Addressing Despair Through CBT
When my immune system declared mutiny and began to throw the synovial lining of my joints overboard, I was in the final year of a Masters program in psychology. Like so many others suffering from RA, I seem to be riding a teeter-totter, with despair and depression on one end, and an endless striving to live at my best on the other. I have been surprised by the amount of helpful parallels I could make between my studies and my experience with the disease.
One such application is called Cognitive Behavioral Therapy (CBT). CBT addresses how we think and behave, and how such thinking and behavior, when maladaptive, can mire us in emotional turmoil. Surely having RA leads to feelings of defeat and hopelessness. At the same time, I have found that concentrating on how I think about the disease helps me when I get stuck in dark places.
One component of CBT is to identify informal logical fallacies in our thought process, known as cognitive misperceptions. These cognitive misperceptions appeal strongly to our emotions, often in painful ways. Though they are frequently invalid, sometimes they are accurate, which makes them informal rather than formal. I list below some of my own cognitive misperceptions that I have identified along the way, and provide a personal anecdote to demonstrate it.
Slippery slope: This comes in the form of, “because of occurrence x, therefore occurrence y.”
When I was first diagnosed, I spent a lot of time researching RA and what the future might hold for me. The picture I painted in my head was grim, and caused me much grief and fear. These feelings came in the form of, “Because I have RA (x), then all of these awful things must happen (y).” It took me a long time to see that probability was not certainty, and that I had many options that could mitigate some of these bad outcomes. This does not mean that my fear departed entirely, for there is legitimate reason to worry with a progressive disease. However, I stopped thinking in deterministic fashion, embraced the uncertainty, and found myself more hopeful.
Illusion of Control: This comes in the form of a tendency to overestimate one’s degree of influence over external events.
I want to feel like I have some control over the course of the illness. The reality is that my control is neither total nor totally absent. I can make healthy decisions, I can reduce stress, I can exercise, I can stretch, I can rest, and I can take medication. Nothing I do however can rid me of RA, nor do all of these things guarantee a symptom free life. On my more optimistic days I believe that everything I am doing is going to drive this into remission. This is an illusion of control. I must accept the harsh reality that my actions may not push the disease into remission. However, I am willing to take the chance, despite my limited control, and do the best I can.
Illusory correlation: This comes in the form of inaccurately perceiving a relationship between two unrelated events.
When I was first diagnosed, I went on a rampage to discover the cause. I scoured my life, searching for possible contributors like air pollution, certain medications I have taken, all of the surgeries I have had, the ingredients in foods I commonly eat, and so on. I then poured through the medical literature looking for studies that might verify my hypotheses. I was desperate for a cause to explain why my life had taken such a dreadful turn.
I now accept that the cause is unknown. Abandoning the search has been liberating for me, and has freed me up to be more present with my family and my daily activities.
Impact Bias: This comes in the form of a tendency to predict the future based on the impact of current feeling states.
Every time I get a mild flare I think, “this will be gone in a few days.” If I am in a lot of pain, however, and the flare is bad, I think, "This is going to be here for a long time!" If I have had a few recent flares, with little down time, I think, “this is going to last forever!” These appraisals are biased by my immediate experience. The reality is that I simply do not know how long a flare will last. Some bad ones have cleared up fast, and some minor ones have stuck around for weeks. As I recognized this thinking pattern, I began to focus less on “how long will this last?” and more on “how can I best manage my life while this is going on?”
Optimism bias/wishful thinking/positive outcome expectation: This comes in the form of a tendency to overestimate favorable and pleasant outcomes. For example: “I expected to quickly go into remission, and was deeply disappointed when I did not.”
Pessimism bias: This comes in the form of a tendency to overestimate the likelihood of negative outcomes.
I had a horrific experience on my first TNF inhibitor and methotrexate combination. My liver was not functioning properly, and I periodically broke out in hives. I had daily migraines, and my life was reduced to one miserable minute after another. My doctor took me off the medication, which ended the hives and migraines; however, she wanted me to try a different TNF inhibitor and go back on the methotrexate. I was pessimistically biased, and thought, “it is just going to be another round of abject misery.” It took a lot to convince me to give it another go. Thankfully it is working effectively enough, though I still have intermittent swelling, stiffness, and fatigue. Had I remained entrenched in my expectation of negative outcomes, I might not have tried this combination that has made my life more manageable.
Selective perception: This comes in the form of a tendency for expectation to affect perception.
When I decided to try the new drug combination, I was restlessly vigilant in watching for side effects. So much so that I might have bordered on hypochondria for a few days. Because I expected side effects, many times I began to perceive them when they were just normal bodily sensations. When I relaxed about the possible side effects of the new drug, I was less stressed overall, which surely helps with RA.
Mood congruent memory: This comes in the form of a tendency to remember difficult times of the past during difficult times in the present, or vice versa, that the past is more favorable when the present is favorable.
When the swelling, fatigue, and stiffness are bad, I remember the past as being just as bad, and it leads me to despair. However, when I am well, I remember the past as easier than it actually was. The unfortunate consequence of this thinking is that when I am down and remembering the past as brutal and difficult, I become more depressed. When I am up, I am naive, and hard days take me by surprise. If I can remind myself that my recollection is biased, and remember the past as filled with both good and bad times, I am more present regardless of how good or bad the day is.
Rosy retrospection: This comes in the form of viewing the past as more pleasant than it was.
We have RA; of course life was better before we had it! This fallacy is subtle though. I sometimes find myself remembering the past as this paradise I used to know, and now I am living in paradise lost. This is quite depressing. However, when I realistically remember how many tough times I had in the past even before RA, I often find myself thinking, “I’ve weathered a few storms already, I can get through this!”
Though this is not an exhaustive list, I hope it shows how CBT can be applied to living with the disease. An exercise I found helpful is to write down what I am thinking when I feel depressed. I take a look at what I have written, and try to find contradictory evidence. I write that down as well. Often just seeing a more complete picture is helpful.
What mental and emotional challenges exist for you, and what have you found helpful to cope?
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