Cognitive Behavioral Therapy (CBT) is the gold standard for the treatment of OCD and related anxiety based conditions. But some simple mistakes can interfere with treatment. Kimberley Quinlan, MA, of the OCD Center of Los Angeles discusses five common roadblocks to effective treatment for OCD and anxiety.
Research has consistently found that the most effective treatment for Obsessive Compulsive Disorder (OCD) and most other anxiety disorders is Cognitive Behavioral Therapy (CBT). The cognitive component of CBT involves investigating and challenging the individual’s irrational thoughts related to their fears. These thoughts are described as “cognitive distortions”, and the process of challenging them is known as “cognitive restructuring”. This process takes place during therapy sessions, and is also practiced by the client between sessions throughout the course of treatment.
The behavioral component of CBT is more time intensive, and requires the client to be gradually, purposefully and systematically exposed to the very thoughts and situations which generate their discomfort, and to do so without responding with either compulsive or avoidant behaviors. This process is known as Exposure and Response Prevention (ERP).
At the OCD Center of Los Angeles, in addition to traditional CBT as described above, we also focus a significant amount of our treatment on what is known as Mindfulness Based Cognitive Behavioral Therapy (MBCBT). Mindfulness Based CBT is not a substitution for cognitive restructuring and ERP, but rather an addition to them. MBCBT focuses on helping clients learn to accept the existence of their unwanted thoughts, feelings, sensations, and urges, and to elect not to respond to them in a compulsive or avoidant manner. This requires the client to choose a different way of thinking about their obsessions and other anxiety symptoms.
In the course of treatment with CBT and MBCBT, the therapist helps the client to challenge the accuracy and legitimacy of the his/her thoughts (obsessions), while at the same time accepting the ongoing existence of those thoughts, as well as the existence of other unwanted experiences such as uncomfortable feelings, sensations, and urges. Over time, clients learn that they are able to tolerate these experiences without doing either compulsive or avoidant behaviors.
Unlike more traditional talk therapy, CBT is a dynamic and directed style of treatment. But there are numerous pitfalls along the way. A seasoned Cognitive Behavioral therapist knows to keep a watchful eye out for certain roadblocks that are likely to hinder a client’s therapeutic progress. Given the fact that obsessions and compulsions occur mostly outside of the therapist’s office, and that the client is responsible for completing a good deal of homework between sessions, the client has frequent opportunities to get sidetracked. Here are five common roadblocks clients need to be aware of when entering into treatment for OCD and anxiety using CBT and MBCBT.
Not doing your homework
One of the biggest barriers to successful treatment is when the client believes that just coming to therapy will make them better. Yes, consistently attending therapy is a cornerstone to improving your symptoms, but it is not all that is required. There are 168 hours in a week, and if you are attending therapy 1-2 hours per week, but not doing your CBT homework, your progress will be extremely slow. When do you do most of your compulsions? At home? At work? At social events? You will need to be committed to practicing mindfulness, and to exposing yourself to your specific obsessions and fears, and to doing both without responding to your discomfort with compulsions or avoidant behaviors.
Performing other compulsions while doing exposure therapy
When human beings experience anxiety, we will often do just about anything to make it go away. During treatment, we help our clients learn to identify the compulsive and avoidant behaviors they are using in an effort to rid themselves of their anxiety. We then help them gradually expose themselves to their fear without using these behaviors.
One common treatment mistake is to replace one compulsive behavior with another. For example, “Annie” always flicks the lights seven times when entering or exiting a room. Our goal is to get Annie to walk through the door without flicking the light switches at all (unless of course she legitimately needs to turn the lights on or off, in which case one flick of the lights is appropriate). If Annie goes through the door without flicking the switches, but then says certain prayers while going through the door, or mentally imagines herself flicking the switches, then she is still doing compulsions. Likewise, if she simply avoids that room in order to avoid the light switches, she is doing an avoidant compulsion. Replacing one compulsion with another will dramatically slow down her treatment.
Another example would be “John”, who always feels the need to mentally review his day in order to get a sense of certainty that he did not harm anyone. John’s exposure would be to purposely have a thought about harming someone, and to then not do a mental review. The goal here is for John to accept the discomfort that this thought causes, while making no effort to mitigate that discomfort. If John performs his exposure, but then seeks reassurance by asking his girlfriend to confirm that he hasn’t actually hurt anyone, he is still being compulsive. And if he also chooses to check his hands for blood or to inspect the silverware drawer for evidence of missing knives, these behaviors are also compulsions, and they will counteract his ERP efforts. These common mistakes do not allow John to be fully exposed to his fear, and in turn, his treatment progress will suffer.
Expecting your therapist to know your OCD and anxiety symptoms
After reading the above points, you may notice that there are many types of compulsions. It is important to be aware of all of them in order to make sure you are completing your exposure assignments correctly and thoroughly. There are four primary types of compulsions.
- overt compulsions
- avoidant compulsions
- reassurance seeking compulsions
- mental compulsions
Overt compulsions are actual physical behaviors that one does in an effort to reduce anxiety and obsessions. Avoidance of a specific feared object, situation, or thought is just another compulsive way of trying to reduce anxiety or obsessions. Reassurance seeking is a common compulsion that is often overlooked during treatment, and involves finding certainty from those around you (often family members or partners) or via other sources such as the internet or newspapers. Last of all, there are mental compulsions. These are often difficult to identify as they are going on only in the mind of the sufferer (for example, compulsive prayer, counting rituals, mental review of situations, etc.). Mental compulsions can easily be overlooked, especially if your therapist is not trained to fully understand and treat OCD. The key is for clients to be aware of all of these different types of symptoms, and to be sure to discuss any and all symptoms with their therapist (including new symptoms that may arise during the course of treatment). If you fail to inform your therapist of all of your symptoms, even those which you find terribly anxiety provoking or embarrassing, there is no way that your therapist can help you fully face your fears.
Constantly analyzing your symptoms
We humans are extremely good at fooling ourselves into believing “If I just figure this out, I will not have anxiety about it”. But if you are invested in trying to understand why you have OCD or other anxiety symptoms, you are almost guaranteed to feel even more confused and anxious.
Unfortunately, it is common practice in traditional talk therapy to analyze the client’s feelings in an effort to get the “root” of the issue. While this may seem like a good idea, it is the exact wrong thing to do for someone with OCD. The last thing someone with OCD needs to do is to spend even more time obsessing about their thoughts, feelings, sensations and urges.
It is critical that you know that there is no profound, deep-seated reason why you are having these thoughts and feelings – you are having them because you have a neurologically based condition called OCD which makes your brain over-focus on unwanted thoughts. Analyzing your thoughts is not just pointless, it will actually make your OCD worse. Analyzing and mentally reviewing your OCD and anxiety symptoms may decrease your discomfort in the short term, but they will increase your discomfort in the long term. That said, we do spend a fair amount of time in treatment reviewing and learning about each person’s thoughts and feelings. But in CBT, this is occurs primarily in the beginning of treatment, and is done in an effort to help clients learn to challenge their cognitive distortions and compulsive behaviors. In other words, it is done not in order to find some hidden, deep-seated issue, but rather to help the client learn more effective ways of thinking and acting when faced with their fears and discomforts.
Resisting the fact that being uncomfortable is a normal part of life
Discomfort is a fact of life. This includes the uncomfortable thoughts, feelings, sensations, and urges that one experiences in OCD and other anxiety based conditions. While this may sound pessimistic, some people actually consider this way of thinking to be realistic, and even optimistic. By actually fully accepting the existence of our discomfort, we are often relieved of it to some extent. Conversely, if you are committed to comfort at any cost, your anxiety and discomfort will flourish.
One of the biggest mistakes I see clients make during the course of treatment is resisting the thoughts, feelings, sensations and urges that they are currently experiencing. When you resist or try to avoid these internal experiences, you are telling your brain that there is something to be afraid of, and that you can’t bear its existence. You are reinforcing the distorted belief that there is a serious threat and that it is intolerable. The goal of Mindfulness Based CBT is to learn to sit with the discomfort – after all, it is there whether you like it or not. Essentially, the goal is to accept that your discomfort is present for you, just as it is everyone, no matter how happy, sad, lucky, unfortunate, rich, poor, tall, short, skinny, overweight, smart…the list goes on. No one is exempt from discomfort. Accepting and tolerating it is the tool that begins your journey to healing.
CBT is highly successful for a number of reasons. First, clients learn to face their fears, and in doing so, become desensitized to them. Second, clients learn helpful cognitive tools to become more mindful and accepting of their unwanted thoughts, feelings, sensations, and urges. And third, these tools can be practiced anywhere and anytime for the rest on one’s life. So if and when you decide to enter onto treatment for OCD using CBT, do your best to avoid these five common pitfalls. If you do so, you will find your therapeutic progress far smoother