or forget the many times when people have not treated him this way. He selectively ignores (or filters out) the times when people have treated him nicely and have behaved in a very trustworthy manner.

Another way that irrational beliefs and distorted thinking patterns frequently get reinforced is through your own behavior. That is, you may act in ways that evoke reactions in other people that confirm your biased beliefs. Because of William's belief that people are untrustworthy and out to take advantage of him, he tends to be very much on guard and standoffish when he relates to others. He goes out of his way to avoid warm and close interactions. As a result of his cool and distant behavior, other people assume that William is unfriendly or that he doesn't like them. Consequently, they are on guard in his presence or try to avoid being around him. This only serves to reinforce William's core beliefs about other people. In other words, William's behavior around people evoked reactions in those people which only reinforced his original beliefs. Another term for this process is "self-fulfilling prophecy."

In addition to the common irrational beliefs identified by Dr. Ellis and listed above, cognitive therapists have identified a number of specific distorted thinking patterns that can cause unnecessary distress and unhappiness. These are discussed in greater detail below.

Distorted thinking styles and irrational beliefs are often hard to identify, at least in yourself. The are much easier to identify when someone else uses them to misperceive your own actions and intentions. The reason they are hard to identify in yourself is because they typically operate in an automatic, subconscious manner. You can distort situations without even realizing that you are doing the distorting. We mistakenly assume that our way of thinking is always correct and accurate.

Probably, the best way to identify potential irrational beliefs and distorted thinking styles is when distressing emotions arise. If you often find yourself feeling tense and nervous, depressed and discouraged, or chronically angry, your thinking is probably distorted. Likewise, if you feel disgusted with yourself or bitter and resentful toward certain other people, you are probably distorting. Overreacting emotionally to relatively minor events is often a sure sign of distorted thinking. Examples include feelings of rage in response to minor frustrations, intense fear to imagined dangers, and significant depression in response to minor losses and setbacks. Intense feelings about adverse events which happened long ago suggest distorted thinking. Frequent conflicts with family and friends can also be an indication of irrational beliefs and distorted thinking.

Unfortunately, some persons with chronic pain find it difficult to identify painful emotions. That's because it is possible to confuse painful emotions with physical pain. In other words, negative emotional states may be experienced primarily as increased physical pain. Therefore, if you experience increased physical pain in reaction to adverse situations and events, you might also consider the possibility of distorted thinking.

8 Styles of Distorted (Limited) Thinking Please note: much of the following materials were adapted from chapter three of the book, Thoughts & Feelings (2nd edition) by Matthew McKay, Ph.D., Martha Davis, Ph.D., and Patrick Fanning. The book is published by New Harbinger Publications (see list of references). This chapter is entitled, "Changing Patterns of Thinking. "

This section describes 8 common distorted thinking styles along with some ways to rationally dispute them. Keep in mind that there is probably not a single one of us who hasn't used at least some of these distorted thinking styles some of the time. When reading about each of these styles, see if you can come up with at least one example where you might have used the distortion in question.

1) Filtering

This distortion is characterized by a tendency to look at only some elements of a situation while ignoring everything else. A single detail may be picked out and the whole event or situation is colored by this detail. A chronic pain patient who was uncomfortable with criticism was praised by his physical therapist for improvements in walking without a cane. However, the therapist also suggested that the patient try to shift his balance just slightly to avoid putting too much pressure on one leg. The patient went home depressed, having decided that his therapist thought he was walking incorrectly. He selected only one component of the conversation to respond to. He simply didn't hear the praise in his fear of possible deficiency.

Each person has his or her own particular type of filter. Some are hypersensitive to any suggestion of injustice or being treated unfairly. As a result they are frequently angry and resentful. Others are hypersensitive to the slightest possibility of danger (either to themselves or a loved one) and often find themselves feeling nervous, worried, and fearful. Depressed people use filters which focus primarily on their personal losses and completely ignore their gains.

Filters can significantly affect the process of remembering. From your entire history involving innumerable experiences, you may habitually remember only certain kinds of events. As a result, you may review your past and re-experience memories that characteristically leave you angry, anxious, or depressed.

By the very process of filtering you magnify and "awfulize" your thoughts. When you pull negative things out of context, isolated from all the good experiences around you, you make them larger and more awful than they really are. The end result is that all your fears, losses, and irritations become exaggerated in importance because they fill your awareness to the exclusion of everything else. In essence, when you filter, you lose your sense of perspective and your thinking becomes warped.

It is also important to keep in mind that negative emotional states can impose filters. For example, if you are feeling depressed, your mind will tend to automatically filter out all thoughts other than those which reinforce depression. Consequently, when you are depressed, you tend to only think about things associated with loss, failure, disappointment, helplessness, and hopelessness. Likewise, if you are feeling angry and resentful , filters will kick into place which magnify the anger, i.e., you will tend to have thoughts of being treated unfairly, injustice, and revenge.

Key Issues with Filtering:                                                 Focusing on the negative 

                                                                                            Filtering out the positive

Alternative (Balanced) Ways of Thinking                       Shift focus

You have been stuck in a mental groove, focusing on things from your environment that typically tend to frighten, sadden, or anger you. To conquer filtering you will have to deliberately shift focus. You can shift focus in two ways: First, place your attention on coping strategies to deal with the problem rather than obsessing about the problem itself. Second, categorize your primary mental theme as: Loss, Injustice, or (fill in your own theme). If your theme is danger, focus on things in your environment that represent comfort and safety. If your theme is injustice (including stupidity , incompetence, etc.), shift your attention to what people do that does meet with your approval.

2) Polarized Thinking

The main feature of this distortion is an insistence on either-or choices: You tend to perceive everything at the extremes, with very little room for a middle ground. People and things are either good or bad, wonderful or horrible. This creates a black and white world, and because you miss all the nuances of gray, your reactions to events swing from one emotional extreme to another. One of the great dangers in polarized thinking is its impact on how you judge yourself. If you aren't perfect or brilliant, then you must be a failure or totally stupid. There is no room for mistakes or mediocrity. A chronic pain patient can no longer do housework like she used to, so now she is complete failure as a wife and mother. Some apply polarized thinking directly to their pain. There are only two options - being in pain or totally pain free. Anything less than being totally pain free is unacceptable.

Key Issues with Polarized Thinking:                            Seeing everything as awful or great with no

                                                                                        middle ground

Alternative (Balanced) Ways of Thinking:                   No black & white judgments

                                                                                        Think in percentages

The key to overcoming polarized thinking is to stop making black or white judgments. People are not either happy or sad, successful or a failure, brave or cowardly, smart or stupid. They fall somewhere along a continuum. They are a little bit of each. Human beings are just too complex to be reduced to dichotomous (either-or) judgments. If you have to make these kinds of ratings, think in terms of percentages: About 30% of me is scared to death, and 70% is holding on and coping...about 60% of the time he seems terribly preoccupied with himself, but there's the 40% when he can be really generous... 5% of the time I'm an ignoramus, the rest of the time I do all right. Likewise, just because I can't do 40% of the things I used to do because of my pain condition, there still is 60% that I can do.

3) Overgeneralization

This distortion has to do with how you go about reaching conclusions about things. When you overgeneralize you do not consider all of the evidence that is available. Instead, you make a broad, generalized conclusion based on a single incident or piece of evidence. A negative interaction with one particular VA doctor regarding your pain problem means that all VA doctors are bad. A rejection by one potential employer because of your back condition means that nobody will ever hire you. One bad experience means that whenever you're in a similar situation you will repeat the bad experience.

This distortion inevitably leads to a more and more restricted life. Overgeneralizations are often couched in the form of absolute statements, as if there were some law written in stone which limits your chances for happiness. You are overgeneralizing when you absolutely conclude that "Nobody understands me..., I'll never be able to trust anyone again..., I will always be sad..., I'll never get a decent job..., Everyone looks down on me now that I am physically disabled." Your conclusion is based on one or two pieces of evidence and carefully ignores everything you know about yourself to the contrary. Cue words that indicate you may be overgeneralizing are "all, every, none, never, always, everybody, and nobody."

A common form of overgeneralizing is global labeling. This occurs whenever you make a sweeping statement aimed at characterizing a person or group of persons. David is a liar and a cheat, Phyllis is stupid, George is a total jerk, Susan is nothing but a gold digger. These labels may contain a grain of truth in that perhaps David is dishonest at times and Phyllis does sometimes make mistakes. However, this does not necessarily make David a basically dishonest person or Phyllis a basically stupid person. Global labeling generalizes one or two qualities or particular observations into a global (often negative) judgment. It ignores the fact that we are complex human beings and that our actions can be characterized in all kinds of ways.

Many people also apply global labels to themselves. These often take the form of self putdowns such as when you call yourself a failure, a looser, stupid, good-for-nothing, etc.

Global labeling is often applied to groups of persons and is commonly called stereotyping. Black people are shiftless and lazy, Southern whites are all bigots, Democrats are wasteful big government spenders, attractive blonde women are airheads, chronic pain patients are whining crybabies who go around exaggerating their pain for sympathy. Although these global labels may simplify your world, they basically ignore all contrary evidence and fail to consider the tremendous diversity which actually exists in groups of people. Also, how do you like it when other people apply derogatory stereotypes to you?

The problem with overgeneralization and global labeling is that they tend to be associated with much more extreme emotional reactions. Anger, fear, and depression can all become magnified when you overgeneralize.

Key Issues with Overgeneralization:                              Making sweeping statements based

                                                                                           on little or no evidence

Alternative (Balanced) Ways of Thinking:                      Quantify 

                                                                                            What's the Evidence? 

                                                                                            There are no absolutes 

                                                                                            No negative labels

Overgeneralization involves the tendency to exaggerate. You can fight this tendency by quantifying instead of using words like huge, awful, massive, minuscule, etc. Moreover, you can examine how much evidence you really have for your conclusion. If the conclusion is based on one or two cases, a single mistake, or one small symptom, then throw it out until you have more convincing proof. Use this variant of the three column technique (discussed further in the next section):

If you overgeneralize, you think in absolutes. You should therefore avoid statements and assumptions that require the use of words such as every, all, always, none, never, everybody, and nobody. Thoughts and statements that include these words ignore the exceptions and shades of gray. To become more flexible, use instead words such as may, sometimes, and often. Be particularly sensitive to absolute predictions about the future such as, "I will always be a failure" or "I'll never be happy as long as I have pain." They are extremely dangerous because they can become self-fulfilling prophecies.

4) Mind Reading

When you mind read you make snap judgments about others by assuming what they are thinking or why they are behaving in a certain way: "He's just acting that way because he's jealous..., she's only staying with you for your money..., he thinks I'm faking and that I'm not really in that much pain..., she thinks that just because I'm not in a wheel chair I should be able to do as much work as I used to." There may not be any evidence for these statements, but you just assume that it is so. In most instances, mind readers make assumptions about how other people are feeling and what motivates them. For example, if your doctor refers you to a psychologist you may conclude, "(a) he thinks I'm crazy, (b) he thinks the pain is all in my head, (c), he thinks I'm ready to go off the deep end, (d) he's tired of dealing with me and is just trying to get rid of me, (e) he thinks the psychologist can help me learn to better cope with the pain."

As a mind reader, you also make assumptions about how people are reacting to things around them, particularly how they are reacting to you. "She looks down on me because I served in Vietnam..., He thinks I'm an alcoholic because I drank too much last weekend..., She thinks I'm a bad father because I yelled at the kids..." These assumptions are usually untested. They are born of intuition, hunches, vague misgivings, or one or two past experiences, but they are nevertheless believed as fact.

Mind reading often involves a process called projection. You imagine that people feel the same way you do and react to things the same way you do. Therefore, you don't watch or listen closely enough to notice that they are actually different. If you get angry when someone is late, you imagine everyone acts that way. If you are hypersensitive to rejection, you expect most people to feel the same. If you are very judgmental about particular habits and traits, you assume others share your belief. Mind readers jump to conclusions that are true for them, without checking whether they are true for the other person.

When you frequently mind read in negative ways, you tend to overreact emotionally. In other words, your emotions are not triggered by actual facts but rather by your erroneous assumptions about other people.

Key Issues with Mind Reading:                                   Assuming you know what others are thinking

                                                                                        and feeling

Alternative (Balanced) Ways of Thinking:                  Check it out

                                                                                        Evidence for conclusion?

                                                                                        Alternative interpretations?

Mind reading is the tendency to make inferences (guesses) about how people feel and think. In the long run, you are probably better off making no inferences about people at all. Either believe what they tell you or hold no belief at all until some conclusive evidence comes your way. Treat all of your notions about people as hypotheses to be tested and checked out by asking them. If you lack direct information from the person involved, but have other evidence, evaluate your conclusion using the three column technique above.

5) Catastrophizing

People who catastrophize, make mountains out of mole hills. They tend to imagine and expect the worst possible consequences. Janice has a bad headache and thinks that she may have terminal brain cancer. Frank's wife is late coming home from work and he imagines that she has been in a serious car accident. John in the example mentioned earlier learns that his Social Security claim has been denied and thinks he is going to be destitute.

Catastrophic thoughts often start with the words "what if." Marilyn reads the news about an earthquake in China and thinks, "what if we have a major earthquake right here?" Harold discovers that his son has experimented once with marijuana and thinks, "what if he becomes a drug addict?" Linda, whose x-rays indicate some spinal degeneration, thinks when asked to do some exercise, "what if my spine snaps and leaves me permanently paralyzed?" Others catastrophic thoughts include, "What if a robber breaks into my home..., What if this airplane crashes..., What if my husband leaves me for another woman... what if my teenage daughter gets pregnant,...what if my pain keeps getting worse and worse?" The list of possible catastrophes is endless. There are no limits to a really fertile catastrophic imagination.

While catastrophes can and do occur, they occur infrequently. People who catastrophize a lot go around thinking as though a catastrophe was about to strike or has already occurred.

Key Issues with Catastrophizing:                                   Assuming the worst will happen

Alternative (Balanced) Ways of Thinking:                    Consider Realistic Odds 

                                                                                          So What?

Catastrophizing leads to significant and unnecessary anxiety. As soon as you catch yourself, make an honest assessment of the situation in terms of odds or percent of probability. Are the chances one in 100,000 (.001%)? One in a thousand (.1%)? One in twenty (5%)? Looking at odds helps you realistically evaluate whatever is frightening you.

Another approach to catastrophizing in some situations is to deliberately consider the worst possible outcome and then say to yourself, "so what?" You should then consider all the rational ways that you can cope with even the worst possible outcomes, or at least reassure yourself that if the feared outcome did occur, you would be able to handle it. For example, you might say, "so what if my pain condition gets worse in the future, I'll deal with that if and when it happens, I will be able to find constructive ways to cope with the pain."

6) Magnifying

When you magnify, you emphasize things out of proportion to their actual importance. Small mistakes become tragic failures. Minor suggestions become scathing criticism. Minor setbacks become a cause for despair. Slight obstacles become overwhelming barriers. Words like huge, impossible, awful, and overwhelming are magnifying terms.

The flip side of magnifying is minimizing. When you magnify, you view everything as negative and difficult. At the same time, it is likely that you minimize your ability to cope and use constructive problem solving. In other words, it is like looking though a telescope and seeing negative things in your life as much bigger than they actually are, and then turning the telescope around, looking through the wrong end and seeing the positive things in your life as much smaller than they really are.

Magnifying is often a problem for those with chronic pain. One form of this is magnification of the pain itself. People who are depressed automatically tend to magnify any form of physical discomfort. Inactivity and isolation from other people give you an even greater opportunity to exclusively dwell on and magnify the degree of your pain. Likewise, those who are anxious and fearful about the meaning of their pain usually tend to magnify the degree of their discomfort. Another form of magnification is to see your medical condition and physical disability as much worse than it actually is or worse than it need be. As you focus your mind more and more on yourself and your own misery, you can easily lose a sense of perspective and proportion.

Key Issues with Magnifying:                                   Enlarging difficulties

                                                                                   Minimizing the positive

                                                                                   Seeing your pain problem as worse than it really is

Alternative (Balanced) Ways of Thinking:             Get things in proportion 

                                                                                   No need to magnify

                                                                                   Perspective taking

To combat magnifying, stop using words like terrible, awful, disgusting, horrendous, etc. In particular, banish the phrase "I can't stand it." You can stand it, because history shows that human beings can survive almost any psychological blow and can endure incredible physical pain. You can get used to and cope with almost anything. Try saying to yourself phrases such as "No need to magnify" and "I can cope."

One of the best ways to keep from magnifying pain and discomfort is to find other things to focus your mind on such as distracting activities. As one pain specialist put it, "People who have better things to do, don't suffer as much." If magnification is the result of significant depression or anxiety, it may be necessary to get psychiatric and/or psychological assistance. People with chronic pain conditions may find it useful remind themselves that there are plenty of others who are much worse off physically.

7) Personalization

Personalization is the tendency to relate everything around you to yourself. A somewhat depressed mother blames herself when she sees any sadness in her children. A recently married man thinks that every time his wife talks about feeling tired she means she is tired of him. A man whose wife complains about rising prices hears the complaints as attacks on his abilities as a breadwinner.

A major aspect of personalization is the habit of continually comparing yourself to other people: "They have more money than we do..., He's more successful with women than I am..., I'm more deserving of disability compensation than a lot of other people who get it..., My pain condition is a lot worse than his..., They gave her a back brace and not me." The opportunities for comparison never end. The underlying assumption is that your worth is questionable. You are therefore continually forced to test your value as a person by measuring yourself against others. If you come out better, you feel good for a short while, if you come out worse, you feel diminished in some way.

The basic thinking error in personalization is that you interpret each experience, each conversation, each look as a clue to your worth and value. As a result, you end up making yourself a lot more depressed or angry than you really need to be.

Key Issues with Personalization:                                    Assuming the reactions of others always

                                                                                          relate to you 

                                                                                          Comparing yourself to others

Alternative (Balanced) Ways of Thinking:                    Check it out 

                                                                                          We all have strong and weak points

                                                                                          Comparison is meaningless

If your tendency is to personalize, force yourself to prove what the other person's frown has to do with you. Check it out. If you can't ask the person, use the three column technique shown above to test your conclusions. Don't jump to conclusions unless you are satisfied that you have reasonable evidence and proof. It is also important to abandon the habit of comparing yourself -negatively or positively- with other people. Comparisons are an exciting form of gambling. Sometimes you win and really outshine someone else. But when you lose, you set yourself up for a blow to your self-esteem and maybe the beginning of a long, deep depression. Your worth doesn't depend on being better than others, so why start the comparison gamble?

8) Shoulds

This distortion involves use of rigid and inflexible rules about how you and others should act. Any deviation from your particular set of rules and standards is bad. As a result, you are often in the position of judging and finding fault. People are constantly irritating and annoying you because they don't act the way they are supposed to. They have unacceptable traits, habits, and opinions that make them hard to tolerate. They should know the rules and they should follow them.

Cue words indicating the presence of this distortion are should, ought, or must. In fact, Albert Ellis called this thinking style "musterbation." Many people not only subject other people to a long list of rules, but also apply a bunch of shoulds to themselves. As a result, they increase their own misery when they constantly fall short of these musts and shoulds. As indicated above, it is perfectly normal to have preferences about how we and others should act. We want to be successful in our actions and avoid making mistakes. We want others to be kind and considerate and responsive to our desires. Problems with shoulds occur when you elevate these preferences and desires to absolute demands. Then when these demands are not met, you consider it really terrible, bad, or awful.

Following is a list of some common shoulds which may be held by those who are having difficulty coping with their chronic pain. While many of these statements may be stated as preferences, problems will occur when they are stated as absolute musts or demands.

- I should be completely free of any pain or discomfort

- Doctors should be able to find the cause of my pain and fix it

- If doctors can't fix my pain condition, they should give me all the medication I need to completely dull the pain

- I should be able to continue doing all the physical activities that I did in the past

- The government should give me full disability compensation if I can't do the job I used to do

- People should understand that I have chronic pain and not expect me to do the things I used to do

- People should leave me alone when I am having a bad day

Related to the shoulds is the "Fallacy of Fairness." This type of should can take two forms. The first form is based upon the use of legalistic rules and assumptions regarding what is fair in your interactions with other people. The trouble is that two people often don't agree on what fairness is. You think you know what is fair in a particular situation, but others may disagree with your idea of fairness. Fairness is a subjective assessment of what you think is expected or needed from others. "You punished me, that isn't fair..., it's only fair that you give me..." Everyone can come up with their own ideas of fairness and use them in a very self-serving manner. You then end up feeling disappointed and resentful because others do not conform to your ideas of fairness. This type of fairness fallacy is often expressed in what are called conditional assumptions: "If he loved me, he'd do the dishes more often..., if this was a real marriage, she'd give me sex more often..., if my doctor could see how much pain I'm in, he'd do a lot more for me..., or if they knew how much pain I'm in, they would approve my disability claim." It is very tempting to make these conditional assumptions about how things would be better for you if other people were only fair or really valued you. Unfortunately, the other person hardly ever sees it that way and you end up causing yourself a lot of extra misery.

The other form that the fallacy of fairness takes has more to do with how you see the world operating. This form is often referred to as "the just world hypothesis," which is the belief or assumption that there should be fairness or justice in the world. For example, you might say to yourself, "people always get what they deserve, if I am good, I should be immune to misfortune." The reality, however, is the there is no absolute fairness or justice in the world. Bad things can happen to good people (e.g., innocent children die or get killed) and good things can happen to bad people (e.g., some people really do get away with murder). If you insist on the just world hypothesis, you are setting yourself up for significant disappointment and/or resentment because life is often not fair and horrible injustice does occur.

Key Issues with "Shoulds:"                                                    Holding arbitrary rules for behavior of

                                                                                                  self and others

Alternative (Balanced) Ways of Thinking:                            Flexible rules and values

                                                                                                 Values are personal

Re-examine and question any personal rules or expectations that include the words should, ought, or must. Flexible rules and expectations don't use these words because there are always exceptions and special circumstances. Think of at least three exceptions to your rule, and then imagine all the exceptions there must be that you can think of.

You may get irritated when people don't act according to your preferences. But your personal preferences are just that - personal. They may work for you but, as missionaries have discovered all over the world, they don't always work for others. People just aren't all the same.

The key is to focus on each person's uniqueness, his or her particular needs, limitations, fears and pleasures. Because it is impossible to know all of these complex interrelations even with intimates, your can't be certain whether your values apply to another. You are entitled to an opinion, but allow for the possibility of being wrong. Also, allow for other people to find different things important.

Likewise, the concept of fairness when applied to human relations is often difficult to apply. The word fair is often a nice disguise for personal preferences and wants. What you want is fair, what the other person wants is bogus. Be honest with yourself and the other person. Say what you want or prefer without dressing it up in the fallacy of fairness.

Finally, even if we can agree on what is fair or unfair, the idea that there is ultimate fairness or justice in the world is a setup for tremendous disappointment. It is not true that people always get what they deserve. Senseless tragedies occur every day to people who do not in anyway deserve it. Learn to deal with life as it comes, even when things don't seem fair.

Summary of 8 Styles of Distorted Thinking

1.    Filtering: You focus on the negative details and magnify them while filtering out all positive aspects of a situation.

2.    Polarized Thinking: Things are black or white, good or bad. You have to be perfect or you are a failure. There is no middle ground or room for mistakes.

3.    Overgeneralization: You come to a general conclusion based on a single incident or piece of evidence. If something bad happens once, you expect it to happen over and over again. You use global labeling by generalizing one or two qualities into a negative global judgment.

4.    Mind Reading: Without saying so, you know what people are feeling and why they act the way they do. In particular, you are able to divine how people are feeling toward you.

5.    Catastrophizing: You expect or imagine disastrous consequences. You notice or hear about a problem and start "what if?" What if tragedy strikes? What if it happens to you?

6.    Magnifying: You exaggerate the degree or intensity of a problem. You turn up the volume on anything bad, making it lout, large, and overwhelming.

7.    Personalization: Thinking about everything people do or say is some kind of reaction to you. You also compare yourself to others, trying to determine who's smarter, better looking, etc.

8.    Shoulds: You have a list of ironclad rules about how you and other people should act. People who break the rules anger you and you feel guilty if you violate the rules. According to the Fallacy of Fairness, you feel resentful because you think you know what's fair but other people won't agree with you. You also feel resentful or disappointed when events occur which violate your sense of fairness or justice in the world.

Changing Distorted Thinking and Hot Thoughts

For most people, it is very difficult to identify irrational beliefs and distorted thoughts when you are in the midst of painful emotions, conflicts with other people, or pain flare-ups associated with stressful situations. That is, even though your thinking may be most distorted at that point, your ability to identify the thoughts as distorted is most impaired due in part to what is called "emotional reasoning." Emotional reasoning assumes that if you feel a particular emotion, you must have a valid reason for feeling that way. For example, if you feel anger toward someone, you automatically assume that the other person has truly wronged you in some way. If you feel depressed, you automatically assume that you really are inadequate and unworthy or that your life truly is hopeless. Likewise, if you feel anxious and fearful, you automatically assume that you actually are in danger. In other words, during times of emotional upset your thoughts tend to automatically reflect whatever you are feeling. Furthermore, these automatic thoughts typically occur outside the range of conscious awareness.

Cognitive-behavior therapists have developed a variety of techniques for identifying and changing irrational and distorted thinking patterns. For more detailed assistance, the reader is referred to books by Burns (1980), Greenberger and Padesky (1995) and McKay, Davis and Fanning (1997). These books are listed in the References section.

You can begin the process of discovering distorted thinking patterns by learning to listen to your automatic thoughts. As soon as possible after you experience emotional distress or a relationship conflict, you should write down the following:

1. Name the feelings or emotions you were experiencing 

2. Describe the situation or event (When? Where? Who? What happened?) 

3. List what you were thinking just before and during the unpleasant feeling (Automatic thoughts).

You can use a piece of paper with the following three columns:

Once you have made progress in identifying your automatic thoughts, try to select a particular "hot thought" that contributed toward your negative mood state or distressing feelings. Once you have identified a particular automatic hot thought, you can begin to analyze it more closely according to the following steps.

Step 1: Identify Evidence that Supports your Hot Thought. This is an opportunity to carefully review evidence that seems to support your hot thought. The challenge here is to stick to objective facts, rather than listing your feelings, impressions, and assumptions. Facts include statements about what actually occurred, such as who said what in what particular situation. It is also reasonable to consider both past and present evidence that supports your hot thought.

Example: Frank has chronic low back pain. About 12 months ago, he quit his last job because the pain got to be too much. While off work, he went though a chronic pain management program and learned some effective self-management coping skills. Feeling more confident that he can return to work despite his back pain, he sent in his resume and was granted a job interview. Unfortunately, he was turned down. Following is his thought journal. 

Frank's Thought Journal

It should be noted that if Frank simply felt disappointed, this would not be considered a problem. Disappointment in such a situation is normal, providing it did not stop him from making further efforts to find employment. For the sake of the example, however, let's assume that Frank felt depressed and, as a result of the depression, he gave up trying. The hot thought that Frank selected was, "No one will ever hire someone with my back condition." Frank identified the following facts to support this hot thought:

1. I have chronic back pain.

2. I had to quit my previous job because of my back pain. 

3. After not working for a year, I applied for a job similar to my previous one and was turned down. 

4. I told the potential employer that I had been out of work because of my back condition. 

5. The reason I was given for being turned down is because it might raise the employer's insurance premiums.

Step 2: Uncover Evidence Against your Hot Thought. This is probably the most difficult part of the technique. The book by McKay, Davis, & Fanning (1997) lists ten key questions you might consider.

1. Is there an alternative interpretation of the situation, other than your hot thought? 

2. Is the hot thought really accurate, or is it an overgeneralization? 

3. Are there exceptions to the generalizations made by your hot thoughts? 

4. Are there balancing realities that might soften negative aspects of the situation? 

5. What are the likely consequences and outcomes of the situation? 

6. Are there experiences from your past that would lead you to a conclusion other than your hot thought? 

7. Are there objective facts that would contradict items in the "Evidence For" column? 

8. What are the real odds that what you fear happening in the situation will actually occur? Think like a bookmaker. Are the odds 1 in 2, 1 in 50, 1 in 1,000 1 in 500,000. Think of all the people right now in this same situation; how many of them end up facing the catastrophic outcome you fear? 

9. Do you have the social or problem solving skills to handle the situation differently? 

10. Could you create a plan to change the situation? Is there someone you know who might deal with this differently? What would that person do?

When Frank thought about the evidence against his hot thought, he came up with the following:

1. Even though I quit my previous job because the pain got the best of me, I did learn some valuable pain coping skills in the pain management program. 

2. Just because one potential employer turned me down after I told him about my back condition, does not mean that all employers would turn me down. 

3. Not everyone with chronic back pain is unemployed. 

4. The Americans with Disabilities Act which was passed by Congress and signed into law requires that employers make "reasonable accommodations" to disabled employees.

Step 3: Write Your Balanced or Alternative Thoughts. This step involves reaching balanced conclusions which take into account the evidence for and against your hot thoughts.

Continuing with our example, Frank came up with the following balanced thoughts.

Having a chronic back condition is a handicap when it comes to getting a job. Even though I am able to do the work, some employers will turn me down on account of my back condition. When applying for future jobs, I need to take into consideration that I have a choice as to whether and to what extent I tell them about my back condition. Even if I do tell the truth, I need to do a better job at selling myself and convincing the employer that I can do the work despite having a back condition. I need to keep applying for jobs until I find an employer who is willing to give me a chance.

Step 4: Re-rate Your Mood. After carefully reviewing your balanced appraisal of the situation, you should re-consider your mood.

After coming up with the more balanced way of viewing his predicament, Frank's feelings of depression and hopelessness decreased considerably. Although he was now more cautiously optimistic, he recognized that he was still slightly anxious about finding employment.

Step 5: Record and Save Alternative Thoughts. It is a good idea to actually write down your balanced or alternative thoughts. For example you can write them down on a 3 X 5 index card and review them when necessary.

In our example, Frank found it very useful to review these thoughts every time he felt discouraged about finding employment.

Step 6: Practice Your Balanced Thoughts. You can use your completed file cards to practice more healthy and balanced ways of thinking. Some even find it beneficial to actually visualize themselves in a situation similar to that which produced the hot thoughts and then reminding themselves of the more balanced alternatives.

Frank imagined the process of interviewing for a job while keeping in mind the balanced perspective. In this way, he was able to remind himself that however one potential employer responded to him in no way reflected on the way that all employers would respond. He also reminded himself, that his main responsibility was to do his best to sell himself and his abilities.

After you have become more skilled at identifying your automatic thoughts, hot thoughts, and balanced alternatives, you can begin to apply this knowledge to more and more situations. The first thing to do when you become aware of a painful emotion, conflict in a relationship, or pain flare-up is to take a signal breath. The signal breath is used to remind yourself that it is time to focus on what you are thinking. You can ask yourself, what is going on right now, what am I feeling, what automatic thoughts are going through my mind, what is the smartest and wisest thing that I can do right now?

Disputing Irrational Beliefs and Distortions through Healthy Action

In addition to trying to directly challenge and change your distorted thinking patterns, a very powerful technique for modifying these thinking patterns is to act in more healthy ways. That is rather than acting in accordance with feelings created by irrational beliefs and distorted thinking, you should try to act in a more rational manner. For example, just because you feel angry at someone doesn't mean that you have to automatically attack and punish them. What would be a more rational way of approaching the problem? Likewise, just because you feel afraid of something doesn't automatically mean that you have to avoid it. In fact, avoiding things that you are irrationally afraid of only reinforces the fear. Finally, just because you are depressed and don't feel like doing anything constructive, doesn't mean that you automatically have to just sit there feeling sorry for yourself. Get up and do something constructive even if you don't feel like it. Healthy action does not mean denying your distressed feelings. Rather, the goal is to act in a healthy manner despite these distressed feelings.

Disputing Irrational Beliefs and Distortions through Emotive Imagery

Another technique for working on irrational beliefs and distorted thinking is through a technique called emotive imagery. Begin by imagining yourself in the situation that you are experiencing the distressed feelings. The idea here is to vividly imagine the adverse situation along with all of the negative feelings associated with that situation. Really allow yourself to feel the anger, the hurt, the sadness, the fear, or whatever distressed feeling you are having. Once you have really gotten into the distressed feelings, what can you say to yourself or remind yourself that would enable you to feel less distressed? What rational alternative ways of viewing the situation can you come up with? Continue the imagery process until the distressed feelings decrease in response to your change in thinking.

A Final Word

Keep in mind that the process of changing your irrational beliefs and distorted thinking takes work and persistence. False assumptions and old negative habits of thinking tend to keep creeping back into your mind. You may find it necessary to dispute your irrational beliefs and distortions strongly, vigorously, and forcefully over and over again. Changing your negative thinking takes practice. The payoff, however, is developing a more healthy, adaptive, and fruitful philosophy of life which will enable you deal more effectively with misfortune while at the same time experiencing greater joy, peace, and happiness.

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