Cognitive Behavior Therapy (CBT) is an effective approach for a variety of issues, including bipolar disorder. It’s based on the ancient philosophical idea that suffering isn’t the result of what happens to us, but the result of how we interpret what happens to us. According to CBT, it’s largely our thoughts that lead to moods like depression and anxiety – thoughts about how things must be, how we should behave, how other people ought to treat us – and by changing our thoughts, we can change how we feel.
Although as a psychotherapist I’m familiar with CBT from a clinical perspective, a lot of my understanding comes from personal experience. I participated in CBT not long after I was hospitalized for a severe manic episode (which was immediately followed by a severe depressive episode) in 2003. By 2004, I was in graduate school studying to become a therapist. Looking back, I can hardly believe this myself. CBT wasn’t the only reason for my transformation, but I doubt I would have come so far so fast without it. In fact, it was a thought record that ultimately helped me accept I have bipolar disorder and move on with my life.
What Is a Thought Record?
Thought records are one of many skills taught in CBT. They are based on the premise that you don’t have to believe every thought you have. Let’s face it, many of our thoughts are half-baked at best and downright wrong at worst (and I’m talking about everybody, not just people with bipolar disorder) – yet we tend to accept what they have to say at face value. A thought record is a way of putting your thoughts to the test. It’s designed to help you change your moods by finding a more balanced way of thinking about things. In short, you identify a dubious thought and "put it on trial."
The end result of a thought record is a more balanced view. However, in my experience, the process of completing one can be just as beneficial as the end result. When you complete a thought record, you turn your attention inward and notice your thoughts and feelings. We are often so out of touch with ourselves that we have no idea what we’re really thinking or feeling. The process helps you slow down and identify what’s going on. When you bring such awareness to your internal experience, there’s often a spontaneous shift in how you feel.
Steps to Completing a Thought Record
You complete a thought record using a worksheet. There are many versions, but a tried-and-true one that’s easily accessible is from Mind Over Mood. This is a classic workbook that's been around for 20 years (a second edition is coming out in October 2015).
It will probably be helpful to have the Mind Over Mood thought record in front of you while you read through this section. You can get it for free on the following page:
There are 7 steps to completing the Mind Over Mood thought record. I’ll give you an overview, though this isn’t meant as a comprehensive guide. The workbook walks you through the process in more detail.
1. Situation: Identify a situation in which you had a strong feeling or reaction, or wish you had handled things differently. Describe what happened, sticking with the facts. Include these details:
- Where and when did it happen?
- Who was involved?
- What, specifically, happened?
2. Moods: Describe the related emotions, for example:
That last one may seem out of place, but I included it because I wanted to point out that you can do thought records for positive as well as negative situations. Contrary to popular belief, CBT isn't about “positive thinking.” It's about finding more balanced and objective ways of seeing the world – which in some cases might actually mean seeing things less positively. For example, say you meet a new romantic prospect, and within a few days you’re thinking “This person is perfect for me!” and “I’ve finally found the love of my life!” That’s a case where a little less optimism would probably be a good thing.
After you’ve identified your moods, rate each one on a scale from 0% to 100% (don't worry about nailing down an accurate percentage – just go with your gut).
3. Automatic Thoughts (and Images): List thoughts and images that pop up in relation to the situation. These thoughts can be so automatic that we don’t even know we’re thinking them. You can start by trying to remember what was going on in your mind right before your mood shifted. Here are a few typical examples of automatic thoughts:
- I’m such an idiot.
- I can’t cope with this.
- I’ll never get better.
- Nobody will ever hire me.
- I’ll never find another relationship.
- Nobody likes me.
- The world is a horrible place.
Once you have your list of thoughts, identify the hot thought. The hot thought is the one with the most “juice” or “charge,” the one most strongly linked to your mood. Circle the hot thought. This is the “defendant” you are going to put on trial.
4. Evidence that Supports the Hot Thought: This step and the next one involve gathering evidence. Your hot thought deserves its day in court, so list evidence that supports it. Since your thinking is currently biased in this direction, this step tends to be easy. However, it’s important to stick with verifiable evidence such as facts, data, probabilities, and percentages. Avoid interpretations and opinions.
Let’s say your hot thought is I’m always screwing up, and let’s say you had that thought after making a fairly minor mistake. These statements would be considered “credible evidence”:
- I made a mistake that set things back by a few hours.
- I forgot a detail.
- I inconvenienced several people.
These statements would not:
- I ruined the whole day.
- I’m horrible with details.
- I could tell the people my mistake impacted think I’m incompetent.
5. Evidence that Does Not Support the Hot Thought: Now take off your defense lawyer hat and put on your prosecutor hat. It’s time for some cross-examination. Your hot thought likely has some holes in its story, and your job now is to find them. This step tends to be harder. Your evidence against I’m always screwing up might look something like this:
- I get things right way more often than I get them wrong.
- I made a mistake in the afternoon, but in the morning I did two things very well.
- No catastrophe resulted from my error.
- I’m usually good at being careful.
- I apologized to the people my mistake impacted, and they assured me it was okay.
6. Alternative/Balanced Thoughts: In this step, you switch to the role of judge. Weigh the evidence from both sides, and try to reach a fair and unbiased “verdict.” In other words, come up with a new thought or thoughts that represent a more balanced and realistic perspective. For example, in the I’m always screwing up case, you might draw these conclusions.
- I make mistakes sometimes, but in general I am not careless or irresponsible.
- I am genuinely trying my best.
- The people my mistake impacted may have been a little upset, but there is no evidence they think I’m incompetent.
- I can improve my work based on what I learned from my mistake.
In the event that your hot thought is largely true, you will need to come up with a plan to address the situation. For example, if your hot thought is I can’t do this job, and you discover that you in fact don’t have the skills or support you need to do the job, that’s a genuine problem you’ll need to solve.
Next, rate how much you believe each new thought, on a scale from 0% to 100%. Often, how much you believe your alternative/balanced thoughts is related to how much your moods have changed in the next step.
7. Rate Moods Now: Rate your moods from Step 2 again, as well as any new moods. If there hasn’t been a change for the better, review each step of your thought record and see if there are any places you could be more accurate, specific, or thorough.
Tips for Success
I won't lie and tell you the thought record is an easy or fun tool to learn. I once did a thought record in which my stressful situation in Step 1 was filling out a thought record! Changing your thinking is a process that takes time, awareness, and energy. But the payoff for your hard work is profound – you can actually restructure the way your mind works (in fact, in CBT the process of changing your habitual ways of thinking is called cognitive restructuring). Over time you’ll automatically think in more balanced ways and have less extreme moods. Your usual hot thoughts either won’t arise, or you’ll dismiss or dispute them as soon as they rear their head.
Here are some tips for succeeding with thought records:
1. Don’t be a perfectionist. You don't have to do thought records perfectly. It’s not rocket science or brain surgery. Just do the best you can and don't think too much. I know it’s ironic that I'm advising you not to think when doing a thought record. But they are as much art as science, as much intuition as logic.
2. Be patient. Learning to do thought records probably takes about as much mental coordination as learning to ride a bike takes physical coordination. For beginners, it can be difficult just to distinguish between situations, emotions, and thoughts – much less identify automatic thoughts, figure out which is the hot thought, and collect and evaluate evidence. Be patient and keep at it. Thought records get easier as you go, and over time they become second nature.
3. Decide on a practice and stick with it. You have to complete thought records regularly and stick with them for a while to see their full benefits. There’s no magic formula since everyone is different, but you’ll probably need to do to at least 2 to 3 a week for at least 2 to 3 months. There are a couple recommended practices. One is grabbing a thought record and filling it out as soon as you notice a strong feeling or reaction to something (assuming it’s practical to do so). Another is completing your thought records at a regular time – for example, each night before bed you can review your day and choose a situation you want to reflect on using a thought record. The important thing is to find a practice that works for you.
4. Celebrate small improvements. If a thought record has worked, your moods will change in Step 7. However, there may not be a drastic change. You may go from, say, 100% to 70% on a mood – but that can be a big breakthrough. Remember, the goal isn’t to eliminate emotions altogether; it’s to gain a balanced perspective in which your emotions are proportional to the reality of the situation. Be proud of whatever progress you make.
5. Consider getting help. Ideally, CBT is a collaborative process between client and therapist. Although you can learn thought records and other CBT skills on your own, you’re likely to progress more quickly with professional help. Individual therapy, groups, and classes can all be effective options. I especially recommend consulting with a professional if you’re having a lot of trouble with thought records or if your moods aren’t improving. Look for a therapist who has proficiency in CBT or cognitive therapy.
The Turning Point on My Bipolar Journey
I mentioned above that a particular thought record ultimately helped me accept that I have bipolar disorder and move on. That thought record was done in a session with a therapist – a very skilled and caring therapist who saw my potential much more clearly than I did – so I have to give her as much credit as the thought record itself.
To make a long story short, I wasn’t one of those people who was relieved when I got a diagnosis. I was devastated. At that time, there was nearly zero positive or hopeful information available – everything I read said that bipolar disorder is terrible to begin with and only gets worse over time. I remained in denial for quite a while because, in my mind, to accept I had bipolar disorder meant I was doomed to a life of One Flew Over the Cuckoo's Nest-style institutionalization (or something close to it).
The therapist helped supply evidence against my belief. For example, she told me that almost nobody with bipolar disorder lives in an institution (which I pretty much already knew, but it was good to get some reassurance). She also told me that, in her many years of clinical work, it was not her experience that people who received treatment got worse – in fact, it was her experience that most people got better.
That thought record helped me gain a balanced perspective on the situation. I realized that, although having bipolar disorder meant I would have some limitations, I could still live a fulfilling life. With that understanding, I was able to accept my diagnosis and commit to recovery – including pursuing goals like going back to school to become a therapist myself.