Joseph F. McCaffrey MD, FACS


A Cognitive Restructuring Story, Part 2

In A Cognitive Restructuring Story, Part 1, I began by mentioning cognitive restructuring and gave the barest outline of what it is about.

I thought I could make its power and usefulness most clear if I gave an example of using it, so I told the story of a patient I took care of years ago and related the emotional state I was in after he died.

When I finally thought to use it, cognitive restructuring helped me clear the emotional turmoil rapidly.

As I mentioned, the premise of cognitive restructuring is that our experience is based on our perceptions. We don’t perceive the outside world directly.Rather, incoming stimuli have to pass through a lot of filters, both physical and psychological.

As a simple example, what’s your right foot feel like now? Hot? Cold? Any pressure points? You can answer the question without difficulty, but until I asked, were you aware of how your right foot felt? Probably not.

However, the nerves in your foot constantly send signals to your brain. The information from your right foot (and everywhere else on your body) goes to your brain constantly. It just get filtered out at a preconscious level unless you need the information (I ask a question or you step on a nail).

Beyond that, we have habits of thoughts and meanings we assign subconsciously that further shape our perceptions.

As a result, our perceptions are quite often distorted.

Since our perceptions determine our experience, distorted perceptions distort our experience. Cognitive restructuring clears up the distortions – it “restructures” our thinking to a more accurate interpretation.

Note that cognitive restructuring is not about “looking through rose-colored glasses” or baseless optimism. Rather it’s about questioning our thoughts and checking to see just how accurate they really are.

There are a number of different exercises you can use to help you do this. Right now I’ll tell you about the one I used to help me deal with the death of my patient. It’s one of the first ones I learned.

The basic steps are:

  • Identify the troubling thoughts
  • Identify the emotions associated with them
  • Objectively look at the thoughts and the beliefs behind them and question them. How true are they? Are they based one on a cognitive distortion? (There are ten common cognitive distortions I’ll tell you about later.)
  • Having looked at the distressing thought objectively, is there another thought that’s equally true or even more true than the thought that caused the distress?

With those steps in mind, I finally decided to sit down and go through the process in writing. It took less than an hour on a Sunday afternoon.

So what were the thoughts that I had running in the back of my mind? Not very pretty:

“He died and it’s my fault.”

“I wasn’t good enough; I didn’t know enough.”

“Somebody else could have done a better job.”

What were the feelings associated with those thoughts? Sadness. Guilt. Anxiety. Inadequacy.

No wonder I hadn’t been feeling so well.

The next step is to look at the thoughts that have been causing all this distress and make an objective evaluation of just how accurate they are.

It’s handy to have a checklist of the most common cognitive distortions close by to compare your thinking to (I’ll send one to you later). As I mentioned, there are ten or so cognitive distortions that a lot of us automatically apply. Which ones we use depends on our particular habits of thought.

The first thought is an example of the distortion of personalization – feeling responsible for things outside your control. He died, but it wasn’t my fault. He was born with a problem with his coagulation system that caused the blood supply to his intestine to clot off. He had a catastrophic complication of his blood disorder and I was doing my best to help him.

Somehow feeling responsible for his death was pretty distorted. Yes, his death was sad, but it wasn’t my fault.

The other thoughts demonstrate a combination of both all-or-nothing thinking (“If I’m not perfect, I’m completely inadequate.”) and positive mental filter (remembering and highlighting all the negatives while minimizing or completely forgetting anything positive).

How accurate are those thoughts?

Well, medicine is a tough field to try to know everything in – you’re going to lose that one. Perfect command of all knowledge at all times, especially in the middle of an operation, is unrealistic.

The realistic evaluation, that I know is true, is that I have a sound knowledge base. I’ve kept up with my medical reading and I’ve always done well academically. On exams, including the recertification exam for the American Board of Surgery, I always test in the upper percentiles compared to my peers.

Knowledge aside, in the operating room (here’s pure surgical ego coming out) I know my technical skills are superior.

So overall, the accurate evaluation is that I’m a competent surgeon with a good knowledge base and excellent technical skills.

So it appears that the thoughts that were causing me all that distress were pretty distorted. Just recognizing that eased some of the discomfort.

What might be some more accurate thoughts to replace the distorted ones? These are what I came up with:

“Of course it’s sad to witness the death of a young man and his family’s grief. I went into medicine to try to help people and it can be painful to be helpless to make things better. But it remains a privilege to connect with people at the most important times of their lives. I can also take comfort in knowing I did my best to support them during this difficult time.”

“A good surgeon will always examine their performance and look for ways to improve. Their standards should indeed be high. But a good surgeon also keeps in mind that perfection is an unattainable goal and seeking it is a fools game that will hinder rather than help.”

“I know that I’m an excellent surgeon. On a given day, for a specific problem, another surgeon might be able to do a little better job for a given patient. Maybe that would have been true for this patient, maybe not. But what is definitely true is that no other surgeon could have cared more than I did for this patient. No one could have had more compassion for his family and what they were going through than I had. The truth is that that no one could have brought more care and dedication to his bedside than I did. The family recognized that it was the most important thing I could give them. In that, I know no one could have done more.”

Can you get any sense of the relief I felt after working through this? The replacement thoughts were true. They resonated with me and soothed the sadness and grief and let me release a sense of guilt that I had needlessly been carrying.

Jackie and I have a library in our home and I did this exercise at the desk in there. It’s a warm and comfortable room. Wonderful cherry bookshelves that my brother Bob made line two opposing walls. The desk is at the end of the room in front of a large window looking out into the yard.

My eyes had filled with tears a bit as I had reflected on these things, but now my heart was lighter and as I looked outside I saw the beauty there again for the first time in a while.

It’s been my observation that perfectionism causes a tremendous amount of pain, not only in medicine but in any group committed to high standards. The irony a perfectionist ideal leads to - is its opposite – cynicism and burnout. Society loses the contribution of those with the greatest commitment to excellence.

It’s almost funny how we accept our thoughts without challenging their accuracy. Some psychologists refer to them as automatic thoughts. Some serve us, but many don’t.

Cognitive restructuring gives us a way to change destructive automatic thoughts, and I hope this example has given you an idea of how effective it can be.

If you want to learn more about cognitive restructuring, there are several sources I can recommend. Here are two:

  • The Wellness Book by Dr. Herbert Benson has a very accessible section on cognitive restructuring. You'll also learn about the relaxation response and the rest of their approach to wellness as well. It’s all good stuff.
  • And while it doesn't have a title I much care for, 10 Days to Higher Self-Esteem by Dr. David Burns is an excellent overview of cognitive restructuring with several exercises you can apply directly.

I hope you take the time to find out about cognitive restructuring. It really is a wonderful tool to help you clarify your thinking.

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