In the practice of Cognitive Behavioral Therapy (CBT), altered moods and negative behaviors are overcome using our thoughts and logic. CBT therapists help Clients identify irrational and disturbing core beliefs.and then use rational contrary thoughts to defeat those beliefs. This strategy has been shown in research to be quite effective; and the reason is obvious: feelings change, but facts do not. A solid fact is preferable to shaky emotional ground at any time.
However, in the treatment ofOCD, the strategy can backfire. OCD is brutal. Obsessions seek to make you rethink everything; doubt your beliefs, perceptions or emotions (as in relationship OCD), your actions (safety and contamination OCD), and even your morals and self-identity (harm OCD, homosexuality OCD). Therefore, MORE thinking, even seemingly rational thinking, does not equal LESS rumination. We find that it is usually futile to try to reason with their intrusive thoughts.
However,CBTIt has been found to be generally the most effective psychotherapy for anxieties. So what to do? It is not a different therapeutic modality, but a different strategy. One of the strategies is this: We don’t hang out with bullies.
You remember the school bully. They say your name, they demean you, they undermine your confidence. Bullies notice where their victims’ weaknesses lie and attack where they are vulnerable. There is the verbal harassment, the continuous teasing. And the threats: there is always an implication, overt or covert, that if it is not followed through, things will get worse.
But as we all know, giving in to a bully doesn’t lead to kindness in return, but rather more bullying. When the victim complies, the bully may back off for a moment, only to return the next day with more taunts and more demands.
The same goes for the “bully” that is your OCD thoughts. These thoughts are not useful things to consider to improve your life. This bully will only serve to scare, intimidate and immobilize you. OCD offers a promise of freedom and peace; whereas in reality, compulsions only provide momentary relief followed by more obsessive thoughts and increasingly intense compulsive impulses. In therapy, our strategy shifts from examining the details of thought content to determining the pattern these thoughts take and learning to recognize that pattern as the bully it is.
For example, a common anxious thought could be the fear of failing an exam. In patients who do not have OCD, psychologists can help the patient remember the amount of preparation she did, her history of being a successful student, or the fact that a grade does not make or break a semester. These cognitive interventions refocus the mind on the facts, or the “most likely” scenario, rather than the worst-case scenario.
But in OCD the strategy is completely different. A patient with OCD faces an exam, and that’s where the mental bullying begins:
“You better wear your lucky sweater and by the way, where is it?” the bully might ask.
“Have you really studied enough?”
“You better check with your teacher again about that question.”
Etc.
So the victim of the bully with OCD feels compelled to engage in superstitions. Or she may engage in repeated checking behaviors, such as asking endless clarifying questions of the teacher and her classmates. These can provide momentary reassurance, while in the long term setting the student up for greater anxiety and lower confidence in their own abilities.
Therapeutically, the goal is NOT to reason with fear. The goal is to help the patient see that these thoughts follow the same modus operandi as the previous OCD-driven ones, and to refuse to accept the OCD-driven demands.
Just as you wouldn’t go out of your way to build your life around what a seventh grade bully said about you, you also don’t build your life around the mental and behavioral obstacles that OCD is trying to make you overcome. You learn to listen beyond the content of the thoughts, recognizing the pattern and realizing that you don’t need to get involved. (Remember how getting involved with the seventh grade bully emboldened them?) Instead, you see the bully come and close the door. There is no reason to listen to what he has to say.
This takes practice and work in therapy, of course. But this strategy prevents OCD sufferers from wasting efforts on useless quests. Once this strategy is adopted, we can proceed to other parts of treatment, such as Exposure and Response Prevention (ERP).
Treating OCD is not easy; but, in some ways it is simple:
- Recognize the bully
- Don’t give him lunch money.
This publication is brought to you in collaboration with the ADAA OCD and Related Disorders SIG.Learn more about GIS.
