Meeting the Challenges of Long-Term Illness

Adjusting Thinking  

By Bruce Campbell

The last article discussed a number of ways to manage depression and worry. This article describes another technique for managing emotions: changing your thoughts.

The Connections Among Thoughts, Feelings and Actions 

To understand the powerful effect that thoughts can have, imagine the reactions of two patients to an increase in symptoms following a short walk. One says: “Another setback! I’ll never get any better.” This person has a pessimistic way of interpreting experience. She sees specific events as examples of permanent, far-reaching negative forces. The thought “I’ll never get any better” tends to lead to frustration, depression and despair. The mood of despair is associated with learned helplessness, the sense of not having control and a belief that effort will not be effective.

Pessimistic thoughts can increase your suffering. Negative thoughts make you feel anxious, sad and hopeless, which in turn makes it difficult to act constructively. Worry and preoccupation with suffering may even intensify symptoms and trigger another round of negative thinking.  The cycle can be very demoralizing and make it difficult to motivate yourself.

Being in a situation in which you seem to lack control can create a sense of helplessness. Modern psychology has coined the term learned helplessness to describe the lasting effects of an uncontrollable bad situation.

But just as feelings of pessimism and despair can be learned in response to experience, so can optimism. Imagine that the second patient responds to her increase in symptoms by saying: “I walked too far today.” She has a more optimistic way of seeing her experience. She sees an event as something specific, limited and temporary. Her thought is more hopeful. It suggests the person can learn from experience, that tomorrow need not be the same. The more optimistic mood is associated with the willingness and even eagerness to try again.

Negative thoughts can be quite common in chronic illness. Focusing on symptoms, for example, can lead to thoughts like “I’m always in pain.” Such thoughts lead to frustration and discouragement. An inner dialogue featuring the word “should” can also produce frustration and anger towards oneself. An examples is saying “I should be able to do more.” Self-esteem can be undermined by thoughts like “I’m useless.” 

The Effect of Expectations on Emotions and Symptoms

A student in one of our early groups provided a good example of how thoughts can affect emotions and symptoms. At a birthday party one year, she took on the role of the good hostess, moving about and worrying whether everyone was having a good time. She found herself tired and cranky after an hour. For a similar party a year later, she decided to create a different expectation for herself. She imagined she was a queen who was observing the situation from a throne. Freed from her self-imposed expectation that she should make sure everyone enjoyed themselves, she found herself with good energy for more than two hours. By making a mental adjustment (changing her thoughts), she reduced her worry, extended her energy and reduced her symptoms.

In this article, we will explore how you can recognize and break the cycle in which negative thoughts and symptoms reinforce one another, so that you can use your thoughts to help you, rather than having them increase your suffering.

Recognizing Automatic Thoughts

The process of changing explanatory style from a pessimistic, helpless one to a more optimistic and hopeful one occurs in three steps. The first is learning to recognize one’s self-defeating thoughts. This is not easy to do because the thoughts are automatic and habitual, so deeply ingrained that they seem self-evident.

A technique for recognizing automatic thoughts is the Thought Record, which is described in the book Mind Over Mood by Dennis Greenberger and Christine Padesky. Using this form offers a way to become aware of your automatic thoughts and their effects on your mood and behavior. (You can find similar techniques in other books, such Learned Optimism by Martin Seligman, Feeling Good by David Burns or books by Albert Ellis.)

To see how this technique works, we’ll use an example of a patient who took a walk one day and felt very tired when she got home. Feeling discouraged, she asked herself what thoughts were going through her mind. The answer: “I’ll never get better. Every time I try something, it fails.” She wrote a description of the event in column 1 of the Thought Record. (See below.) In the second column, she recorded her emotions at the time, noting that she felt depressed and hopeless. And in the third, she wrote the thoughts going through her mind when the emotions were strongest: “I’ll never get better. Every time I try something, it fails.”

The purpose of this exercise is to help you gain some distance from your thoughts, to remove their taken-for-granted or self-evident character. Often we are more harsh and judgmental toward ourselves in our inner dialogue than we would be with others. Self-defeating thoughts often go through our minds when something upsetting occurs. Because these thoughts are automatic, they can be hard to recognize and it can take some time to develop this skill.

Evaluating Negative Thoughts

Once you have identified negative thoughts, the next step is to examine them for “reasonableness.” In evaluating your thoughts, ask yourself to what extent the thoughts are valid. Negative thoughts tend to ignore facts or to select only the worst aspects of a situation. One way to determine reasonableness is by asking “What is the evidence for and against my thoughts?” The idea is to suspend temporarily your belief that the thoughts are true, and instead look for both evidence that supports and evidence that refutes the thoughts. Writing down the evidence you find helps you gain distance from your thoughts and makes them less self-evident.

You use column 4 in the Thought Record for evidence for, and column 5 for evidence against. The patient in our example wrote in column 4 that she has frequent setbacks and that she had often felt worse after exercising. She wrote in column 5 that she had improved over the last year and knew that many CFIDS patients improve.

Your thoughts at moments of strong emotion may seem irrefutable, so it may help to have in mind some questions you can ask yourself in order to find evidence that does not support your thoughts. Among them:

Seeing Alternatives

In the first step, you identify your self-defeating thoughts by recording the thoughts associated with strong emotions. In the second step, you challenge the accuracy of the thoughts by testing them to find distortions and irrationalities. In the last step of the process, you propose a new understanding of your experience.

You use column 6 of the Thought Record for this purpose. What you write in column 6 should be either an alternative interpretation of your experience (if you refuted the thought) or a balanced thought that summarizes the valid points for and against (if the evidence was mixed). In either case, what you write should be consistent with the evidence you recorded in columns 4 and 5. Reviewing the evidence she had written in columns 4 and 5, our patient decided that the evidence was mixed. She wrote a balanced thought that combined the evidence for and the evidence against. “I have frequent relapses and don't know if I will have lasting improvement. But I've made progress and that gives me hope.” 

The Goal: More Realistic Thinking

The process described here involves changing deeply ingrained habits of thought. The long-term results can be dramatic, but improvement is gradual. The reason to use thought records is not to replace negative thoughts with positive but inaccurate ones. I am not suggesting you adopt something like the motto “every day, in every way, I am getting better and better.” Rather, the goal is to learn to see your situation in an accurate, yet hopeful way: retraining your habits of thought in a more realistic direction. The kind of thinking advocated here integrates all evidence both positive and negative. It should reduce your stress by helping you feel better, less anxious and sad. And, at the same time, it should help you to deal more effectively with your illness.