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Cognitive Diary Example

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The following is an example to help learn how to identify and change irrational thinking. It is best to read the articles defining the irrational styles of thinking prior to trying to identifying the styles in the example. It uses the format of the COGNITIVE DIARY CBT SELF-HELP app. Read: Understanding and Using the Cognitive Diary.

Back-stabbing Doctor

EVENT: Colleague is passive-aggressive in front of the residents.

EMOTIONS: frustration, hurt, distress

DISTRESS RATING: 9--Feeling desperate

THOUGHTS: "A doctor I work with feels I am "too proud" and independent in my work. He dislikes my personality, and that's ok--we don't have to be buddies. But he has taken to telling each new group of residents that there is no point discussing anything with me because I am overbearing. He tells them they should just avoid discussion and agree with me. When I present an assessment in rounds he covers his eyes and bows his head. After he leaves, if I need to speak to one of the residents about a patient having problems, I can see them bracing themselves as I approach or rolling their eyes even though we may have never yet spoken to each other! I am viewed as a competant and compassionate doctor by families and co-workers, but this treatment is distracting and disheartening. It is making it difficult to provide safe care, to the point that I have considered leaving my practice.”

CAN YOU IDENTIFY THE IRRATIONAL THINKING IN THIS EXAMPLE? There are at least 3 irrational beliefs.

HOW CAN YOU CHANGE THE THINKING? What is another way of thinking about the situation that won't cause the feelings of frustration, hurt, and distress?

The Cognitive Diary CBT Self-Help app helps you to determine some ways to challenge the irrational thinking. Once you have done that, it is important to read the rational challenges frequently until they automatically come to mind rather than the irrational thinking.

ANSWER:

This question was submitted to Passive-Aggressive Examples and is discussed in the Passive-Aggressive Example regarding possible ways to handle the situation. However, there also appeared to be some irrational thinking that could be addressed so it is discussed here as well.

Irrational Beliefs:
1) Mind-reading. The mind-reading tendency is very strong and understandable in this type of situation especially if she has evidence that he primes the residents about her before she meets them. Most people would probably engage in mind-reading under these circumstances. However, she is still interpreting the residents' reactions and then reacting accordingly. This is often how introverts manage a social context--they "read" the situation and then try to respond in a way that fits in. The problem here is that she doesn't believe she has a response that allows her to present herself in the way she prefers--as "compassionate and competent." Therefore, she feels she lacks control over the situation and sees her only option is to quit her practice.

Other options are available but she may need to step outside her comfort zone and be more flexible. For instance, as I tell my clients, if you observe extroverts, they do not typically engage in mind-reading. Extroverts are not trying to figure out what other people are thinking and then adjust their behavior accordingly. Instead, they just act. And what happens? Generally, others respond to them in a positive way. So, one rule I set for myself with mind-reading is that if somebody doesn't say something directly to me, I pretend it doesn't exist. Therefore, it does not influence my ongoing interaction with that person.

Why is this useful in this situation? Because it is not the first interaction with someone that is the problem, it is the second, third, fourth interactions. In other words, if she is concerned about their negative reactions to her, then she creates a self-fulfilling prophecy by acting in a way that actually creates a negative impression. Instead, if she ignores their initial reaction and focuses in a way to create a positive interaction, then they are likely to base their opinion on their experience of her rather than on the colleague's statements. In this way, she undercuts the doctor's attempts to make her look bad.

2) Catastrophizing. When she makes the statement that it is "difficult to provide safe care, to the point that I have considered leaving my practice" it appears that she is catastrophizing. Obviously, I don't have the full information regarding the situation but it is unlikely that this colleague's behavior could cause such an extreme situation--unless she allows it. For instance, if the residents just nod and agree but then ignore her assessment, it could compromise care if she doesn't insist upon appropriate follow-through.

She appears to be a very conscientious doctor who would prefer to leave her practice than to affect the care of her patients. Unfortunately, however, there are many ways people such as her colleague can appear in her life and she needs to have effective ways to deal with them. In this situation, she needs to remind herself that because she is competent, even though she may have to step outside her comfort zone, she is not the type of person to let her patients' care be compromised. Therefore, the situation is not likely to be catastrophic.

Recognizing that the issue may not be patient care, however, may lead her to having to recognize the true reason for leaving her practice. Most likely it is due to not wanting to deal with this unpleasant situation. To manage this situation she needs to use methods that may not be consistent with her personality and may be uncomfortable for her. For instance, in the Passive-Aggressive Example response, I suggested that she could get to know the residents informally prior to her colleague's interference.

3) External Control. Most likely, this doctor usually operates with a great deal of internal control: "Give me a problem to solve and I will figure it out." With the medical problems of her patients she is able to competently diagnose and treat with compassion. But this problem is different--she is confronted with an arrogant, sociopathic person who just wants to hurt her. This is one of the more difficult situations that people can encounter. But enounter we do--very few people can get through life without being confronted by such a person.

So, in this situation she feels helpless and out-of-control. Thus, this is the irrational thinking style of external control where a person feels that their efforts don't make a difference because it is outside forces that are acting on them. Most likely she is an introvert who normally feels very much in control but when it comes to manipulating social interactions she feels helpless. This is exactly what her passive-aggressive colleague is trying to achieve: by making her feel helpless he can make her appear less competent which makes him appear more competent.

She needs to recognize that she still has ways to control the situation. The only way he can win is to allow him to control her reactions. If she recognizes that she still has control over her reactions and how she deals with the residents, then he cannot control her. In this way she takes away his power in the situation.

Obviously, this is a very difficult situation. But one thing to always remember when we are confronted with difficult people: we may not be able to control them, but we always have control over our own reactions.

How Can This Thinking Be Changed?
"This doctor is cruel and hurtful but I will not allow him to control my behavior. I still have choice in how I respond and the relationships I develop with the residents. I do not know what the residents are thinking and I will not make assumptions. I have good interpersonal skills and I will just ignore how this doctor is trying to poison my relationships with the residents. Instead, I will focus on developing personal relationships with them just as I do with my patients. "

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