Insomnia and Anxiety (Series in Anxiety and Related Disorders) (30 page)

Thought Record

113

alone may adequately address many problematic sleep beliefs that contribute to

insomnia. Nonetheless, there are many instances where this form of intervention is

not sufficient and a more potent cognitive intervention may be needed. In such

cases, a more intense and structured intervention as described in the following text

should be considered.

Thought Record

The Thought Record is a tool for modifying thoughts and beliefs. In the short term,

it is meant to target the thought–distress connection and interrupt the automaticity

of this process. In the long term, the goal is belief modification, which would pre-

sumably decrease future cognitive vulnerability to insomnia. The Thought Record

itself is fairly simple and enjoys many years of use as a cognitive therapy tool

across multiple disorders. Although various renditions of Thought Records exist,

the main components are the recording of the situation in which the troubling

thought or mood occurred, the mood, and the associated problematic thoughts.

The Thought Record also typically includes a column or space wherein the veracity,

utility, or accuracy of the thought is challenged. Most Thought Records ask for a

rerating of mood after the disputation to assess if the thought modification was

associated with a mood improvement. We will discuss the type of Thought Record

used in our (CEC and JDE) clinics and clinical trials. The exact record form we use

is shown in Fig. 8.1 (Edinger & Carney, 2008).

Situation
: This column asks for the situation in which the person noticed a trouble-

some mood or thought. One of the reasons for recording the situation is that some-

times there is a relationship between certain situations or settings and recurrent

troubling thoughts or moods. In such cases, one can develop a preemptive plan to

decrease the likelihood that these thoughts and moods might arise. For example,

Mr. R monitored his thoughts, mood, and the situation in which it occurs on the first

three columns of a Thought Records for 1 week (Fig. 8.1). When Mr. R returned to

therapy, he discussed his Thought Records and noticed that he tended to worry

about whether he was going to sleep well when he sat down to watch television at

night. He noticed that it was the first time each day that his surroundings were quiet,

and something about that situation made him anxious about his ensuing night’s

sleep. In addition to teaching Mr. R how to challenge catastrophic thoughts on the

Thought Record, he began a relaxation practice at this time in the evening and

noticed that he no longer had these anxious thoughts.

Mood
: The mood column is used to record emotions and their intensity. The main chal-

lenge facing people when completing this column is the tendency to confuse thoughts

with moods. Moods are often best described using a single word rather than a phrase.

Thus, feeling “blasé” may be a mood but “I feel like I can’t get anything accomplished,”

may be best conceptualized as a thought about feeling “blasé.” This column also

provides a rating of the intensity of the mood (usually 0–100%). This rating can serve

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8 Cognitive Strategies for Managing Anxiety and Insomnia

Mood

Do you feel

(Intensity 0-

Evidence for the

Evidence against

Adaptive/Coping

Situation

Thoughts

any

100%)

thought

the thought

statement

differently?

Sitting

Anxious

It feels like

I have trouble

It is not 100%

Telling myself

Anxious

on my

(90%)

I’m going to

sleeping when

true that I

that I’ll

(40%)

couch

have a panic

I feel anxious

will NEVER be

never sleep

watching

attack.

like this.

able to sleep.

makes me feel

evening

Something’s

more anxious.

It just feels

I’ll

news

wrong.

The truth is

like I won’t

definitely

sleep at least

that I will

I should have a

sleep, so I

a little.

absolutely

beer.

won’t.

Just because

sleep and I

I need to find

it feels like

can’t know how

a way to calm

I won’t sleep

well.

down.

doesn’t mean I

I’ve noticed

won’t—that

I have a really

that yoga

emotional

big day

helps with my

reasoning.

tomorrow.

anxiety, maybe

I feel really

if I do

What am I going

sleepy, so it

something

to do? I can’t

is possible I

relaxing, I’ll

keep going on

could sleep

improve my

like this.

well.

odds of

I’ll go

There is

sleeping well.

“crazy” if

likely a cost

this continues.

to telling

I am never

myself that

going to get to

I’ll never get

sleep.*

to sleep. It

could become a

self-

fulfilling

prophesy.

Fig. 8.1
Thought Record for Mr. R

as a precognitive challenge value that can be compared to the postcognitive challenge

mood rating to assess whether mood improved. In the case of Mr. R, he rated anxiety

as his prominent mood and rated it quite high (90%).

Thoughts
: This column is where people record their thoughts for analysis in subse-

quent columns of the record. Some of these thoughts are automatic and perhaps

out-of-awareness. It may take some encouragement to expose what is truly occur-

ring underneath the thought process in the situation. In cases wherein it is difficult

for someone to identify many thoughts, it may prove helpful to use techniques such

as the “downward arrow.” Some of the questions that facilitate further exploration

can include “And then what?” For example, if someone records the thought, “I am

going to get sick if this continues,” it may be helpful to ask “So you are concerned

that you might get sick? And then what would happen? What would happen if you

were to get sick?” When people examine their thoughts in this way, it often uncov-

ers catastrophic thinking. In the example above, it would not be uncommon to

uncover fears about becoming disabled, committing suicide, becoming seriously

mentally ill, or finding out that insomnia is linked to a fatal condition. In the case

of Mr. R, he acknowledged a fear of “going crazy.” Catastrophic thoughts can be

typical in those with insomnia (Harvey & Greenall, 2003), and the downward arrow

technique can make these fears more explicit. Other helpful questions include: “If

this thought is true, what’s so bad about that?” or “What’s the worst part about

that?” or “What does that thought mean to you?” It is important for the person to

Thought Record

115

fully explore their thoughts on the issue without censorship, or the Thought Record

will become a superficial and not particularly helpful exercise.

A common strategy when using Thought Records is to circle the “hot” thought

(bolded in the case of Mr. R in Fig. 8.1); that is, the thought most tied to the intense

mood in the Mood column. In some cases, there is not a thought that is most linked

to the identified mood state in which case it may be that the mood has not been ade-

quately characterized. For example, someone may choose to record angry feelings,

ignoring sad or hurt feelings. Thus, the thoughts may be more linked with loss and

sadness while the mood is rated as angry. The other, more likely explanation is that

the thoughts recorded do not include the most troubling thought, but simply “scratch

the surface” and avoid the most difficult cognitions. Asking some of the questions

above can make the Thought Record more productive. In addition, there are several

helpful Cognitive Therapy resources available to elicit “data-rich” thoughts on the

Thought Record (Beck, 2005; Beck, 1995; Greenberger & Padesky, 1995).

Evidence for the Thought
: Gathering the evidence for the thought is not included in

all versions of the Thought Record. The purpose is to acknowledge the kernel of

truth in the person’s thoughts. It can be validating for individuals to hear that their

thoughts are not ridiculous and there is a “reason” why they find the thoughts so

compelling. This exercise may be helpful in combating resistance that can develop

during the disputation or challenge part of the Thought Record. Thus, the evidence

for the thought that “I am going to become sick” may be that a depression devel-

oped subsequent to the insomnia. It is important that evidence written in this col-

umn be factual. Thus, Mr. R’s evidence that “It just feels like I won’t sleep, so I

won’t” is an example of emotional reasoning and not factual. Socratic Questioning

(that is, using questions to elicit particular responses) focused on factual evidence

in this column, which can be used to challenge cognitive errors and communicate

the idea that thoughts are not facts. We generally ask people to modify the piece of

evidence listed in this column so that it is factual, or we ask them to consider cross-

ing it out if it is not really an evidence. In other cases, we ask them to address the

cognitive error in the evidence against the thought column.

Evidence against the Thought
: This is the column most associated with Cognitive

Therapy as it is the column wherein the disputation occurs. It is here wherein the

veracity or the utility of the thought comes under scrutiny. Traditional Cognitive

Therapy focuses on thoughts being erroneous. In some cases, clients might receive

a list of Cognitive Errors along with reasons for why they are incorrect to aid them

in disputing thoughts. For example, they may receive information that

“Catastrophizing” is an example of a cognitive error because it overestimates the

likelihood of the most extreme possible alternative occurring. Or “all or none/

dichotomous thinking” is an error because it considers only two extreme outcomes

and ignores the far more likely moderate “everything in between.” For example, the

thought that “I didn’t sleep at all last night” is highly unlikely as most people sleep

sometime (however, briefly) during a 24-h day. It may be that the person only slept

for 2 h but claims to have not slept
at all
. This type of thinking fuels anxiety, so we

ask people to modify it to something more accurate and thus more helpful.

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8 Cognitive Strategies for Managing Anxiety and Insomnia

In Mr. R’s Thought Record, he addresses the emotional reasoning listed in the

evidence for the thought by acknowledging that it was not a fact in the evidence

against the thought column and added that just because something feels as though

it is true does not necessarily mean that it is true.

There are many questions that can help with the evidence against the thought

column. For example, a classic restructuring question is whether something is true

100% of the time. Mr. R acknowledged that it is not 100% certain that he would not

sleep well. Another common question is to ask whether there is a particular down-

side to having that particular hot thought. We do not advocate focusing on “errors”

exclusively as it is often more helpful to focus on the adaptiveness or cost of buying

into particular thoughts instead. In Mr. R’s case, we do not focus on whether it is

accurate that he will have a panic attack. Arguably, we could say that he is catastro-

phizing by assuming that his anxiety symptoms will culminate into the worst possible

outcome – a panic attack, especially since these symptoms did not actually end in

a panic attack in this instance. Instead, we focus on the
cost
of focusing on whether

he will have a panic attack – in his case, the cost is feeling more anxious, thus making

it more likely that he could have had a panic attack. Focusing on the accuracy of

thoughts can become tricky when people are accurately perceiving negative out-

comes, but focusing on the adaptiveness of particular thoughts is a useful endeavor

(i.e., that some thoughts are anxiety-provoking and thus not helpful).

Adaptive, balanced, coping thought
: This column attempts to acknowledge the kernel

of truth in the evidence for the thought while focusing on the evidence against the

thought. Thus, the thought is modified into a more helpful, adaptive, and balanced

cognition. We refer to it as a coping thought because we encourage people to write

down the thoughts that are most helpful to consider when they are particularly dis-

tressed. Mr. R’s examples are: “Telling myself that I’ll never sleep makes me feel more