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Brief Interventions for Anxiety Disorders with Children and Adults

Section 14
Cognitive Distortion

Question 14 | Test | Table of Contents

(See Appendix at the end of this Manual for reproducible Client Worksheet #6)

The Five R's of Anxiety...
A cognitive approach to encourage client use of rational, positive thinking.

By learning to think clearly without irrational distortions, you erase your negative self-image and become free to reprogram yourself as you want yourself to be. I like to break this goal into what I call "The Five R's":
Realize that Anxiety is part of your thoughts.
Recognize when Anxiety is affecting your life.
Refuse to let Anxiety control your life.
Replace negative and irrational thoughts with reality.
Relax and reprogram your unconscious mind.

The First R: Realize
that Anxiety is part of your thoughts.
When we are prone to anxiety, many of us see the world as if we were looking at it through a fish-eye lens on a camera. We see all 360 degrees, but everything in view is distorted.

Some of us confuse the facts and fictions about ourselves because of our basic personalities. Maybe we are what some cardiologists call a Type A personality: we get our self-worth from working day and night. We never take time to relax. We expect perfection of ourselves. If we don't achieve the pinnacle of success (and for Type A's, there's always another mountain peak behind the one they are climbing), then we are total failures.

Others may have a poor self-image because of having had unfortunate childhood experiences, handicaps, or an adult trauma. Still others see themselves in negative, irrational ways because they can't measure up to the unreasonable expectations someone else has put on them.

Once we discover that we are looking through a fish-eye, we can change lenses and see things as they really are. In fact, we can use an infrared filter and perceive things usually hidden in the dark.

People achieve extraordinary things when they choose the proper lens through which to view their limitations. Helen Keller was stricken with an illness that left her deaf and blind at the age of nineteen months. Yet she graduated from college with honors, wrote two books, toured the world, and promoted the education of persons similarly afflicted. Everywhere she went, she was revered for her extraordinary accomplishments. Jeff Blatnick won a gold medal at the Olympics in the Greco-Roman wrestling competition even though he learned two years previously that he had Hodgkin's Disease. How did these two surmount such handicaps? By focusing on the abilities they had rather than on their limitations, they sent their unconscious a positive message.

The first step in overcoming a distorted view of ourselves is to realize that negative and irrational thoughts are a part of our consciousness. Once we admit the possibility that we are not thinking clearly, we can choose a new lens with which to look at ourselves, so that we can see our real potential.

The Second R: Recognize
when Anxiety is effecting your life.
Being able to discern exactly when you are thinking negatively and irrationally is called cognitive awareness. The process of changing those thoughts into rational ones is called cognitive restructuring. This therapy, which has become an important part of the mainstream of modern psychiatric research and practice, holds that moods are created by "cognitions," or thoughts. Your perception of what is happening to you -- rather than the actual events themselves -- affects the way you feel. And your mood determines your ability to function as you wish. For instance, when you're depressed or fearful, you open yourself to more anxiety, which undermines your ability to think, work and relate well to people and situations.

Whenever you feel depressed, angry, or afraid you can use cognitive restructuring to examine your thought processes and determine whether they are distorted. If you find you are not thinking clearly, you can replace the distortion with the reality of the situation. By adopting the rational thought patterns about what is going on in your life, you boost your mood and eliminate a certain amount of anxiety. In this way you can help yourself avoid panic attacks.

Scientific research under the critical scrutiny of the academic community has shown that cognitive restructuring is more effective in relieving depression than antidepressant drugs. And it is relatively simple to learn. You can do it either with a therapist or alone.

The Big Ten
Here is a list of the Big Ten cognitive distortions that affect most anxious people:

1. Perfectionism causes you to set unreasonably high standards for yourself and others. If you are a perfectionist, you may achieve at levels the world considers normal or even above par, yet you see yourself as a failure or credit your accomplishments to mere luck. The reality of the situation is that you are a person of worth regardless of your achievements. You deserve love, happiness, and self-acceptance as you are. You will have a lot less anxiety if you don't drive yourself to achieve unrealistic levels in everything you do.

2. Rejectionitis is the practice of exaggerating a single rejection until it affects everything else in your life. When your club elects your opponent as president, you believe your whole life is ruined. When a woman reacts coolly to you at a party, you tell yourself you're a social reject. Rejectionitis is like stuffing seemingly insignificant little grains of gunpowder into a cardboard cylinder. They're completely harmless unless you light them with a match. Then everything explodes.

The reality of rejectionitis is that you cannot expect everyone else to prefer you to others. After all, you have your favorites among acquaintances, too. You do have qualities that appeal to some people. To prove that this is true, make a list of your good qualities and make another list of people who like you.

3. Negative focus is the habit of letting one negative situation in your life obliterate all the positives. It's looking through an electron microscope and seeing only the cancer cell. A good way to stop practicing negative focusing is to go to relaxation mode and picture all the good things about yourself. Then affirm that they and you are great.

4. Refusing the positives goes a step farther than negative focus. You tell yourself that even the good things in your life are negatives! For example, you tell yourself you are a business failure, even though you had turned a profit . Why do you refuse to see that you are a success? Your self-image may be so poor and you are so overwhelmed by negative thoughts about yourself that you couldn't feel comfortable thinking of yourself as a success.

Most people who suffer from panic disorders are depressed. One form of refusing the positives and inviting depression is telling yourself you can no longer do the things you used to enjoy. "I used to travel, go to the theater, play racquetball, and do book reviews for my club," you say. "But now those things bring on panic attacks." The reality is that your attitude brings on the attack, not the activity you once enjoyed.

You may go even farther with refusing the positives. If someone gives you a compliment, you turn it into a criticism. When your friend praises your hair, you reply, "Oh, it doesn't fit my lifestyle. I've got an appointment at the beauty parlor for a complete redo right now." Or if someone compliments your work, you immediately counter with "I was lucky to have clinched that deal. The competition backed out at the last minute." The reality is that most people don't pass out compliments if they don't want to give them. If they like something you did, rejoice! Let the image-building work and nourish your unconscious.

Refusing the positives is a habit that is easy to end. When someone compliments you, just say, "Thanks," and not another word, no matter what you think. Eventually you will start believing the words are true.

5. The white-is-black phenomenon occurs when you use neutral or even positive facts to make negative conclusions. One of the most common ways to do this is to interpret someone else's actions as being hostile to you when they actually indicate that person's own discomfort. For instance, a clerk in a store snaps at you and you jump to the conclusion that you have done something wrong. In reality the clerk is in a bad mood because she has just been taken to task by her boss.

You can do black-is-white thinking when someone fails to return a business call. "I'm not important enough," you may tell yourself. "Otherwise, she'd call back." Sometimes you don't stop to think that perhaps the caller was out of town or facing a business emergency or just plain too tired to make the call. You turn white into black and make yourself feel inferior rather than looking at the situation as it really is and saving your self-esteem.

Another black-to-white kind of thinking takes place when you predict that everything you do will have dire consequences. You do this when you tell yourself you will have a panic attack and make a fool of yourself if you go out in public. Your black-is-white thinking brings about a self-fulfilling trauma. You create enough anxiety about your panic disorder to create adrenaline.

The way to "white out" the black is with reality thinking. Remind yourself that you are not the cause of everyone else's strange behavior. And recognize that you cannot know the outcome of a future event. Try predicting a happy ending instead of a tragedy for a change.

6. Stretch-or-shrink thinking is the habit of either stretching the truth into an anxiety-producing fiction when you've done something that you're less than proud of, or, of shrinking it until it's invisible if you did something good. When you stretch-think, it's like blowing up one of those giant balloons used for parades. Deflated, the balloon is just a pile of limp plastic. Inflated, it becomes a dragon towering over you.

It's easy to stretch-think when you make a simple mistake. Suppose you forgot your best friend's birthday. "She'll never forgive me. How could I have been so thoughtless? But that's the way I am, a stupid, inconsiderate idiot," you tell yourself. The truth is that everyone forgets birthdays. A clue to how prevalent this mistake is that the greeting card industry makes millions on belated birthday cards. Besides, if you were truly inconsiderate, you wouldn't be concerned. The reality is that you can apologize to your friend, celebrate her birthday after the fact, and chances are you will be forgiven. If not, then your friend is the one who is distorting her thinking, not you.

By the same token, you may be shrinking all the good things about yourself until even you can't see them. When you do something that pleases you, take time to pat yourself on the back. Acknowledge yourself aloud, if you can. The reality is that you aren't being vain or conceited in complimenting yourself. You are sending good messages to your unconscious, which in turn will enable you to function without anxiety.

7. Creating excuses means letting your emotions substitute for the truth about what is happening. It's like feeling angry because today is the day you have to go to the dentist. "I got up on the wrong side of the bed," you tell your spouse. Because you feel angry, you act angry. You give yourself permission to nag as much as you like. When you think in fantasies, you are apt to tell yourself that you are feeling anxious, and therefore you are anxious -- too anxious to go to the supermarket. Or you are likely to wake up in the morning feeling sad because of a dream you can't remember. "I'm sad," you say, "and my life is a mess." Counter excuses by realizing that your distorted thoughts bring on negative feelings. Affirm that you are already feeling calm, happy and at peace. Use affirmations to change your feelings.

8. "Should" and "ought" statements cause you to act in ways you would prefer not to, simply because you believe some imaginary boss is telling you that you will be less than perfect if you don't. "I should make my bed, be on time, be nicer to my children," you tell yourself. Giving in to this negative thinking can only lead to resentment and guilt. The reality is that you alone are responsible for your actions -- not your father, mother or the next-door neighbor. You are perfectly capable of setting up your own standards of behavior, and it really doesn't matter what others think about it. They are responsible only for their actions, not yours.

9. Mistaken identity means telling yourself you are all bad because you made a mistake. It's like feeling bad forever because you broke a rule or because something bad, like an anxiety attack happened to you. "I'm just stupid," you say. "I'll never amount to anything." Or you didn't turn your body far enough around when you hit the tennis ball backhand, and you smashed it into the net. "I'll never learn."

The reality of mistaken identity is that everyone makes mistakes. You are still a person of worth even if you make one. You can make positive contributions to life even if you fail dozens of times. Thomas Edison made thousands of mistakes before he invented a workable electric light bulb. Just try saying, "I made a mistake," and let it go.

10. Saying "My fault" assumes responsibility for a negative event even when the responsibility is not yours. In this case, you don't make the mistake. Others do. Yet you assume all the blame. If your husband drinks too much and makes a scene, you say it is, "My fault". Saying "My fault" inevitably builds up anxiety, because you can't make anyone else behave differently that way. The reality of "My fault" thinking is that no one can control another person, and no one should.

The Third R: Refuse
to let anxiety control your life.
It is one thing to recognize cognitive distortions after you have suffered the consequences. It is still another to be able to spot them while you are in the process of distorting so that you can immediately replace them with a positive thought. Here is the way to do this.

The blue dot technique: Paste blue dots in strategic places to remind yourself to relax. Now you can use the blue dots, or other colored dots if you wish to differentiate, for becoming aware of cognitive distortions. Each time your eye falls on a dot, ask yourself what you are thinking about.

You can paste the blue stickers around the house, your office, inside the car, on your watch, etc. This will help you to become aware of your mind chatter. For example, you are waiting at a traffic light when you notice a blue dot on the dashboard. What are you thinking? "You'll never make your appointment in time! You should have left earlier!" This is stretch-or-shrink thinking. You are telling yourself how inadequate you are because you made the mistake of starting too late. Once you got to the appointment, you found that your unconscious had received the message literally. It obediently made sure that you acted in an inadequate way and stammered nervously.

When you become aware of such distorted thinking, you immediately affirmed that you are a person of worth, one who deserved success. Since you already had been affirming and visualizing these same things at the relaxed level, you are able to stop these cognitive distortions at the feeling level. This is the level at which the unconscious more readily hears the message. That way your unconscious will not create actions. Thus, you avoided creating situations that would have caused you problems.

The Fourth R: Replace
negative and irrational thoughts with reality.
The Fourth R is replacing negative thoughts with positive ones to reprogram your unconscious. It involves planning ahead. You monitor your cognitive distortions and plan how you will confront them with reality. The easiest way to do this is to sit down with a pencil and a piece of paper that has three columns. The headings should be:

1. Problem Thinking 2. Cognitive Distortion, and 3. Positive Replacement.

Find a quiet place where you can do some serious thinking about what has been happening in your life. To fill in the first column headed "Problem Thinking," record thoughts that are creating negative emotions. These are thoughts that keep you from feeling good physically or prevent you from enjoying a happy relationship with a loved one or a friend or interfere with your financial success, for instance.

Let's say you are angry because you invested a lot of time and effort in buying a new dress for your husband's annual company Christmas party. Your husband takes one look and says you are too heavy to wear such a youthful style. You smolder with rage. Your thoughts are that he's inconsiderate and unappreciative. At the same time you're telling yourself, "I'm ugly and inadequate and always will be. Nothing I do ever pleases him." Write down these thoughts about yourself in the first column.

In the second column, "Cognitive Distortion," write which one of the ten cognitive distortions you are using to interpret the actual event. In this case, you would be using stretch-or-shrink thinking or stories.

In the third column, labeled "Positive Replacement," write down the reality of the situation. You might write, "I am attractive because I have...," and write down your good points. Or write, "My husband does not like the new dress, but it is not necessary for him to approve of everything I wear. I like the way I look in this dress. I enjoy wearing it."

Here are some other examples of how you can replace irrational thoughts with reality. A rational response to "I have a knot in my stomach that keeps me from giving a speech; everybody will notice my nervousness" is, "Everybody's nervous giving a speech. It's all right to experience that feeling. I am very capable of speaking." An irrational "Nobody loves me" can be replaced with, "I can think of three or four people who love me." And the thought "I can't love myself because I've made so many mistakes" can be replaced with, "Everybody makes mistakes. I can forgive myself just as I would another who did the same thing. Besides, I have many lovable qualities."

The actual process of writing down these positive statements on paper is a way of communicating with your unconscious. You are letting your unconscious know firmly that you are not going to accept these irrational feelings. Once you get the hang of writing down negative thoughts and replacing them, you will have discovered how not to let anxiety rule your life.

The Fifth R: Relax
and reprogram your unconscious mind.
With the Fifth R, you can learn to reprogram your unconscious so that your anxiety is decreased in the future. You do this by relaxing, going into alpha and using the carefully planned visualizations and affirmations you learned to formulate in.

You can use the Fifth R, Relax and reprogram, to think clearly about any problem. Perhaps you tell yourself, "I am unattractive because I'm too short...too tall...too thin...too fat." Write down your distorted thinking. Then make a list of all the realities that apply to you. List ten attractive things about yourself. Maybe you have a good complexion, even teeth, luxuriant hair, nice cheekbones, a lovable personality, and sympathy for others. List them, then spend more time relaxing. Picture and affirm your good points and you will be surprised at how much more attractive you feel when you are around those whom you want to impress. Why? Your unconscious will send you the good feelings that allow you to feel good and relaxed around others. You can't help but seem more attractive.

Briefly, here are the steps to follow to prevent anxiety attacks.
1. Write down your distorted thinking.
2. Confront your distortions with reality.
3. Write down ten positive ways in which the reality applies to you.
4. Relax, visualize and affirm that these realities are already true for you.
5. Relax and let your unconscious recreate your self-image.

Manufacture the Positive
Now that you have seen how cognitive distortions increase anxiety, you know that thoughts are like mood creating products which you manufacture in your brain. You can generate good, positive thoughts that will build you up and keep you calm, or you can let bad thoughts roam around in your mind, creating anxiety and a bad self-image.

You need to remember that you are the manager of your thoughts! You can choose which thoughts you want to manufacture. Realizing you have that choice is a real wake-up call. You don't have to let your negative thoughts manipulate your life! By confronting your cognitive distortions with reality, then programming yourself to think positively, you can prevent anxiety from controlling your life. (excerpt Handly)

Personal Reflection Exercise #6

The preceding section contained practical applications of presenting a working model of cognitive thought distortions for use with Anxiety Disordered children and adults. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

Cognitive bias and attitude distortion
of a priority decision

Svenson, O., Lindholm Öjmyr, T., Appelbom, S., & Isohanni, F. (2022). Cognitive bias and attitude distortion of a priority decision. Cognitive processing, 23(3), 379–391.

Peer-Reviewed Journal Article References:
Foerster, A., Moeller, B., Huffman, G., Kunde, W., Frings, C., & Pfister, R. (2021). The human cognitive system corrects traces of error commission on the fly. Journal of Experimental Psychology: General.

Król, M., & Król, M. E. (2019). A valence asymmetry in predecisional distortion of information: Evidence from an eye tracking study with incentivized choices. Journal of Experimental Psychology: Learning, Memory, and Cognition, 45(12), 2209–2223.

Miguel, F. K., Amaro, M. C. P., Huss, E. Y., & Zuanazzi, A. C. (2017). Emotional perception and distortion correlates with Rorschach cognitive and interpersonal variables. Rorschachiana, 38(2), 143–159.

Whiteman, S. E., Kramer, L. B., Petri, J. M., & Weathers, F. W. (2019). Trauma type and suicidal ideation: The mediating effect of cognitive distortions. Traumatology, 25(4), 262–268.

QUESTION 14: What are the five R's for dealing with Anxiety? To select and enter your answer go to Test.

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