Changing Self-Talk: A Cognitive Therapy Primer
Note: Chronic illness brings physical suffering from symptoms, but it also creates mental suffering, caused by things like worry, uncertainty, regret, guilt and grief. The articles in this series focus on ways to ease the second type of suffering: psychological pain.
I’ve mentioned several times in other articles in this series that the inner dialogue we have with ourselves, called our self-talk, can be a source of mental suffering. I’ll say now that I believe unhealthy self-talk is at the root of much of our psychological pain.
This article presents a solution: using Cognitive Therapy to reduce mental suffering by making self-talk more realistic and more positive.
We all talk to ourselves all the time. Some of the talk is about things outside us. For example, when we find something we've lost, we might say to ourselves, "There it is." Another part of our inner dialogue is about ourselves. It is the things we say to ourselves about ourselves. For example, when we can't find something, we might say something like, "You dummy; you're always losing things."
Self-talk is a habitual way of responding to our experience and often takes the form of an internal critic who can be very negative and pessimistic. For example, if you experience a relapse, your inner voice might say something like, "You'll never get any better. Every time you try something, you fail." Or your inner voice may blame you for becoming ill, saying things like “If only you’d taken better care of yourself, you wouldn’t have gotten sick.”
Unrealistically negative thoughts make you feel anxious, sad and hopeless. These feelings, in turn, make it difficult to act constructively. Preoccupation with suffering may even intensify symptoms and trigger more negative thinking.
Cognitive therapy is based on the idea that how we feel depends on how we think. If we have inaccurate negative thoughts, they will create negative moods. Cognitive Therapy offers a way to have more accurate thinking. It works by enabling you to recognize and gradually change unrealistic habitual thought patterns called cognitive distortions.
Some of the most common distortions are:
1) Overgeneralization or Catastrophizing
Drawing a broad conclusion based on a single incident or insufficient evidence. For example, if exercising results in a relapse, concluding that exercise will always be impossible. An alternative approach is to evaluate each experience in its uniqueness. For example, if one exercise program is not successful, analyzing why and experimenting to find a level of exercise that does not produce a relapse.
2) Jumping to Conclusions (Mind Reading)
Assuming we know what others are thinking and feeling. For example, if a person doesn’t contact us, we may conclude that they don’t care about us any more. But there are other possibilities. Perhaps the person has not known how to respond or did not want to disturb us with a call. Or maybe they themselves have been ill or out of town. An alternative to mind reading is to take the initiative and contact the person ourselves.
Using inflexible rules about how we or others should act. We feel guilty when we violate these rules. For example, we may say “I should be a better parent” or “I should provide for my family.” An alternative is to tell ourselves that we have an illness that imposes significant limits. To be realistic, we can adjust expectations to match current abilities. For example, we may say to ourselves “I can’t do everything I used to do, but I can still find ways to contribute.”
In cognitive therapy, we learn to identify, refute and replace our cognitive distortions. Over time, our unrealistic thinking will give way to more rational, balanced thinking. And, because cognitive distortions often lead to feelings of hopelessness and helplessness, replacing them can lead to a more optimistic and effective approach to life.
Cognitive therapy proceeds in a three-step process:
Step 1: Recognizing Automatic Thoughts
The first step to changing your habitual thinking is to recognize it. This is not easy to do because our thoughts are automatic, so deeply ingrained that they seem self-evident. The technique I’ll describe is based on the book Mind Over Mood by Dennis Greenberger and Christine Padesky.
You can find similar techniques in other books, such as Learned Optimism by Martin Seligman or Feeling Good by David Burns. And you can learn them from psychologists who specialize in Cognitive Therapy.
To see how this technique works, imagine someone with ME/CFS or FM who took a walk one day and felt very tired when she got home. Feeling depressed and hopeless, she asked herself what thoughts were going through her mind at that point.
They were, "I'll never get better. Every time I try something, it fails." She recorded her experience by writing a brief description of it (“Walked 15 minutes; very tired after”), noting her emotions (depressed, hopeless) and the thoughts she had when the emotions were strongest (“I’ll never get better”).
The purpose of this step is to help you gain some distance from your thoughts, to remove their taken-for-granted or self-evident character. Because these thoughts are automatic, they can be hard to recognize and it can take some time to develop this skill.
Step 2: Testing Automatic Thoughts
Once you identify your automatic thoughts by recording them, you next evaluate them to identify distortions and irrationalities. To help you determine to what extent your automatic thoughts are valid, ask yourself what is the evidence for and against your thoughts. Writing down the evidence pro and con helps you gain distance from your thoughts and makes them less self-evident.
In our example, the person might write under “Pro” that she has frequent setbacks and exercise often makes her symptoms worse. Under “Con,” she might note that many people with ME/CFS and FM improve and that she has made progress in other areas of her life.
Step 3: Seeing Alternatives
In the last step, you propose a new understanding of your experience. It 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 our example, the person might write, “I have frequent relapses, but I've made progress and that gives me hope. I would still like to develop a safe way to exercise, so I’ll start by asking other people what’s helped them."
The Goal: Realistic Thinking, Not Positive Thinking
Using cognitive therapy to understand your experience, you acknowledge the negatives in your life and look at them in a balanced, realistic way. Cognitive therapy does not mean adopting 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, manner, retraining your habits of thought in a more realistic direction. Even though improvement with Cognitive Therapy is gradual and takes patience and determination, the long-term results can be dramatic and even life-changing.