“What is wrong with me?”
“Why do I feel restless all the time?”
“I think too much. Why am I always so nervous?”

Here again the reader may try to see which of these kinds of dysfunctional thoughts bother him most. The cognitive approach would then involve trying to replace the pathological thinking with realistic thinking. This may be done with a therapist, on paper or simply through “self-talk.” For example the thought “If someone criticizes me, I am useless,” could be replaced by “If someone criticizes me, they may be right, in which case I can try to correct myself or their idea may be unfounded and just be their opinion.” This is easier said than done, of course, as our thought patterns tend to be repetitive and deeply ingrained.

Outside the biological domain, most psychologists and psychiatrists work with a tripartite model of human experience. In this circular model, emotions, ideas (cognitions) and behavior are interconnected. The psychoanalytic school and many of its offshoots, such as Gestalt Therapy emphasize the emotions, which generate thoughts and behavior. The behavioral school focuses primarily on behavior, arguing that it is the only observable entity. The cognitive school works mostly with the cognitions and claims to be able to change the ensemble through altering the thought processes. Thus, once we identify the anxiogenic thoughts, like those mentioned above, and replace them with reasonable ones, the problem is resolved. The debate as to whether this is true still rages on.

Much of this discussion may seem academic and theoretical but there are serious practical implications to these ideas. I was reminded of this recently when I went to the local handy store on my daily walk. A young man loading up the refrigerator at the store, knowing I was a psychiatrist, collared me and presented me with his difficulty doing multiple-choice exams. He would obsess about each of the possible choices on the exam and then feel totally blocked. It was clearly affecting his performance and possibly undermining his possibilities of completing his degree. I politely referred him to a cognitive therapist but couldn’t help wondering about which negative cognitions were hindering his task completion. They could have been any of the following:

“I’m not smart enough to understand the course material.”

“If I don’t get a good grade on this course, my friends will think I’m stupid.”

“If I don’t pass this course I’ll be stuck at a menial job for the rest of my life.”

“My teacher is trying to trick me and make me fail so he can feel smart himself.”

“I’m just not made to be a student.” etc., etc.

The possibilities are infinite but any of them could be enough cause underachievement and the effort to neutralize them is vital.

PANIC DISORDER

In Panic Disorder, the catastrophic interpretations involve perceiving sensations as indicative of impending physical or mental disaster. For example, perceiving a slight feeling of faintness, the person is convinced he is in danger of imminent collapse, or on experiencing palpitations, he believes that this is evidence of an impending heart attack.

In the mental domain, perceiving unusual or racing thoughts is seen as evidence of an impending loss of mental control and, consequently, insanity. The thoughts may sound like this: “I am losing my mind”; “I am going to end up in the mental hospital”; “What if I lose control and end up hurting someone?”

The cognitive therapist works with a client to help him identify these pathogenic thoughts and then to detoxify them. This is done in a number of ways, including finding rational thoughts to displace the dysfunctional, catastrophic ones and practicing relaxation techniques to counteract the anxiety response. Education is used as well to explain the neurophysiology of anxiety and its natural neuro-chemical limits. At times, it is necessary to design a hierarchy of anxiety-provoking situations so the client may gradually, step-by-step, expose himself to more and more threatening situations. This is known as “Systematic Desensitization” and is used to help people learn to adapt to feared situations (phobias) in graded doses.

If we break these techniques down to their essentials, we realize that we are coming very close to common sense, i.e., to what discerning people and wise counselors have long been advocating. If you are afraid of something and your fear is irrational, expose yourself to the feared situation over and over again until you have mastered it. Che Guevara, a hero of the 1960s generation, was known to have said, “Courage is not the absence of fear but rather the ability to act in the presence of fear.” He was thinking like a cognitive therapist.

The other side of the equation is that if you misperceive a situation through irrational thinking, you may attempt to render your thinking more objective. Then you may compare your realistic analysis with your fearful thoughts and discriminate between the reality and the illusion. Spiritual advisors have been suggesting just such an approach since time immemorial.

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DR. IBRAHIM KREPS is a psychiatrist in private practice in Pointe-Claire, Montreal, and a regular contributor to Islamica Magazine