We often talk about identifying the risk factors and intervening with injured workers early to prevent or help those with delayed recoveries. Some of these issues are obvious; aging, having a weakened immune system, or a history of joint problems, for example. But others may not be quite as apparent or self-explanatory, yet they can have a major impact on the outcome.

Psychosocial risk factors cover a wide range of conditions, such as depression, traumatic stress, and childhood abuse. Among the most telling are catastrophic thinking, guarding behavior and perceived injustice. There are vast amounts of research from the past couple of years that point to these as major indicators of a poor outcome, possibly even more so than the medical factors associated with an injury.

The good news is that cognitive behavioral therapy can be instrumental in helping patients overcome these factors. Understanding exactly what these are can help workers’ compensation practitioners get appropriate care to affected injured workers as soon as possible.


Ruminating about irrational worst-case outcomes, exaggerating the threat value of pain sensations, and feeling helpless to deal with pain are included in definitions of catastrophic thinking. It’s essentially anxiety run amok.

People who catastrophize believe in negative outcomes. They greatly exaggerate potential danger, whether real or perceived. In terms of their health, they believe the worst about any physical ailment before any medical tests are even done. They assume any physical peculiarity will be devastating and that they won’t be able to cope with it, and they become almost obsessed with it.

This type of thinking can actually lead to the outcome the person fears, as it can become a self-perpetuating vicious cycle. It also causes a spike in the stress hormone cortisol and decreases a patient’s ability to react effectively.

The types of statements catastrophizers may think or say out loud are:

  • The pain is terrible and won’t ever get any better.
  • I can’t cope with the pain.
  • I can’t get the pain out of my head.
  • Something must be terribly wrong with me.

Unless someone points out to the person that he is catastrophizing, he thinks his thinking is rational and necessary. Those who catastrophize feel pain more intensely than those who don’t.

Fear Avoidance Behavior (Guarding)

Anyone with pain would be concerned about doing something that could worsen it. However, some people take it to the extreme. They develop such a fear of the pain that they believe any movement could aggravate the underlying condition and cause more pain. These injured workers become so preoccupied with their symptoms they avoid activity — even rehabilitative efforts. This fear of pain and avoidance of activity results in deconditioning, and actually exacerbates their pain.

We know that activity — including work — is one of the best remedies for chronic pain. But injured workers with fear avoidance behavior predict pain when they undertake any activity, resulting in delayed returns to work. Eventually, they may even avoid doing activities of daily living, to avoid the pain they fear.

Fear avoidance behavior explains why some injured workers with acute pain end up with chronic pain. They are overly fearful about the pain and feel a sense of helplessness about the initial injury. They take a passive role in treatment, preferring massage or other procedures done to them instead of being an active participant.

Perceived Injustice

Often closely tied in with catastrophic thinking and fear avoidance behavior is a sense of unfairness and blame. In the case of an injured worker, it could be faulting the employer for having an unsafe work environment, another employee, or something else. They may also think about retribution in some way.

Even if the injured worker does not blame anyone specifically, she may feel she was unjustly injured, that no one understands the severity of her pain and that her life is forever changed.

People with perceived injustice feel greater pain intensity, often leading to further delayed recoveries. Some studies also suggest perceived injustice is correlated with opioid prescriptions.

How CBT Can Help

CBT is an invaluable tool to help injured workers with destructive thinking patterns that cause or perpetuate their chronic pain. More than anything, it engages the patient and teaches him to take charge of his pain and his life.

The techniques teach the injured worker first to be aware of and monitor his thoughts, then to change them. It involves homework and practicing the skills. Doing so helps him return to function. It ‘rewires’ his brain to have more healthy thoughts and actions.

One CBT exercise we use that helps address catastrophic thinking and fear avoidance behavior requires the injured worker to tell himself, ‘I can cope with this pain,’ even if he doesn’t believe it. The brain and its pain response believe what is being said. The messages resonate, helping to alleviate the negative thinking. This helps the brain better deal with pain signals.

By taking control of their thoughts, injured workers can take charge of their lives and their pain. The positive thoughts help decrease the stress arousal response.  

CBT also relies on other practices, such as mindfulness, relaxation and meditation. Each person is different so the treatment is somewhat varied for each person.


Psychosocial risk factors gone unchecked can be debilitating, leaving the injured worker in chronic pain and unable to function much at all. An expertly trained CBT psychologist can teach techniques that transform these workers, and in a short period of time.