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?

We’re not trained monkeys!

One time I was carrying out some work for a large organisation that wanted to train a lot of people to do some assessment work. It annoyed me for some reason, and I’ve finally hit on the problem (OK, several years too late, but never mind!). The problem was that instead of teaching principles, I was asked to train on process and procedure. Now I don’t know whether this is a ‘me’ thing, or a more general thing, but I find that if someone tells me to do something following a certain structure or format, I NEED to know the underlying framework so it makes sense to me.

What does it give me? It gives me flexibility – and this is why I haven’t yet posted on specific questions to use when learning skills in carrying out cognitive behavioural therapy. Today’s post is an endeavour to look beyond the specific questions to ask and into the underlying direction and rationale for the questions. I think that for occupational therapists, physiotherapists, nurses, social workers – anyone who uses CBT alongside other therapies or activities – it’s necessary to be very flexible, because we can’t rely on the pre-determined structure of a CBT session to ‘programme’ the level we might work at.

For example, I was working with a woman yesterday who was undergoing a trial implantation procedure. She had been through many pain management programmes and seen many different therapists over the 10 or more years she had experienced her neuropathic leg pain. I was talking with her about what would happen when she returned home with her new device implanted, and working to draw up a daily plan of activities. As I started to sketch out the most important activities in her day and put in a rest period, I noticed a change in her affect.

At this point I asked her ‘What was going through your mind just then?’

She replied that she would never have stopped doing her household tasks ‘just to take a break’.

In many cognitive therapy sessions, this would have been the cue to work with her automatic thoughts and help her challenge her underlying rule that ‘you should always finish a job you start’. The typical pattern of enquiry would be to ask what that thought meant about:

  • herself as a person
  • other people in general
  • what it would be like to violate that rule
  • what it meant about her pain

In this case, given the timeframe I had and the purpose of the session, I decided to follow a behavioural tack. After confirming that she was ready to try taking short breaks, and reflecting to her that I wondered if she might find it difficult at first to stop in the middle of a task, I started working with her to identify ways she could remind herself to take a break – and reward herself.

Now if we were following a ‘trained monkey’ approach, we may not have siezed this opportunity – we may have either decided it wasn’t an important focus for the session, or tried to work through the questions that are usually used to help someone challenge their thinking.

What am I trying to say here?

  • That it’s important to think beyond a formula or recipe
  • That attending to the overall purpose of the session is important, but to take opportunities as they arise
  • That choosing from a range of options, and being respectful of the individual’s values, can mean the door remains open
  • That knowing the underlying principles of cognitive behavioural therapy opens up options that relying on a process can’t offer

What are some of the principles?

  1. The basic foundation of CBT involves understanding the cognitive elements as well as the behavioural elements
  2. ‘Homework’ is not the only way to assist with behaviour change!
  3. Behaviours respond to behavioural reinforcement that includes rewards, recording results, and social modelling – thoughts and beliefs, while important, don’t always have to change first. They may in fact change as a result of discovering that new behaviours are working.
  4. Having in mind the formulation (explanatory model) that is being developed and/or confirmed helps guide your interventions.
  5. Core beliefs may be the reason someone finds it hard to use a new strategy. Unhelpful core beliefs, especially those that are applied rigidly, may be resistant to change.
  6. Past events don’t need to be revisited except insofar as they help you and the person gain insight into their current beliefs and behaviour.

What do I mean by process?

This is what I also call ‘cookie cutter’ therapy. This is therapy that relies on a series of standard sessions and is applied to any and all patients. Or has a standard formula for every session. Or standard home-based activities.

People and therapists are not monkeys. We don’t respond to the same process, format, style or approach. We also don’t work at the same pace. We don’t have the same issues or factors influencing our experiences.

As occupational therapists, physiotherapists, nurses, social workers, speech language therapists and others use CBT within their practice, we can offer distinctive flavours of therapy, and this means our clients/patients have a greater chance of finding something that works for them. What we must guard against is rote learning a series of questions or standard sessions and thinking that this is sufficient.

More on CBT tomorrow – and next week, some worksheets! Don’t forget you can subscribe via RSS feed (click the link at the top of the page), or bookmark this site. You’re always welcome to comment, and I’m happy to be contacted too. Just head to the ‘About’ page.

Some theory – and how we can put it into practice

Before we start on cognitive behavioural therapy, we need to know what we’re on about – for me in pain management, CBT assumes:

  • that people are capable of change,
  • can accept self responsibility for their actions,
  • that what we think and believe about a situation can affect our emotions and responses, and
  • that we can implement a whole range of strategies that can make a difference to life

We may not make a huge difference in terms of the actual medical condition – but as we know, the diagnosis is not the same as the health condition! And it’s health status on which CBT really has an impact in chronic health conditions.

Although it’s similar to the way CBT is applied in mental health situations in terms of looking at thoughts, beliefs, rules, attitudes, emotions and behaviours – it’s much more about the helpfulness of these things than the ‘accuracy’ of them. In mental health, often the thoughts are inaccurate – ‘other people think I’m bad’ or ‘I must keep my hands clean or else it will be a disaster’ or ‘I’m totally inadequate and nothing I do is good enough’.

In chronic health it may be more like ‘I can’t trust medicine to fix me’, or ‘If I keep bending, my pain will get worse’, or ‘I should be able to cope with this’. Some of these thoughts are accurate, some are inaccurate – and some may be accurate but are unhelpful.

So, as therapists, we are concerned with helping people become aware of usually hidden thoughts and beliefs. We then help the person identify whether these beliefs help them achieve their life goals (or valued/important activities), then alter them or work to establish ‘exceptions’ that may help them rather than hinder them.

At the same time, we’re working with the person to achieve personally relevant goals – things like achieving refreshing sleep, being able to return to paid employment, communicating well with their families, having invigorating leisure time. These activities require planning, monitoring achievement, altering behaviours and recruiting support in order to achieve them. And yes, these are all legitimate areas for input by an interdisciplinary health care team.

The process for me is to start with really good assessment across the domains that are relevant for the health condition in question. In pain management, I’m interested in attitudes, behaviours, compensation, diagnostic beliefs, emotions, family and friend interactions, and work – amongst a lot of other things. From this I want to add in – what does this person want to be able to do? What does the person referring him or her want them to do (why did they refer this person?).

Then I want to work with the person to help them achieve their goals – this means developing some ‘working’ explanations for how they’ve arrived at having the problems they are experiencing. Because I use a biopsychosocial model, I try to put together the information from all three domains – biophysical, psychological and social. This process can take quite a while, and doesn’t need to be complete – and for me, has to be shared with the person.

Most of the time the person is quite clear about how well this explanation ‘fits’ for them – and it’s not so unfamiliar for many of us who work as therapists. We usually give an explanation for the treatment we are giving – the main difference is that we work collaboratively with the person and recognise that we actually don’t know whether what we are suggesting is the ‘correct’ answer. This is because in most chronic health management situations, it’s not a simple 1+1 – it’s more a case of multiple factors interacting in a bunch of ways!

Applying CBT isn’t confined to cognitive theories, or behavioural theories, it’s much more about values – and readiness to act, based on importance and confidence – as well as allowing people the opportunity to choose.

How does this differ from normal therapy? Not a lot really – it’s simply expanding our treatment model to include factors that we know influence whether a person will or won’t change their behaviour. And this should apply to any health professional – physiotherapists need to know that people will carry on with their exercises, occupational therapists need to know what stops someone incorporating working to quota, social workers need to know how to help people approach anxiety-provoking activities, and nurses need to help people complete daily recordings!

But – more tomorrow!

Checking thoughts during activity

Why would we want to work with thoughts?

It’s not always essential to directly address thoughts but many times thoughts become quite unhelpful and prevent the person from engaging in your therapy. It can prevent them from adopting new skills (eg using pacing or even maintaining activity despite pain), or mean that they ‘resist’ therapy because something you’re asking them to do generates uneasiness.

By listening carefully to the meaning of what the person is saying, it’s possible to increase the level of rapport between you and the client, demonstrate your level of understanding and acceptance of them, and help them directly learn about their beliefs. This can be a powerful way for them to start becoming aware of what might be maintaining disability or avoidance – and helps you help them to consider both the good things about their beliefs, and the not so good things. Then they are able to make informed choices, which is really what we as therapists help people do.

Take a look at my ‘Coping Skills’ section, and click on ‘Checking thoughts during activity’ for a description of ways you might being able to identify and work with thoughts during activity.


Responding to real but unhelpful beliefs

One of my beefs about cognitive therapy has to be the concept of ‘maladaptive’ or ‘erroneous’ beliefs. For many people experiencing pain, their beliefs are based on experience since developing persistent pain – so we could readily be called out if we suggest that their belief that ‘I always get a flare-up when I lift boxes off the floor’ was erroneous! It actually does happen, they do get pain every time they do this activity.

The problem with this thought is that it may be accurate, but it’s not helpful. And while the statement itself may be accurate, the underlying (and unstated) belief is something like ‘…and I shouldn’t have to experience pain’, or ‘…and I won’t cope with a flare-up’, or ‘…it’ll be horrible/awful/a disaster if I have a flare-up’.

So we’re not going to win if we reality-test the original statement, instead we need to help the person recognise the unstated rules, beliefs or attitudes that are being repeated, and help them work out more helpful ways of supporting action.

Eliciting the underlying statements can be tricky. Many people with pain haven’t actually explored their belief that they ‘shouldn’t’ have ongoing pain – I mean, who wants pain? And all our media and health professionals and medications and everything suggests that having pain is unnecessary and wrong! BUT people do have ongoing pain, not everyone can have their pain reduced, and pain is a fact of life (especially in developing countries).

Sooo, what can someone who isn’t a cognitive therapist say or do to help?

Some ways to elict automatic thoughts first:

  • What was going through your mind just then?
  • What do you think was going to happen just now?
  • What do you guess you were thinking about?
  • Do you think you could have been thinking about __________ or __________?
  • Were you imagining something that might happen or remembering something that did?
  • What did this situation mean to you? Or say about you?
  • Were you thinking __________? (Therapist provides a thought opposite to the expected response.)
  • It’s helpful to have a card with some of these prompts written down if you’re not used to asking this type of question…

    Once you’ve helped the person access their automatic thoughts (remember they can also be images!), then it’s helpful to probe more to find out what is driving that thought.  Some useful questions are:

    • What would it mean if that were true?
    • Why does that bother you?
    • What does it say about you if that were true?
    • What is the effect of thinking like this?

    Then it can be helpful to gently challenge these beliefs – like ‘what does ‘not coping’ really mean?’, ‘why do you think you were singled out to have ongoing pain, if no-one is supposed to have it?’

    Asking for evidence to support the underlying rules, attitudes and beliefs needs to be done empathically, but consistently.  Some people will find it really hard to identify just what they do mean by their automatic thought, and may need some time to become aware that it’s their evaluation of the experience that is troublesome rather than the experience itself.  And its always up to the person to make a choice about whether they want to reconsider their automatic thoughts or not – it’s just your role to help them identify the consequences of their choices.

    If they want to avoid activities because ‘it hurts’ the consequences are known – it will gradually become more difficult to maintain activity, and they will be acting against some of their values.

    If they want to continue to believe that they ‘shouldn’t experience pain’ – they may continue seeking treatments, only to find that they’re disappointed again and again, which can be demoralising.

    As a therapist, it’s really helpful to check your own automatic thoughts when you start to do this work – perhaps you avoid challenging people because you believe ‘people should be happy after they’ve seen me’, or ‘I shouldn’t upset people’.

    Perhaps you are worried that you may harm someone if you ask them to continue with an activity when they’re sore…

    Perhaps you think people ‘shouldn’t’ be asked to persist with activities ‘because I wouldn’t want someone doing that to me’.

    The effects of our own automatic thoughts and underlying beliefs shouldn’t be ignored, because thoughts are powerful drivers even when they’re not fully expressed!

    Remember, in chronic pain, people don’t die of pain – they suffer from fear, demoralisation, lack of hope, feeling out of control and feeling pessimistic for the future.  It’s our job to help them recognise that they can take control, and while pain is unpleasant (and it truly is!), it can be managed and life can be good.

    Changing the inner critic – positive statements

    How often do we mutter to ourselves ‘ahh! you stupid xxx, that’s going to hurt’, or ‘I don’t want to do that, it’s never going to work’!

    In pain management, challenging negative statements is a tool that is often used. This requires a good deal of work on the part of the person with pain to identify their statements, work out what is unhelpful about them, then replace the statements with new ones. For busy occupational therapists, physiotherapists and others for whom cognitive therapy is an adjunct to their core work of doing, this process can change the focus of therapy away from doing to thinking about doing.

    An alternative and pragmatic strategy is to help the person use a positive statement just prior to attempting a difficult task without working with the underlying beliefs that form the automatic thought. Although this doesn’t directly generate reconceptualisation, from a behavioural point of view it provides an interruption to negative automatic thoughts, replaces it with a more positive one, and pairs this more positive statement with an attempt at mastery, thus reducing anxiety. This strategy builds on the idea that brains cannot attend to much more than one thing at a time, and the deliberate use of a positive statement means the brain is attending to the statement more than the associated anxiety.

    Practically what do you do?

    Ask the person to identify a statement they might use to encourage a child – something like ‘give it a go’, ‘you can do it’,keep going’, ‘it’ll be OK’. You can pair this statement with a relaxing out breath to give it further ooomph!

    Then ask the person to attempt the activity they are bothered about, but just before doing so, say the positive coping statement to themselves. After the activity, they can say something like ‘Yay! I gave it a go!’ or ‘well done’ irrespective of the success or failure of the attempt.

    To introduce this to the person who may not be convinced of the usefulness of this kind of statement, ask them what they think competitive swimmers say when they are lined up just before a race. Do they look at the competition and say ‘ohhh! they’re big, they’re fast, that water’s going to be cold, don’t know if I can make it’, or do they say ‘I’m going in to win! Let’s get going’.

    Try it for yourself – especially if there’s a job you’re putting off!