Monday, August 29, 2011

Cloudy thinking: Cognitive therapy tackles it

By Louise Kinross

Several years ago I read Feeling Good: The New Mood Therapy by Dr. David Burns, an adjunct clinical professor of psychiatry at the Stanford University School of Medicine. Dr. Burns has written a number of bestsellers about how the way we think shapes the way we feel. When people are depressed or anxious, according to this model of cognitive behaviour therapy (CBT), they have distorted thoughts flooding their minds – often that they're not even aware of. If they can be taught to identify these distortions and replace their irrational thoughts with more realistic ones, their mood lifts. I found the approach effective and liked that it challenged common beliefs such as the idea that work and ability determine worth.

Dr. Jacob Towery is a colleague of Dr. Burns. He is on the adjunct clinical faculty at Stanford and works with children and adults in his private practice. During a two-year fellowship in children's psychiatry at Lucile Packard Children's Hospital, Dr. Towery found that CBT – which has since evolved into something called TEAM therapy – "has real-world application for parents of children with complex disabilities." I wanted to know how we could use these techniques to improve our lives.

BLOOM: What are the basic principles of cognitive behaviour therapy?

Dr. Jacob Towery: Thoughts and behaviours and feelings influence each other. There are going to be events that happen in life, but the events themselves don't necessarily cause us to feel a certain way. It's more what we tell ourselves about these events that influences how we feel, which then influences our behaviours and further influences our thoughts. If we can change how we think about things, then we can change how we feel, which has a dramatic effect on our mood and behaviours.

BLOOM: Is CBT unique in challenging common values about ability and worth?

Dr. Jacob Towery: CBT was one of the first types of therapy to try to address these beliefs and Dr. David Burns was one of the founders of CBT. David has now developed a new model of therapy called TEAM which is founded on CBT but focuses on empathy at a very sophisticated level – helping people feel understood – and respecting the patient’s agenda. I think these therapies focus the most on challenging common beliefs about ability and worth.

BLOOM: How could CBT be helpful for parents of children with disabilities?

Jacob Towery: One benefit is that a parent can work with someone who can understand what they're going through at a very deep level and empathize and validate what that experience of raising a child with complex needs is like. The other is that if the parent is feeling depressed or anxious as a result of what they're going through, that's changeable. The child's disability can't be changed, but the parent can learn to see it and experience it differently and to come to a different place in how they feel about it. It is possible to raise a child with complex disabilities and not be depressed and anxious.

BLOOM: Sometimes it can be hard to focus on what your child can do because for children with multiple disabilities, there are so many things they can't do.

Dr. Jacob Towery: Right, exactly. And I want to emphasize that there’s nothing that says a person has to change their thoughts or beliefs or focus. The techniques we’ll discuss should only be used if the parent is already feeling accepted and understood by the therapist and is choosing to want to see things differently, which is challenging. If the parent does want to change their thoughts, it can be helpful to write a daily mood log where they write down the thoughts that are making them feel sad or upset or angry. For example: “My child will never be able to accomplish what other children can.”

There's probably a certain amount of sadness that is appropriate and healthy for a parent of a child with multiple challenges. To know your child will have to struggle more than other children do is unfair. Sometimes parents don't give themselves permission to grieve the loss of the healthy child they expected and therapy can provide the space to experience that sadness. But once you have grieved, continuing to tell yourself “My child will never do anything” might be an overgeneralization. Is it really true that your child will never do anything? What if we focus on what the child can do? Perhaps the child can make eye contact now, but didn't used to be able to. Maybe your child can smile and generate a smile in you as a parent. Maybe they can give another person a hug and make that person feel good. It's all about what we focus on. We can focus on the 100,000 things that a child can't do, or on some of the things that they can do, and we will feel differently depending on our focus.

BLOOM: So overgeneralization is one common distortion. What’s another?

Jacob Towery: Let's say a parent has the thought: “My child is worthless because he will never have an independent job and another child is worthwhile because he does have a job.” That's a type of black-and-white thinking. If the parent wants to challenge that thought, we can help them recognize that most things in life fall more into shades of gray and are more nuanced. They aren't one extreme or the other. We could collaborate to come up with a thought like: “Although my child won't have a job and pay taxes like some other children, my child can still make me smile. My child does acts that are kind and generous. My child can give me a kiss and pet an animal. Those things are important and worthwhile. So although my child might have different abilities, it doesn't mean he's worthless.”

BLOOM: There’s a chapter in Dr. Burns book Feeling Good called Dare to be average that looks at how destructive our perfectionistic tendencies can be. But what if my child’s IQ is below average? Do some of the same principles apply?

Dr. Jacob Towery: It’s not the reality of a child having cognitive deficits that leads to suffering, it’s our thoughts that there’s something wrong with that, that intelligence is the only measure of worth, and that because my child is less intelligent he’s worthless. These thoughts can be defeated. One of the techniques we can use is the double-standard technique. People are often much harsher with themselves than they would be if talking to a friend in a similar situation. With the double-standard technique the therapist pretends to be the patient’s best friend – because we often talk to our friends in a more forgiving, consoling and compassionate way. In this technique, the therapist role-plays being a best friend of the patient, but one who has had all of the same life experiences, values and thoughts as the patient.

The therapist might then verbalize some of the patient’s negative thoughts from the daily mood log, pretending to be the patient’s best friend and say something like: “I’m really struggling because my 9-year-old son isn’t as verbal as other kids and I feel the only value that’s important is someone’s cognitive ability. So I feel my child is kind of worthless.”

The patient might then respond as they would to a good friend: “You’re being really hard on yourself. You’re saying intelligence is the only thing that’s valuable. I don’t think that’s true. I don’t know if Mother Teresa had an IQ of 150 or 40, but I know she helped a lot of people in need and was incredibly compassionate. Even though she may not have had a genius IQ she helped the world in profound ways. Then there’s the Dalai Lama. He seems to be a pretty bright guy but I don’t think that’s why people love him universally. He hugs people and speaks in a gentle way and is very generous with his time.

"To say intelligence is the only thing that matters is silly because every person is a composite of many different abilities, values and characteristics. Intelligence is only one part of what makes someone human. What about how generous someone is, how thoughtful they are, how kind they are? Maybe your child is not the greatest at complex problem-solving but he appreciates music or can sing a tune. Maybe he’s not the best at reading but he’s good at giving hugs and is socially tuned-in so that he knows when to make a little joke. That in itself is a form of intelligence."

The therapist might then ask: “Is this really true, or are you just saying that to make me feel better?” And if the parent recognizes that what they’ve said is true, the therapist might follow up by asking whether it’s just true for the “friend” or true for the parent as well. This often leads to a sudden and profound change in mood when the patient realizes that what they’ve said to the “friend” is not only true, but also true for themselves. The double-standard technique gets to the parent’s ability to speak in a more gentle and kind way to themselves.

BLOOM: But our society doesn’t seem to value things like compassion and kindness in people.

Dr. Jacob Towery: We need to accept that some of these things aren’t valued as highly as we would like them to be valued and we wish the world were different. Our children’s gifts aren’t as valued and we can feel a healthy sadness about that. However, if we’re telling ourselves “No one values my child” we can challenge that by going out and asking other people their opinion and sometimes we find out we’re very wrong. I have a cousin who has Down syndrome. Let’s say I had the thought: “The world doesn’t value her because she doesn’t contribute.” I could go out to talk with my aunt and my aunt’s neighbours and I could say: “How do you feel when my cousin comes and visits with you and gives you a hug?” And the neighbour might say “I enjoy living beside her because she’s so sweet and she makes the world a better place.” We can be convinced that no one sees value in our child yet when we go and check this out, we sometimes find our thoughts about what other people think don’t line up with what they actually think.

BLOOM: How can CBT help parents of children who didn’t make the gains they had hoped for? It's a popular idea that if you only work hard enough, anything is possible, and that disabilities can be 'overcome.'

Dr. Jacob Towery: Many of these platitudes are changeable and we can defeat them if they're causing us distress. Let's say I have a child with severe cerebral palsy and I do everything possible and my child still needs a wheelchair. I may have the thought: "If only I had done more, then my child would be able to walk." It can be helpful to examine the evidence in support of, and against, that thought.

Let's start with evidence in support. My child is not currently walking, so maybe that fact suggests that I didn't do enough. Other children are walking, so maybe if I'd done more my child would be like them. Then there have been extraordinary cases where people have pushed and something miraculous happens.

But there's a lot of evidence against the idea. As a parent, I may have spent years of my life getting my child really good rehab and going to heroic efforts and yet he still can't walk. So maybe the thought that I didn't do enough isn't true. There are plenty of other parents who made similar efforts and spent hundreds of thousands of dollars and years of their life on their child's rehab and yet their child still can't walk. It might be that we all suck as parents, or is it more likely that there are some children who just can't walk and even when parents do everything right, they still can't walk? There's no law in the universe that says every child can walk. A lot of this has nothing to do with my ability as a parent. Some children are simply born with certain syndromes or difficulties and they can't walk.

Then as a parent, I could ask myself, "Is the evidence stronger in favour of that thought or against it?” And if the evidence against the thought seems much stronger, it might change how strongly I believe that thought. Then the thought might not bother me anymore or cause distress.

BLOOM: It makes sense to me that we can accomplish a lot by identifying the distortions in our thinking and changing our thoughts. But when the rest of the world seems to be moving in the opposite direction in terms of values, how can we maintain our more positive beliefs?

Dr. Jacob Towery: We all drift in and out of enlightenment – places where we feel confident and settled with our beliefs – and then inevitably our negative thoughts return and we go back to thinking: “It’s unfair, my child isn’t as good as other children, my life should be different now.” This model of therapy can teach parents how to handle those thoughts quickly – so they don’t suffer for days or weeks at a time. Sometimes we need to learn how to accept some truth to the thought we’re having, which allows us to not be as bothered by it. For example, any parent of a child with complex needs is going to have to come to a place of acceptance that their situation is unfair. It is harder for their family than other families and sometimes it may feel like more than they can bear. Whenever we have the idea that something is unfair, it leads to resentment and anger but if we have the thought that something is unfair and that’s just the way it is, there’s nothing I can do to change it, there’s something about that act of acceptance where we’re not struggling against it, not wishing it were different, that causes less suffering and struggling and allows us to empathize with our situation more.

BLOOM: How would you help me change the thought: “I’m a failure because I couldn’t change the outcome for my son?”

Dr. Jacob Towery: Well let’s define terms. How would you define the word failure?

BLOOM: I don’t mean it in the sense that I feel there’s something inherently wrong with me, that I’m a failure as a person. I guess I mean that I didn’t succeed at something I wanted to succeed at that was important for my son.

Dr. Jacob Towery: And how many parents have not succeeded at something that they’ve wanted for their child? I think that applies to every single parent I’ve ever met. I don’t know a person that’s succeeded at everything. It sounds to me like you wished you could overcome the impossible and have the best for your son and that makes complete sense and is not something I would want to change about you.

But how about reframing the thought: “I’m a failure because I didn’t overcome my child’s disability.” Perhaps we could say: “I am a human being because I was not able to overcome my child’s disability.” Or, “I did everything I could for my son but he has such a severe disability that no one could have overcome this.” Or “It would be wonderful if my son hadn’t been born with a disability, but this is the way life is now.” Or “I’m imperfect and there are probably some things I could have done slightly differently with his rehab but every time I made a decision I did what I thought was best.” Or “If I was God, I could have overcome my son's disability.”

BLOOM: What can parents do to nurture the new, more realistic thoughts so that the old destructive ones fade away?

Dr. Jacob Towery: There are several things. One is to write down both the negative and reframed thoughts and rehearse the more positive thoughts several times in the subsequent days. With many of my patients we tape record our sessions, especially as we are going into the double-standard technique, and then have them listen to it again later for homework. By practising a number of the techniques with an experienced TEAM therapist and getting skilled at using them, even if the old thought returns, parents can quickly defeat it.

From Dr. Burns: "Reading Feeling Good might be a useful first step for parents wanting to learn more about how to overcome feelings of depression and anxiety. My Feeling Good Handbook would also be a good choice, as the introduction describes my own intense concerns when my son was born. He had to go to the pediatric intensive care unit due to difficulties breathing. The story brings out the powerful impact of our thoughts – and not events – on how we feel and illustrates how cognitive distortions can interfere with a loving and healing relationship with our children. There are large numbers of cognitive therapists in Canada although there are no certified TEAM therapists (we are just developing our certification)." See Feeling Good Institute for American TEAM therapists or contact Dr. Towery.


once again, thank you for this informative post!

Excellent article Louise..THANK YOU! :)

Some great techniques in this that will help a parent.

lots of love
Diana x

So simple yet sometimes so hard to remind ourselves of these truths. Thanks for posting this!