Cognitive behavioral therapy

Working with thoughts: habits take time to change

If only there was a magic wand. I could make millions out of a ‘quick fix’ to changing habits! Unfortunately my magic wand is red and glittery – and plastic. I call it my ‘self management’ wand because it reminds me that self management is no quick fix, and a good deal of the work we need to do is about helping people recognize unhelpful thoughts and behaviors that might work in the short term, but not so in the long term. Changing patterns for sleeping well despite chronic pain is no different – what might have been going on for years isn’t likely to change overnight.

Some of the thoughts that people have when embarking on cognitive behavioral therapy for insomnia can be quite unhelpful. One woman I worked with became despondent and eventually gave up because she got very irritable and felt too exhausted to carry on with sleep restriction, and told me her husband didn’t want her to stay up until she was sleepy as we had planned ‘because he can’t stand me being grumpy all the time’. She’d been having problems with sleep for four years, and we had worked on a sleep program for three weeks.

Today I’d respond a bit differently: when someone says ‘Oh but I just can’t do this’ I’d spend more time exploring how long the sleep problem had been going, and discuss the short term vs long term gains. If the problem with sleep has been going on for a long time, the difficulty from sleep restriction over a fortnight or so in order to improve sleep over the long term might be worth it. It’s worth using something like a decisional balance chart, or ‘pro’s and con’s’ chart that draws up the good and not so good of each habit that influences sleep. Habits like going to bed early after a few nights of poor sleep might help the immediate fatigue – but the probability of waking during the night is increased, which in turn maintains the poor sleep pattern. Forgoing the sleep program because of irritability or fatigue might keep the peace at home in the short term – but maintains the erratic sleep pattern that can interfere with good relationships in the long term.

If someone is raising the concern that they won’t be able to cope with excessive sleepiness during the initial phases of sleep modification, it’s worth considering introducing change over a Friday to Monday – that way the excessive sleepiness is confined to the weekend. In really challenging cases, the person might be able to take a week off work or a holiday, and time the program to commence during this time.

There is good reason not to change the planned program too much because of the person’s fears of being ‘too sleepy’. This is because one aspect of a sleep program is to evaluate the person’s fears that not being able to sleep will lead to ‘catastrophic’ consequences. By not challenging this belief, a tiny bit of doubt can remain in the person’s mind that the program won’t work in the real world – or when the person isn’t seeing the clinician.

Many people start a program but don’t manage to carry it out. This seems especially common with regard to that horrid part of sleep management: getting out of bed in the middle of the night if you’re not asleep. You’ll probably know these thoughts: ‘oh it’s so nice in bed, it’s too hard to get out of bed’; ‘maybe if I stay in bed I’ll just fall asleep, if I get out of bed I’ll just wake up properly and then I’ll never get any sleep’; ‘I’ll wake my partner if I get out of bed so I’ll just lie here and rest’.

Something worth considering is to explain to the person that at night some of the parts of the brain that help to evaluate and judge and monitor impulse control (frontal lobes) are affected both by fatigue – and by circadian rhythms. In other words, it is actually harder to reason logically at night, leading to more difficulty following through with difficult actions. By letting the person know that ‘it’s not your fault, it’s your brain letting you down’, it can help the person understand why it can be more difficult and as a result, help them apply some additional ‘push’ to overcome that tendency.

Working with catastrophic thoughts
One of the maintaining factors in insomnia is worry, or rumination. Now while there are some subtle differences between these, I’m going to treat them as the same for the purposes of this part of my discussion.

It’s common to think that being a ‘worrier’ causes insomnia – and to a certain extent, especially in the initial stages of the problem, that’s true. It’s very common for people with pain to be worried about a lot of things in the early stages of the pain problem, and what better time to think about these things than when in bed? Well, actually it’s not an especially good time, particularly in the middle of the night because it helps to maintain alertness, and more importantly, because of the problems with logical reasoning (see above). What typically happens is that thoughts just run around and around without coming to any resolution.

Once insomnia is established, self-perpetuating thoughts can maintain it. Things like ‘I’ll never get any sleep tonight’, or ‘tomorrow is going to be a write-off’. By working through these thoughts, perhaps using a whiteboard and listing the thoughts and working through to the ‘worst case scenario’ (in other words, following the catastrophic chain of thinking, we can work through to the underlying fears that have real emotional sting. Then we need to do some reality testing. Reality testing in this case involves making some estimates of how likely it is that each of these thoughts will come true. Using a percentage, each thought that has been jotted down is given a rating in terms of how probable it is that the fear will come true.

The next step is to work out how often each of the catastrophes actually DO come true. For example, if the thought is ‘I’ll never get to sleep tonight’ – how often has that actually come true? How often does the person actually get not a single moment of sleep at night? Probably the answer will be near to nil. The next catastrophe can be discussed the same way – how likely is it that tomorrow is a write-off? It helps to define what ‘write-off’ actually looks like: is it falling asleep at work? Is it forgetting to do a specific task? The question to ask is ‘how many times have you slept so badly that you fell asleep at work?’ Again, the answer is probably next to nil, but might be once or twice.

Then it’s important to point out the mismatch between the feared probability and the actual occurrence of the catastrophe.

You can do some maths here if you like: work out the number of nights in a year where the person has had insomnia, multiple this by the probability they give of ‘never sleeping’, and arrive at a number. Then work out the number of days where the person has actually fallen asleep and multiply this by the number of nights of insomnia. This quite clearly points out the disparity between what the person is worrying about – and the likelihood that it actually happens.

It helps at this point to remind the person again that at night, their logical thinking goes awry and so it makes it harder to think clearly, so some helpful phrases could be brought in to counter that fear. Something like ‘I won’t sleep at all tonight’ could be countered with ‘I probably will sleep at least a bit, and even if I do have a bad night’s sleep, it’s not very likely that I’ll fall asleep at work, so I can deal with it just fine.’

By using information from the person, and working through the maths, it helps to reduce the emotional reasoning that can otherwise influence behavior.

Let me know what you think – worth trying this approach for other catastrophic thoughts?


Some awesome CBT worksheets and resources

If you’re like me, you probably want to be able to put your hands on some easy-to-use worksheets for use with clients.  While I’m happy to make up my own, it’s nice to find some resources on the web – so thanks to therapyworksheets I’m linking to some of the worksheets I like from this blogsite.  These are NOT all pain-related ones, sorry.

First up is Lynn Martin’s CBT worksheet page.  Lynn has a whole raft of professional qualifications, but her original training is as a registered nurse.  Her site also contains a couple of concise summaries on CBT, and links to resources.  To use her worksheets you’ll need to cut and paste (and then probably reformat) into another document – but that’s hardly difficult is it?!

The next is from Specialty Behavioral Health, which has a lot of pdf documents on various mental health problems – including some helpful ones you could use if you were setting up a new practice, such as an intake form, consent form, privacy notices and so on; plus a range of specific CBT forms such as the Daily Mood and Thought Record, and one that I think I probably need: Common procrastination profiles.  I notice that these have been based around student issues such as writing a dissertation, breaking up with a boyfriend and so on, but they could be easily adapted.

Some lovely ‘personal growth’ worksheets are available from Intuitive Life Coach.  Some of these are very simple indeed – but because they’re well designed, they’re easy to use.  One example is the LifeScape Worksheet which is described as  ‘a tool to help you create a certain scenario or experience in your life. The point of this exercise is to draw a specific “picture” of the scenario using descriptive phrases that capture the essence of the experience—the feeling of the scenario as if you were experiencing it right now.’

Psychology Tools is a ‘central repository for materials useful to psychologists and other mental health professionals. The aim of the site is to provide free downloads of copyright-free materials, and also links to copyright materials.’  You can submit your own materials if they’re copyright-free (creative commons) – I haven’t done so yet, but will do.  Nothing here on pain management, but several resources on various disorders and even one on self esteem.  I liked the link to the Wellbeing Wizard – all about wellbeing(!), some nice information on Systems (such as how to draw a genogram), and I was impressed with the resources on mindfulness.

The last one for today is called Living CBT, which is adivision of the Manchester Centre for Cognitive Behaviour Limited. The Centre provides training and consultancy services across the UK at CBT-Centre UK. They have some simple pdf and word document resources including a pain diary, activity diary, and a great set of helpful self statements that are worthwhile copying and plastering all over your own workplace, not to mention for patients!

NEW: (March 2011) I just received an email from James Hardie from Moodjuice, a self help website developed by a team from the NHS Scotland.  This site has both patient and professional areas, lots of resources, and for professionals, a “build your own” resource area.  Excellent stuff, and I’d love to see more of this on the web.

NEW: (April 2014) I’m not sure why I’ve left this site out for so long, truly one of the most comprehensive sites I’ve seen, with a wonderful range of worksheets including case formulation, a self-help CBT book, and loads of patient resources – GET Self Help and Therapy Resources

Why do they want me to see a psychologist – I’m not nuts, I just have pain!

Explaining to someone that seeing a psychologist about chronic pain might be helpful can be a bit like this:

Yup, brick wall – hard object!

I can see it from the person’s point of view – it’s taken a long time (usually) for medical and other people to recognise that this pain isn’t simply going away, and isn’t about the person being ‘pathetic-why-don’t-you-just-pull-yourself-together’, so when someone suggests that psychology might be helpful it’s like saying ‘You’re nuts, you’re just losing it’ – or worse, ‘you’re a hypochondriac’.

I thought it might be helpful to review some ways to introduce the idea of seeing a psychologist (or other allied health person), or using a CBT perspective in pain management. (more…)

Self efficacy for returning to work

Of the two dimensions I usually assess with people not working because of chronic pain, lack of importance given to returning to work is often identified by ‘onlookers’ as the main reason someone hasn’t yet returned. I don’t know how many times I’ve heard about ‘secondary gain’ getting in the way of people making progress – and yet when I look in to research into returning to work, it’s self efficacy, or confidence to successfully return to work, that has more press than any other aspect (oh, apart from physical ability vs job demands).

I’ve blogged about self efficacy several times now because it seems to be one of those factors that pops up all over the place – as Bandura himself puts it ‘Self-efficacy beliefs determine how people feel, think, motivate themselves and behave.’

I mainly look at self efficacy in terms of confidence to achieve a desired result. When I’m looking at the process of returning to work with someone, the two facets I review first-off are importance and confidence. Using the Prochaska and DiClemente transtheoretical model, both of these elements can be used to determine the stage that someone might be in terms of their readiness to take action.

Let me unpack that a little. If you recall the stages of change model, there are several stages before someone is ready to actually do something to achieve a goal. At these pre-action stages (Precontemplation, Contemplation, and Preparation), people have yet to decide whether action is the right thing to do, let alone work out how to do it.

At the Precontemplation stage, action is nowhere on the scene.
At both Contemplation and Preparation, the person is often ambivalent and maybe not yet ready to even learn what to do.

To help people work out whether they want to take action, it’s worth exploring these questions:
(1) Have they thought about returning to work at all? (Precontemplation)
(2) How important is returning to work at this stage in the person’s rehabilitation? (Contemplation)
(3) How confident is the person about actually returning to work at this point? (Contemplation)
(4) If importance is high, but confidence is not, what things are concerning the person about returning to work? (Factors that influence Preparation)

A study by Shaw & Huang (2005) showed that the areas that people are concerned about (ie, the things that reduce confidence) are divided into two main areas –

  • concern about resuming physical activity, and
  • concerns about resuming work.

The concerns about resuming work were divided into three main areas –

  • meeting job demands,
  • obtaining help, and
  • coping with pain.

In fact, out of 348 statements that were coded in this study, 253 were about self efficacy, while the remaining 95 were expectations about returning to work. Expectations were around financial security, re-injury, workplace support and self-image.

So, some of the areas that may be contributing to low confidence for returning to work may be:
– can I do what I have been employed to do at work?
– can I do these tasks to the standard that my employer wants?
– can I do them as well as I want to?
– can I be reliable at work?
– can I (or do I want to) ask for, and get, help?
– can I change the physical environment at work so I can do the job?
– can I cope with the pain?
– can I prevent the pain from taking over?
– can I avoid injuring myself?

This list isn’t exhaustive, but based on Shaw & Huang’s work, covers many of the factors that people think about when they are concerned about going back to work.

Once the areas of low confidence, or concern, are identified, our job is about helping people develop confidence in those areas.

Often it is simply problem-solving ways around their concerns. Things like ensuring there is a clear description of the task demands (especially during any work trial or gradual return to work), clarifying quality requirements, ensuring reporting lines are clear, and arranging for physical environment alterations and any adaptive equipment to be available from the outset.

Other times it’s much more difficult – especially where there is a mismatch between what the client has been able to achieve in the past and what he or she can do now (this especially holds for people who push themselves to achieve well, or previously worked at 110% and now can ‘only’ manage 98%).

This may mean working through some cognitive therapy to reframe or challenge automatic thoughts, (eg ‘I’m working at this level because it’s part of my rehabilitation’ rather than ‘I must always work incredibly hard’, or ‘Most people work at 90%, and that’s all I need to achieve’, or ‘It’s OK to work at 90%, it means I can keep going for longer and be reliable the next day’).

The process of building confidence through cognitive therapy can be very challenging, especially if the person hasn’t had any exposure to CBT during their pain management rehabilitation. In fact, I often find that people may have had some CBT-based pain management, but until they reach the work environment, the real objections or core beliefs haven’t been explored, and the real ‘work’ of cognitive therapy begins only once those objections are raised.

Shaw, W., Huang, Y. (2005). Concerns and expectations about returning to work with low back pain: Identifying themes from focus groups and semi-structured interviews. Disability & Rehabilitation, 27(21), 1269-1281. DOI: 10.1080/09638280500076269

Goal setting: A critical skill for change

Pain management is many things to many people, but most of us would agree that if life hasn’t changed in some way after pain management, then it hasn’t really been effective.  For change to actually happen and be maintained, Prochaska and DiClemente and others (eg Miller, Rollnick and colleagues) identify that people must believe the change to be important, and that they have the ability to make it happen successfully.

I’ve posted earlier on self regulation (eg this reading, and this post), making the point that it is made up of several components, one of which is goal setting.

When I went to Google to search the words ‘goal setting’, 13,200,000 hits came up in 0.16 seconds, so goal setting seems to be rather popular – and yet it’s often the most difficult session to facilitate in the three week pain management programme I work in, and some of the ‘goals’ I’ve seen written for patients just don’t look anything like the kind of goals that can actually be measured! So perhaps goal setting is both popular but not easily carried out in ‘real life’.

So, how do we set goals?
It sounds easy if you’ve learned to set goals early in life, but for so many of the people I see it’s not a familiar activity. The research literature in psychology abounds with various models and influences on goal setting and achievement, which doesn’t really help a busy practitioner who may well be drawing on knowledge from first year professional training! And unfortunately, the information readily available online is often of variable quality.

I’m going to start with some random thoughts, mainly based on conclusions drawn from a motivational approach – tomorrow I’ll fill in with some literature!

Firstly, goals need to be relevant to the person. That means that the person believes that the goal is important. Importance is predicated upon things that the person values (see the New Zealand School Curriculum definition here)- these are usually abstract beliefs that, through action, become evident. The same action can represent many values (eg daily exercise can represent ‘time out’, ‘commitment to my wellbeing’, ‘a way to keep my partner/husband/dog happy’). And similarly, values can be fulfilled or operationalised in many different ways (eg ‘caring for my family’ can be achieved by ‘being in a high paid job’, ‘being home when they get home after school’, ‘always going to sports activities with the kids’).

Sometimes, the values appear to conflict with each other – it’s quite common for someone (perhaps yourself?) to value ‘being healthy’ while at the same time valuing ‘relaxing’ – how those values are played out in the real world may mean the person eating healthily in one part of the day, then drinking alcohol as a primary way to relax! I’ve seen this in people who say on the one hand that they’d like to return to work, but on the other, they don’t think they can – because they can’t continue working in the way that they’re used to. There is a conflict between two different values: the values that constitute ‘being a good worker’ (which is operationalised as ‘always doing a job at 120%’) and ‘being able to cope’ (which is operationalised as ‘never allowing my pain to fluctuate’).

The second is that goals need to be achievable.
That is, the person needs to feel confident enough that they can actually succeed in making the goal happen. When pain becomes chronic, confidence to achieve goals can often be eroded, especially if pain is feared or avoided. Successive failures to achieve goals only serve to confirm that taking a risk by setting a goal should be avoided. And this seems to be much more the case if the goal is particularly important – and of course, if it’s not important at all, it just won’t happen!

It almost goes without saying that goals need to be specific and measurable
– exactly what is it that the person has to do, and how will they know they’ve achieved. This is much more difficult if the area of goal development is complex, or requires sub-goals to be achieved in order to attain a longer-term goal.

Tomorrow: some readings on goal and goal-setting, and over this week – tools to use to help people set and maintain goal-directed behaviour.

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