Black and white thinking must be abolished

Black and white thinking, for those readers unfamiliar with cognitive distortions, refers to the tendency to reduce complex ideas and situations into simple, dichotomous, and mutually exclusive categories.

Think of good or bad, yes or no, all correct or all wrong, acute pain or chronic pain, neuromatrix or peripheral mechanisms, cure the pain or manage the pain.

It’s a way of simplifying arguments or decisions that can work well when the situation requires very fast decision-making, or where the options are very limited.

It doesn’t work at all in the messy and complicated worlds of clinical reasoning, theory development, or in discussions to broaden understanding.

I’m pondering this because of the way various aspects of pain management and the science of pain are misrepresented as opposed to each other, when maybe it’s not quite so simple.

I hope (crossing fingers and toes) that I’m not doing prone to doing it too often on the pages of this blog, or elsewhere for that matter!

There are multiple strands of research into pain at present. 

There are the reductionists who focus exhaustively on smaller and smaller elements of biology to explain the processes involved in nociception and transmission from noxious input to the perception of pain and back to the responses as a result. 

There are the phenomenologists who focus on the ‘lived experience’ of the individuals who have pain.

There are those who are furiously investigating laterality and cortical processing.

There are others feverishly working on ways to abolish all pain, and those who are equally enthusiastically researching why so many people are unbothered by their pain even though it’s severe.

Can you see all those opportunities for opposing views? for argument and debate?  It’s common for any of us to think mainly in terms of our own orientation, and there are many factors in human cognitive bias and group decision-making that get in the way of us working towards consensus – or even hearing each other.  And that can lead to trouble within teams, especially multi- or inter-disciplinary teams.

I wonder if it’s time to apply some of the cognitive techniques we can use with patients to ourselves as clinicians.  Let’s take a quick look at some of the basics.

Firstly, why do we use black and white thinking?  Well, it simplifies things.  If we’re feeling a little bit sad, we’re more likely to tell a loved one that we’re feeling “terrible”.  We don’t mean to exaggerate, we’re aiming to get empathy from the person we’re talking to, so we unintentionally use dichotomous language – we think in terms of feeling “amazing” vs feeling “terrible”.   Humans like to identify patterns, and to group similar things together so we can generalise.  We like to reduce an argument into “either – or”.  And when we do this, once again because of our tendency to look for information that confirms our own position, we often fail to recognise other alternatives, or information that doesn’t fit with our own views.

What we can do is step back and carry out some metacognition – thinking about our own thinking.

Some questions we can use to challenge our own position are:

  • How did I come to that conclusion?
  • What’s the evidence for the other position?
  • Is it possible to use “and” instead of “either/or”?
  • What are the other options?
  • Are there parts of my argument that can’t explain something the other position can explain?
  • This idea is only an idea – not my personal possession
  • Consider saying things like “at the moment my position is…”, “I’m attracted to this idea currently…”

I’ve personally found it useful to relax a little and recognise that in the end, the data will speak for itself.  So, for example, I was initially not keen on mirrorbox and laterality training for CRPS.  The studies, especially in the early stages, weren’t carried out in people with the degree of chronicity and complex psychosocial background that I saw.   Over time, and as the evidence has been gathering, I’ve changed my position.  I don’t mind acknowledging this change – in the end, it’s not my ego that’s important, nor “my” ideas – it’s what helps this person at this time with this particular problem.

Having said this, developing critical thinking skills, and in particular, being able to unpack and delve into how a study has been conducted and whether the conclusions drawn are supported by the data is vital.  Cherry picking, or selecting studies that support one view or another while ignoring or failing to account for studies with conflicting findings, just doesn’t do – again I try to relax a little, because in the end the balance of evidence does fall one way or another.  Or, in the case of chronic pain management, maybe there is so much to learn that what we know now is not even beginning to find answers.

If you’re keen to learn more about how to develop critical thinking, Foundation for Critical Thinking has a wealth of information.


  1. This is an excellent post. It does make me wonder about one thing: in your various posts you expressed opinions to the extent that painkillers are not helpful and using them as a tool for pain control (other than at a fixed daily dose) should be discouraged, and so should treatments aimed at reducing pain intensity in general. This is consistent with what I heard from my pain management program.

    I always thought of this as an “either-or” thinking. I find that regular physical therapy, and occasional additional doses of painkillers, are very important for management of my pain. I am not alone in that, too – the approach on which I settled was based on conversations with several friends who manage chronic pain on their own. But I got consistent feedback from doctors that this is a bad plan to pursue, that it needs to be “either/or” with respect to CBT or ACT therapy which I was offered.

    Interestingly, this also touches on the “acute vs. chronic” distinction. Through experience I found that some pain variations are normal – whether they are random day-to-day variations, or short term flare-ups caused by various activities, and the sane response to those is to just let them be. But some exacerbations feel a lot more “acute” and won’t go away on their own without external interference, usually physical therapy to release the affected muscle or joint. I even have a personal cut-off point – if my pain was at least 2 points higher than my average every day for 2 weeks, then it’s probably time to head to my physio, because it’s not going to go down. In fact, my longest “experimentally verified” period was 6 months – I was in the middle of CBT course when I experienced one of those exacerbations, decided to follow my CBT therapist’s advice and avoid active intervention, focusing instead on relaxation/pacing/acceptance. The outcome was that I got progressively worse, losing more and more physical function despite my best efforts to not reduce my normal activities and exercise. After 6 months (I was persistent!) gave up on CBT and went back to my physio, which settled the problem after 4 sessions, though it took me another 4 months to rebuild what I lost in strength and flexibility. Would have been faster, too, if I hadn’t waited for so long 😉 That was about the point when I completely gave up on my pain management program as well, because of their insistence on the “either-or” approach to this.

  2. Great post Bronnie
    seems most people are more practised in being right, than being curious. That is our training as health care professionals – don’t get caught out being wrong!
    Also seems that we are not well practised at metacognition. I found that interesting since the reason I became interested in working with people with chronic pain was that I could not explain my patient’s presentations based on what I learned in school. They didn’t fit into the box, so I wondered if the box (paradigm) might be incomplete or wrong.
    Actually, learning that most people do not question the theoretical premises by which they understand things, including pain, was eye-opening to me. Knowing that made it way less frustrating when I listen to people presenting their view of pain, pain treatment and people in pain.
    Pain is complex so we need to ensure that when we teach others about it they don’t lose sight of that – while at the same time we need to provide frameworks which ‘simplify’ the information so people can manage and then integrate the new info. Such arrogance can be created in people who learn a little about pain and think they get it.
    My sense is you get all this, so really this comment is to once again thank you for your great posts.
    Neil Pearson
    p.s. I hope life is more peaceful for you these days

    1. Thanks Neil, it means a lot to me that you think I “get it”! I hope I’m a bit comfortable with ambiguity now – because I started off in my career with a firm belief that what I did was “correct” without a skerrick of evidence. And I’ve seen all sorts of dogmatic viewpoints over the past years that emerge as “the truth” and “the right and only way” only for them to be superceded by gathering evidence that puts that particular baby to bed. Evidence doesn’t dictate treatment choices entirely – we also need to acknowledge the place of culture, finances, resources and individual choice – but at the same time, to fail to accommodate conflicting evidence just because it doesn’t fit with personal beliefs seems to me to be unethical.
      I was going to say that life was a little less quake-filled but we just had another wee quake as I wrote the sentences above! We’re not over it yet. Getting a bit tired of it now, the novelty has worn off!

  3. This is a nice “touchstone” post, something to return to whenever — should ever — confusion reign. Thanks for that.

    I am a CRPS patient. My educational and vocational backgrounds are heavy with training in (non-medical) critical thinking and theory.

    In my experience, “black and white thinking” is often chosen by medical professionals as the preferred mode of persuasion to steer patients’ decision-making processes. After nine years of dealing with a lot of ego-driven and heavy-handed intent, when I discern such thinking being used as a tool in lieu of sharing ideas/theories/research? That person’s credibility is almost impossible to rehabilitate.

    Just a few months ago, I had an initial appointment with a pain management doctor. Within 5 minutes of our introduction, with a sketchy and incomplete history, and without a physical exam, he proposed Ziconotide via intrathecal pump. He did not disclose that Azur Pharma was funding his study on Prialt, or even that he was conducting such a study. His theoretical framework? My remaining choices, should Ketamine infusions fail, were Prialt or suicide.

    Sad to say, the critical thinking many have employed over my nine year journey with CRPS has more to do with the financial rewards of, say, some sort of procedural intervention rather than the real value, supported by theory and research, of something much less expensive, like an enlightened course of physical therapy, or the use of adjunctive medications.

    1. I recognise what you’re saying Bianca! And in NZ we don’t even have all that much financial reward to explain why some providers focus immediately on costly interventions rather than taking the time to (1) fully assess why this person is presenting in this way at this time (2) consider all the possible hypotheses for this person’s presentation (3) consider the preferences of the patient – and broaden the range of preferences to suggest some alternatives the person might not have heard of and (4) work with the person to identify the most appropriate way forward. Maybe it’s time limitations, maybe it’s lack of training to be truly patient-centred, maybe it’s lack of critical thinking, maybe it’s laziness or lack of energy, or maybe it’s because the clinician likes the buzz of applying a certain intervention. Whatever the reason, it doesn’t serve anyone particularly well.
      Thanks for taking the time to comment, it’s great to see that people read my rants!!

  4. Hi Bronnie

    I’m surprised no one else is struck by the title! ‘must be abolished’? that sounds pretty black and white to me.

    You do actually go on to note that there is a time and place for black and white thinking – just not in complex scenarios, but if you are going to start dishing out ironic headlines, then you need to give me a bit more of a heads up.

    Great blog as ever


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