This article is no longer available at the OC Foundation website, so I have posted it below.
For more info, see the related thread: Key Cognitive Errors in OCD.
Cognitive Therapy for OCD: What It is, When to Use It and When Not!
By Deb Osgood-Hynes, PsyD.
Director of Psychological Services
MGH OCD Institute at McLean Hospital
Harvard Medical School
Although cognitive therapy has been available for more than 20 years, only in the past seven years has there been exploration into the benefit of cognitive therapy in the treatment of Obsessive-Compulsive Disorder. So what is cognitive therapy (CT)? Several basic principles offer an understanding of the foundation of CT. First is the premise that thoughts and feelings are closely connected; thoughts influence feelings. Second, changing your thoughts can contribute to changing your feelings or mood. This includes feelings, such as, fear and anxiety often associated with OCD; but can also apply to feelings such as, anger, guilt, depression, etc. Third, while you can’t always change a situation or control an OCD triggering event (nor is this always clinically advisable when treating OCD), you can change the way you think about an event and in this way facilitate a reduction in your distress level. CT offers options for developing a new internal dialogue in response to emotion-triggering situations or thoughts.
The first step in CT is to increase your awareness of patterns of unproductive thinking. The following five cognitive domains are a compilation of some of the unproductive thinking patterns elaborated more extensively by Steketee and Frost (2002) and Burns (1989). As you read through, consider whether these patterns apply to the way in which OCD biases your thinking.
You can’t just talk away all your OCD. Nor can you talk away all feelings of doubt and uncertainty. But with creative brainstorming you may be able to identify cognitive strategies which will enhance your treatment outcome. CT is primarily a tool to supplement Exposure and Response Prevention work. CT can help you challenge the falsehoods the OCD is telling you. It can motivate you to stay in an exposure situation longer and/or work harder to resist rituals or avoidance behavior. It can help you learn to better tolerate doubt and uncertainty.
Here are four general questions to get you started in talking back to your unproductive thinking. Depending on your type of OCD, some avenues of questioning may work better than others. You will need to experiment with what works best for you. Consistent practice in using CT strategies is needed and it takes time to learn. Talk with your therapist about how to do this and whether this treatment strategy is right for you and your symptoms.
Identify your unproductive patterns of thinking.
Ask: Where is the evidence that what the OCD is telling me is actually true? Try to estimate the actual probability of a feared situation happening. Remember to consider the probabilities of all the possible steps between your actions or thoughts and what you fear may happen. What is the evidence for and against your specific interpretation? Are you confusing thought with fact? Is your causal relationship logical?
Even if internal self-talk appears logical and accurate, are the feared consequences really as awful or catastrophic as the OCD is trying to make them out to be? Reduce all-or-nothing thinking.
Do a cost benefit analysis. Look at the time, energy, effort and general cost to your quality of life by listening to what the OCD is telling you. Is the actual probability of a feared event worth this cost?
What is the norm? How would someone without OCD do a particular task or how might they respond to an intrusive unwanted thought?
Now that you have a general idea on how to do cognitive therapy, let me offer some times when you should not use these strategies. First, beware when CT efforts turn into one big repetitive self-reassurance ritual. Are you trying too hard to convince yourself there is no evidence for the feared event? Are you using the CT to reassure yourself about a thought or situation so you don’t have to sit with the doubt and uncertainty generated by it? Therapy for OCD, in part, involves learning to tolerate the discomfort of doubt and uncertainty. Are you trying to use the CT to give you clarity about a situation in an effort to get it to “feel right”? If so, throw the CT out the window for these OCD triggering events and consult with your therapist on possible self-talk strategies that focus on how to better tolerate the experience of doubt, uncertainty and/or events not feeling right.
Second, are you doing a flooding type of ERP by facing your worst-case fears and thoughts? This may involve going into a previously avoided situation and deliberately thinking your worst fears or may involve writing out a script or recording on tape your most feared intrusive thoughts and situations? The way to reduce fears and anxieties is to face them. Facing feared situations, thoughts and images provides an opportunity for habituation and symptom reduction. Use of cognitive therapy strategies during flooding-style ERP tasks can dilute the intensity of the exposure task and thereby reduce potential for habituation gains.
Third, are you making a consistent effort to generate more productive self-talk but instead it feels like it is turning into an obsession? Do you just feel totally confused about what you should be doing and seem to be spending too much time trying to figure it out? Are you caught up in whether you are doing the CT correctly or perfectly? If so, you may want to put your use of CT on hold until you can discuss this with your therapist. CT should be productive. It’s purpose is to help you do your ERP, not give you another item over which to obsess. The goal of this article is to offer you a sampler of what CT is and its potential benefit in treatment. I hope it has also increased your awareness of when CT may interfere with treatment progress.
For more info, see the related thread: Key Cognitive Errors in OCD.
Cognitive Therapy for OCD: What It is, When to Use It and When Not!
By Deb Osgood-Hynes, PsyD.
Director of Psychological Services
MGH OCD Institute at McLean Hospital
Harvard Medical School
Although cognitive therapy has been available for more than 20 years, only in the past seven years has there been exploration into the benefit of cognitive therapy in the treatment of Obsessive-Compulsive Disorder. So what is cognitive therapy (CT)? Several basic principles offer an understanding of the foundation of CT. First is the premise that thoughts and feelings are closely connected; thoughts influence feelings. Second, changing your thoughts can contribute to changing your feelings or mood. This includes feelings, such as, fear and anxiety often associated with OCD; but can also apply to feelings such as, anger, guilt, depression, etc. Third, while you can’t always change a situation or control an OCD triggering event (nor is this always clinically advisable when treating OCD), you can change the way you think about an event and in this way facilitate a reduction in your distress level. CT offers options for developing a new internal dialogue in response to emotion-triggering situations or thoughts.
The first step in CT is to increase your awareness of patterns of unproductive thinking. The following five cognitive domains are a compilation of some of the unproductive thinking patterns elaborated more extensively by Steketee and Frost (2002) and Burns (1989). As you read through, consider whether these patterns apply to the way in which OCD biases your thinking.
1) Over importance of thoughts. Does the OCD influence you to put too much importance or significance on the mere presence of a thought? Many OCD sufferers believe that just because a thought is present, it must carry some importance. This is not necessarily true. Try this experiment. Allow yourself to be aware of all thoughts entering into your mind over the next three minutes. Some thoughts could be important and some may be totally random or nonsensical and not have any significant meaning. OCD makes a sufferer believe that all thoughts have equal importance. Related to this is the belief that thinking a thought is the same as doing an action; or the mere presence of a thought will result in an unwanted action or will cause an event to happen.
2) Over estimation of threat/all-or-nothing thinking. Do you tend to overestimate the actual probability or level of threat associated with a particular event? Do you catastrophize a situation, immediately conjuring up as a probability the worst-case scenario? Are you considering only information the OCD is trying to emphasize; magnifying this out of proportion while minimizing or disqualifying other evidence to the contrary? Do you think in terms of black-and-white or all-or-nothing without considering the grey area or steps in between?
3) Difficulty with doubt and uncertainty. Do you have a difficult time tolerating uncertainty? Doubt is a common symptom of OCD and frequently generates a great deal of distress when the OCD won’t allow a situation to “feel right” or won’t allow you to feel a comfortable degree of certainty about a particular thought or event. Observe your internal self-talk about having to sit with the discomfort of doubt and uncertainty. Do you wish for this discomfort to go away immediately?
4) Over responsibility. Does the OCD influence your thinking by telling you to take complete responsibility for situations in which anyone else would not consider you responsible? Do you believe you have the power to prevent negative or catastrophic events from happening by doing mental or physical rituals? Do you excessively concern yourself with, or blame yourself for, a negative event which may or did happen?
5) Reasoning-Logic based on emotions. Are your conclusions about a situation based more on your strong emotions and less on actual fact? Are you confusing a feeling as evidence of a fact because that’s what the OCD is telling you? Do you say to yourself “I’m feeling anxious; therefore, this situation must be dangerous” or “I’m feeling guilt; therefore, I must have done something bad?”
Once you’re able to identify areas of unproductive thinking, what can you do? Talk back. Look at ways you can change your interpretation of an event. Look at ways you can change what you say to yourself in response to an unwanted intrusive obsession. Consider ways to reduce your emotional reactivity to OCD-triggering thoughts and situations based on the above patterns of thinking. While this might sound simple, it is not so easy or straightforward. 2) Over estimation of threat/all-or-nothing thinking. Do you tend to overestimate the actual probability or level of threat associated with a particular event? Do you catastrophize a situation, immediately conjuring up as a probability the worst-case scenario? Are you considering only information the OCD is trying to emphasize; magnifying this out of proportion while minimizing or disqualifying other evidence to the contrary? Do you think in terms of black-and-white or all-or-nothing without considering the grey area or steps in between?
3) Difficulty with doubt and uncertainty. Do you have a difficult time tolerating uncertainty? Doubt is a common symptom of OCD and frequently generates a great deal of distress when the OCD won’t allow a situation to “feel right” or won’t allow you to feel a comfortable degree of certainty about a particular thought or event. Observe your internal self-talk about having to sit with the discomfort of doubt and uncertainty. Do you wish for this discomfort to go away immediately?
4) Over responsibility. Does the OCD influence your thinking by telling you to take complete responsibility for situations in which anyone else would not consider you responsible? Do you believe you have the power to prevent negative or catastrophic events from happening by doing mental or physical rituals? Do you excessively concern yourself with, or blame yourself for, a negative event which may or did happen?
5) Reasoning-Logic based on emotions. Are your conclusions about a situation based more on your strong emotions and less on actual fact? Are you confusing a feeling as evidence of a fact because that’s what the OCD is telling you? Do you say to yourself “I’m feeling anxious; therefore, this situation must be dangerous” or “I’m feeling guilt; therefore, I must have done something bad?”
You can’t just talk away all your OCD. Nor can you talk away all feelings of doubt and uncertainty. But with creative brainstorming you may be able to identify cognitive strategies which will enhance your treatment outcome. CT is primarily a tool to supplement Exposure and Response Prevention work. CT can help you challenge the falsehoods the OCD is telling you. It can motivate you to stay in an exposure situation longer and/or work harder to resist rituals or avoidance behavior. It can help you learn to better tolerate doubt and uncertainty.
Here are four general questions to get you started in talking back to your unproductive thinking. Depending on your type of OCD, some avenues of questioning may work better than others. You will need to experiment with what works best for you. Consistent practice in using CT strategies is needed and it takes time to learn. Talk with your therapist about how to do this and whether this treatment strategy is right for you and your symptoms.
Identify your unproductive patterns of thinking.
Ask: Where is the evidence that what the OCD is telling me is actually true? Try to estimate the actual probability of a feared situation happening. Remember to consider the probabilities of all the possible steps between your actions or thoughts and what you fear may happen. What is the evidence for and against your specific interpretation? Are you confusing thought with fact? Is your causal relationship logical?
Even if internal self-talk appears logical and accurate, are the feared consequences really as awful or catastrophic as the OCD is trying to make them out to be? Reduce all-or-nothing thinking.
Do a cost benefit analysis. Look at the time, energy, effort and general cost to your quality of life by listening to what the OCD is telling you. Is the actual probability of a feared event worth this cost?
What is the norm? How would someone without OCD do a particular task or how might they respond to an intrusive unwanted thought?
Now that you have a general idea on how to do cognitive therapy, let me offer some times when you should not use these strategies. First, beware when CT efforts turn into one big repetitive self-reassurance ritual. Are you trying too hard to convince yourself there is no evidence for the feared event? Are you using the CT to reassure yourself about a thought or situation so you don’t have to sit with the doubt and uncertainty generated by it? Therapy for OCD, in part, involves learning to tolerate the discomfort of doubt and uncertainty. Are you trying to use the CT to give you clarity about a situation in an effort to get it to “feel right”? If so, throw the CT out the window for these OCD triggering events and consult with your therapist on possible self-talk strategies that focus on how to better tolerate the experience of doubt, uncertainty and/or events not feeling right.
Second, are you doing a flooding type of ERP by facing your worst-case fears and thoughts? This may involve going into a previously avoided situation and deliberately thinking your worst fears or may involve writing out a script or recording on tape your most feared intrusive thoughts and situations? The way to reduce fears and anxieties is to face them. Facing feared situations, thoughts and images provides an opportunity for habituation and symptom reduction. Use of cognitive therapy strategies during flooding-style ERP tasks can dilute the intensity of the exposure task and thereby reduce potential for habituation gains.
Third, are you making a consistent effort to generate more productive self-talk but instead it feels like it is turning into an obsession? Do you just feel totally confused about what you should be doing and seem to be spending too much time trying to figure it out? Are you caught up in whether you are doing the CT correctly or perfectly? If so, you may want to put your use of CT on hold until you can discuss this with your therapist. CT should be productive. It’s purpose is to help you do your ERP, not give you another item over which to obsess. The goal of this article is to offer you a sampler of what CT is and its potential benefit in treatment. I hope it has also increased your awareness of when CT may interfere with treatment progress.
