CBT approach in the real world


While there are many papers published about the outcomes from using a cognitive behavioural approach, there are very few describing the process ‘in the real world’. This leaves a gap for many clinicians who may read about it, maybe have training in delivering this type of intervention, or work in a team where it’s an integral part of practice – but who may not know how it ‘works’ except as it’s delivered in a pen-and-paper, sitting-in-a-clinic-room kind of way.

Today I’m describing one way I go about integrating a CBT approach into my work.    This case study is a compilation of several people I’ve worked with, in order to protect patient privacy.

Simone has neuropathic pain in her dominant hand. She’s a tough cookie who worked in a shearing gang. She’s tiny, has a command of the cussing vocabulary that has to be heard to be believed, and she’s very reluctant to use her hand although she has really good movement.

Simone’s always been a physical kind of person and loved riding motorbikes, rock climbing and gardening. She doesn’t think any of these things are manageable now, and so she spends most of the day ‘pottering’ in the garden or with friends or, as she puts it ‘death by DVD’.

Her goals are to get fit again, to decide on her ‘next best steps’ for returning to work, and to feel more confident about using her hand BUT she’s made it very clear that she’s not going to do ‘pretend’ activities like handcrafts or ‘just holding the bike throttle’ – she wants to start doing proper things again.

Oh my, where do we start!

We’ve started by reviewing what she knows about pain management – naming all the different types of strategy that can be used, and ranking them in order of priority for review. Simone said she needs to ‘get fit again’ and sees exercise as a big part of this; she also recognises that she can be quite inconsistent in her activity patterns, and although she knows about activity pacing, she doesn’t like doing it.

I asked her about her daily routine and she laughed saying that she just ‘does’ and hates planning, so instead I gave her 12 cards representing the amount of energy she has to ‘spend’ over the course of a day. I asked her to allocate her cards into three areas of living: self care, fun and work. She divided the cards quite evenly, so I then asked her whether this was how she wanted to spend her energy. She said no and that it was very different from her pre-accident pattern, so I asked her to show me what that looked like. She pushed almost all of the cards into the ‘work’ pile, and kept only one for self care and two for fun.

I asked her what was different about her self care now compared with before, and she described the process of showering – and while she talked, I was able to identify her automatic thoughts about each task. She said she always thought it should be enjoyable but now it just felt hard. She said she didn’t think she should have to ‘think’ about how she undressed, washed herself, dried herself, and got dressed again. Now she felt her body was skinny and ugly and her arms ‘wouldn’t work properly‘, and so she avoided looking at it, and didn’t use moisturizer and didn’t shave her legs any more.

She was very articulate about the automatic thoughts and images that she had while showering and we were also able to identify some of the emotions that were generated by these thoughts, and how this affected what she did.

I used a whiteboard to jot down the situation, her thoughts, linking to her feelings and on to her actions, and Simone was quick to say that these thoughts weren’t helping her.  NB all the underlined phrases above refer to automatic thoughts she was having.

We haven’t yet explored these thoughts nor tried to do anything with them (maybe we won’t do anything, just notice and do what is important?) – but part of understanding her situation is about listening to her thoughts as I’ve outlined above. This is Simone’s ‘lived experience’, but it’s absolutely possible for her to evaluate her situation differently and come to a different conclusion about them.

For a very quick example, I might ask her what does it mean to ‘have’ to think about each movement she does?  What does it say about her? What does it mean to have a rule that says showering ‘should’ be easy – when clearly, showering for her is not. If she says she feels ‘dumb’ or ‘useless’, I may explore other situations in her daily life now where she feels ‘dumb’ or ‘useless’ – and help her notice her emotional response to this.  What effect does having this emotion have on her actions? On what she does and how she goes about it?

Simone has described patterns of thoughts that are very judgmental about her capabilities.  While a psychologist may explore some of the origins of this, and the effect on her mood and especially her vulnerability to depression, what I’m inclined to explore is how her automatic thoughts and underlying ‘rules’ are affecting her willingness to engage in activities that she previously enjoyed – like having a shower – and both be aware of this vulnerability in terms of goal setting (she’s not keen on doing this!), and help her generate some more positive self statements she can make when trying a different approach. I’ll also ensure the goals are achievable but also ones she really values.  If they’re ‘too easy’, she’ll judge them as not worth the effort while if they’re too difficult and she can’t see why she should persevere (ie they’re not important to her), she may give up.

I’ve suggested already that she treat each new method as an experiment.  We don’t fail at experiments – we can learn from each attempt. When she tries a new approach, we’ll go through the things that worked well, and the things that she would do differently.  I’ll also use motivational approaches to encourage her to recall why she used to enjoy showering – she loved it because she felt energised, she could pamper herself (remember that Simone was working in a very masculine environment), and she was able to take some time out.  These are important things she can focus on as she develops strategies to return to this very important activity.

Shannon, E. (2002). Reflections on clinical practice by occupational therapists working in multidisciplinary pain management programmes in the UK and the USA Australian Occupational Therapy Journal, 49 (1), 48-52 DOI: 10.1046/j.0045-0766.2002.00291.x

Strong, J. (1998). Incorporating cognitive-behavioral therapy with occupational therapy: a comparative study with patients with low back pain. Journal of Occupational Rehabilitation, 8(1), 61-71.


  1. Oh my, this woman sounds a lot like me! Different diagnosis, but similar behavior and attitudes. Many things that used to be pleasurable or easy (requiring no thought) are now work! and require thought to do.
    I like the thought of experimenting to see what makes things better to me….this helps at least to move on past the dissappointment that things just aren’t that way anymore.

    1. It also reduces the chance that you feel bullied into doing something that doesn’t ‘fit’ for you – and therefore not have a go. The only proviso I have to this is that sometimes it’s important to use a strategy until you become skilled at it before it ‘works’ – remember learning to drive? How many bunnyhops?! It’s also important to know what the strategy is intended to achieve, so you can monitor the outcome in terms of that. For example, diaphragmatic breathing doesn’t appear to be very helpful for reducing pain in people with fibromyalgia, yet it can still reduce distress. Distress can make the experience of increased pain feel far worse, so by reducing distress it’s a lot easier to get through. If you only monitored the pain intensity, then this strategy wouldn’t appear to be helpful, but if you monitored distress, you can see that it would help in another way. Exercise is another strategy that springs to mind – initially it doesn’t feel like it’s doing a lot, and it can increase pain temporarily, yet over time it’s a very helpful strategy.

  2. HI Bronnie
    I love reading about your ideas for clinical practise, they help keep me going when I’m feeling a bit fed up with the world of pain management. Like you I’m a big white board user for jotting down ideas, sharing information with clients. I also tend to invite clients to use pain management strategies as experiments that they trial and then we evalaute for their effectiveness, it help break down the authoritarian approach and gives them more control. I love the energy cards idea – can I steal it?
    And lastly, I was amused to see reference to an article I wrote in 2002 at the end of your article. It was written after my churchill felllowship visit to the UK and US – now feels like a very long time ago, and I think my ideas on pain management practise have evolved enormously since then!

    1. Beware, your past will catch up with you! Thank you for your encouragement, it’s so nice to know that what I’m writing strikes a chord. Of course you’re welcome to steal the ‘energy cards’ – I believe if everyone owned their own, it came from an activity using match-sticks that I used when I was a student! But of course, matches are not quite as easy to come by now and macaroni just didn’t appeal. I hope we can cross-fertilise in the most positive way possible via the power of the interweb!

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