Cope with Your Stress

You're at the mall with your father, who has Alzheimer's. One moment he's standing placidly next to you. The next moment, he's gone.



Where is he? You immediately start whipping yourself. You're a failure as a caregiver. That thought sends you into an emotional tailspin. Your failure as a caregiver proves that you're a worthless person. What's wrong with you anyway? You never keep close enough watch on Dad. Now you feel really terrible. He's sure to wander out into the middle of the boulevard and get hit by a car. Then the whole family will hate you.



Now how do you feel? Probably really awful -- depressed, stressed out, self-hating, and berating yourself for ever thinking that a dolt like you could care competently for someone with Alzheimer's disease.



If any of this sounds familiar, then a pair of pioneering Philadelphia psychiatrists, Aaron Beck, M.D., and David Burns, M.D. have two words for you: cognitive therapy.



"Cognitive" refers to your thought processes, the very processes people with Alzheimer's lose. Cognitive therapy is a powerful, deceptively simple self-help technique for dealing with emotional negativity by consciously changing the way you think. It's especially good for relieving the anxiety, depression, and helplessness that are rife among Alzheimer's caregivers. Cognitive therapy is easy to learn. It does not require any medication, or a professional therapist (though many psychotherapists teach it and coach people in its use). Many people become quite skilled at it simply by reading Dr. Burns' two books on it: Feeling Good: The New Mood Therapy and The Feeling Good Handbook.



What causes negative feelings?


The cause of negative emotions -- anxiety, anger, impatience, depression, frustration, guilt, irritability -- is a matter of opinion. To Freudian psychoanalysts, these feelings are the result of repressed feelings that typically date back to childhood relationships with one's parents. To biological psychiatrists, they stem from chemical imbalances in the brain. In recent years, the Freudians have lost considerable ground to the biological psychiatrists and their new battery of antidepressants: Prozac, Zoloft, and Paxil, among others. Antidepressants successfully pull people out of serious depressions, and may benefit some depressed Alzheimer's caregivers. But before you ask your doctor for a prescription, try cognitive therapy.



To cognitive therapists, negative emotions are caused by distorted thinking. This view is comparatively new to the mental health profession, but it was first espoused more than 2,000 years ago by the Greek philosopher, Epictetus, who said, "People are not disturbed by events themselves, but rather by the views they take of them." Shakespeare reiterated this in Hamlet: "There is nothing either good or bad, but thinking makes it so."



Recent research shows that cognitive therapy has a great deal to offer people who must contend with the stress, anxiety, and frustrations of Alzheimer's caregiving. In a 1989 study, researchers at the University of British Columbia in Vancouver analyzed 28 separate studies comparing how people fared after different types of mental-health therapy. Those using cognitive therapy did better than 98% of those who had no therapy, better than 70% of those who took antidepressant drugs, and better than 70% of those who tried the various forms of talk psychotherapy. Not bad for an approach that costs much less than any other.



The 10 forms of "distorted thinking"


Dr. Beck developed cognitive therapy in the late 1960s when he discovered that simple exercises designed to correct distorted thinking had powerful benefits for those suffering from depression and anxiety attacks. He and Dr. Burns documented 10 types of distorted thinking. How many of these emotional traps have you fallen into?

  • All-or-nothing thinking. You see things as black or white. If your father wanders away from you at the mall, you're not the perfect caregiver, therefore, you're a total failure.




  • Labeling. An extension of all-or-nothing thinking. You make a mistake by taking your eyes off your father for a moment, but instead of thinking "I made a mistake," you label yourself a worthless person.




  • Overgeneralization. The tip-offs are the use of the words "always" or "never." Your father wanders away and you think: I'm never able to keep an eye on him. I always mess up.




  • Mental filtering. In complicated situations that involve both positive and negative elements, you dwell on the latter. Your father had a good time at the birthday party you made for him, but didn't eat any cake. You filter out everything but the cake and whip yourself for being a lousy baker.




  • Discounting the positive. The tip-offs here are the phrases: "That doesn't count," "That wasn't good enough," or "Anyone could have done it." You manage to have your father bathed, dressed, and happy at your cousin's wedding. A relative praises your caregiving, and you think: "Anyone could have done it."




  • Jumping to conclusions. You assume the worst based on no evidence. Your father wanders away at the mall, and you assume he'll be hit by a car.




  • Magnification. You exaggerate the importance of problems, shortcomings, and minor annoyances. Your father drops a plum into the toilet, and you believe you need your entire plumbing system replaced.




  • Emotional reasoning. You mistake your emotions for reality. "I feel nervous about sending Dad to adult daycare, therefore, it must be wrong for him."




  • "Should" and "shouldn't" statements. You can't let go of the fact that your Dad wandered away from you at the mall: "I shouldn't have allowed that to happen. I should always have an eye on him." Other self-demanding tip-off words include: "must," "ought to," and "have to."




  • Personalizing the blame. You hold yourself personally responsible for things beyond your control. Your Dad can't handle a church social, and you think: "I'm a bad caregiver."


Ways to untwist your thinking


"When you feel badly," Dr. Burns explains, "your thinking becomes negative. This is the ABC of emotion: 'A' stands for the Actual event, 'B' for your Beliefs about it, and 'C' for the Consequences you experience because of your beliefs."



Let's return to the mall scenario. The actual event is that your father wandered away from you. Your beliefs are that you're a failure as a caregiver; you're a worthless person; you never watch him well enough; he'll get hit by a car. The consequences of those beliefs are anxiety and depression. Cognitive therapy tries to change the "Bs" so you don't experience the "Cs."



How can you change your beliefs about what happened at the mall? Dr. Burns recommends subjecting any negative belief to the following tests:

  • What would you say to a friend? "People are generally much harder on themselves than they are on others," Dr. Burns says. Suppose a caregiver-friend's father wandered away at the mall. Would you call the person a worthless failure? Probably not. You'd probably say something like: "I know how horrible you feel. But it's not your fault. People with Alzheimer's develop an uncanny knack for slipping away. My mom did the same thing several times when I only took my eye off her for a second. It's impossible to keep them under constant surveillance."




  • Examine the evidence. You accuse yourself of never watching your father well enough. But is that really true? You've installed gates and all kinds of hardware around your home to deter his wandering. You've alerted the neighbors, nearby shopkeepers, the mailman, and the police to his tendency to wander. You've gotten him a medical ID bracelet that says "Alzheimer's" and has your phone number. You've done everything Alzheimer's experts advocate doing. But in spite of your best efforts, your father still managed to slip away. That's unfortunate, of course, but overall, you watch your Dad quite well.



    You also jump to the conclusion that he'll get hit by a car. But is that really true? It's possible, of course, but lately your Dad has been quite leery of crossing streets. Chances are he won't wander out into traffic.




  • Experiment. If anything bad happens to your father, you think all your relatives will hate you. Really? That time he tripped over your nephew's tricycle at your sister's house and sprained his ankle, no one berated your sister. She'd done everything she could to Dad-proof her home, but your nephew found his trike in the garage and wanted to impress his grandfather with how well he could ride it. Everyone understood that his injury was not your sister's fault. If something bad happens because your father wandered away at the mall, chances are they'll feel the same way about you.




  • Look for partial successes. Instead of thinking that you're a "complete failure" as a caregiver, consider all your successes. You've managed your father quite well when several relatives insisted that only a nursing home could handle him. Your caregiving has strained things with your spouse and kids, but less than you had feared. And by keeping him out of a nursing home for the past year, you've saved the family about $30,000.




  • Take a survey. You berate yourself because your Dad wandered off. Call a few other caregivers you know. See what they say about it. Chances are they'll offer comfort, not condemnation.




  • Define your terms. Your father's wandering made you feel worthless. Define "worthless." The dictionary says "completely without value." That's not you. You've given your father remarkably patient and loving care. Your friends have called you a saint. OK, so you're not perfect. He wandered away. But that doesn't make you worthless.




  • Solve the problem. The mall security staff calls to say they found your father in the popcorn store. Apparently he was attracted by the aroma. You realize that it's impossible to keep him under constant surveillance while you're shopping. You decide to shop only when he's at daycare. For emergencies when you have to take him shopping with you, you buy children's mitten-keepers, and clip one end to your sleeve, and the other to his.


Just seven steps to feeling better


Seven steps may not sound like many, but simplicity is one of cognitive therapy's major strengths. It's quick and easy, and once people understand the basic concepts, almost anyone can practice it. Sometimes, though, cognitive therapy's very simplicity puts people off. They say: "It's so simple, it can't possibly work." Of course, that's jumping to a conclusion -- predicting the worst possible outcome on the basis of no evidence. Experiment. Try the seven steps that cognitive therapists recommend and see if the process has value for you:




  1. Get pen and paper. Write everything down. The act of writing automatically puts some distance between you and your negative thoughts. It helps provide perspective.




  2. Identify the upsetting event. What's really bothering you? Is it simply the fact that your father wandered off? Or that you feel his misbehavior reflects badly on your caregiving?




  3. Identify your negative emotions. You might feel annoyed and worried about the wandering, and depressed about your abilities as a caregiver.




  4. Identify the negative thoughts that accompany your negative emotions. About the wandering: "I'm not vigilant." About your caregiving: "I'm a lousy caregiver."




  5. Identify distortions and substitute rational responses. About the wandering: "I'm usually obsessed with watching Dad, especially when we're out together. I did slip up for a moment at the mall, but thank God that's a relatively safe place to wander. Security is bound to pick him up before he gets hurt or into any real trouble." About your caregiving: "Everyone thinks I'm a good caregiver. I am. But I'm not perfect. This was a moment of imperfection, but that's all it was --a moment."




  6. Reconsider your upset. Are you still plunging into an emotional tailspin? Probably not. But you still feel annoyed about your Dad wandering away. That's OK.




  7. Plan corrective action. You decide to shop only when he's at daycare. For emergencies when you have to take him shopping with you, you buy children's mitten-keepers, and clip one end to your sleeve, and the other to his.


Count your blessings


"A major task of adulthood is to balance striving to excel and accepting personal limits," Dr. Burns says. "Cognitive therapy has helped me accept my limits without feeling ashamed of myself."



"Cognitive therapy is simply a more organized way to implement traditional psychological self-care advice," says New York psychotherapist Alan Elkin, Ph.D. "It boils down to counting your blessings. Most stressful, depressing, or anxiety-producing events are not inherently awful. What makes them feel awful is the way we react to them. Counting your blessings forces you to step back, get some perspective, and see challenges in a larger context. The problem with counting blessings is that it's vague. Cognitive therapy is a step-by-step program, and when negative thoughts are spinning out of control, an organized program really helps."