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Cornerstone of cognitive therapy.


Guest Tricia

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David Veale and Rob Willson say, "Testing whether your symptoms best match Theory A or Theory B is the cornerstone of the cognitive component of therapy"

​I have spent the last few weeks re-studying cognitive therapy, as behaviour therapy has no effect any more. However, I cannot even apply the above theory to my own situation. I am aware my obsession is ridiculous. I do not fear harm. I do not believe I'll go crazy when exposed to certain contaminants (actually wish I would, as it seems preferable to the unbearable feeling I experience).

I keep reading how people with OCD have an inflated sense of responsibility. This may have been the case for me years ago, but it certainly doesn't apply to my fear of contamination.

A therapist in the past tried to explain that I was overestimating the chance of encountering what I fear. I disagreed with him and said it was inevitable, even on food in a supermarket trolley. After a ten minute discussion he came round to my way of thinking (going from his 1 in 10,000 chance to my 1 in 50). He then, quite understandably, said, "But, what does it matter, what harm will come to you?" I told him I didn't worry any harm would come to me and could not explain why it mattered - mattered so much that when I faced exposure (and not the top in my hierarchy) for months I would have chosen to die than continue with it. My psychologist had already told me to stop before | finally admitted defeat.

Even David Veale states that if we test out Theory B for a few months and don't find it works we can revert to Theory A. However, as I said, I'm not sure what I would write for either theory. And, even if I could, how does that help me?!

Edited by Tricia
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Like all these things, this "behavioural experiment" approach of theory A and B is a tool and will work for some. Paul Salkovskis also favours it in "Break Free From OCD"

Amongst the problems with it is the fact that the sufferer might keep doubting then reapply the experiment and get a diffferent answer.

To my latest and state -of the- the -art clynical psychologist such tests are extremely useful - but then so to is the concept that when we acknowledge our OCD intrusions as exaggerated risks pulled into sharp focus rather than perceived as low and in peripheral focus , we can apply a mindful approach to stop ruminating and just be - moving away from the affects of the intrusion.Caramoole and Bear like this approach.

So there are in fact two very current tools in cognitive therapy that will work for many - but of course not for all. They haven't resolved my problems either.

It's all about finding something from what's available that may work for an individual. It's like seeking the "philosophers stone" - e.g. after 40 years PolarBear found it with I think it was Cipralex plus an anti-psychotic risperidone - these drugs took away he said 80% of his intrusions and CBT did the rest. But drugs response and usefulness varies subjectively from person to person.

It's good to see you still looking for that philosophers stone, as indeed am I still. Here's hoping something clicks for readers of this post from these two tools , and ultimately for us.

Meanwhile its hug time from me. :hug:

Edited by taurean
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My lovely therapist asked me to use the technique and wanted me to go down the route of picturing the evidence for theory A and B as in a court scene.

I said I don't need to do that because I actually know all the thoughts are OCD. So I can simplify the approach by basically telling myself the things I am reacting to are plants from OCD which it has obtained from a trigger, and then is telling me I am or could be involved - personalising the story.

Since I know I wasn't and wouldn't want to , then I've gone as far as I can go with that behavioural experiment stuff- but the OCD keeps hitting me with it in repetitive thoughts which don't get stopped by knowing and proving its OCD.

Also it's making negative unwanted free associations to pin the distress to a place or thing. The therapist is thrown by that and the general guidance from the forum worthies is to seek not to respond so undermining the negative neural pathways the OCD is trying to set up.

Edited by taurean
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when I faced exposure (and not the top in my hierarchy) for months I would have chosen to die than continue with it.

What is it exactly that you experience that would make you want to die?

It seems that in the past you have had better periods (from memory) like when you did Nurse training or when you felt able to have the children. Can you identify anything that was particularly different at this time in your life?

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My lovely therapist asked me to use the technique and wanted me to go down the route of picturing the evidence for theory A and B as in a court scene.

I said I don't need to do that because I actually know all the thoughts are OCD. So I can simplify the approach by basically telling myself the things I am reacting to are plants from OCD which it has obtained from a trigger, and then is telling me I am or could be involved - personalising the story.

That all makes sense to me, Roy.

What is it exactly that you experience that would make you want to die?

It seems that in the past you have had better periods (from memory) like when you did Nurse training or when you felt able to have the children. Can you identify anything that was particularly different at this time in your life?

Caramoole, it was a long time ago when I was nursing (veterinary and then human) and my OCD was at its best at the time, although I did overly check etc. But if my OCD had remained like that I would never have sought help or even accepted a diagnosis of OCD.

When my children arrived it returned with a vengeance and has not let up since. In fact, I was very ill when I got married and told my husband I wasn't fit to have children. He didn't appreciate how ill I was as my obsessions were less obvious (not contamination again until after my son was born - I say 'again' because I had a contamination fear as a child). My nursing career had already ended, before my marriage, as I had a persistent ear infection and was forced to leave.

As to what I am actually experiencing that makes me want to die is hard to describe. There is absolutely no concern of harm, that I am sure of. It's simply that I feel an overwhelming sense of being dirty and that seems unbearable. Writing that down sounds rather ridiculous, but it's truly how I have felt. I recall an occasion when I became 'contaminated' and my husband was very kind for once, and repeated it wouldn't harm me. I told him he didn't understand. I didn't for one moment think it could, but told him I wished it would - just to end the fear.

This is very different from the childhood obsession I overcame, which revolved around a terror of germs, illness and ultimately death.

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The ERP is a wonderful tool in many ways but you and I are ones where it hasn't been a real success story.Here is why in my case.

It sounds like it should really work well for contamination but look at all the people in the forum and Ashley - even for him who has done well and keeps his exposures up to date, he is still a sufferer.

For those where the OCD is very specifically focused, it seems it can work very well for some but still not for others.One guy recently successfully reported controllong his homosexiual OCD using ERP. Legend used it successfully.

In my case, when I first drew up - using a workbook - my hierarchy for ERP I had 4 obsessions in the hierarchy - the top one being filtering out words and book and film titles then mind-reading their meaning then personalising me into them then repetitive thought looping on them.

The news didn't feature specifically on the list, it was contained within the second trigger of violent themes and personalisation from e.g. media, posters, adverts.Stopping interracting and going to looping thoughts was also a key goal for these triggers.

The fourth item was dumbing down negative associations and labelling things and places.

Working throguh graded exposures for these triggers was only of some value when I wasn't in a very low place - had no fight at all - and when looping repetitive thoughts were not kicking in. It did not make any difference if these were in place because the lack of resilience allowed the thought loops to kick in and the ERP failed.

I would say the news and the negative asslociations are now the top two triggers.

I get by when not in an episode of low resilience quite well for a while - can be a few months - using essentially controlled exposures blanking and discard techniques. I also use a technique I call "living in daytime compartments" - I leave be the isles in the supermarket with all the violent computer games and DVDs - that "compartment" is of no value to me. And for adverts posters and whatever, I look to blank and refocus away or turn the page in a newspaper.

Edited by taurean
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The positive we take from this is we all actively encourage others to seek help using CBT and ERP and meds where of value, and we still keep looking for that elusive philosphers stone for ourselves. But we do point out they don't work for all.

From my view, for very long periods I can be in a really good place, then relapse and don't really know why - obviously there is a trigger but then there is every day when you look at my trigger hierarchy.

My doctor and the therapists and pyschiatrists think the meds will help - well at the moment there has been no change in symptoms on that either - albeit trying only the one drug.

Edited by taurean
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behaviour therapy has no effect any more.

I'm not sure how to take that statement. I'm not sure how proper exposure therapy could result in no effect. Exposures properly done will cause an effect (a negative one at the outset). If no effect is realized, either the therapy is being done wrong or there is no problem anymore.

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Why isn't ERP working for you? You should be getting some kind of result from it.

I think sometimes (as Eric has described in the past) exposure is undertaken and simply endured but other behaviours (possibly not identified) remain in place therefore the treatment is ineffective and simply becomes an exercise in experiencing heightened anxiety.

It's something that's seen on the forum a lot where people undergo therapy but continue to use compulsions as a way of dealing with things, hence limited or no progress :(

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Bear that is a little altruistic.

I don't dispute that in many ways and in general you are right but I think I explained my position on ERP quite well. And it isn't as simple as that.

But I do really admire the way you keep a focus on the crux of the matter.

Edited by taurean
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I know I'm going to be the stick in the mud on this one. I'd like to hear from Tricia and Daisy as to why they think the behavioral side of CBT didn't work for them. I cannot fathom ERP having 'no effect' on someone with severe OCD. At the very least there should be a good sized rise in anxiety because of the exposure.

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I'd like to hear from Tricia and Daisy as to why they think the behavioral side of CBT didn't work for them
I don't dispute that in many ways and in general you are right but I think I explained my position on ERP quite well. And it isn't as simple as that

What about Roys problems with ERP Bear? Any suggestions as to what might be going on there?

I think this is quite an interesting/important thread by way of thrashing out and trying to identify what mistakes (if any) were going on. Especially as these are 3 very long-standing sufferers who've suffered for decades often without effective support. I know in my own experience there are lots of behaviours/compulsions that I wasn't remotely aware of and still find that identifying them is like taking an onion apart layer by layer

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That's sort of the way I look at it. It's one thing to outright say ERP doesn't work but it's another to delve into it and figure out why it didn't work. I think there can be quite a few reasons why someone found ERP lacking. I also think it's important to figure out what was going on and try to rectify it.

Roy said:

It did not make any difference if these were in place because the lack of resilience allowed the thought loops to kick in and the ERP failed.

What the above tells me is that Roy was unable/unwilling to stop the compulsions and that's why ERP failed. At least in this instance we have a reason as to why and something to work on in the future.

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I think my theme is just too wide and the jump from being triggered inol a constantly-whirring constantly-repetitive "thought loop" means anxiety remains high and habituation and easing off of the power of the intrusion doesn't happen.

I am at terms with that and the controlled exposure seems to work well out of episode and when I have sufficient mental strength to deal with it.

Edited by taurean
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What the above tells me is that Roy was unable/unwilling to stop the compulsions and that's why ERP failed.

In that it was too uncomfortable and frightening??

I hope this thread evolves to be one where we can peel through those onion layers with no-one taking anything too personally but that we can all see it as an investigation of problem areas, common mistakes, useful suggestions and personal experiences :)

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I think my theme is just too wide

That's one area I don't quite agree with you on Roy. It can seem too wide in one jump but there are often ways around this....it's about working out a way. We have to think of ourselves as pioneers.

For what it's worth I had the same theme myself years back.

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Roy was unable to stop the thought loop compulsion is the real cause.I truly believe that if a med could ease that lock in the brain that causes this very specific repetitve sticking then progress with overt ERP would be more likely.

Thought loops harve often started up when I have been under scrutiny from peers on a course. For a few courses I have had for example a word or a phrase absolutely totally constantly running in my head and just would not stop however involved was what I was doing.

When I explained this to colleagues they were incredulous J could function at all let alone complete the course.

Many holidays have similarly been spoilt by these loops. Even taking a Rubick's cube on one failed to heal the brainlock and ease the compulsion neural urges maintaining the loop.

Edited by taurean
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Hello PolarBear,

I have no idea why CBT and ERP hasn't given me any relief.

Obviously i myself must be doing something wrong, and the Doctors and Therapists who i have seen in the past must of been telling me to do the wrong things.

I am pleased for you that you eventually found relief.

I would just like to add that i have tried numerous SSRI's and unfortunately have so far not been able to tolerate the side effects from them,i am having another go at them to see if i can now.

I am not going to say anymore on this as i don't want anyone reading this to be put off trying,because as i said CBT and ERP does work for a lot of people.

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