Beliefs, thoughts and feelings – and how to change them

It will come as no surprise to many of us that our beliefs and thoughts are very powerful and have a significant impact on our wellbeing. Many people with long-term conditions and persistent pain develop health-related anxiety as a result of mistaken or distorted beliefs and expectations.

The impact of health-related anxiety can be significant:

  • Healthcare seeking behaviour
  • Activity avoidance
  • Change in social roles e.g. employment

Some GPs use CBT tools in their consultations – they may have received training or they may do it naturally.

Here we offer a few pointers and tips of ways we can spot unhelpful thoughts and how we can challenge and rebalance them.

The substance of this page is adapted from: Promoting optimal self-care: Consultation techniques that improve quality of life for patients and clinicians (NHS publications 2005)

The cognitive behavioural ‘5-area’ model

Our beliefs affect our thoughts which affect our feelings. Our feelings affect the way we behave, and in the context of persistent pain and long-term conditions, affect self-efficacy to engage in change and self-management.

Patients don’t present explicitly with concerns about their beliefs or thoughts, but they do present with feelings.

Part of addressing feelings involves identifying beliefs and thoughts which may be contributing. And in turn this increases the chances of engaging patients with self-management.

This can be illustrated by the 5 areas cognitive behaviour model.

How can we apply this ‘5-area’ model to persistent pain?

Using the 5 areas model we can look at how interventions (mostly self-care) can be divided between these areas

Physical strategies

  • Wise use of medication
  • Relaxation
  • Massage
  • Understanding sleep
  • Stretching

Behavioural strategies

  • Pacing
  • Goal setting
  • Getting fitter and more active
  • Rewards
  • Choosing to eat well
  • Increasing pleasurable activity

Cognitive strategies

  • Acceptance
  • Mindfulness and medi-tation
  • Self-reassurance
  • Reframing negative thoughts
  • Problem solving

Emotional strategies

  • Manage common emotions: - Depression - Anxiety - Anger - Frustration
  • Use CBT
  • Medication

Environmental strategies

  • Problem solving e.g. work, housing – signposting resources and hand over.
  • Assertiveness in relationships

Fear and avoidance behaviour

These types of beliefs are not uncommon and result in a cycle of avoidance of the very things that may improve symptoms followed by disuse and disability which then reinforces the whole cycle.

One of the key things we can do is challenge and reframe these misconceptions.

Unhelpful thoughts and how to challenge them!

Below, we look briefly at the different types of unhelpful thoughts our patients (and we?) may experience. We hear these kinds of statements all the time in our consultations. Just start to look for them and there will hardly be a consultation that goes by where you don’t spot one!

Overgeneralisation:

These thoughts tend to contain ‘always’ or ‘never.'

"Everyone with knee arthritis always ends up having a knee replacement and most of them are even worse off after!"

Crystal ball thinking:

An assumption of an ability to predict what people will think or what will happen in the future.

"If I go for a walk to the park with the grandchildren I won’t be able to do anything with them once we get there. The other grandparents will think I am rubbish."

Dwelling on negatives:

This is seeing life through a negative filter focussing only on the negative things that happen – it increases the risk of depression.

"No one at the party wanted to talk with me except about my pain. I must be so boring and now look fat too."

Dismissing positives:

This is the ugly twin of dwelling on negatives. These thoughts dismiss good things as ‘not counting’.

"It doesn’t count that Philip and Jane talked to me because they are my friends already and they have to talk to me!"

Labelling:

Jumping to conclusions about self or others.

"I’m a failure, I’m hopeless, I can’t even get out of bed because of the pain and get the kids to school on time."

Apportioning blame to self or others:

"It is my fault I have got fibromyalgia because I never managed to lose any weight and I never tried at sport at school."

All or nothing thinking:

This is the belief that everything must be a complete success, or it is a complete failure.

"I can’t run 10km since the operation, so it isn’t worth doing anything at all."

"I ate that sweet, so I might as well have the whole packet."

Size alteration/ catastrophising:

Exaggerating the magnitude of a problem.

"The whole world is against me, can’t get an appointment at the GP’s, letter from the Benefits Agency."

"All my patients bring lists of 15 problems… for me to solve!"

World instructions:

These are 'should' and 'should not' statements – they make us feel rebellious and urge us to do the opposite!

"I should never eat any sweets or chocolate."

Of course, it is much more helpful if patients can learn to spot and notice these thought patterns themselves.

It can be useful to get them to write down their thoughts between consultations and ask them if they can spot any patterns.

Having identified these thoughts, how can we help the patient change them? Here are some ideas:

Highlight the thought

Repeat the unhelpful thought aloud or write it down.

Ask the patient to score out of 100 how much they really think it is true.

Highlight how it may be an unhelpful thought and reframe it to something more realistic.

Now go back and ask them to re-score the original thought – this defuses it and increases self-efficacy.

Everyone with knee arthritis always ends up having a knee replacement and most are worse after. (95/100)

Some people with knee arthritis end up with ng a knee replacement but many don’t. I can do things to reduce my chances of needing one.

Original score drops to 10/100!

Review true events

This is building up a body of evidence of what has actually happened.

My cousin has knee arthritis and actually she is much better since she started the Escape Pain programme. She hasn’t needed an operation yet.

Use the best friend method

It is much easier to give advice to others than to yourself! Ask the patient to imagine they were listening to their best friend who had just expressed the same thought.

What advice would they give?

Note a friend may not challenge the thought!

I’m a failure, I’m hopeless, I can’t even get the kids to school on time.

You did get the kids to school on time in the last two weeks. You are such a caring mum, make their packed lunches and they are always so pleased to see you when you collect them. Lots of us are a bit late sometimes.

Put the thought to the test

This is experimenting with the thought to look for evidence whether it is true or not.

All my patients bring a list of problems.

I will do a quick audit of how many problems each patient brings and how long the consultation takes.

This will provide evidence that the initial thought is false and can be reframed… and move the conversation on to strategies to manage time and patient expectations!

Make thoughts more balanced

This can be helpful for light-switch/ all or nothing thinking and involves placing the thought more in reality.

“I can’t run 10km anymore since the operation, so it isn’t worth doing anything at all!”

Becomes through discussion:

“I can’t run as far as I would like but I can walk, and I am building up my strength. I could make a plan to gradually increase the distance I walk.”

Change the language/ grammar

This involves replacing black and white language with language which allows for some possibility!

So: I will, or I can’t become I might

I should becomes I could

Resources

A template based on the 5 areas model for patients to self-complete can be found here: