In the weeks after her mother died, Stacy’s mind was filled with thoughts about things she believed she’d done wrong and ways she’d let her mother down. “I shouldn’t have gotten so impatient with her”; “I should have been kinder, should have spent more time with her.” She was even tormented by the inaccurate belief that she had caused her mother’s death by failing to “try harder to get her to eat.” Painful thoughts and emotions coupled with harsh self-judgments and fear about the future. “I’m a horrible daughter”; “I’ll never forgive myself.”
When staff at the nursing facility where her mother had lived reassured her that she’d been loving and encouraging, she dismissed their input as platitudes intended to assuage her guilt. The hospice physician explained that her mother’s appetite had diminished because she was dying from an irreversible terminal disease. Pushing food would not have prolonged her life and would have elevated the risk of aspiration and choking. Yet, Stacy’s self-castigating beliefs persisted.
One of the factors known to influence the trajectory of someone’s bereavement is the “cognitions that the mourner holds about the loved one. Specifically, thoughts about the person who died, reflections on their relationship, and assessment of one’s own ability to survive (whether in a practical or literal sense) without the deceased.” Second-guessing oneself, regrets, anxiety about the future, and/or occasional guilt-laden thoughts are common in those who are grieving. These usually resolve over time as a grieving person accesses support and gains perspective. In some cases, though, when a griever becomes caught in patterns of disproportionately negative thoughts, it can increase the risk of complicated or prolonged bereavement.
As such, it’s important for those working with grieving clients or patients to be aware of some of the cognitive distortions common during times of loss. Cognitive distortions are inaccurate thoughts, beliefs, or mental filters that can negatively impact perceptions about oneself, others, and the world. Distortions are not based on facts. They are often automatic, unconscious, and can cause one to believe that things are worse than they really are.
Thoughts that bring sadness or regret are normal parts of bereavement. Recognizing cognitive distortions does not mean these thoughts and feelings are “negative.” It means recognizing when patterns or habits of thought are unnecessarily intensifying or prolonging emotional and psychological pain or blinding those who are grieving to their underlying strengths or positive experiences.
Though we are all susceptible to cognitive distortions, those struggling with emotional pain, mental and physical fatigue, and the disorientation of grief may be even more susceptible. Stress, vulnerability, and sadness can make it easier to fall into and reinforce negative thinking.
In his pathbreaking book Feeling Good: The New Mood Therapy, psychologist David Burns identified ten core cognitive distortions associated with depression and/or anxiety. Stacy’s grief illustrates several examples also common in those who are grieving:
All-or-nothing thinking: Seeing things in black-and-white categories. Stacy’s belief, for example, that she is a “horrible” daughter because of some perceived failure to measure up. Instead of simply acknowledging some regrets as she looked back and allowing herself to be human, thus imperfect, her belief that she is a bad daughter is global and inflexible.
Disqualifying the positive: Rejecting positive experiences as unimportant or as “not counting.” Think about how Stacy rejected the staff’s assurances that they had witnessed ongoing expressions of love and care for her mother and chose to over-focus on perceived failures.
Jumping to conclusions: Asserting a negative interpretation despite a lack of evidence, or evidence to the contrary. Stacy’s insistence, for example, that she hastened or caused her mother’s death despite education and information to the contrary.
Stacy may also have been reinforcing this negative belief with personalization: believing she was the cause of an external event for which she was not responsible. Believing things beyond her control were her fault.
Should statements: Judgment-laced statements about what one “should,” “should not,” “must,” or “ought” to do. The emotional consequence of these statements is often guilt, anger, or a sense of failure. “I shouldn’t have gotten so impatient with her”; “I should have been kinder, should have spent more time with her.”
Fortune teller error: Anticipating or being convinced that the future will turn out badly, as with Stacy’s certainty that “I’ll never forgive myself.” According to psychotherapist Michael Schreiner, “In the throes of grief, fortune telling manifests as the idea that you’ll never be happy again, that there’s no reason to expect anything good out of life anymore, that how you’re feeling now is how you’re going to feel forever.”
In the decades since Burns identified these and other cognitive distortions, dozens more have been recognized. Jo McRogers, a social worker specializing in grief, has found all-or-nothing thinking and should statements to be among the most common grief-related cognitive distortions. Another is the control fallacy, in which someone over- or underestimates the amount of control they have over situations or events—either thinking they are in complete control or have none.
Stacy’s belief that she had control over whether her mother died (“If I had pushed more food she would not have died”) is an example of an exaggerated sense of control. On the other hand, the death of a loved one can be so overwhelming it can shatter one’s sense of control and create a belief that one is helpless before the pressures of external events. That effort is futile.
Mental health counselors are familiar with ways to help clients examine patterns of distorted thinking and strategies for changing them. For those not trained in counseling, though, while it can be helpful to gently point out cognitive distortions, this also has the potential to come across as blaming, judgmental, or invalidating. Or as attempts to “reason” someone out of what he or she is feeling or impose “positive thinking.”
McRogers suggests we can often help patients and clients take small steps. For those paralyzed by a belief that they have no control over their situation, for example, she suggests finding concrete, achievable ways one can gain even “the simplest level of control.” This may mean intentionally drinking more water or eating a nutritious snack as an expression of self-care. It may mean taking a short walk to move one’s body or breathe fresh air.
Health care professionals can also notice and draw attention to exceptions to negative thoughts. If someone consistently discounts the positive, observing or inquiring about positive exceptions can raise awareness about the existence of these self-sabotaging cognitive patterns and begin to alter narratives about oneself and the capacity to cope. Rather than offering general reassurances, for example, the staff at the nursing facility might have recalled a specific instance of Stacy’s kindness towards her mother and paused to explore this exchange and anchor it into her awareness.
Being alert for cognitive distortions in patients and clients can sensitize us to their challenges and make it less likely we will reinforce unhelpful patterns of thought. Listening for distortions can guide us as we offer patients and clients information, resources, or psychoeducation. It can broaden our awareness as we hear their stories, inquire into their concerns, and offer support.
Scott Janssen is a social worker.
