When Seeing Is Not Believing: A Cognitive Therapeutic Differentiation Between Conceptualizing And Managing OCD
A Prelude To Cognitive-Behavioral Techniques For The Treatment Of OCD
by Steven J. Phillipson, Ph.D.
Center for Cognitive Behavioral Psychotherapy
The following is a basic description of a traditional Behavioral approach toward the treatment of Obsessive-Compulsive Disorder (OCD). The author will attempt to explain how cognitive mechanisms (i.e., style of thinking) and time tested behavioral techniques (i.e., exposure and response prevention), can augment treatment strategies available for OCD. The paper will address the importance of a healthy rapport between client and therapist. A historical perspective will then be presented to familiarize the reader with traditional cognitive-behavioral principles. The main thrust of this paper will be to delineate the differences between the person's conceptual understanding of OCD and specific cognitive management strategies. The person's conceptual understanding (CU) of OCD provides a rationale for specific treatment components. Cognitive management (CM), on the other hand, mitigates anxiety and reduces the frequency of disturbing mental prompts.
Consistent findings from studies testing the effectiveness of different therapies strongly suggest that the working alliance (the bond between therapist and client), is paramount in predicting therapeutic success. The following interpersonal aspects of treatment play a significant role in fostering an atmosphere of collaboration: 1) level of comfort; 2) confidence in the therapist; and 3) a commitment to the treatment process by the client and therapist. The therapeutic relationship is 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, such that, at the end of each session, both parties come to an agreement as to the upcoming week's challenges and goals. All too often clients say, "You made me touch the door knob," as they review their previous weeks assignment. A cognitive therapist may immediately respond by saying, "The way I remember it, we had an agreement that you would do it." It is essential that the client accept the responsibility to participate willingly in his or her own therapy. Through a joint effort, clients can choose to share the challenges of this difficult therapy with an experienced partner.
Cognitive principles focus on fostering a sense of therapeutic independence on the part of the client. Cognitive therapists teach strategies and perspectives for responding to the challenges that life has to offer so that individuals can gain a greater sense of self-efficacy (i.e. developing faith in their abilities to achieve specified goals). Equally as important as knowledge, training, experience, and credentials on the part of the cognitive therapist are warmth, understanding, and compassion.
Typically, a cognitive-behavioral psychotherapist 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. It is hoped that any professional will disclose information about his or her own training, experience, and professional credentials. The client is encouraged to become informed about the therapist's theoretical background and method of practice. This may include asking questions such as: 1) what percentage of the therapist's caseload consists of an OCD population? and 2) what type of training in the treatment of OCD or other anxiety disorders does the therapist have?
To those who are considering embarking on the difficult process of cognitive-behavioral therapy for OCD, it is strongly suggested that therapy should not be taken in small doses; ambivalence and looking for a quick fix are not a winning formula. On the other hand, taking responsibility for the end of this life-destroying condition is paramount. Jump in and do not look back! There are a variety of success stories offered by former OCD clients that can be found on the Internet at www.OCDonline.com. These stories provide a general model for the positive mental framework that contributed to the success of these clients.
Traditional Cognitive-Behavioral Therapy for Depression
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 that distorted and irrational patterns of thought operate at the heart of depression. These patterns revolve around our automatic reactions toward life circumstances that create upsetting emotional consequences. CBT was developed to assist people to respond rationally to automatic irrational thoughts. Automatic thoughts are defined as reflexive cognitive reactions toward upsetting thoughts that are beyond our conscious control. To the delight of many psychologists, research findings strongly suggest that the long-term application of cognitive-behavioral principles yield a better outcome than medication. This approach teaches the person to identify the irrationality of his or her reflexive reactions or beliefs (automatic thought = B) that occur in response to upsetting events (activating event = A). The therapy challenges the notion that the actual situation (A) is responsible for the periodic upset (emotional consequence = C) that is experienced. The foundation of CBT is predicated on the philosophy of the ancient Greeks, which stipulates "Nothing in life is actually bad, lest we perceive it to be so." Traditional cognitive-behaviorists focus on teaching clients to substitute automatic irrational thoughts (B) with rational thinking (disputation = D).
An example that illustrates 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, one's future is predicated on the choices one makes. Ultimately, the effort John makes will determine his success. Further, his hobbies, peer relationships, and occupational participation all contribute to the fullness of his life. The existence of an intimate relationship is not the sum total of his wholeness.
Traditional CBT presumes that all people have irrational thoughts. The therapeutic interventions are based on the therapist's faith in people's ability to learn how to differentiate between being rational and irrational. At the heart of this model is the belief that we learn to think in dysfunctional and/or irrational ways from such sources as society, family, and religion. Traditional CBT for people suffering with OCD is, therefore, likely to be counter-productive toward achieving a beneficial therapeutic outcome. This approach assumes that people 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. It is common for a person with OCD to say, "It feels so real, yet I know it's literally impossible for it to be legitimate." Most can even predict that the risk of danger is infinitesimal, yet they "feel" overwhelmingly compelled to act out some escape response. In a previous article, entitled "Speak of the Devil" published in the OCF Newsletter, a rationale for the mind's duplicity is explained.
Using traditional CBT techniques to treat OCD, 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 any child, let alone my own? Cognitive restructuring may provide temporary relief from the anxiety that plagues the person. However, obsessions will inevitably focus on other elements of uncertainty that concern the person and will cause the anxiety to resurface. "Excuse me Doctor, all that makes sense but I did enjoy killing ants when I was a child and I heard a news report about a guy who went crazy and killed his children and himself shortly after hearing voices telling him the world is coming to an end." This CBT strategy presumes that the client is not aware of the irrational nature of the thoughts and can, therefore, be frustrating and alienating to those who suffer from them. OCD is less a manifestation of people who have irrational thoughts than it is an anxiety disorder in which people respond instinctually to feelings of being in grave jeopardy. Devoting a significant amount of time in an attempt to explain the irrational nature of the thought content misses the underlying characteristics of the disorder: this is an anxiety disorder, not a thought disorder.
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. Individuals who have OCD often report that they had these same ideas in their pre-morbid state (life before OCD), but where able to disregard them, much like anyone else would. There is no evidence that people who develop anxiety disorders change their basic thought patterns. What does appear to change is the intensity of the experience associated with what is perceived to be threatening thoughts. There is a small sub-sample of people with OCD who possess what is referred to as "overvalued ideation" in which they lose the ability to discern the irrational nature of their thoughts. However, the majority of people with OCD are aware of the excessiveness and absurdity of their thoughts and perceptions. Nevertheless, they continue to experience a great deal of distress from the thoughts. Therefore, helping OCD suffers to see the irrational nature of the thought content is counterproductive.
Cognitive Interventions For Obsessive Compulsive Disorder: The "Thinking" Behind Treating OCD
Analogizing the therapeutic challenge of OCD with that of a battle in wartime might prove a beneficial perspective toward understanding how to deal with this elusive condition more effectively. The two basic components of this battle entail the behind-the-scenes strategizing and the front line conflict. It is important not to confuse the appropriate application of these two separate strategies when managing OCD. The manner in which one conceptualizes a battle and the behavior exerted in fighting it, are very different. This important differentiation is illustrated in the book "Brain Lock," in which the author, Schwartz, encourages people to tell themselves that it is their OCD which is the cause of the upsetting thoughts. "It is not me, it is my OCD" is one of the four pillars of his therapeutic premise. For example, thinking about having sex with your own child emanates out of having this disorder and not from being a despicable person. While this awareness can facilitate a healthier conceptualization of the person's condition, it is unlikely to enhance one's management of the condition, such that there will be a long-term benefit. This "therapeutic" response is also somewhat misguided due to recent research, which strongly suggests that 80% of the non-clinical population experiences these same thoughts. It is recommended that the person substitute the conceptual statement, "It is not me, it is my OCD" with "It is not me, it is how the natural human brain works." In the presence of an obsession, Schwartz's response serves as a short-term reassurance in that it offers immediate but temporary relief. Perhaps it is better to suggest to oneself that since this thought fits into the theme of the OCD, "I'll take the risk and accept the ambiguity of its legitimacy." Accepting the possibility that there may be a legitimate risk that something might be wrong can facilitate the overall benefit of the therapy. This contrast will be discussed in detail later in this paper.
An innovative approach in Cognitive Therapy (CT) for OCD is the application of cognitive conceptualization & cognitive management to help the client to develop a therapeutically sound response-set to this anxiety disorder. Cognitive conceptualization focuses on removing the sense of culpability, shame and guilt that is pervasive among OCD sufferers. Conceptualizing the treatment and understanding the rules of OCD allow for a greater sense of commitment to engaging in the difficult and seemingly contradictory suggestions. 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 latter goal, cognitive-management (CM), is instructive in helping people respond effectively to the cognitive prompt or physiological experience of the perceived danger. When the least resistance is applied to this prompt the principles of habituation are most apt to take effect.
It is important to note that one's thought content and one's genuine beliefs can be very different. People are not responsible for the ideas that occur to them through automatic cognitive processes. Helping people to separate themselves (i.e. their "genuine" identity) from the emotional and/or moral implications of what this disorder seems to represent, is a major portion of cognitive conceptualization. Many of those who suffer from either the purely obsessional form of this condition and/or responsibility OC (hyper-scrupulosity) experience tremendous amounts of guilt and shame. This shame is a consequence of having these thoughts and believing oneself to be responsible for the well being of others. The articles written by Dr. Phillipson, including "Thinking the Unthinkable," "Guilt Beyond a Reasonable Doubt," and "Speak of the Devil" highlight the importance of accepting our brain's ability to produce horribly upsetting thoughts, without concluding that these thoughts are evidence of our being evil.
Surveys consistently show that approximately 80% of the population experiences violent and upsetting thoughts. These thoughts are most likely due to the automatic associations produced by the brain. In other words, there is no reflection on one's character for having a brain which produces these thoughts. This idea is in stark contrast with a traditional therapeutic notion that the unconscious mind possesses deep-seated evil intentions. Given that intrusive thoughts are common amongst a non-clinical population, it would be unreasonable to have someone strive for an absence of these thoughts. The horrible ideas of the person suffering from OCD are differentiated from the thoughts of the person without OCD by the experience of tremendous anxiety that accompanies the OCD sufferer's thoughts. This experience of anxiety is most likely produced by an overly sensitized amygdala. The amygdala is a small portion of the brain stem responsible for activating an organism's preparation for emergencies. Brain mapping studies seem to suggest that when OCD sufferers are confronted with feared stressors, it is the amygdala that is most active. With this in mind, it may be comforting (not therapeutic) to know that the content of one's obsessions does not characterize one's true identity. For instance, the spike "Oh my God, I may be gay," is only meaningful because of its accompanying anxiety. It does not imply that the person is actually homophobic or having a sexual orientation crisis. [Do not use this information in response to a spike. Such use will only serve as reassurance.]
The rationale for this seemingly counterintuitive treatment is also a facet of cognitive conceptualization. When one gives in to a ritual, the brain's sensitivity to the perceived threat is increased [see accompanying diagram]. Understanding that giving in to a ritual can have negative consequences is instrumental in fostering a sense of determination in the avoidance of relief-seeking behaviors. On the other hand, gaining insight into this treatment rationale does very little in regard to responding more effectively to the experience of imminent jeopardy. This is particularly true when the intensity is high and the threat feels very real. The amygdala is not a thinking part of the brain! It only transmits experience and therefore cognitive learning has no effect on it. No matter how many times a person learns that AIDS is in not likely to be transmitted by doorknobs, the anxiety caused by the perception of threat can only be reduced by taking on the potential risk through contradictory repetitive acts. For example, the person may repeatedly touch public doorknobs and then resist the impulse to hand-wash.
Cognitive conceptualization also involves empowering clients by helping them discover their ability to make their own choices. For example, such a choice could involve differentiating between surrendering to a ritual or embracing the risk of the obsession. Taking full responsibility for making choices enhances a person's sense of self-efficacy. Self-efficacy is the degree of confidence that the person has in his or her ability to achieve a desired outcome. Statements such as, "I had to wash because I couldn't stand the anxiety," are frequently heard in the initial phases of therapy. This serves to distance a person from considering what options are available to him or her in the moment of being challenged. Acknowledging the availability of a choice provides an opportunity to access resources that can be used to effectively manage the situation. Conceptualizing the overwhelming urge to ritualize as having no choice but to yield to the anxiety limits the faith one has in his or her capacity to change his or her life. Within the statements, "I HAVE TO" or "I CAN'T STAND THE ANXIETY," a person gives up the opportunity to examine his or her available resources in making a healthy choice.
"I chose to wash my hands because the doorknob might have had AIDS on it, therefore, I was not willing to live with that possibility!" This statement contrasts with the belief that performing rituals in the face of threat is obligatory. It is common for people to experience a diminution in the urgency to perform a ritual once they accept their willing collaboration and make the active choice to give in. Studies measuring pain tolerance have shown that our ability to tolerate pain is greatly increased after we realize that we have the power to decide whether we wish to seek relief or withstand the discomfort. In general, the greater our perceived sense of control over pain is, the more we are able to tolerate discomfort. Undoubtedly, it is important for people to understand that they can have a significant impact on the psychological outcome. This cognitive aspect is critical in treatment and will probably command an entire future article devoted to this premise.
It is essential that one's method of generating cognitive responses not be pre-programmed, rote, reflexive reactions. The more one infuses a genuine emotional emphasis into the responses, the more they will enhance the potency and efficacy of the therapy. "There may be AIDS on the doorknob. I'll choose to TAKE THE RISK and touch it anyway." Within this response set there will be a greater degree of benefit when the infinitesimal chance of danger is actually considered. Making the decision to live with the uncertainty and truly accepting all possibilities is, therefore, most beneficial. Exposure exercises using loop tapes to repeatedly expose oneself to the unsettling nature of a noxious thought might not be the best form of exposure. The passive nature of just listening over and over again may not prompt the mind to be fully engaged in the acceptance of the thought. By deliberately creating the thought the person has the opportunity to really "get into it." Being purposefully emphatic about the nature of the upsetting thought contributes to greater levels of habituation.
"Yes, I might be gay, but for now I'll kiss my girlfriend anyway and probably not enjoy the experience." It is critical that people realize the choices available to them and not make choices based on their thought content. If someone has obsessions related to their sexual orientation, there would be a tremendous amount of anxiety regarding the pleasure derived from engaging in intimate acts with significant others. Since anxiety and sexual arousal are mutually exclusive events, they can't occur together. If someone with OCD were to base the decision to make sexual advances on his or her level of inspiration, all sexual activity would come to a grinding halt. Paradoxically, this decrease in sexual activity will ultimately fuel the justification for the fear that one might actually be gay.
As a result of yielding to the urge to ritualize many people feel a tremendous amount of guilt and regard themselves as being emotionally weak. It is critical to understand that relief-seeking is actually a biologically programmed response characteristic of human beings. It is instinctive to look for a solution to a dangerous situation when the anxiety center (amygdala) of the brain is activated. The therapeutic guidelines offered by cognitive-behavioral therapy are actually counter-intuitive. The therapeutic response flies in the face of an overwhelming urge to obtain comfort and seek relief. Within the fabric of each human being lies a basic drive to resolve emotional conflict when it reaches a heightened level. The therapy requires a diametrically opposite response. In an apparent emergency, the therapeutic option is represented by the door labeled DO NOT ENTER. The door labeled EMERGENCY EXIT is of course the one that gets you deeper into the quagmire. While encountering a highly charged feeling of jeopardy, in the moment in which the bullets are flying, making the choice not to give in to relief-seeking requires a leap of faith toward these principles. Engaging in the therapeutic guidelines is actually a very brave act. Few people make the effort to give themselves credit for touching a doorknob or accepting the possibility that they may be of harm to their own children. Among the general population there is a pervasive misunderstanding that these seemingly "normal" events (i.e., touching a doorknob), are natural, therefore, why "should" the person make a big deal over being able to confront these anxiety-evoking events? The reason to praise yourself for these acts of courage is that it would be tantamount for the non-OCD sufferer to be asked to lie down on train tracks and experience the feeling of being in danger without getting up. Remember that the part of the brain responsible for anxiety is not a thinking part, but only understands the experience of danger. Cognitive conceptualization assists sufferers in developing a healthy and informed understanding of how the mechanisms of OCD operate. It also provides a rationale for the efficacy of this very powerful treatment. However, it would be ill-advised to use cognitive conceptualizations in direct response to an anxiety-provoking situation, since such a response would tend to be reassuring in nature, and reassurance is the antithesis of the treatment core.
The second goal of CT, referred to as cognitive-management, involves teaching sufferers to respond effectively to obsessive threats in the moment of being challenged. Cognitive-management also focuses on the importance of one's disposition while engaging in exposure exercises. You are on the front line of a battle and bullets are flying. What do you do? (Hint: Put away the training manual). For the purposes of our battle with OCD it is generally a good idea to respond in such a way that there is little to no "conflict or mental chafing" in response to being spiked. The main objective is to reduce/eliminate the fruitless efforts of mentally escaping the threat, in formulating a response to the upsetting thought (i.e. spike). When your brain sees that you are no longer running from the feared topics, a long-term consequence is that it will generally not bother transmitting the warning. This is, once again, the basic principle of extinction.
The principles of extinction and habituation are the basic foundation of cognitive management for OCD. Extinction is the process whereby variables that reinforce the repetition of a behavior are removed. In English this means that events tend to stop occurring when we take away the rewards for their ongoing nature. Behaviors and/or thoughts, which are not reinforced, will tend to decrease in frequency. An example would be ignoring a child during a tantrum. By not consistently giving in to the child's demands, the tendency for the child to throw tantrums will decrease. In a behavioral treatment for OCD, not washing one's hands after touching the floor repeatedly will reduce the brain's sensitivity to the dirtiness of the floor. By consistently not seeking an answer to the question, "Am I a danger to my own child if I touch him without washing my hands?," eventually the brain will reduce its need for resolution.
Habituation is the biological tendency for the brain not to focus on information, which is continually present. Individuals who live close to a train track tend not to be aware of the passing train's presence until a visiting friend mentions the surprising loudness of the passing train's sound. Habituation is represented in behavioral treatment for OCD by purposefully repeating in one's head the nature of the spike. The "purposeful" repetition of the upsetting thought will communicate the irrelevant nature of the spike's theme to the brain. This repetition will also reduce the brain's sensitivity to the emotional intensity of the spike. After you touch the bottom of your shoe, find out how difficult it would be to purposefully remind yourself, every five seconds for a five minute period, that your now going to get sick and spread disease.
The following scenario is an example of extinction and habituation. While changing her daughter's diaper, the mother has an automatic thought (spike) 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 let's do it now." This response is based on the premise that through acceptance, the mind will reduce its sensitivity to these ideas (e.g. extinction). Escape or intolerance regarding the feared stimulus (spike) tends to perpetuate its strength. Having this mother purposefully create the thought (approximately 15 times) while changing a diaper would act as a purposeful exposure (e.g. habituation) and also further reduce the mind's sensitivity to these topics.
III. Exposure and Response Prevention
The most basic element of CM involves the therapeutic procedures known as Exposure and Response Prevention (ERP). Exposure and response prevention are the definitive non-medical treatments of choice. The general guidelines of this procedure involve having people purposefully expose themselves to stressors without engaging in a ritual. These exposure exercises may entail having the client rub his hands on a sidewalk and not washing, or purposely creating the thought, "God is an asshole!" and then not praying for forgiveness. By purposefully choosing to come in contact with items or thoughts that are anxiety provoking, the brain tends to send back a less intense signal of fear because it habituates to the anxiety of the stressor. Choosing to expose oneself to the feared item without the escape response is the most critical component of the therapy. A second and almost equally important aspect of the treatment involves not giving in to it inadvertently. Rather than just saying "NO! I won't give in," it is advisable to allow for the possibility that there is an actual risk.
Behavior therapy's contribution to the treatment requires people to come in contact with the feared items. There are basically two means of being spiked: having the environment or your own mind create it by accident (inadvertent) or going after it by choice (purposeful). Whether mentally or physically, an exposure exercise attempts to purposefully reproduce the elements of the inadvertent spike. The cognitive element of therapy (i.e., self talk), which facilitates the impact of the exposure exercise and produces more resilience to relapse, involves making purposeful mental statements about the possibility of an actual risk being present. The thought that "there's AIDS on the doorknob" or the statement, "Stay away from knives as you might be a risk to others," illustrates how inadvertent spikes can cause people to become hypervigilant about their surroundings. The exposure exercise would entail having the client purposefully grab a knife and take it to bed saying, "Tonight I make sushi out of my husband... I hope I have enough rice to go with it." Humor counts! The more you laugh at the OCD, the more disrespect you give it. Hence, the less power it has.
Merely utilizing cognitive responses such as, "I'll take the risk and accept the possibility that the danger may be real," without embracing a genuine acceptance of that risk, is a rote exercise and therapeutically useless. Another aspect of cognitive management entails purposefully creating the awareness and accepting the nature of the "risk," while engaging in the exposure exercise. This strategy enhances the impact of an exposure exercise by combining the behavior of touching a toilet seat with self-talk: "OK, maybe I will now get AIDS, so death come and get me." Choosing to accept the risk by eliciting physical discomfort and cognitive warning, shuts down the brain's natural tendency to warn its host that he or she should feel horrible until the danger is removed. For the purely obsessional client, it is encouraged that, along with creating the spike ("today I'm going to push ten people in front of a train"), one would also remind him- or herself that in the end, "one never knows what evil lurks in the heart of men." Attempts at reassurance inspire the brain to automatically scan for any possible exceptions. "The Dr. says that people with OCD NEVER actually act out their fear. Thank God, now I don't have to worry about harming my daughter" or "Gee he's only known me for three months. I wonder if he can actually be sure that I have OCD and that I am not actually a psychopath. After all, didn't Jeffery Dahmer claim to have OCD?"
Seeking out the risks on purpose (i.e. rubbing one's hands on the floor and then eating a sandwich), armed with the disposition of "come and get me," is by far the greatest facilitator of daily therapeutic gains! Without a doubt, the more aggressive one is in confronting the disorder, the less distress it will cause. Developing an aggressive disposition toward being challenged is 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 a person seeks out anxiety-provoking challenges, there tends to be a greater likelihood that levels of anxiety be reduced. Thus, as we turn the tide of the condition's momentum from endless escape to approach, we aggressively seek challenges and decrease the likelihood of finding them.
Cognitive-management also involves facilitating greater levels of tolerance toward anxiety by making space for the discomfort and looking upon it as something to be managed effectively. An important aspect of cognitive-management is not waiting for the anxiety to subside. The reduction in anxiety will happen naturally and spontaneously, once the person genuinely accepts the initial increase in anxiety. When you feel anxious it is important to: 1) rate the level of discomfort on a scale from 1 - 10; 2) Describe the anxiety in terms of what is actually going on in your body (rapid heart rate, sweaty palms etc.); 3) assess your willingness to allow for the anxiety to be there at this level (i.e. "Hey its only a 5, no problem I've successfully dealt with 7's"); and 4) assess your willingness to have this amount of anxiety dwell for a specified time period (i.e., "At this level I'm sure I can allow it to be there for at least 30min. At 3:30pm I'll reassess my tolerance"). By engaging in this process one rises above the experience, creating a more manageable distance and less discomfort. Paradoxically, the chances of obtaining relief is increased the less one seeks it out.
The quest to eliminate the spike is probably the greatest cognitive misconception 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 to focus on its existence or disappearance. Thus, relief-seeking increases the person's vigilance towards his or her anxiety. 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."
Previous articles by Dr Phillipson, especially "Thinking the Unthinkable" and "Speak of the Devil," provide a very comprehensive account of CT for OCD. These articles highlight the importance of self-talk in invalidating and effectively mediating the seemingly endless cycle of fear/escape within OCD. A critical aspect of this therapy focuses on the premise that the responses to the disorder are not designed to make it "go away." Rather, by perpetuating the condition this perspective allows the anxiety to burn itself out due to lack of reinforcement (removal of the escape response). The idea is that the less one toils with the bully the greater the likelihood that the bully will find someone else to pick on.
"Within The Question Lies The Answer"
Often clients will state that the intensity of their anxiety makes it difficult to discern the legitimacy of the threat. "It feels so real!" is the calling card that seduces a person to be tempted to give in to the ritual. Clearly, reassurances are of no value in dispelling an OCD sufferers concerns. "Within the question, lies the answer." Many OCD sufferer's have found that accepting this premise on faith is a powerful guideline that helps people realize that they have the ability to resist performing the rituals. This statement encourages people to make a choice toward "risk taking" when the nature of one's spike leaves "any doubt" about its legitimacy. This perspective can be of benefit when people are confronted with what appears to be a genuine risk. Focusing on the awareness that there is doubt (i.e., "Am I really in danger?"), then making the determination to accept the risk (i.e., "Maybe I am in danger, but I'm going to accept the risk and not undo the danger."), will eliminate a tremendous amount of problem solving. For example, I worked with a woman who suffered greatly from hypochondriacal OC revolving around the possibility of having breast cancer. She used the model in the following manner. During a breast self-exam she would regularly come across possible lumps that may not have 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 repeatedly running to her doctor for reassurance, she was willing to stick to her annual appointments. Each lump presented itself as a question about its legitimacy and sameness. She chose to accept the risk and ambiguity that actual tumors would probably not activate a never-ending search for an answer. When dealing with the "real thing" people tend not to question it.
As previously mentioned, cognitive therapy for OCD (CT) has two primary applications: 1) to help people understand the guidelines of an anxiety disorder's overall game plan (i.e. mental mechanisms); and 2) to provide specific suggestions in the face of challenge. For those with OCD, the purpose of being challenged refers to the 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 foci of CT for OCD will most likely facilitate progress when they are integrated in treatment.
In summary, CT for OCD involves providing clients with specific responses to the spikes. There is also an educational component to CT. This involves helping sufferers understand that the content of their OCD concerns are separate from and do not reflect their basic human nature or character. Treatment also provides an opportunity to highlight generalized strategies, which facilitate anxiety management. Providing reassurances and educating the OCD sufferer about how unlikely their risks actually are can be counterproductive and alienating. Cognitive therapy strategies are ineffective substitutes for the behavioral assignments (i.e. exposure and response prevention), which are paramount in bringing about therapeutic benefits. The immediate goal of therapy is not to eliminate the spikes or to feel better. The techniques are designed to manage anxiety and to stop the endless cycle of ritualizing. The long-term indirect dividends of these strategies are to reduce the spike frequency and to reduce the frequency and intensity of the associated anxiety.