A Prelude to Cognitive-Behavioral Techniques For the Treatment of OCD
by Steven Phillipson, Ph.D.
Following is a basic description of Cognitive-Behavioral principles for the treatment of Obsessive-Compulsive Disorder (OCD). This article will present an explanation of how attending to cognitions (styles of thinking), in addition to time tested behavioral methodology, might augment the existing successful treatment strategies available for OCD. As a prelude, I thought I'd take this opportunity to discuss my personalized approach to treating this condition.
Consistent findings from studies, testing the effectiveness of different therapies, strongly suggest that it is the working alliance (bond between therapist and client) which is paramount to therapeutic success. The following interpersonal aspects of treatment make a great deal of difference in fostering an atmosphere of collaboration: 1)comfort, 2)confidence and 3)a true commitment from both client and therapist. I look at the therapeutic relationship as a partnership in the fullest sense of the word. To be successful both parties need to bring their fullest devotion to the explicit and implicit contract of therapy. This means that at the end of each session both parties come to an agreement as to the upcoming week's challenges. All too often I hear clients say, "you made me touch the door knob". To which I immediately respond "The way I remember it, is that we had an agreement that you would do it". The client must accept the responsibility to willingly participate in his or her own therapy. I feel that through a joint effort, clients can choose to share the challenges of this most difficult therapy with an experienced partner. Cognitive principles focus on fostering a sense of therapeutic independence on the part of the client. We teach strategies and perspectives for responding to the challenges that life has to offer so that persons can gain a greater sense of self-efficacy (i.e. the faith in one's own ability to achieve specified goals)
Equally important to knowledge, training, experience and credentials are warmth, understanding and compassion. My daughter's recent hospital stay reminded me of the fear and vulnerability one experiences when confronted with illness. We become self-focused within our own pain and desperately look for guidance and reassurances. All too often those in the helping profession become callous to that pain and vulnerability.
Typically the cognitive-behaviorist believes that self-disclosure is a healthy part of any relationship, including a therapeutic one. Therefore answering questions about oneself is considered a natural and healthy part of the therapeutic exchange. I would hope that any professional would at least be willing to disclose information about their own training, experience and credentials. Operating from the client's perspective, I would encourage anyone to become as informed as soon as possible about the therapist's background. This is why I've included my academic, professional and research history on this web site. see the staff
Recently my mentor, (Gordon Ball, Ph.D.), to whom I am eternally grateful for supporting the initiation of my career as a specialist with OCD referred a client to me. As we discussed the case, he said that of all the things he has heard about me in the past twelve years, demanding commitment from my clients was by far the most consistent feedback he has received. To those who are considering embarking on the difficult process of behavior therapy for OCD, I strongly suggest you do not take the therapy in small doses. Ambivalence and looking to be fixed is not a winning formula. Taking responsibility for the end of this life destroying condition is paramount. Jump in and do not look back! The success stories offered by a few of my gracious and giving clients generally offer a mental framework for a positive therapeutic outcome.
Cognitive Interventions for Obsessive Compulsive Disorder
The "Thinking" behind treating OCD
Cognitive-Behavioral Therapy (CBT) is most often associated with the work of Albert Ellis and Aaron Beck dating back to the early 1970's. The basic premise of this therapy is based on the belief that at the heart of depression exist distorted and irrational thinking patterns. These patterns revolve around our automatic reactions toward life circumstances which create upsetting emotional consequences. CBT was developed to assist persons to respond rationally to automatic irrational thoughts. Here automatic thoughts are defined as mental reflexive reactions to upsetting events. Basically, the approach teaches persons to learn to identify our reflexive reactions or "beliefs" (automatic thought=B), that occur as a consequence to upsetting events (activating event=A). The prevailing sense in society is that it is the actual situations (A), that are responsible for the periodic upset (emotional consequence=C) we experience. Traditional cognitive-behaviorists focus on teaching clients to substitute rational thinking (disputation=D) for automatic irrational thoughts (B).
My favorite example to illuminate this A,B,C premise is a story about Mary and John. It seems that after dating for approximately one year Mary decided to end her relationship with John (activating event=A). Following the termination of the relationship, John experienced dramatic periods of depression (emotional consequence=C). John's reaction to the break-up in his internal dialogue, i.e. self-talk (belief=B) was something like this..."now I'll never find someone to love... my life will be filled with emptiness". Traditional cognitive therapists would encourage John to challenge these self talk statements (D=disputation) by examining the possibility that although this is truly an upsetting experience... ones future is predicated on the choices one makes. Ultimately John's success with future relationships will be determined by the effort he makes. The fullness of his life is determined largely by his hobbies, peer relationships and occupational participation. The existence of an intimate relationship is not the sum total of his wholeness. ("John needs a relationship like a fish needs a bicycle").
Traditional CBT believes that within us all there exist irrational ideas. This therapeutic intervention is based on therapists faith in our ability to learn how to sort out the difference between being rational and irrational.
At the heart of this learning model is the belief that we learn from society, family and religion how to think in dysfunctional and irrational ways. Traditional CBT for persons suffering with OCD is therefore likely to be counter productive toward achieving a beneficial therapeutic outcome. This approach assumes that persons, who wash after touching doorknobs or become distraught after having an upsetting thought, are reacting irrationally to a rationally safe situation. The problem is that the vast majority of OCD suffers are painfully aware that what they are doing is bizarre and irrational. Most can even predict that the risk of danger is infinitesimal, yet they feel overwhelmingly compelled to act out some escape response (see Speak of the Devil).
Using traditional CBT the sequence of therapy would go something like this: activating event A="The thought of killing my daughter while changing her diaper" occurred; automatic thought (belief) B="this means I'm a horrible parent and may actually be putting my child at risk by being alone with her"; emotional reaction C=anxiety/guilt; rational responses D="the chance of harming her is minimal", "what evidence do I have that I would ever harm a child let alone my own". "But excuse me Dr. all that makes sence but I did enjoy killing ants when I was a child and I heard a news report about a guy who went craze and Killed his children and himself shortly after hearing voices telling him the world is coming to an end. This strategy is frustrating and alienating to most that have been on the receiving end of a traditional CBT efforts treat OCD with this method. Traditional CBT was developed as a powerful treatment for depression... cognitive therapists who specialize in the treatment of depression would do well not to attempt to transfer this strategy to anxiety disorders, particularly OCD!
Persons who have OCD overwhelmingly mention that in their pre-morbid state (life before OCD) they would have these exact same ideas and blow them off like anyone else would. There is no evidence that persons who develop an anxiety disorder change their most basic thinking patterns. What changes is the intense experience associated with what is perceived to be threatening thoughts. There is a small subsample of person's with OCD who posses what is referred to as "overvalued ideation". This is the situation where the OCD sufferer looses the ability to deep down discern the irrational nature of what their mind is telling them. Most large majority of persons with OCD are incredibility frustrated by feeling anxious about material which they are aware is absurd. Therefore helping persons see the irrational nature of the thought content is counterproductive.
Cognitive Therapy for OCD
I often analogize the therapeutic challenge of OCD with that of a battle in wartime. The two basic components entail, 1) the behind the scenes strategizing and 2) the front line conflict. It is important not to confuse the appropriate application of these two separate strategies when managing OCD. The manor in which one conceptualizes a battle and the behavior exerted in fighting it, are very different. An example of the importance of this differentiation exists in the book "Brain Lock". Here, Schwartz encourages persons to tell themselves that it is their OCD, which is behind the upsetting thought. "It is not me, it is my OCD" is one of the four pillars of his therapeutic primes. In other words thinking about having sex with my own child emanates out of having this disorder and not in being a despicable person. This awareness can facilitate a healthier conceptualize of a person's relationship with their own condition. However, as a direct response to a threatening situation (spike), as in the moment of being challenged, this response offers a non-therapeutic effort at reassurance. Better to suggest to oneself that since this thought fits into my OCD's theme I'll take the risk and accept the ambiguity of its legitimacy. Accepting the real feeling that there is a risk, that something might legitimately be wrong would facilitate the overall benefit of the therapy.
Cognitive Therapy (CT) for OCD predominantly focuses on the above mentioned two aspects of this anxiety disorder. This next section will discuss in detail the first of these two focuses. 1) Initially it involves having sufferers develop a healthy and informed understanding of how the mechanisms of OCD operate. For the purposes of this paper, this focus will be referred to as cognitive conceptualization. This includes helping persons separate themselves (i.e. their genuine identity) from the emotional or moral implications of what the disorder seems to represent. Many persons who suffer from the purely obsessional form of this condition and responsibility OC (hyper-scrupulosity) experience tremendous amounts of guilt and shame for having these thoughts or being responsible for the wellbeing of others. The articles previously written by Dr. Phillipson Thinking the Unthinkable and Speak of the Devil highlight the importance of accepting the ability of our brain to produce horribly upsetting thoughts and not concluding that these thoughts are evidence of our being evil.
Also involved within this first aspect of CT is having clients appreciate that giving into a ritual or embracing the risk of the obsession, requires making a series of genuine choices and are not pre-programmed reflexive reactions. Critical aspects of this initial focus involve reshaping one's response set to the risks. This involves conceptualizing one's relationship with their condition as that of making choices in the matter of giving in to a ritual, or not. "I choose to wash my hands because the doorknob might have had aids on it". This perspective is in contrast to perceiving the reaction to cognitive threats as obligatory or as having no choice in the matter. "I had to wash because I couldn't stand the anxiety". In practice this translates into having persons reframe their disposition from, "I had to wash my hands because the amount of anxiety was too great" to "I chose to wash my hands because I decided that the level of anxiety was more than I was willing to deal with at that time". Research has clearly demonstrated that acknowledging our choice in the matter of facing difficult life challenges increases ones tolerance to adversity. Consistently, studies have shown that our ability to tolerate pain is greatly increased as we acknowledge our choice in relation to the decision to seek relief, or tolerate the discomfort. As our perceived sense of control increases so does our willingness to tolerate discomfort. This cognitive aspect is so critical it will probably command an entire future article devoted this premise.
A small but potentially critical aspect of Cognitive-conceptualization involves educating persons about the actual risks pertaining to their specific concerns. Unfortunately medical science does not offer absolute certainty. Therefore telling someone that the chances of getting aids from a door knob is slight at best, does little to remove the overall concern. Some persons claim to have been guided by their disorder for so long that they have forgotten their actual instincts. In addition, becoming informed that persons, who spike about being a danger to others, rarely actually do damaging things. that persons with anxiety disorders almost never develop schizophrenia might educate, but rarely provides lasting relief.
The second goal of CT, here referred to as cognitive-management, involves teaching sufferers to respond to obsessive threats in such a way that there is little to no debate in response to being spiked. The main objective is to reduce/eliminate conflict or mental escape in formulating a response to the upsetting thought (i.e. spike). The product of this process is referred to as habituation (i.e. becoming less emotionally responsive to being threatened). Also included in cognitive-management are principles, which enhance greater levels of tolerance toward the physical discomfort, generated by the anxiety. These include making space for the discomfort and looking upon it as something to be managed effectively rather than just achieving relief.
The quest to eliminate the spike is probably the greatest cognitive misconceptualization that people bring to the therapeutic process. Ultimately the goal of CT for OCD is to manage the spike (i.e. mental risk) effectively not focus on its existence or disappearance. The same can be said about the experience of anxiety. Relief seeking increases our vigilance in being aware of its existence. Tolerating anxiety focuses on creating room for the experience. Making room for its presence allows the brain to focus on other information. Anxiety not focused on is anxiety minimally experienced.
An example of this goal is represented by the following example: While changing the diaper of her daughter a mother gets the thought that she "should" suffocate her child with a pillow. A therapeutic response would entail having the mother say "OK, maybe I'll kill my daughter, so lets do it now". This response is based on the premise that it is only in the escape or intolerance of the feared stimulus that the disorder grows or maintains its strength. Having this mother purposefully create the thought while changing the diaper approximately 15 times for each diaper change would act as a purposeful exposure to the feared situation and thus allow for the therapeutic effects, e.g. habituation of exposure and response prevention to take full effect. Seeking out the risks on purpose (rubbing one's hands on a toilet seat and then eating a sandwich) armed with the disposition of "come and get me" is by far the greatest facilitator of daily therapeutic challenges!
Cognitive conceptualization focuses on helping remove a sense of culpability, shame and guilt, which is pervasive among OCD, sufferers. Accessing the ideas and philosophy of cognitive-conceptualization in the midst of a challenge would be ill advised since it would tend to be reassurance oriented. The later goal (cognitive-management) is instructive in helping persons respond effectively to the cognitive prompt of the danger with the least resistance. Thereby allowing habituation.
The articles in this web site, especially Thinking the Unthinkable and Speak of the Devil provide a very comprehensive account of CBT for OCD. These articles highlight the critical relationship between the sufferer's cognitive and emotional experiences and the self-talk, which invalidates the seemingly endless cycle to the condition. A critical aspect involved in this therapy focuses on the premise that the responses to the disorder are not designed to make it "go away", but rather just not perpetuate the condition. This perspective allows the anxiety to burn itself out due to lack of reinforcement (removal of the escape response). "The less one toils with the bully the greater the likelihood that bully will find someone else to pick on" is the general idea.
Developing an aggressive disposition toward being challenged is also tremendously advantageous toward a successful recovery. Aggressiveness is defined as actively seeking out anxiety provoking challenges (touching toilet seats, creating the thought of jumping in front of an on coming train). Paradoxically, when ones seeks out anxiety provoking challenges, there tends to be a greater likely-hood that experiencing reduced levels of anxiety is achieved. This phenomenon comes about due to turning the tide of the condition's momentum from endless escape to approach. As we seek challenges there is less likelihood of finding them.
As previously mentioned, Cognitive therapy for OCD (CT) has two primary applications... 1) help persons understand the guidelines of anxiety disorders overall game plan (i.e. mental mechanisms) & 2) provide specific suggestions in response to the moment of being challenged by an awareness that there is some imminent danger. The specific application of cognitive principles as a management strategy is paramount. Cognitive principles to help sufferers develop a healthier disposition toward their anxiety disorder is critical. These two focuses of CT for OCD are most likely to facilitate progress when they are integrated into one another. Merely utilizing cognitive responses such as "I'll take the risk and accept the possibility that the danger may be real" without engendering a genuine acceptance of that risk is rote and therapeutically useless.
At this point a brief mention of an original saying which for some OCD sufferers has provided a powerful guideline toward not engaging in rituals is offered. "Within the question lies the answer." This statement suggests that when confronted with a seemingly genuine risk, relying on the awareness that there is doubt ("am I really in danger") and thus making the determination to accept the risk ("I may be, but I'm going to accept the risk and not undo the danger") will eliminate a tremendous amount of problem solving. A woman I worked with who suffered greatly from hypochondriacal OC about possibly having breast cancer used this model in the following manor. During a self-exam she would regularly come across possible lumps which may have not been there at her previous exam. She would use the experience of the extreme doubt as a signal that it would be worth taking the risk and accepting the ambiguity of having this fatal disease. Rather than running on a regular basis to her doctor for reassurance she was willing to stick to her annual appointments.
A final aspect of Cognitive Management entails purposely creating the awareness and nature of the risk while engaging in the exposure exercise. This strategy suggests that the impact of an exposure exercise is enhanced by combining the behavior of touching a toilet seat with the self talk "OK maybe I will now get aids, so death come and get me". Choosing to accept the risk tends to shut down the brains natural tendency to warn its host, through physical discomfort and cognitive warnings that you should feel horrible until the danger is removed.
In summary, CT for OCD involves providing persons with specific responses to the spikes, educating sufferers about the distinction between having these concerns and separating ones identity from the topics of the condition, and highlighting generalized strategies which facilitate anxiety management. It goes without saying that providing reassurances and attempting to educate the OCD sufferer about the truly limited risks involved in the spikes is counterproductive and alienating. With all this in mind please never accept these cognitive strategies as a substitute for the behavioral assignments which are ultimately paramount in bringing about the therapeutic benefit.