The ‘C’ in CBT stands for ‘cognitive,’ which is to do with thoughts, perceptions, knowing and understanding. (The ‘B’ and the ‘T’ are for ‘Behavioural Therapy,’ but more of that in Parts Two and Three.) Our cognitions determine how we make sense of the world and our experiences in it, and how we see ourselves and other people.

“Often we go through life having thoughts and acting as though these thoughts are facts,” Dr Peter McEvoy, a specialist clinical psychologist with the Centre for Clinical Interventions in WA, recently told RTWMatters. Sounds plausible – but how is it relevant to the return to work field? 

Well, let’s imagine a female worker – we’ll call her Ms W – who develops wrist strain related to repetitive computer work. When she returns after a week of sick leave, Ms W might think, “My coworkers all resent me because I’m on modified duties. No one believes that I am really hurt. They all think I’m faking the pain to get out of doing data entry.” This is an opinion rather than a fact.

While it is unlikely to be true that all Ms W’s coworkers think she is faking her injury, some might. However, it is also possible that this thought is more indicative of Ms W’s anxiety about her injury than the facts of the situation. Regardless of whether the thought is true or not, thinking it will influence Ms W’s feelings, behaviours, and, in the long run, her rehab outcomes. Why?

Believing that her injury is viewed with suspicion might lead Ms W to feel anxious and depressed and cause her to interact awkwardly and defensively with her colleagues, or to withdraw from them altogether. She might feel the need to prove that her injury is real and this could lead her to be less active and to move stiffly, so that people get the message that she is in pain. The stress of going to work under these circumstances might also cause Ms W to adopt an awkward posture and to keep her muscles tensed, leading to additional strain. If people respond poorly to these coping mechanisms of Ms W’s, and if stress exacerbates her injury, she might stop coming to work altogether, and her workers’ compensation claim might become drawn out and difficult.

From the perspective of CBT, the point at which Ms W’s rehab took a turn for the worse was when she mistook a thought – “Everyone thinks I’m faking,” – for a fact.

If Ms W signed up for CBT, her therapist might assist her with recognising the thoughts that cause her distress and learning to assess these thoughts more objectively, for example by listing the evidence for and against a particular thought.

On the balance of the evidence and with the assistance of her therapist, Ms W might conclude that it is not a fact that everyone thinks she’s faking her injury. Ms W would then need to develop more helpful and objective thoughts about her situation, such as:

• People are often busy and stressed at work. The way in which they react to my requests for help isn’t necessarily a reflection on me.
• Some people at work have been supportive of me and seem keen to help me get better and return to normal duties safely.
• It is more helpful to focus on recovery than worrying about proving to people that I am injured. After all, I don’t really know what other people are thinking anyway.

Dr McEvoy told us that part of the CBT process is getting the person having therapy to “act like a scientist, where they identify the thought and start to scrutinise it a little bit.”

Ms W’s discoveries in therapy might seem like simple commonsense, but stress, pain, previous life experiences and unsupportive coworkers or supervisors can make commonsense hard to come by. Ms W’s persistence, however, should pay off. As a result of putting on her scientist’s hat – or lab coat! – and looking objectively at her own thoughts, she should begin to feel less anxious and depressed, and more capable of coping with her situation.

Of course, the ‘C’ of CBT is only the beginning. According to Dr McEvoy, it is important that the client learns to “challenge the thought and check it out, not only with their thinking, but with their behaviour, which is the ‘B’ part of CBT.”

Stay tuned for Part Two, in which we put the ‘B’ into CBT, and Part Three, in which we discuss when and how to broach the big ‘T’ – therapy – with workers.

Thanks to Dr Peter McEvoy for his assistance with this series of articles. You can find out more about the Centre for Clinical Interventions, a specialist state-wide service funded by the WA government, here.