This was my first meeting with Harry, and as soon as he lowered himself into my chair with a heavy sigh, I knew it would be a difficult counseling session. “There’s no point,” he said. “I might as well die right now.” After spending some time to establish that he was not suicidal but rather voicing his distress prompted by a recent cancer diagnosis, I asked Harry to tell me when there was a point.
What were his reasons for being alive now? After thinking for a while, he told me that he looked forward to talking to his brother every day, and he cherished the rescue dog that had been part of his family for the last 3 years. Over several more conversations, Harry identified many more reasons for living, however long or short his life might be.
Harry’s initial comments represent one of the most common types of distorted thoughts — focusing solely on the negative — that people tend to have when facing difficult problems.1 These thoughts are distortions not in the sense that they reflect false problems, but in the way that they highlight certain parts of a situation to the exclusion of all others. When Harry said that there was absolutely no reason to live his life every day because he was just going to die anyway, he was using a mental filter that only took the negative into account. When he was able to identify some reasons for living, things that gave him purpose, he showed that he could see more than one truth about his situation.
Harry’s negative mental filter represents just one type of cognitive error that we all tend to use at certain times. Other common types of cognitive distortions include:
Black-and-white thinking Seeing things in extremes (“I’m either going to be cured or I’m going to die.”)
Overgeneralization Viewing one negative event as indicative of your entire life or character (“My husband spends so much time taking care of me. I’m such a weak and needy person.”)
Discounting the positive Discarding positive experiences despite the evidence (“My test results show that the treatment is working, but I think the cancer will probably return.”)
Mind-reading Assuming others’ thoughts and intentions (“My friend hasn’t called me to see how I’m doing because she doesn’t care about me.”)
‘Should’ statements Directing yourself or others with unrealistic “shoulds” (“I should not burden my friends and family or ask for help, no matter what.”)
Personalizing Believing that you are the sole cause of an external event (“If I wasn’t so stressed out, I would not have gotten cancer. It’s all my fault.”)2
USING CBT TECHNIQUES
Cognitive behavioral therapy (CBT) is a way to challenge the above distortions and replace them with more adaptive thoughts that reflect a more complete picture of the situation.1 In turn, people learn to cope more effectively with their cancer.
From 2009 to 2013, the National Cancer Institute funded multiple CBT training sessions for clinicians engaged in supportive counseling with cancer survivors. The prevalence of these training sessions indicates the growing recognition of cognitive behavioral therapy as an evidence-supported technique for a variety of people who seek psychosocial help. For people with cancer, cognitive behavioral therapy offers a way to cope with the stressors related to having a life-threatening illness.
Health care professionals can use CBT techniques on a regular basis. To start, ask your patient to write down typically distressing thoughts as they occur. When does the patient tend to have these thoughts? Are the thoughts triggered by certain events? How does the patient feel when having these thoughts? How does the patient’s body feel? What does the patient usually do to cope with these thoughts and feelings? Does it work? Exploring this process is the key to changing what does not work.
Although feelings seem automatic and uncontrollable, they are caused by our thoughts and beliefs about the things that happen to us. Once we identify those thoughts and whether they are helpful or not, we can choose new thoughts that are based in reality but cause less distress. Thinking something different helps us do something different.2
For example, if your patient thinks “I absolutely cannot tolerate getting chemotherapy” every time he or she goes for a treatment, the patient will likely feel anxious, fearful, or angry in the room. The patient may have clenched fists and become irritable, or avoid getting treatment. By helping your patient answer the following questions, the patient might gain a new perspective:
What is the evidence for your thought or belief? “I get very upset whenever I enter the treatment room. My stomach is in knots when I see the chemo chair.”
What is the evidence contrary to your belief? “Even though I feel anxious, I usually show up for treatment. My stomach eventually relaxes and I can sit down.”
What would your friend think about your belief? “He would tell me that I can handle more than I think, that I’ve dealt with worse things in the past.”
What is a more helpful way to look at this? “Getting chemo is an unpleasant experience, but it’s not the end of the world. I have been dealing with it, and with support, I can continue to do so.”
While helping your patients to challenge their negative thoughts and replace them with more constructive beliefs, you must first acknowledge their distress. Moving too quickly to new thoughts can be invalidating. Acknowledge what is true about your patients’ negative beliefs, but then point out that few things in life are true in all instances all the time. How is it helping your patient to hold onto those distorted thoughts, to dwell exclusively on the negative parts? Looking at all sides of a situation leads to a better quality of life.
Harry knew he had a serious illness and initially felt hopeless. His belief that there was “no point” prevented him from living. Once he started paying attention to more than one truth about his situation — that he was still alive today and that he still had reasons to live — he rediscovered his life. And he chose to make the most out of it.
1. Cagle JG, Loscalzo M. Using cognitive and behavioral approaches throughout the cancer experience. In: Christ G, Messner C, Behar L, eds: Handbook of Oncology Social Work: Psychosocial Care for People With Cancer. New York, NY: Oxford University Press; 2015:345-350.
2. Sage N, Sowden M, Chorlton E, Edeleanu A. CBT for Chronic Illness and Palliative Care: A Workbook and Toolkit. West Sussex, England: John Wiley & Sons Ltd; 2008.