Coping with Real, Remembered and Imagined Stress III: Cognitive Methods
By Monica Neel, PSYD, Brett Thombs, PHD, and Jim Fauerbach, PHD
“…FOR THERE IS NOTHING EITHER GOOD OR BAD, BUT THINKING MAKES IT SO…”
—Shakespeare, Hamlet, Act 2, Scene 2
We could easily argue with the above quote by Shakespeare and say that some things truly are good or bad, regardless of what we think about them. However, it is easy to see that how we think about events can often intensify and prolong our feelings about them.
THE POWER OF MEMORIES
Being able to remember past events can be a gift in that we can learn from the past. We can remember wonderful events, reliving them in our minds and, perhaps, work toward making them happen again. We can also, of course, remember upsetting or even tragic events. This is also a gift, although perhaps a less obvious one. For example, our memory of tragic events can enable us to learn valuable lessons that we can then pass on to others. Similarly, we can also honor the memory of individuals, treasuring them, and perhaps sharing their goodness with others. In these ways and many others, memory of the past is a gift that helps to enrich or to protect our lives and those we interact with. Memory can also be a curse in that many times we find ourselves endlessly ruminating over past events without ever finding a way to let the memory fade into the background.
Being able to anticipate the future can also be either a gift or a curse. For example, we can plan ways to make good things more likely and bad things less likely. By the same token, anticipation and planning often turn into anxious worrying about bad things that might happen, or good things that might not happen, and these thoughts can cycle endlessly throughout the day.
HOW THOUGHTS INFLUENCE FEELINGS
It is impossible to understand our feelings without also understanding how our thinking influences them:
- Feelings of sadness or depression, for instance, can be triggered by self-criticism or thoughts of loss.
- Anxiety stems from thoughts related to anticipated threat or danger.
- Guilt is associated with thoughts that we are bad or have not lived up to expectations in some important way.
In general, moods and feelings also play a powerful role in what we notice around us (attention), what we think about (cognitions), and what we remember(memory). When feeling anxious or down, we notice more negative things around us, we begin to think in more pessimistic ways about ourselves, others, and the world around us, and we recall more memories of other times we have felt anxious or sad. Similarly, when we are anxious or sad we tend to be overly cautious and to exaggerate the possibility that even minor threats will occur and overwhelm us.
Perhaps not surprisingly, when we are thinking negatively and feeling depressed or anxious, our behavior also changes. When anxious or depressed, we tend to avoid those people, places, and things about which we are anxious or depressed. By avoiding these things, we never challenge our thoughts or allow our feelings to change. Thus a vicious cycle is brought to life: Negative thinking intensifies anxiety and depression which then motivate us to avoid things that upset us.
Becoming comfortable with one’s self after trauma requires developing new skills. It is very important to develop the ability to challenge patterns of thinking that lead to greater distress. We want to be able to recognize stressful situations when we see them, and not to unnecessarily create stress with negative thought patterns. Before outlining some thoughts on negative thinking it is important to highlight the obvious. Stress is real, and after a bad accident the most stressful situations often involve learning to face people and situations with a new appearance, lessened abilities, or reduced confidence. As we become more comfortable with these changes, those around us will be more comfortable interacting with us. By the same token, as those around us are comfortable interacting with us, we become more comfortable with the changes. In this article, we describe cognitive methods of improving your comfort with those changes brought about by a burn injury. Other articles in this newsletter and self-help materials (see References and Resources on p. 15) discuss the utility of social skills training in helping to smooth out difficulties in relationships.
THE IMPACT OF TRAUMA
Following a burn injury, changes in appearance and function, and memories of the trauma can all have a significant impact on how you think, feel, and act. A common post-trauma reaction is the development of disturbing beliefs about the world, people, and yourself. Frequently, after a very stressful event, we find ourselves ruminating about it (for example, “I wish things could be the same as before I got hurt”). Similarly, it is quite common to anticipate how upcoming events will turn out, and we find ourselves worrying about them beforehand (for example, “What if the accident happens again?” or “What if they notice my scars and make fun of me?”).
You may tend to adopt the view that even objectively safe situations are dangerous or to view yourself as incompetent or unable to cope with daily stressors. We tend to respond to this belief by either exaggerating the likelihood that the thing we fear will happen (for example, “I am certain that the accident is going to happen again, it’s just a question of when” or “I know that people will always look at my scars and be uncomfortable”). Another common response to the “What if…” type of worrying is called catastrophising (for example, “If I let myself get near to where the accident happened, I will be so anxious I will lose control and maybe cause another accident. Similarly, “If someone makes fun of my scars, I will feel devastated and never want to go out again.”). The way we think about changes in our appearance can also lead to changes in how we act. Imagine going to a social outing with a group of friends and noticing someone staring at you. If you focus on the possibility that the one staring at you may be critical of your appearance, then you may feel anxious or sad and wish to leave the situation. If, on the other hand, you focus on self-acceptance and are aware that you cannot be responsible for how other people think or feel or how comfortable they allow themselves to be, then you are likely to continue to feel happy and to keep having fun with your friends. Again, cognitive work is only part of the answer. Of equal importance are learning to relax, re-enter society, and practice ways to respond to new social challenges.
USING PROBLEM-SOLVING TO REDUCE STRESS
In the first two articles in this series,1,2 we described how it is all-too-common these days for our ruminations about the past and worries about the future to create distress in the present moment. We also described how simple focusing (for example, present sensory focusing, diaphragmatic breathing) and exposure (for example, in vivo, imaginal) methods can help break the endless cycle of ruminating and worrying. We suggested that, in most cases, it is useful to set aside up to 1 hour each day to focus on turning automatic thoughts about the past or future into problems that can be solved. In this section, you’ll learn some methods for doing so.
During your recovery, you may have experienced feelings, like sadness, guilt, shame, or rage that can seem overwhelming. While you cannot change what has happened to you, you can learn from what has happened and begin to find peace with it. An important goal in the recovery process is accepting the reality of what happened. Acceptance frees up energy and allows that energy to be used for the task at hand. The task at hand is, broadly speaking, to dedicate yourself to living fully and fruitfully in the present moment. You may feel angry, sad, or guilty about the accident and how it happened. You may feel anxious about returning to the place you were injured. You may feel distress about changes in your appearance. These are some of the most common feelings that people have after a trauma. They are healthy feelings and it is important to experience them in healthy ways. If you find yourself endlessly thinking about how you were before the injury or asking yourself “What if…” or having catastrophic thoughts, try thinking about them as a source of motivation. They may be telling you to
- Pay attention to important things that have changed.
- Try to see if there is anything useful to learn from what has happened.
- Use that new knowledge to plan for your future.
Thinking about important losses and about how to prepare for the future is essential for recovery. In the discussion below, we encourage you to work with your thoughts about how you were injured (traumatic memories) and about the changes in your appearance (body image).
SAFETY AND PREVENTION
A major problem in recovering from trauma is finding a way to think about the bad things that happened. Some people find that their accident undermined their feeling of safety. Safety comes from knowing that threatening things can be prevented from harming us. That is, we feel safe when we know that we can do things that make bad things less likely. We often try to control bad things by preventing them from happening or by stopping them once they have started. For example, if you have been embarrassed at a restaurant by someone’s staring or rude comment, you may wish to avoid the embarrassment by leaving and by avoiding similar public places. This is clearly a situation where new tools for managing social reactions would be helpful. Perhaps a future article in this series could address some strategies. Cognitive work is useful in these situations to improve your comfort with yourself. That is, by accepting and valuing yourself you can reduce the discomfort that may arise when other people act inappropriately. Furthermore, this may help to prevent the all-toocommon and all-too-human mistake of seeing stress where none truly exists.
When you notice that you are “exaggerating the likelihood that bad things will happen” or when you notice that you are thinking that “if it does happen it would be catastrophic,” try asking yourself the following questions:
- What is the evidence for or against the exaggerated thought or the catastrophic thinking?
– If my fear does come true, what is the worst that could happen?
- What is the best that could happen?
– What is a more realistic outcome?
- Is there another way to explain what happened (for a past event)?
– If it really did happen exactly as I remember it, is there another way to think about the upsetting part of the memory (for example, what I did, what they said or did, etc.) that helps me be more accepting and less critical?
- Does it somehow help me to think this way? What effect do these thoughts have on me, my daily life, and the people around me?
– Most of the time, worrying makes us tense and anxious and no more prepared to deal with what is really happening.
– Most of the time, thinking badly about ourselves, other people, or the world prevents us from enjoying good things or coping well with challenges.
- What could happen if I allowed myself to be more accepting of what has happened, and to think more realistically about things?
– You may get a feeling of safety by knowing how likely it is that bad things will happen. If you can more accurately predict that certain people, places, events or situations make accidents or rude behavior more likely, you can prepare ahead of time how to deal with them. Even more importantly, by knowing how to take control of situations and our responses to them you may feel more empowered.
The exercises in this box and the ones that follow may be useful in helping you to think through some of what you has happened to you. The exercises in the left-hand columns may be helpful in thinking about how you were injured and in returning to the same activities and locations. The exercises in the right-hand columns may be helpful in thinking about the ways that your wounds or scars have changed your appearance.
List your thoughts about any places, people, events, situations, and behaviors that you think made your injury more likely.
BODY IMAGE-RELATED TASK
List any thoughts or reactions that you have had while observing your altered appearance that made the experience more upsetting to you.
Doing the above exercises may generate some feelings that are quite unpleasant. You may tend to get caught up in these feelings when they come. You may also often try to run away from them. This time try something a little different. Try holding the feeling without being consumed by it. Allowing yourself to do this consistently may open your mind to new ways of thinking about what happened or about any changes in your appearance.
CONTROLLABILITY AND PREDICTABILITY
All of us want to have some control over our safety, and to be able to predict those situations in which we are less safe. Human beings evolved the ability to remember dangerous situations they had experienced. Just like our ancestors living in caves, if we can tell what makes danger more likely, then we can plan for how to handle such situations in the future. One important part of this learning is identifying causes of the bad events.
The exercise that follows may help you to identify things you can do to help increase your comfort and acceptance of changes in your appearance caused by the burn.
What thoughts do you have about what made the accident happen?
- What signals could have warned me that this accident was more likely to happen?
- Are there any ways that this accident could have been prevented?
BODY IMAGE-RELATED TASK
What thoughts do you have as you observe your new appearance?
- Are there things that I can do to make my new appearance as good as possible, or things that I can do to help me to accept these changes in my appearance?
CAUSES AND COMFORT
When bad things happen, we want to know “Why?” or “What caused this?” When the cause is unknown, we are uncomfortable. For example, if you do not know how your accident occurred, you are more likely to be uncomfortable when in similar settings. In a similar way, when bad things happen because of things that cannot be changed, or that affect all parts of our lives, we are uncomfortable. If you believe that the things that caused your injury are always nearby and that they can invade anytime and anywhere, then you will be uncomfortable wherever you go. In a similar vein, if you are uncomfortable with your new appearance, you might feel awkward in many social situations.
The following scenario illustrates these concepts:
Imagine someone named Joe standing at a corner near a bus stop surrounded by people, with cars, trucks and busses zooming past. No matter which way Joe walks, he is in immediate danger. The danger signals are clear and unmistakable and lead Joe to stay where he is. Now let’s see what happens when traffic stops because of a red light and Joe has the pedestrian signal to cross safely. The safety signals are clear and unmistakable, but Joe does not recognize them. Joe had been hit by a car a week ago and is now convinced that anytime he is close to a car he is in extreme danger. Joe does not recognize that the specific cause of his accident (a car in motion) is no longer present (all traffic has stopped). He is making common mistakes in his thinking: Joe believes that the cause of his accident is global (any car or truck) and always present (anytime and anywhere) and that he has no skills that can prevent its recurrence. These thoughts prevent Joe from being able to tell that it is safe to cross the street at the crosswalk with the pedestrian light when traffic has stopped. Relatedly, Josephine is standing next to Joe at the bus stop feeling threatened by the crowd of strangers since she recently experienced a very hurtful comment in a similar situation. She is making the same mistakes in her thinking as did Joe. She believes that the cause of her distress is global (any stranger) and always present in social situations (anytime, anywhere), and that she has no skills to cope with another insult.
This exaggerated fear is nature’s way of making sure that we stop, look, and listen. By taking time to identify causes and to learn from the experience, we can plan how to get control over our lives again.
We may be able to know on a rational level that these ways of thinking are inaccurate, yet this is exactly what many of us experience after a trauma or when challenged by an altered appearance. We begin to fear that we are in danger, no matter where we go and no matter what we do. In response to feeling threatened, we begin to avoid many places that we think put us in danger. This exaggerated fear is nature’s way of making sure that we stop, look, and listen. By taking time to identify causes and to learn from the experience, we can plan how to get control over our lives again.
Thinking About Causes of the Problems. The first excercise below may help you to further refine your understanding of what caused the burn injury, and the second exercise may help you to further clarify things that you can do to help increase your comfort and acceptance of changes in your appearance caused by the burn.
Think about what you described above as the cause of your accident. Are there more specific ways to describe it? Write down the specific causes of your accident.
- What thoughts do I have about what I did or did not do?
- What thoughts do I have about what others did or did not do?
- What safety features or practices were not being used?
- What evidence do I have that I will never be able to cope with the situation again?
- What evidence do I have that I will eventually be able to feel safe and cope well doing the activities and while in the place I was hurt?
BODY IMAGE-RELATED TASK
- Think about what thoughts or behaviors make it harder for you to begin accepting the changes in your appearance. Write down the specific causes.
- What did I feel when looking at and touching my skin? What thoughts did I have? Did these thoughts make me feel better or worse?
- What do other people say or do that helps me feel more comfortable about my appearance?
- What evidence do I have that I will never be able to get used to my new appearance?
- What evidence do I have that I will eventually be able to tolerate and accept these changes?
Thinking About Controlling and Preventing Problems. In the exercise on the left, you can use the work you have done in the earlier exercises to help you to prevent another burn accident and to feel more comfortable in similar situations. Similarly, you can use the work you did in the above exercises to help you increase your comfort and acceptance of changes in your appearance caused by the burn.
- What are some of the ways in which you can prevent another accident when you go back to the same place and activities where you were hurt?
- Are there ways to make the place where the accident happened safer?
– What can I do or not do?
– What can others do or not do?
- Are there other ways to lower the risk of the activities that I was doing when I got hurt?
- What safety features or procedures can be put in place, revised, or re-instituted?
- How can I make sure that these safety features and procedures are put into practice?
BODY IMAGE-RELATED TASK
- What are some of the ways in which you can prevent negative thinking from making you feel worse about your new appearance?
- Are there ways to make my scars better (for example, scar massage, pressure garments, reconstructive procedures)?
- Are there ways to make my scars less obvious (for example, cosmetic image enhancement, reconstructive procedures)?
- Are there standard ways of talking to myself, or relaxing and focusing (for example, rubbing lotion on my skin) that can increase my selfacceptance and comfort?
- Are there things I would like my friends and family to do (for example, massages, act natural around me), or not do (for example, avoid looking at or touching me), that would help make me more comfortable with my new appearance?
When all of these lessons have been learned and applied consistently over time, it is possible that your safety will be maximally protected and that you will be able to return with greater confidence to the place and activity you were engaged in when injured. Similarly, when all of these lessons have been learned and applied consistently over time, your self-acceptance will begin to return and you can more confidently observe and touch the areas of your body that have changed. At that time, when you return to the scene of the accident or are ready to begin accepting the changes in your appearance, try using the present sensory focus and diaphragmatic breathing from the first article in this series1 to help maintain your attention on the task at hand. Remember, you may feel distress the first couple times; that is expected since work this important can take time. If you feel more uncomfortable than you would like, try using the exposure methods described in the second article of this series2 so that you can become more comfortable each time you do this. As noted above, there are many resources available to help learn new behaviors in awkward, unpleasant, or rude social situations, some of which are referenced below. Finally, one also has to ask, is it time to actively pursue social change through mass media outlets in order to improve societal acceptance of atypical appearance?
WHEN TO SEEK PROFESSIONAL ASSISTANCE
There are times when distress is severe or prolonged and too difficult to overcome solely with your own resources. If this is the case, the guidance of a mental health professional can allow for a more systematic training in overcoming negative thinking or help you to find another strategy that will work best for you.
1. Neel, M., Fauerbach, J.A. Coping with Real, Remembered and Imagined Stress: Focusing Methods. Burn Support News, Spring 2003
2. Neel, M., Fauerbach, J.A. Coping with Real, Remembered and Imagined Stress: Exposure Methods. Burn Support News, Fall 2003.
Beck, J. S. (1995). Cognitive therapy: Basics and Beyond. New York: Guilford Press.
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Cash, T. F., & Pruzinsky, T. (Eds.) (2002). Body Image: A Handbook of Theory, Research, and Clinical Practice. New York: Guilford Press.
Cash, T. F. (1997). The Body Image Workbook: An 8-Step Program for Learning to Like Your Looks. Oakland, CA: New Harbinger Publications.
Cash, T. F. (1995). What Do You See When You Look in the Mirror?: Helping Yourself to a Positive Body Image. New York: Bantam Books.
Craske, M. G. and Barlow, D. H. (2000). Mastery of Your Anxiety and Panic—Third Edition (MAP-3): Client Workbook. San Antonio, Texas: The Psychological Corporation (800-211- 8378; Fax: 800-232-1223; http://www.PsychCorp.com/).
Quayle, B. (2004). The Book of Image Enhancement for Burn Survivors: A Common Sense Guide to Creating Your BEST Image. Washington, DC: International Association of Firefighters and IAFF Burn Foundation.
Quayle B. “When People Stare,” Burn Support News, Summer 2001.
Quayle B. “Tools to Handle Questions and Teasing,” Burn Support News, Fall 2001.
Partridge, J. (1990). Changing Faces: The Challenge of Facial Disfigurement. London: Changing Faces (Penguin).
Sarwer, D.B., Pruzinsky, T., Cash, T.F., Goldwyn, R.M., Persing, J.A., Whitaker, L.A. (Editors). The Psychological Aspects of Cosmetic and Reconstructive Surgery (to be published in 2006). Baltimore: Lippincott, Williams & Wilkins.
Monica L. Neel, PsyD, recently completed her psychology post-doctoral fellowship at the Johns Hopkins University School of Medicine. Currently, she is teaching several university courses and is establishing a private practice.
Brett Thombs, PhD, is a psychology post-doctoral fellow at the Johns Hopkins Pediatric Burn Center at Johns Hopkins Hospital and at the Johns Hopkins Burn Center (formerly the Baltimore Regional Burn Center) at Johns Hopkins Bayview Medical Center. He is study coordinator for the NIDRR burn model system grant awarded to the Johns Hopkins University (H133A020101, Theresa San Agustin, MD, Program Officer).
James A. Fauerbach, PhD, is the chief psychologist at the Johns Hopkins Pediatric Burn Center at Johns Hopkins Hospital and at the Johns Hopkins Burn Center (formerly Baltimore Regional Burn Center) at Johns Hopkins Bayview Medical Center. He is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine and is Principal Investigator for the NIDRR burn model system grant awarded to the Johns Hopkins University (H133A020101, Theresa San Agustin, MD, Program Officer).
This story is an excerpt from The Phoenix Society’s® Burn Support News, Winter Edition 2004, Issue 4. Burn Support News is a tri-annual publication that contains articles on the emotional, psychological, and social aspects of burn recovery. All Rights Reserved.