How to Think about Thinking: A Psychiatrist's approach
Psychiatry deals with the intangible parts of the brain; some might call it the mind. And how we know the mind exists, how the mind most commonly communicates to its owner is by having thoughts. In health, our thoughts serve a purpose. They help us to understand, to connect and to solve. Unfortunately, the opposite is also true. Our minds are prone to aberrant, unproductive thoughts too. Psychiatrists examine and understand thoughts to see if they are a symptom of mental illness.
Psychosis is the most extreme example of thought disorder. In psychosis, patients develop fixed false beliefs, known as delusions that lead the patient to make conclusions that become increasingly separated from the reality in which they live. Thought disorder also presents as an incoherent jumble of words and images such that the mind feels overwhelmingly full. At times there is an absence of thought and the patient feels their mind go blank for prolonged periods of time. This is called Thought-blocking.
Patients with anxiety and mood disorders can experience their thoughts as working against them and their expressed wishes. Some of these thoughts can be called intrusive, egodystonic thoughts. This means these thoughts are unwanted and are not in line with their values, yet they intrude into their lives seemingly outside of the patient's control. There are also instances when a person's thinking starts off where they would like, but they can not seem to move away from the subject and this causes distress. This kind of thinking is called rumination.
There are many approaches in mental health treatment to the many problems that can arise with thinking. The psychiatric approach mainly is medication and though in my experience this can be a blunt instrument for a very complex process, medications are very effective in severe cases of disordered thinking, like psychotic disorders or severe obsessive disorders. In these cases, the medications can help quiet the mind, offering not only relief, but giving the thinker back some control. Medications help to get a patient to a place where they can use nonpharmacologic approaches better, like getting out of the house to see friends or exercise, and medications can help patients make better use of talk therapy.
When the thinking process is coherent, organized and based in reality, but are still problematic and generate distress and anxiety, there are 3 main approaches:
1) Thoughts can be meaningless: We have thousands if not millions of thoughts a day, surely our brain will conjure up some doozies. Just because we have these thoughts, does not mean these thoughts are true or predictive. So it is not the thought that is the issue, but the emotional impact and meaning that is given to the thought. Meditation/mindfulness takes this approach. The goal is to observe the thoughts you are having, but then to let them pass by bringing the attention back to a predetermined focus, like the breath.
This is a useful approach in conditions like obsessive compulsive disorder where the meaning or implications of the obsessive thought is catastrophized and all-consuming.
2) Thoughts can be meaningful: insight-oriented therapies approach our thoughts as signals of something deeper that may be going on and therefore should be interpreted as such. In this kind of therapy the therapist listens for patterns and themes that come up. By making the patient aware of what might be going on but unconsciously, can provide greater understanding and relief. For example, many of my patients constantly feel guilty and not good enough. At face value, it could mean the patient could work harder or do more, but that is usually not the issue. Rather, guilt was the corrupted love language of the person's upbringing, and a representation of one's helplessness in knowing how to deal with being made to feel inappropriately responsible as a child.
3) Meaning does not matter, because we can change our thoughts: This is the main approach in cognitive behavioral therapy. In this therapy, the patient is asked to pay attention to the automatic negative thoughts a situation brings up, and to challenge these thoughts with evidence that support or challenge them. Once this has been done, the patient is tasked with coming up with a more realistic, balanced thought that better reflects the situation and to use this thought instead going forward.
How one approaches their thoughts must be personalized. There is no one-size-fits-all.
Lastly, I think it is important to mention that mentally healthy people struggle with distressing thoughts too. And just because you may have thoughts that bother you does not mean something is wrong. In fact, just like how wolf cubs play-fight in preparation for the real thing, our rich internal worlds can serve the same purpose. And I suspect this will only increase as we live in a diminishingly physical world.