It is estimated that humans produce hundreds, if not thousands, of thoughts per hour. This staggering amount of information is designed to help you make sense of the world. Thoughts come from countless sources, including your observations, your expectations, and your own personal experiences. Your mind uses categories and labels to sort through and organize all of this information. Your mind groups your thoughts and uses themes like good/bad, always/never, right/wrong, and love/hate. Check in with your mind now. What are your thoughts? Perhaps you are noticing your curiosity about this chapter. Maybe you are thinking about how you slept last night. See if you can identify how your mind categorized these thoughts. Perhaps you labeled your curiosity as “helpful” and your sleep last night as “problematic.” Take a moment or two to consider the content of your thoughts.
Minds are not 100% accurate. Nor do they only produce helpful thoughts. Minds are often even less accurate and less helpful when they are sleepy or feeling strong emotions. For example, if you are exhausted and concerned about your sleep, you may be more likely to have thoughts like I am never going to sleep tonight! Of course, this thought just feeds the insomnia spiral. You experience an unpleasant emotional reaction such as frustration or hopelessness. These feelings then activate your nervous system, telling it that something is wrong. This sends a signal to your body to be more alert so that it can attend to the problematic situation. This, of course, makes it harder to sleep.
Cognitive restructuring (CR) can help you change myths about what “normal” sleep is, catastrophic thoughts about what will happen if you do not sleep, negative thoughts about other things in your life that increase stress or anxiety, and thoughts that interfere with your willingness to change sleep-related behaviors. Here are some clues that cognitive restructuring will likely be useful for you:
Negative cognitions are thoughts that are either distorted or unhelpful (or both). Negative cognitions activate your body and interfere with your wake and sleep cycles. Negative cognitions also increase discomfort. They make it more likely that you will choose short-term solutions for your sleep. They make it less likely that you will make choices that support sustainable sleep patterns in the long term. They have a disruptive impact on your sleep. They feed your insomnia spiral.
There are three things you need to know about negative thoughts. First, it is normal to have negative thoughts about your sleep. Negative thoughts are a very human response to a challenging situation. Second, negative thoughts tend to increase when you are sleepy or are feeling strong emotions. Most people who struggle with sleep have lots of negative thoughts about sleep. Third, negative thoughts feed negative thoughts. Once a thought shows up, it will cue another negative thought, and another. Therefore, negative thoughts are expected, but they also contribute to your insomnia. This is why cognitive strategies are such an important part of CBT-I.
One type of negative thought is a distorted thought. Distortion literally means an alteration of the original state. A cognitive distortion, then, is a thought that has a kernel of truth in it, but has been altered in some way. Cognitive distortions misrepresent the situations they describe. For example, you may say “I didn’t sleep a wink last night,” when you actually slept for a few hours.
There are recurring themes in the manner in which our minds distort our thoughts. Below is a list of common types of cognitive distortions. Read the descriptions and see which you engage in most often.
Cognitive distortions can be about any topic and still impact your sleep. In fact, none of the examples of cognitive distortions listed above are about sleep. Yet they share a common tone of judgment and blame. This can increase your arousal and negatively impact your ability to fall asleep and stay asleep.
A second type of negative thought is an unhelpful cognition. Unhelpful cognitions are thoughts that, regardless of how accurate or distorted they are, have a negative impact on you. An example of a nondistorted but unhelpful cognition about sleep is Even if I fall asleep right now, I will only get five hours of sleep! This thought may be true, but it is also counterproductive because it produces emotional responses (such as anxiety and frustration) that interfere with what your body needs for sleep.
There is an effective tool for managing these negative cognitions. It is known as “cognitive restructuring,” which literally means changing or restoring the content of your thoughts. Cognitive restructuring helps you strip away distortions, leaving you with more accurate thoughts. Cognitive restructuring also helps you recognize accurate but unhelpful thoughts. There are three steps to cognitive restructuring, and we will look at each in turn:
You may be quite aware of the thoughts that are causing you distress and feeding the insomnia cycle. If you are, go ahead and write them down. Then move on to step 2. However, many people are not exactly sure what is going through their minds. Oftentimes, thoughts are so quick and automatic we are unaware of them.
“Thought records” are a tool designed to help you become more skilled at identifying and working with your thoughts. Worksheet 10.1 is a version that we like. We encourage you to use a spike in emotions to help you identify your negative thoughts. When you notice such a spike, first list the feelings you just noticed (for example, “fear” or “dread”) in the third column. Then write in the first column a very brief explanation of the situation (for example, “Preparing for bed”). Then ask yourself, What was going through my mind? and write your thoughts in the second column (for example, “What if I don’t sleep tonight?”).
Here are a couple of hints to help you with step 1. First, try to capture your thoughts precisely as you said them to yourself. The way you talk to yourself really does matter. A thought like I’m such an idiot! will affect you very differently than the thought I sure made a mistake! Second, consider whether the thoughts you identified are specific enough to work with. If they are lacking in detail, it can be helpful to dig deeper. Start with the thought that showed up, and then ask yourself, And then what? in order to get more information. For example, the thought I am scared I won’t be good at my presentation tomorrow if I don’t sleep tonight is activating but lacking detail. Are you worrying about failure? Job security? Judgment from colleagues? Once you have more details, you have a greater capacity to work with your cognitive distortions or unhelpful thoughts.
The next step in this process is to spot the “negative” in your thought. This can be tricky, and referring to the list of distortions can help you. With the thought I’ll never get to sleep, the distortion is the word “never,” because it is not physically possible to never sleep. Sleep is required to live, and eventually your sleep drive will win out and force your body to rest. The data to support the thought is not there; no one on this planet has lived without sleeping. The data against the thought is strong: eventually you will fall asleep. You now modify the original thought to strip away the distortion, while leaving the kernel of truth: I struggle to get to sleep, or Getting to sleep is really hard for me, or I am afraid that I won’t ever sleep. These thoughts, without the distortion, are painful but not absolute. They will naturally have a different influence on your emotions and behaviors than the thought that contains the word “never.”
The final step in our thought record is to consider: What next? Take a look at your alternative thoughts and notice if your emotions and physical sensations have changed. If yes, how have they changed? What are your feelings now? What are your options now? We believe that alternative thoughts will allow you to recognize the option of alternative behaviors. If your thought has been modified from I’ll never get to sleep to I am afraid that I won’t ever sleep, what shows up? Perhaps your emotions have shifted from fear to sadness or frustration. Perhaps the recognition is that yes, sleep is currently challenging for you. You can recognize that you are addressing this issue by reading sleep books and trying new techniques for your sleep. Your alternative behavior could be to reach for your personalized sleep program to remind yourself of what actions you are taking to improve the quality of your sleep. The goal in this step is to lessen the amount of control your negative cognitions have on your actions. If you look back at the 3P model in figure 3.1, you will see how this can interrupt the insomnia spiral.
Remember George from chapter 3? He is a self-employed businessman whose sleep problems started after the birth of his third child. His current difficulties include trouble falling asleep and waking too early in the morning (around 3 a.m.). He is fatigued during the day, concerned about his job productivity, and anxious about how to fix his sleep problems. Take a look at worksheet 10.1 to see how George would complete a thought record. Some key thoughts are acknowledged. These thoughts are then challenged and replaced. Finally, alternative actions are identified.
Date
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STEP 1: Awareness |
STEP 2: Challenge |
STEP 3: What Next? |
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What is the situation? |
What is your thought? Be specific and identify each one separately. |
What are your feelings? |
Can you find any distortion? If yes, what is it and what is the more accurate thought? |
Is the thought unhelpful? If yes, what is a more helpful thought? |
What are your feelings now? How does challenging your thoughts influence your choices? |
Sample: George
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STEP 1: Awareness |
STEP 2: Challenge |
STEP 3: What Next? |
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What is your thought? Be specific and identify each one separately. |
What are your feelings? |
Can you find any distortion? If yes, what is it and what is the more accurate thought? |
Is the thought unhelpful? If yes, what is a more helpful thought? |
What are your feelings now? How does challenging your thoughts influence your choices? |
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Tossing and turning at bedtime. |
I will fail at my job tomorrow. |
Panic, anger. |
Distortion: I will fail. Accurate: It may be more difficult to do my job. |
Very unhelpful to think I will fail. More helpful to recognize it might be harder to do my job. |
Frustration and acceptance. I do not like having to work harder, but it is my reality at this time. Settle down. |
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Waking up multiple times during the night. |
This insomnia is killing me. |
Fear, sadness. |
Distortion: killing me. Accurate: challenging and painful. I will not die from this insomnia. |
Yes, unhelpful. More helpful to know sleep is challenging right now. |
Determination. I am ready to do what it takes to change my relationship with sleep. |
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Fatigue and “fog” during my business presentation. |
I am a failure. |
Disgust, embarrassment. |
Distortion: I = failure. Accurate: I am struggling with this presentation right now. |
Very unhelpful to label myself and all I do as a failure. More helpful to recognize this is a tough time. |
Concern and anxiety. I will need to take some extra time and care to make sure I am running my business as best I can. |
Here are some common cognitive distortions specifically about sleep. Do any of these sound familiar? Notice how we challenge these thoughts. Can you consider these alternative thoughts?
It is true that many sleep-interfering factors are partially out of your control, such as pain, allergies, menopause, and depression. But there are also many factors that are under your control. These controllable factors include lifestyles, unhelpful habits, and stress management. Removing this distortion can help you to identify what you can control. Focus on the areas of your life that are open for change. This book highlights all that you can do to improve your sleep.
“I should be able to sleep whenever and however I want to.”
No one has this type of control and consistency. In fact, no two nights of sleep are really alike. There are natural and daily fluctuations in sleep, just as with your appetite and mood. Nobody has control over when they fall asleep and wake up. Eight hours of sleep is an average, not a given.
“I have to work harder at my sleep.”
This pressure perpetuates a tug of war with the Insomnia Monster. You will find your sweet spot with sleep when you determine when to work harder and when to let go of the rope.
“I have to make sleep happen right now.”
This puts you at risk for getting trapped in an ineffective spiral, just like the Chinese finger traps. This creates anxiety, as well as a “fix it” attitude, at a time when your brain would instead benefit from some willingness.
Sometimes people misunderstand our intent when we introduce cognitive restructuring. They think we are suggesting that they “think positively,” or that they control their mind and stop having negative thoughts. If this is how you try to work with your thoughts, chances are you will simply increase your struggle. Instead, we encourage you to use your willingness skills as you work with your thoughts. Can you be willing to have whatever thoughts show up, but then choose to respond differently to them?
Regarding the “think positively” misconception, it is common to feel pressure to generate new thoughts that are optimistic and hopeful. It makes sense that people think this is what cognitive restructuring is about, since the brain is designed to categorize, and the opposite of negative is positive. However, we actually are encouraging you to go from negative to realistic, not from unrealistically negative to unrealistically positive. If an optimistic, hopeful thought is truly a realistic appraisal, then all is well and your mind will be pleased to know this information. However, if this is an example of forcing a positive attitude, it will most likely backfire. You will not believe it. It will not work. Your mind will see right through you! It is far more effective to remove all distortion, even the positive. This often requires leaning into (rather than resisting) some discomfort. This takes some willingness to resist the urge to replace all your negative thoughts with positive ones.
The second misconception is thinking that you have to stop having certain thoughts. Because of the way our brains are wired, this is simply not possible. Yet you might find yourself with thoughts such as Stop thinking that way! and You must think positively! We want you to recognize that this is really just another form of negative thought patterns! It is both unhelpful and distorted—no one can control what thoughts enter their mind, and no one is capable of positive thoughts 100% of the time. Consider these alternative thoughts: I am doing the best I can by noticing my thoughts and their content. The goal is not to get rid of thoughts, but rather to catch them in action and provide a more viable alternative thought. As you practice cognitive restructuring, be sure not to fight your mind. Instead, simultaneously practice willingness for all types of thoughts to exist in your mind. And then use your alternative thought to guide effective action.
“I do not have any thoughts that interfere with my sleep. Do I really need to keep a thought record?”
It is most likely that you do have thoughts that interfere with your sleep but that you are unaware of them. Thoughts can be very tricky. It can be difficult to notice them. Use your body for clues that you may be engaging in negative thinking. If you notice tension, discomfort, or strong emotions, these will be linked to important thoughts. You can take a close look at the thoughts that you identify in this manner to see if they are distorted or unhelpful.
“I do not have my thought record sheet with me. Should I track my thoughts anyway?”
The worksheet is there to help guide you in the process of cognitive restructuring, and to serve as a reminder to work on this skill. If you do not have a copy of the worksheet with you, go ahead and use whatever is close and handy. Some other options include index cards, paper, journals, or a cocktail napkin! It is fine to create your own version of a thought record. As long as you have a way to track, you will find benefit in this intervention.
“I cannot figure out how my thought is unhelpful. What do I do now?”
It is possible that you are actually trying to challenge more than one thought at once. What happens if you break down a complex thought into parts, and treat each part as a separate thought? It will be easier to spot the unhelpful elements when you look at one idea at a time.
If you find you are still struggling with uncovering the unhelpful parts of your thought, ask yourself this question: “And then what?” This line of questioning will also help you to break down thoughts and get to their core. For example, let’s say you feel anxious and your thought is: I am so tired. The thought is not distorted—you are tired. Yet it is not immediately clear why this thought would make you anxious. One could be relieved to be tired. Probe further. Okay, I am tired. Now what? What is the worst that could happen? Asking yourself these questions can help you get to the distorted thought, such as I can’t stand it! or I am sure to mess up when I am this tired.
“Are you sure this intervention will help me?”
No. But we suspect it will. Using the thought record to monitor what you are thinking will help you better understand what your mind tells you about sleep. It also may help to create some distance between you and your thoughts (there is much more on this in chapter 12). Catching and correcting distorted thoughts may decrease your arousal and your struggle with sleep. This is not a guarantee that it will solve all your sleep challenges. It is simply an acknowledgment that cognitive restructuring is a powerful tool.
“Do I have to do the thought record every day?”
We encourage you to complete at least one thought record a day at first, just to get skilled at recognizing thoughts and their connection to your feelings. After that, use the thought record in response to strong emotional reactions, or when you are aware that you are thinking about your sleep or the cost of your insomnia.
“I keep trying to replace my negative thoughts with positive thoughts. Why can’t I convince my brain to be more optimistic?”
The goal of restructuring is not to generate positive thoughts. The goal is to look for unhelpful patterns that are hiding in your thoughts. When you restructure these unhelpful thoughts, you want to replace them with more workable, more accurate thoughts. Sometimes these new thoughts are positive. More often they are not. However, the accuracy allows you to have a more clear understanding of your situation, which will better guide effective action.
“Now that I understand how these negative thoughts impact my sleep, I need them to stop. How can I only have helpful thoughts about sleep?”
You can’t. Stopping thoughts is not the goal of cognitive restructuring. We have learned that trying to stop or suppress thoughts can lead to more distress, not less. These negative thoughts are habits. It takes time and practice to make new habits. However, even after you have developed new habits, you will still have negative thoughts. What will be different will be your habits about how you manage or respond to these negative thoughts.
“I am feeling overwhelmed and lost in this process.”
If the thought record feels overwhelming, consider doing a thought record around the thought record! Seriously. Something important is showing up. Are you placing too much pressure on yourself by forcing yourself to push harder than is comfortable? Perhaps slowing down could be the most supportive move. Are you uncovering some really important and big feelings about sleep and your life? Perhaps talking to someone such as a friend or trained clinician can benefit you at this time. Remember, the intensity of your reaction is providing you with important information.
Are you trying to monitor too many of your thoughts? We are not suggesting that you write everything down! Focus on the thoughts that seem to be connected to your sleep. These are most likely predictions about how you will sleep, thoughts about what it will mean if you do not sleep well, or thoughts about stressful life events that have your body “wired.” Or focus on thoughts that are blocking you from fully implementing a behavioral sleep program.
Use worksheet 10.1 to start working with your distorted or unhelpful thoughts. Spend some time considering what types of thoughts tend to feed your insomnia spiral. Identify your thoughts about sleep. Identify your thoughts about your life more generally that also impact your sleep patterns. Remember to look out for the four most common targets of cognitive restructuring: (1) myths about what normal sleep is like, (2) catastrophic thoughts about what will happen if you do not sleep, (3) negative thoughts about other things in your life that increase stress or anxiety, and (4) thoughts that interfere with your willingness to change sleep-related behaviors. Keep in mind that bodily sensations and strong emotions can help you to uncover important thoughts.
Pay attention to your thoughts every day. It will take time and practice to help your brain catch and change the problematic patterns. Use your willingness skills to lean into your experience, even as you challenge your thoughts. Be careful not to have cognitive restructuring add to your struggle.
You can expect to still have negative thoughts. You are human. Humans have inaccurate thoughts every day. The goal is not to get rid of certain types of thoughts. The goal is to decrease the impact of these negative thoughts on your sleep and well-being.
You can expect to see a change in how you respond to your negative thoughts. You will become more aware of the thoughts. You will be more likely to pause. You will be less likely to take your thoughts at face value. You will notice yourself fact-checking, asking questions such as Are there any distortions lurking in this thought?
With practice you will get quicker and quicker at identifying and replacing negative cognitions. You likely will see patterns in the type of negative thoughts your mind generates. This will allow you to challenge similar thoughts much more quickly. For example, you may say to yourself, Oh, there I go catastrophizing again. I know I will survive.
Over time, you may notice that you have fewer negative cognitions to challenge. Or you may not. Either way, this process of pausing, questioning, and restructuring will help you step out of the insomnia spiral. You will find yourself using your more accurate and helpful thoughts to inform your behavioral decisions. As a result, your ability to stick to your behavioral program will improve. You also will notice less physiological arousal as you change your self-talk.
There are no clear, quantifiable measures of progress with cognitive restructuring. Use effectiveness as your compass. Is it getting easier to notice and challenge negative thoughts? Does changing the way you are thinking help to calm your mind and nervous system so that you feel less anxiety, tension, or other distress? Does challenging negative thoughts help you stick to your behavioral program?
If you have completed many thought records over the course of several weeks and perceive no benefit at all, we encourage you to try the other cognitive strategies in this book. You may also want to take a break from cognitive restructuring if this tool is having the undesirable effect of getting you really “caught up” in your head. Ideally, cognitive restructuring will give you some distance from your negative thoughts and allow you to gain a more realistic perspective. Occasionally people have the opposite experience. This is not effective.
If you are finding cognitive restructuring helpful, continue to use this tool in addition to working your behavioral sleep program. You can pause here, and put your time and effort into these treatment components. Then, once you have been following your behavioral program for at least six to eight weeks, you are welcome to skip to chapter 13 to evaluate your progress thus far.
Alternatively, you can add to your arsenal of cognitive strategies. Refer back to worksheet 5.1 to remind yourself which other cognitive strategies seemed relevant to you. Then proceed to either chapter 11 to learn about designated worry time, or chapter 12 to learn about the acceptance-based strategies of mindfulness and cognitive defusion.