A Cognitive Restructuring Story, Part 1

If you suffer from chronic anxiety and worries, chances are you look at the world in ways that make it seem more dangerous than it really is.

For example, you may overestimate the possibility that things will turn out badly, jump immediately to worst-case scenarios, or treat every negative thought as if it were fact. You may also discredit your own ability to handle life’s problems, assuming you’ll fall apart at the first sign of trouble. These irrational, pessimistic attitudes are known as cognitive distortions.

 
In this note I want to give you a quick introduction to one of the most powerful psychological techniques discovered in the last few decades.  The technique is based on the premise that much psychological angst is based not on what actually happens in our life but on our perception of what is happening.   Since most of our perceptions are distorted, our internal experience is usually warped.

It turns out that when people clear up distortions, they feel a lot better.  The way to do that is called Cognitive Restructuring.
Jackie and I first heard about it when we became certified in mind-body medicine quite a while back (early 90’s? – I should keep a better journal).  We trained with the people at what was the Harvard/Deaconess Mind-Body Institute.  Cognitive restructuring is one of the cornerstones of their approach to wellness and for good reason.

Although cognitive distortions aren’t based on reality, they’re not easy to give up.    We all develop certain habits of thought, ways we typically respond to or think about things.  Our way of thinking can become so automatic that we’re not even aware of it – we just do it.

Some habits serve us, others don’t.  I our habitual way of thinking isn’t helpful, change is possible, but, like changing any habit, it can be a bit of a challenge to change at first.  But it’s well worth making the effort. 
I’ll tell you about the most common cognitive distortions at some point, but right now I want to tell you a story that will show you how perceptions can be changed and why one might want to put in the effort to do so.

Quite a number of years ago, I arrived at the hospital bright and early one Monday morning and got the message that my colleague who had been covering for me had admitted a patient to my service.

The patient was a man in his early 20’s.  A couple of years previously I had biopsied a lymph node in his neck that turned out to be a lymphoma.  Treatment of that cancer rarely requires surgery and would fall to physicians in other specialties.  However I was the one who made the diagnosis and had to explain it to the young man and his family.  As I did so we developed a good relationship.  

That was why he asked for me when he needed to be admitted.
The treatment of the lymphoma had gone well.  He missed a year of school as he endured radiation treatment and a round of chemotherapy, but the cancer was gone.  Now, a few years later, he was going to school at the local community college, playing guitar in a band and in love with his girlfriend.  A good kid from a nice family.

He came to the hospital because he had some crampy stomach pain and nausea.  I won’t bore you with the medical details, but he had none of the signs you’d expect with appendicitis or the other common causes of abdominal pain in a young person.

The surgeon who was covering for me thought it might be gastroenteritis.  .  He admitted the young man for IV fluids and so we could keep an eye on him.

After I saw my patient and went over things,  I thought the covering surgeon was probably right.   Gastroenteritis will usually get better on its own over a few days and I fully expected that he’d be better soon with just some rest and IV fluid.

But things changed.  Over the course of the day the pain got increasingly worse.  Yet every test and x-ray and scan I ordered came back normal.

 
By that evening he was in excruciating pain that even morphine wasn’t touching and I had no idea what was going on.
My recommendation was for an exploratory laparotomy.  Crudely put, to open him up and see what was going on.

 
Surgeons aren’t big fans of operating without a diagnosis.  With the tests available today it doesn’t happen as often as it used to.  But there are still times when the decision to operate without knowing what it is you’re dealing with.  It’s one of the harder decisions a surgeon has to make.

The parents and the patient trusted me and agreed to surgery,  which is how I found myself that same night in the operating room standing on the surgeon’s side of the table under the glare of the lights.  I made the incision…

The entire small intestine was black, gangrenous. 

My first thought was “I can’t fix this.  This kid is going to die.”

Then I thought about the parents and girlfriend out in the waiting room and the conversation I’d have to have with them.

My mind was racing.  Why would a twenty year old have gangrenous gut?  That’s a problem of old people with bad vascular disease.  In that population, the classic warning to keep in the back of your mind is that bowel losing its blood supply could cause “pain out of proportion to physical findings”, but this was a young man. 

 
Was there some weird thing with lymphoma that I didn’t know about that would put him at risk for this? What about his chemo?  Those drugs can have significant long term consequences.  Could this be some weird long term side affect?  What about…

I wanted to be anywhere but there.  But you can’t do that when you’re the surgeon.  You have to deal with things as best you can.  Ideally you appear calm and methodical as you do it,  regardless of your inner turmoil.  The rest of the operating room team looks to the surgeon for leadership.  Nothing can make a bad situation worse quicker than the rest of the people in the room sensing uncertainty in the operating surgeon.

This is where training and focusing on the task at hand comes into play.  It’s an ischemic bowel issue.  Go through the check list.  Does it look like it’s a venous or arterial problem?  How much is clearly dead and how much can I safely leave?  Don’t get blinded by the obvious problem and make sure there’s nothing else going on.

Long story short, we got through the operation.  I spent a lot of time in ICU with him for the next couple of weeks.  The nurses did a great job of caring both for him and his family.  He lived long enough and became stable enough that we could transfer him to a tertiary medical for evaluation for possible bowel transplant. 

 
He died there.

It turned out that the reason his bowel died was that he had a congenital blood problem that made his blood more likely to clot easily. We made the diagnosis within a day or two of surgery.  There was nothing we could have done differently.

When I checked in with the docs who were taking care of him at the medical center, they were very complementary about the treatment we had given him and our approach to the whole situation and some of the post-op challenges that came up ( a simple example: he needed high dose anti coagulation to keep from clotting off anything else, but he just had major surgery and treating him with anti coagulants put him at great risk for bleeding.  Using anticoagulants in that situation was walking a tightrope.)

As you might imagine, that case was an emotional drain on me. 

 
And of course, he wasn’t my only patient I was responsible for or the only challenge I faced over the weeks I was caring for him.   I was also trying to have some life of my own outside of the ICU and the hospital.  It was just a lot to deal with, but that what surgeons do and I had thought I’d been a surgeon long enough that I would handle it OK.  I usually did.

But this time weeks went by and I still found myself feeling crummy.  Kind of down.  Not clinically depressed, but not feeling very good about myself and not enjoying life very much.

I knew it was somehow related to that case, but didn’t know quite why.  It finally occurred to me to try cognitive restructuring – you know, practice what I preach.  It was quite remarkable what came up and how quickly the emotional turmoil can depression cleared once I took only half an hour or so to clear up my perceptions.

I want to tell you about that, but this page has gotten overly long as it is.  If you want, you can find the rest of the story at:

A Cognitive Restructuring Story Part 2