All or Nothing Thinking: How to Cope with Pain Series

All or nothing thinking is one of the most common, problematic ways of coping with pain. It’s right up there with catastrophizing, fear-avoidance, and refusing to accept the chronicity of pain. All of these problems prevent people from coping with pain well and being able to live a full life despite having chronic pain. Since we have reviewed the other problematic ways of coping with pain in previous posts, let’s discuss all or nothing thinking today.

All or nothing thinking defined

All or nothing thinking is a type of thinking that leads to perceiving a situation as having only two ways to look at it. We come upon a situation and conceive of it as leaving us with only an either-or choice: it has to be either this way or that way.

Sometimes, these two options are conceived as both bad in some way. The common, everyday phrase for this kind of all or nothing thinking is being “stuck between a rock and a hard place.” There’s no middle ground – at least in our initial way of thinking about the situation. So, when engaged in all or nothing thinking, we think about some situation and conceive of it as having only two responses and oftentimes we see these options as both bad.

Some examples of this kind of all or nothing thinking are the following:

• A patient complains that she doesn’t want to take opioid medications for pain anymore because they cause sedation, constipation, and she doesn’t like how her friends and family look down upon her for having to take them; but she thinks that the only alternative is to not take the medications and subsequently live in intolerable pain and suffering.
• A patient believes that since he can’t work anymore he must be a loser.

Notice that in these examples the people engage in all or nothing thinking because they seem to be able to only consider two possibilities, and both of them are bad. In the way they are approaching these problems, there seems to be no middle ground. As far as they are concerned, it’s an either-or situation and both options are bad.

Sometimes we engage in all or nothing thinking in yet a different way. While we conceive of a situation as having only two options, we see these options as not both bad, but rather as either all good or all bad. Again, there’s seems to be no middle ground. We have either two potential ways to respond – either the best way or the worst way.

Some examples of this kind of all or nothing thinking are the following:

• A patient tends to believe that he has to clean the entire garage if he were to clean it or he might as well not even bother with it at all.
• A patient believes that, unless there is a cure for her chronic low back pain, she has to remain on disability.
• A patient says to her provider, “My life used to be perfect. Now, it can’t get any worse.”

Notice that in these examples the people conceive of their situation as having only two possible ways to look at it. It never occurs to them that there might be some middle ground. For them and the way they see it, there are really only two options – either one that’s all good (or would be all good if it could be obtained) or one that’s all bad (i.e., the one they are living with).

All or nothing thinking is a cognitive distortion

Psychologists characterize all or nothing thinking as a type of cognitive distortion. Cognitive distortions are habitual ways of thinking about things or perceiving things that fail to accurately reflect reality. We have discussed cognitive distortions before in posts related to catastrophizing and mind reading. These types of habitual ways of thinking are also cognitive distortions.

Cognitive distortions, such as all or nothing thinking, tend to occur automatically, without much awareness of the person who is doing it. Typically, we don’t intentionally make a choice to view things in such black or white ways. Rather, they occur reflexively or habitually. We sometimes call cognitive distortions ‘automatic negative thoughts’ to capture the characteristic of them as going on without much intention or awareness on our part.

Another important characteristic of cognitive distortions is that they tend to influence what we believe about any given situation. Without much awareness that we are engaging in all or nothing thinking, we tend to believe that the way we are perceiving a situation is in fact the way the situation is. In other words, when engaged in all or nothing thinking, we mistake the either-or way of perceiving the situation as reality itself. We thus tend to think that in reality we really do have only two limited options. So, therefore we feel stuck in a no-win situation.

It can be hard to get outside of the all or nothing thinking and see the situation from a different perspective. Sometimes, of course, if someone comes along and helps us to see that there is some other way of looking at the problem, we come to see it too and we are subsequently grateful. We might exclaim, “Oh! I never thought of it that way!” This kind of help liberates us, if you will, from the no-win either-or way that we were conceiving of the problem and we can then cope better with the problem. Other times, though, we might not see any other way of looking at the problem, even if others are trying to help us see it differently. In fact, we might respond to their assistance with thoughts that they are just minimizing or invalidating the severity of the situation. Still other times we might think that they just don’t get it – they have never lived through what we are living through and so we think that they are unable to understand. In such cases, it can be hard to get outside of our either-or way of conceptualizing the problem and see that perhaps we have more than just two limited options.

All or nothing thinking leads to poor coping with problems

All or nothing thinking doesn't lead to coping well with pain. It’s easy to start seeing the reality of life with chronic pain in binary ways that leave people stuck and exhausted and possibly hopeless and lonely:

• “I have to be on opioid medications or face intolerable pain and suffering.”
• “I have to clean the entire house or not at all.”
• “I have to be cured or remain on disability for the rest of my life.”
• “You either have chronic pain and so ‘get it’ or you don’t have chronic pain and so can’t understand where I am coming from.”
• “I’m on disability and so I must be a loser.”
• “My provider didn’t cure me… so she must be incompetent.”
• “My previous provider wanted to talk to me about learning ways to cope better, but he doesn’t get it. I’m coping extremely well under the circumstances. It’s just that the pain is so bad. He’s supposed to fix that – not talk to me about how I could cope better with it.”
• “Before chronic pain, my life was perfect.”

Notice that these common sentiments admit of no middle ground. They are ways of seeing life with chronic pain in stark, either-or ways. All of them are no-win situations. They either leave people with two bad options or one good option and one bad option, but the good option is typically unobtainable. Either way, when engaged in such ways of thinking, they leave people stuck.

As such, all or nothing thinking leaves people feeling pretty lousy about themselves or their lives in general. Put yourself into such ways of thinking, entertain what it would be like for a moment, and you can see how easy it would be to begin to feel stuck in life, becoming anxious, angry, alienated, dejected, hopeless, or depressed.

From here, we can see how all or nothing thinking doesn’t lead to coping with pain very well.

Please note that we are not criticizing or judging anyone for not coping well when engaging in all or nothing thinking. No one is perfect and no one copes perfectly with life’s adversities, including chronic pain. We are simply trying to describe one of the ways in which we sometimes don’t do it very well. By describing it, without criticism, we can learn from our common mistakes and subsequently learn how to approach the problem of living with chronic pain differently and more effectively.

A student wouldn’t learn very much if her teachers only told her that she was doing things well, even when she wasn’t. No, at some point, her teachers have to provide her with feedback about the things she is not doing well. Now, of course, they do it without judgment or criticism, but rather warmth, respect, and a high regard for her well-being.

It is in this spirit that we discuss problematic ways of coping such as all or nothing thinking.

Overcoming all or nothing thinking

To overcome all or nothing thinking and subsequently come to better cope with pain, people need to develop two internal skills. One skill is being able to maintain what we call an ‘observational self.’ The second skill is what we call ‘ego strength.’ These skills are closely related to each other, but let’s review them one at a time.

What we mean by an observational self is the capacity to step outside ourselves and think about how we are reacting at any given moment. In common everyday language and situations, we refer to our observational self when we say things like ‘Think before you speak!’ or ‘Listen to yourself!’ or ‘Think about what you are doing.’ In each of these situations, the speaker is asking the other person to reflect on what he or she is saying or doing. When we take ourselves as our own object of consideration, and think about how we are reacting, we are engaging in our observational self. In other words, as human beings, we have the capacity to think about thinking! We can consider and reflect on, not only our thinking, but our ways of conceptualizing a problem or how we are reacting to it or how we are feeling about it and what it is that we want to do about it.

We can use our observational self to think about whether we are engaging in all or nothing thinking. It helps, of course, to do what we have been doing today, which is to learn about all or nothing thinking. We can subsequently use our newly learned understanding of all or nothing thinking to begin identifying it in the moment. In doing so, we use our observational self skills. We step outside the given moment and observe how we are perceiving a situation. In doing so, we can come to recognize that we have been engaging in all or nothing thinking. We identify it and name it to ourselves. “Oh, there I go again. I am engaging in all or nothing thinking.” Notice that this ability assumes that we are able to step outside of ourselves and begin to reflect on what it is we are thinking. In other words, we use our capacity to engage in our observational self.

Once identified, we can begin to challenge the accuracy of the all or nothing thinking. Inherent in our understanding of all or nothing thinking is that this kind of thinking distorts our understanding of the reality of the situation. The reality is not really what we think it is. By understanding this aspect of all or nothing thinking, we come to see that perhaps we have more than two, limited options. Maybe we remind ourselves that there must be more than two ways of looking at the problems that confront us – even if we don’t see it right a way. By challenging the accuracy of how we have been conceptualizing a problem, we come to see that perhaps we are not as stuck as we thought we were.

More often than not, in these situations, it is helpful to have someone you trust help you to see the problem differently. We often say, in everyday life, ‘Two heads are better than one’ because another person can have a different perspective from the one that we have. In this way, another person can help us to get outside of ourselves and access our observational self. Subsequently, we can then come to see that how we are thinking about a problem is not the only way to think about it. In other words, we can identify that we have been engaging in all or nothing thinking. We then come to understand that we have more options than simply two bad options. It’s at this point that we often look at our trusted companion and say, “Oh! I never would have looked at it that way, but that’s a great idea!” It’s the proverbial light bulb moment.

Now, it requires ego strength to allow ourselves to see the point of view of another. It’s our capacity to tolerate feedback from another and learn from them. We call it ‘ego strength,’ because it is a sense confidence that we are still a good person even if we didn’t think of it first or have to learn from another. We might say that it is an inherent sense of security that we are still okay even if we don’t know everything and sometimes have to rely on others for help.

We likely all know people with a low level of ego strength and people with a high level of ego strength. People without a lot of ego strength tend to have difficulty admitting it when they don’t know something. They have trouble tolerating feedback from others and get defensive or irritable. They tend to think it is weak to ask for help. They tend to deny that they are struggling to cope with a problem, because doing so would mean for them that they are weak. People with a high level of ego strength can acknowledge when they don’t know something. They can admit that they are not doing something well and can ask for help. And they do these things without feeling ashamed. They remain confident in some manner that they are still a good person, even if they need help coping with a problem.

We need at least a certain level of ego strength to allow others to help us. It takes a certain degree of internal strength or confidence to acknowledge that we need help and to listen to the feedback of others. The pay off here, though, is that the feedback of others can help us to step outside of ourselves and see our problems from a different point of view. We sometimes need a different perspective and we can only get it from another person. There’s no shame in that! It’s called learning and learning is good!

So, in overcoming all or nothing thinking, we need to rely on our capacities for our observational self and our ego strength. We need to step outside of our all or nothing thinking and recognize it as not accurate to the reality of the situation. Oftentimes, in such situations, we require feedback from another person who sees the problem differently. We need to allow this different perspective in, and acknowledge that we can learn from it. We need to acknowledge that we are not coping perfectly and can learn a thing or two from others. However, we can only acknowledge that we aren’t coping well if we know that it is not weak or shameful to do so. We need to be able to maintain some degree of confidence that we are still a good person even if we aren’t coping well at the present moment. In other words, we need to have at least a certain level of ego strength.

Coping with pain well

It’s possible to cope with pain well. It’s possible to live well despite having chronic pain. Now, it takes a lot of work and the majority of this work lies in learning how.

The work involves developing your ego strength and capacities for engaging your observational self. With such skills, you begin to catch yourself in all or nothing thinking. You challenge whether it accurately represents the options that you have. You also allow trusted others to help you to see problems differently, allowing you to see that you have more options than you thought you had. It can be quite liberating to see that you have options when you initially thought that you were stuck.

Of course, to have these kinds of insights more frequently, it takes practice. All or nothing thinking tends to be automatic or habitual. It is often hard to see that you are doing it. You have to catch yourself in all or nothing thinking, reflect on it, and come to see that you have more than two, limited options. With practice, however, you get better and better at it. In other words, with practice, you come to cope with pain better and better. At some point, you come to be able to live well even if you do have chronic pain.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-13-2014