At the Greenwich OCD-UK conference I was pleased to be asked to give a short talk on ‘what is CBT? I hope this accompanying article will be helpful for some readers in giving a brief overview of some of the main ideas in CBT for OCD.
CBT is a psychological treatment that looks at how we think (C), and how this affects what we do (B). In treatment we consider other ways of thinking, and how this would affect the way we behave. CBT is used successfully in many psychological problems including other anxiety problems such as panic, post-traumatic stress disorder and social phobia, also in eating disorders, addictions and psychosis. The basic idea in CBT is the same across all these different problems, and my preferred way of understanding it draws on a situation we can all readily imagine:
It’s the middle of the night, you’re in bed. You hear a noise
from downstairs.
You might think: ‘It’s the stupid cat again’, feel angry,
put your head under the pillow and try and go back to sleep.
You might think: ‘It’s my partner coming in, I haven’t
seen them all day!’, feel happy and get out of bed to say hello.
You might think: ‘It’s a burglar’, feel frightened and
call the police.
What this shows is that the same event can make people feel completely different emotions (angry, happy, anxious), and result in them behaving in very different ways due to different beliefs about the event. CBT is based on this intuitive understanding of how we all think. So how does this help us understand how to treat OCD? We believe that OCD works in exactly the same way:
A disturbing image crosses your mind: you throwing your dog under a train.
You might think: ‘Damn it, that’s made me forget what I was
going to say’ and feel angry, and frown.
You might think: ‘Wow, what a creative and funny person I am! I’m
going to write that down’ and feel happy, and go and tell your friends.
You might think: ‘Because I’ve thought that, I must want it
to happen, I must be sure I try and undo that thought’, feel anxious,
and check, seek reassurance and avoid taking the dog near the train track.
In summary, it’s not the thoughts themselves that are the focus of treatment; it’s what you make of those thoughts.
In this article I’ll look at the thoughts themselves, the belief or meaning attached to the thoughts, and what OCD makes people do as a result of this meaning or belief. I’ll describe some of the things we would try in CBT to tackle the problem.
The intrusive thoughts
In treatment for OCD, one of the first things we ask people to do is to
think of a recent specific example of when the problem was really bad.
We ask people to go into a lot of detail, and try and find out what thought
(or doubt, image or urge) popped into their head at this time.
In previous OCD-UK newsletters I have read about examples of such intrusive thoughts:
A horrible thought that I may have said something inappropriate.
A thought that there might be blood in my food.
A thought that I am contaminated from the toilet.
People with OCD often ask if treatment can help them get rid of these intrusive thoughts, as they are so distressing and horrible. We ask them to consider whether all intrusive thoughts are always horrible. Usually people can think of an occasion when they suddenly had a thought that was helpful, such as suddenly remembering a friend’s birthday is coming up, or having a memory of a lovely holiday pop into their head. We can conclude from this that getting rid of the thoughts themselves isn’t a realistic or desirable goal. Often people are surprised to find out that everyone has all sorts intrusive thoughts – including the nasty ones: thoughts of harm coming to people, images of violence, urges to check things, doubts about whether they have done something.
Challenging the meaning attached to the thoughts
In CBT we explore an alternative meaning or belief about the intrusive
thoughts. Often people readily come up with an alternative idea - but
what is it that keeps the old meaning attached to the thoughts alive?
Simple answer: ‘rituals’ in all their guises: washing, checking,
writing lists, tapping, touching, repeating, cleaning, trying to get a
‘just right’ feeling, praying… Therefore in CBT we look
at how OCD convinces you that all these things are necessary and that
otherwise something bad will happen, and it will be your fault. We look
at the possibility that OCD is a liar. All these strategies have come
about in the first place to make you feel safer and less anxious, but
in fact do the exact opposite. Even if they provide temporary relief from
anxiety, all these rituals make the meaning attached to those intrusive
thoughts, images, urges and doubts feel more true, therefore keep the
need to do the rituals going, making the meaning feel more true …
we represent the cyclical nature of the problem when we draw out a model
of how the problem works - we sometimes call it the ‘vicious flower’
– one of Paul Salkovskis’s diagrams shows the general idea.
So how do we deal with all these rituals? Here are some common ones, along with an idea of possible ways we might tackle them in CBT:
Checking
A classic OCD lie. In treatment we ask people to stop checking. A key
stage in the evolution of CBT was the development of ‘Exposure and
Response Prevention (ERP)’ which is being exposed to what makes
you feel anxious, and not doing checking or other rituals. In CBT we go
beyond this, using what we call ‘behavioural experiments’
to find out what happens when you don’t check. Rather than just
riding out your anxiety in the feared situation (as in ERP), essentially
we are testing out the belief that you are responsible for harm by seeing
what happens when you don’t check. We always acknowledge that there
is a risk that something bad will happen if you don’t check, but
the guarantee with continued checking is that OCD will always remain a
problem.
Avoidance
OCD often tells people to avoid all sorts of things: public toilets, children’s
playgrounds, people with diseases… By avoiding situations, you never
have the chance to find out what really happens. So in CBT, we ask people
to consider doing the opposite to avoiding the situation (for example
if OCD has made you believe that you are at risk of dying from contamination
from germs – in treatment we would put our hands down the toilet).
This allows you to find evidence for yourself about whether OCD has been
lying.
OCD also tries to make people avoid thoughts – this is impossible, in fact when we experiment with this idea in treatment, we find out that trying not to think of something makes it worse. Veterans of OCD-UK events will have heard the ‘white polar bears’ example ad nauseum – briefly: try not to think of white polar bears – don’t think of their fluffy white faces… funnily enough you can’t help but think of them. When OCD makes you believe that if you have a thought of harming children, that means that you will do it, it make sense to try and banish those thoughts from your mind as that is such a horrible idea. If you are challenging that belief and looking for evidence that this isn’t a helpful way to appraise those thoughts, in CBT we might bring on those thoughts – perhaps going to a children’s playground and deliberately thinking of harm.
Reassurance
If you believe that you are responsible for harm, or capable of being
a paedophile, or that you can’t be trusted to lock your house, it
seems like a good idea to ask someone to if you have done anything to
risky, whether you have sexually abused anyone while you were drunk, whether
the door is locked… This asking for reassurance strengthens the
belief that you really are responsible, thus keeping the anxiety high.
In CBT we experiment with not asking for reassurance, and seeing what
happens to the obsessional belief.
Looking for trouble
OCD tunes you in to risk. It makes you more likely to spot ‘risky’
situations – and to notice those intrusive thoughts. This makes
it seem as if the world really is a dangerous place, and increases anxiety.
In CBT we consider the possibility that there is a risk attached to most
things, but experiment with whether being on ‘full alert’
the whole time makes the OCD belief weaker or stronger.
Mental argument
On ‘Who wants to be a millionaire’, when Chris Tarrant says
‘Are you sure? Is that your final answer?’ – does that
make the contestant feel less anxious? Or does that questioning make them
feel less sure, and more anxious? OCD often makes people mentally check
or argue with themselves, and we ask people to try not to engage in these
arguments, and see what happens.
Different types of OCD
I’m sure a number of readers will wonder whether this kind of treatment
would suit their particular kind of OCD – maybe you don’t
check, or wash, or count, or do any of the things that people readily
think of as part of OCD. OCD is a chameleon – it appears in many
forms in different people. One of the greats things about CBT is that
however the problem manifests itself now or in the future, the same tools
are useful in getting rid of it.
Make sure you are receiving CBT!
Recent research suggests that people sometimes believe that they are receiving
Cognitive Behavioural Therapy (CBT) from their health professional but
are in fact receiving another form of 'talking' therapy or counselling
which might be less effective. It is widely recognised that CBT is the
most effective treatment for OCD because it focuses on the 'here and now'
of the problem as opposed to other talking therapies which tend to focus
on ‘past problems’ or spend time continually talking about
childhood. Remember, if in doubt, ask!
Back
to Top ^ | Homepage
| E-mail this page to a friend
OCD-UK is a non-profit making charity and not associated with any other
organisation.
Medical information is provided for education/information purposes only, you should obtain further advice from your doctor. Any links to external websites have been carefully selected, however we are not responsible for the content of these third party websites.
Copyright © 2004-2008 OCD-UK. All rights reserved.
WC3 XHTML 1.0 Validated | WC3
CSS Validated | Sitemap
| Accessibility
