The Cognitive Behavioural Therapy Iceberg

I attended the first half of a 6-day Cognitive Behavioural Therapy (CBT) Immersion course at the end of January. The second half is taking place at the beginning of November. The purpose of the course is to be able to offer CBT in a brief context while knowing when it may be necessary to refer onwards. It’s a course offered in partnership between Wilfred Laurier University and Qualia Counselling Services. Qualia is a company in Kitchener, ON that specializes in providing CBT services. Both our instructors are social workers in the mental health field, one of whom is actually the founder of Qualia.

While the course was not specifically targeted towards using CBT for pain management, they taught us 10 basic CBT skills/tools and the theory behind each of them in part 1. The purpose of this blog post isn’t to review the course (though I will say, they were great at using stories and visuals to teach AND it was mind-blowing to watch how they communicate during client demos) or to discuss those tools but to talk about a key concept and revelation that I took away from it.

The premise behind CBT is that our thoughts/beliefs influence our mood, behaviour, and physiological reactions (and vice versa). Often, this happens without our awareness. CBT helps to (1) bring this process into awareness, (2) challenge the automatic thoughts/beliefs, and (3) start to change them. There are both cognitive and behavioural interventions to achieve this process (hence, CBT). An analogy they used that I found helpful is this CBT Iceberg:

CBT Iceberg

Case Example Brian
I would like to use the following case study of a fictional person named Brian throughout the post to explain what this CBT Iceberg is:
  • Brian is 46 years old and has had low back pain for 5 years
  • His back pain started after a car accident when he was rear-ended. His x-rays and MRIs at that time showed no fracture or nerve compression but he had mild degenerative disc disease (DDD)
  • He used to be a manager at the local bank but had to stop working 4 years ago because he found it too difficult to concentrate and was unable to stay seated for extended periods of time without his back flaring up
  • He had physiotherapy for a year but did not benefit much from it. He was told that he needed to work on his TA and multifidus activation. Although he practiced it, he still had ongoing pain.
  • He has a wife and two children. His wife has to do most of the housework and driving the kids around as he has too much pain. His wife also works full-time.
  • He usually stays at home most of the time, as his pain always increases when he goes out.
  • Sometimes, when he gets tired of his pain, he’ll do something that he really wants to do, like take his kids out to the park, but he pays for it for a week.

Automatic Thoughts

Above the surface of the water are our automatic thoughts. They are fairly easy to access if you were to pause and notice what you are thinking. That is, we can become conscious of them quite easily. They occur all day and everyday.

Today is garbage day. Brian is tired of letting his pain kick him around so he decides that he will take out the garbage today. He manages to do it, with much grunting, groaning, and grimacing. He collapses on the couch after, with extreme pain in his back.

What might be some of Brian’s automatic thoughts?
“This sucks”
“I can’t even do such a simple task without extreme pain”
“It’s not worth living like this”
“I did it, but I sure paid for it”
“I should be able to do more than this”
“I used to be so fit”
“My kids must think I’m useless”
“Something must be really wrong in there”

Rules for Living/Assumptions

The next level of the CBT iceberg is Rules for Living. These are under the surface of the water, meaning they tend to be more difficult to access and not something we are conscious of unless we really do some self-reflection. Rules are heavily influenced by culture and our experiences. They consistently subconsciously influence our behaviour.

As humans, we need to have rules and cannot function without them. The problem is when these rules are rigid/inflexible/outdated such that they negatively and unfairly affect our automatic thoughts, mood, and behaviour.

Some examples of Rules for Living are: “The less you give a damn, the happier you’ll be”, “What doesn’t kill you makes you stronger”, “If the doctor can’t find it, it can’t be fixed”, “I should always do what I’m told”. The last example is an example of a rule that may have been helpful for a 5 year old, but if that person holds onto that rule (i.e. is rigid and inflexible about it) as an adult, that may not be so helpful.

What might be some of Brian’s rules for living?
“If I have pain, it means that something is wrong”
“If I don’t provide financially for my family, then I am a bad father”
“Being a man means doing all the heavy lifting”

Core Beliefs

The final level of the CBT iceberg is Core Beliefs. In our course notes, Core Beliefs are described as “thoughts that have migrated to truth”. In other words, these are thoughts that are repeated so often (consciously, subconsciously, via messages we receive from others or our environment), that they feel true. These, too, are below the surface of awareness and can sometimes be painful to acknowledge (no pun intended).

Some examples of Core Beliefs are: “I am not pretty enough”, “The world is evil”, “I am not good enough”, “I can’t cope”, “I’m not normal”, “Everyone is out to get me”.

Similar to Rules for Living, core beliefs can be helpful but the problem is when they are rigid and unchanging. “Everyone is out to get me” is probably a helpful core belief if you are in a war-torn country and you need to be very careful about who you trust. However, holding onto that, even subconsciously, can impact your automatic thoughts/behaviour negatively once you are out of that situation. Core beliefs can also be more positive, such as “I am enough”.

What might be some of Brian’s core beliefs?
“I’m useless”
“I’m broken”
“I’m falling apart”
“My back is unstable”
“My back is degenerating”

Why do I bring these up?

I think that as clinicians, what we say to someone and what we do with them can really impact their core beliefs. Consider what a change it might make to someone if their core belief was “I am strong” or “I am robust” vs “I am falling apart” or “I am broken” or “I am unstable”. I think perhaps this is why I feel strongly biased against hypotheses about mechanisms behind manual therapy or exercise that make it seem like our bodies are fragile cars in need of constant tuning (e.g. TA/MF activation, deep neck flexor training, joints being out of place, joints not gliding properly, fascia needing to be broken down, unstable joints, releasing trigger points, etc). Especially if these hypotheses are refuted by research.

Now I recognize that what a clinician says and what a client hears may be different as I’m sure no clinician is intending to impart these negative core beliefs. Amidst the sea of uncertainty, I think I would rather choose another science-based hypothesis, even if not well-researched yet, that is more likely to empower people instead.

What if we could help Brian understand that pain is more about sensitivity than damage or weakness. What if Brian’s core beliefs were:
“My body can adapt”
“I’m not broken”

And then the rules for living that follow may be:
“If I have pain, it doesn’t necessarily mean something is wrong.”
“Changing my nervous system takes time”
“If I can’t provide financially for my family now, I can still be there for my family in other ways”

How could his automatic thoughts be more balanced?
“Even though my pain increased when I took the garbage out, I know that I did not do any more damage”
“I am sore but safe”
“Even though I cannot do this task now, I know that I will be able to eventually if I gradually increase how much I do”

I found this framework a helpful way of thinking and better understanding human behaviour, including my own. I think my core beliefs are that the human body is adaptable and robust, and I am therefore biased against anything that challenges my core beliefs. Indeed core beliefs are maintained by a “tendency to focus on information that supports the belief and ignoring evidence that contradicts it”. I’ll try to stay open to changing though if evidence suggests I need to…

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