Cornerstone of cognitive therapy.

[PolarBear]

No, no. It's good to talk about daisy. Rather than off-putting, it's an opportunity for people to see that there's a way forward.

Could you explain what you did for ERP and maybe a basic synopsis of what obsessions you were working on at the time? Up to you.

[Guest PaulM]

A bit late to the discussion but I am happy to see the cognitive part of CBT being explored. For me anyway it's a critical part of CBT.

The behaviour part of CBT (using ERP) was not very helpful without the cognitive bit.

CBT is far more involved than just keep doing something until it doesn't bother you anymore. Different aspects of it will work better for some than for others, and maybe that's where the focus on behaviour for some of us has broken down.

It did for me. In fact, for a long time I was reluctant to try CBT again and considered ERP rather barbaric. But, getting help from some exceptional doctors to use all of the tools CBT offers and structuring ERP in a really controlled and extremely gradual process seemed to help me greatly.

If I get flooded, I'm going to worry more. That's a given. In fact, if past experience is any indication I am liable to go backward not forward. This has resulted in some seriously negative impact in my life. But if it's a small step - seemingly insignificant to an outsider - that allows me to maintain the mindset that this exposure is helping me get better, then I'm more likely to see some success.

Edited February 1, 2015 by PaulM

[Guest Tricia]

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.

I should have added the words 'on me' to that sentence about exposure therapy no longer having any effect. I also should have gone into more detail (although I did in another message). I meant positive effect. Yes, there was a negative one, and not just at the outset. I am no wimp and would have stuck with it, if it had only raised my level of fear for a few days. When you still feel terrible after months, and are contemplating suicide, you know it's time to stop. That was my psychologist's view, anyway.

Those who experience great relief with medication are certainly at an advantage. There is no way in the world I'd be standing here (I cannot sit down) dressed in my underwear with my teeth chattering, bitterly cold for the 25th winter, if my level of fear would subside. This is killing me and yet the fear is greater than the cold, the pain and the misery... Every bone aches with the cold.

I am pretty desperate and have not written this to moan, but to hear from anyone with advice. PB, if you think you may know where I am going wrong please tell me.

Edited February 1, 2015 by Tricia

[Guest Tricia]

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

Caramoole, a psychologist at the Maudsley felt I must still be relying on compulsions, during therapy, but truly I wasn't.

Due to the nature of my obsession, the only overt compulsions that could have worked were for me to carry on washing myself and my possessions. I did not do either. Any covert compulsions would have been useless, as I don't worry about harm (and I certainly wasn't neutralizing and pretending it hadn't happened). I was also told I might be using distraction (odd really when some say to do that!) but I wasn't at that time. (I've tried that approach since) I lived with the fear and waited for it to subside. Which it never did. OK, my heart may have stopped racing, but the mental feelings were even worse after three months than they had been at the three hour point.

Edited February 1, 2015 by Tricia

[Hal]

There is no way in the world I'd be standing here (I cannot sit down) dressed in my underwear with my teeth chattering, bitterly cold for the 25th winter, if my level of fear would subside. This is killing me and yet the fear is greater than the cold, the pain and the misery... Every bone aches with the cold.

Can I ask you something Tricia......how were you able to cope with visiting your mum while she was in hospital?

Are you able to override the fears around wearing clothing sometimes? I hope you don't mind me asking, I'm just trying to get a clearer picture of what you're experiencing.

[PolarBear]

I am no wimp and would have stuck with it, if it had only raised my level of fear for a few days. When you still feel terrible after months, and are contemplating suicide, you know it's time to stop.

Are you saying you would do an exposure, finish it and the anxiety stuck around for months? Or are you saying you continued to do the same exposure for months and you were highly anxious the whole time?

[ailo]

This is a really interesting thread!

i tryed an exposure once who made me really ill- i know they were starting to rough, top on my list the first day and i just got a few times. maybe two- they got home to me the first time- second were at phone. i didnt see them in person after that terrible exposure day, i just was told to write an sms how things were doing, i had to write a contract on have to not do conåulsions or i was going to do it again. i think that contract really frightens me, and i got ocd on not breaking my contract. so i pushed myself maybe to much. when i got treatment i had my own appartment, and had a car, was social and was indepentent. after that i sold my appartment, i sold my car. im not driving- i cant touch any of my belongings who were therte. its even exposure telling you this.

so-- im scared trying erp again. if they are as bad as the oce before. i actually has ocd on those people too. to go to the area they might have walked, or to get treatment to a place they might been with meetings. i really felt they ruined my chase to get better and made me many many times worse. (i had of course ocd before that too)

i think cognetive therapy would be good on me. i am in waiting list too ocd treatment and erp, but now i really feel im progressing. i m motivated and work well on my own even if i go throgh a nightmare- i really hope erp wouldnt ruin it. i dont know if im ready or if its right for me.

i could use some coach though. cause i feel this is going to be tough.

tricia- i wonder as well how ocd can make us want to freeze and be without cloaths. i would rather go hungry and in my underware then have anxiety. still try to work on it

[Guest Tricia]

Can I ask you something Tricia......how were you able to cope with visiting your mum while she was in hospital?

Are you able to override the fears around wearing clothing sometimes? I hope you don't mind me asking, I'm just trying to get a clearer picture of what you're experiencing.

Hal, of course I don't mind you asking. I am grateful to you, and if you or anyone can offer suggestions I will seriously consider them as I can't go on like this every winter.

I knew my mum was going to die and had to go to her. Obviously, I also had to wear clothes. I am crying now as I recall what she said to a nurse, "I have no one to wash my clothes". She knew I would be terrified of them, but I couldn't let her down and managed even to pick up her nightdress that a nurse had thrown on the floor (I am so afraid of anything that's touched the ground).

I took her laundry to her bungalow to wash and noticed the front and back lawns were long. I couldn't bear to leave them like that (my mum was such a neat person) and I cut them several times over the weeks (with shears as it would spread contamination less than a mower - took me hours!!). When my mum was still at home I rarely visited (there was that one occasion in 2013) because her neighbour has several cats that use her garden (and even concrete paths) as their toilet. So cutting the grass was very frightening for me. Several times I had to clean up after the cats, also foxes and dogs. It seemed as though I was really being tested!

I stood up at every hospital visit (I'm so afraid of chairs, even in my own home) and, after my mum's death, at the funeral home and register office, but managed to sit in the chapel at her funeral.

The fear of wearing clothes (or facing the outside world) never lessens. When I do wear clothes, I then wash them outside before I can bring them indoors and place them in the washing machine.

[Guest Tricia]

Are you saying you would do an exposure, finish it and the anxiety stuck around for months? Or are you saying you continued to do the same exposure for months and you were highly anxious the whole time?

Actually both, PB.

When I was in therapy, I left my therapist's office, returned home and kept my outer clothes on for the first time in years (usually I remove them in the garden and wash down with the garden hose (problematic in winter when frozen) before heading straight for the bathroom to have a long shower).

He had asked me to make a cup of tea (without even washing my hands) and to take it into the living room and sit down on the sofa (I had not sat down on the sofa for years). I even kept my shoes on!!! This was all so alien to me and yet it made perfect sense, and I was as convinced as he that by the end of the day the fear would have reduced somewhat. I placed contaminated objects on my bed (the cleanest area of the house in my mind) and went weeks waiting to see an improvement. I just became worse. My psychologist called a halt to it when I was still prepared to persevere. (My husband tells me I was on the verge of a total breakdown) I did keep the contaminated stuff on my bed for about two years and didn't have a good night's sleep in all that time. Only when I removed them and washed all the bedclothes did I eventually begin to relax and sleep well.

[Guest Tricia]

Ailo, maybe we did both take on too much, but it makes us very wary of repeating the experience doesn't it. It's why, like you, I am looking again at the cognitive side of things, but I truly am stuck with that right now.

Also, I feel as frightened by any object now and there is no hierarchy as such for me.

tricia- i wonder as well how ocd can make us want to freeze and be without cloaths. i would rather go hungry and in my underware then have anxiety. still try to work on it

Yes, it's quite amazing the lengths some of us will go to to avoid fear. A dear friend of mine broke her arm and refused to have a plaster cast as she said it would feel contaminated. The doctors agreed to some kind of plastic one, but what she failed to tell them was that she intended to remove it every time she returned home in order to scrub that arm. She kept it up for months and the bone took so long to heal. Imagine her pain!

Edited February 2, 2015 by Tricia

[ailo]

Ailo, maybe we did both take on too much, but it makes us very wary of repeating the experience doesn't it. It's why, like you, I am looking again at the cognitive side of things, but I truly am stuck with that right now.

Also, I feel as frightened by any object now and there is no hierarchy as such for me.

Yes, it's quite amazing the lengths some of us will go to to avoid fear. A dear friend of mine broke her arm and refused to have a plaster cast as she said it would feel contaminated. The doctors agreed to some kind of plastic one, but what she failed to tell them was that she intended to remove it every time she returned home in order to scrub that arm. She kept it up for months and the bone took so long to heal. Imagine her pain!

Yes, it makes me very frighten to repeat erp. I really would like advices on that. I feel i do progress some now, and really dont want to fall down again. I think i will try as polarbear said, to make a list. But as you write, its difficult to have a hierarchy, cause everything feels unsafe, still i think something might be a litle easier then others..

I really feel for your friend. How painful that must be!! i would be so worried. but i actually think i can understand her. cause i do so much weird and harming things myself. It feels better to be clean and cold without jacket, then to weare a conteminated jacket,

I were at the hospital the other day and i had alot of stuff with me/ in my arms. i couldnt put it down inside the hospital, cause then it would be conteminated. it was so exhausting, and i really felt it in my arm..

I am on the waiting list on erp. But im really not sure what i want to do. i feel pressured to try it again. i dont want people to think i dont want to get better.

but if i can progress some myself now, it would be great.

Im in a new apparment now. i dont have my boyfriend here. Its tough, but i think i can get more focus on working at my ocd. Maybe im no optemistic that i will try and work myself, but im terrified of what happened with erp. atleast i can take it slowly now, and feel im in control.

[ailo]

Btw, Im so sad to read that you have to wash your cloaths outside, before going into the house. even in the winter. I really feel sorry you have to do that, It sounds exhausting and cold, and i get why you might not go out too much. But i hope you will be able to stop this compulsion some day.

[taurean]

This discussion proves how totally devastating and how seriously difficult to overcome some of the forms of contamination OCD can be.

The concept of clothing being contaminated in the outside and therefore must be cleaned to come back in is a horrific concept I can see how massively problemmatic that is.

OCD seeks to restrict us in these ways. In my case at the moment if is always seeking to make links to distress and label things with distress.

In this way it is seeking to cramp my movements and what I do.

Unwanted neural pathways can be readily formed but are difficult to stop following so I need to keep doing what I want to do and resist those unwanted negative intrusions so as not to give them power to trace in new pathways.

Re contamination if you follow OCD guys blog he is also trapped (jn 2 rooms) in his home.

[PolarBear]

Actually both, PB.

When I was in therapy, I left my therapist's office, returned home and kept my outer clothes on for the first time in years (usually I remove them in the garden and wash down with the garden hose (problematic in winter when frozen) before heading straight for the bathroom to have a long shower).

He had asked me to make a cup of tea (without even washing my hands) and to take it into the living room and sit down on the sofa (I had not sat down on the sofa for years). I even kept my shoes on!!! This was all so alien to me and yet it made perfect sense, and I was as convinced as he that by the end of the day the fear would have reduced somewhat. I placed contaminated objects on my bed (the cleanest area of the house in my mind) and went weeks waiting to see an improvement. I just became worse. My psychologist called a halt to it when I was still prepared to persevere. (My husband tells me I was on the verge of a total breakdown) I did keep the contaminated stuff on my bed for about two years and didn't have a good night's sleep in all that time. Only when I removed them and washed all the bedclothes did I eventually begin to relax and sleep well.

My feeling after reading this is that it was too much. You have extreme OCD, no doubt, and overcoming it is going to be a case of baby steps, not big strides into the unknown. As soon as I read what you wrote I said, no way, that's too much to take on all at once. It's no wonder you've had such a terrible time of it.

You can't overcome what your mind is telling you is right in big, leaping steps. You've got to do it slower. Some people are able to handle taking fairly big steps all at once but for others it's got to be slower and more methodical, with rest periods (with no exposures) in between for the person to recuperate.

In your example above, having a cup of tea without washing your hands should have been the entire exposure. That's it. No sitting on the sofa, no leaving your shoes on. Just getting you to have a cup of tea without washing your hands would have been a big enough exposure. And it had an end -- once the cup of tea was done, the exposure would have been over.

[PolarBear]

More to the above, you talk about having 'contaminated' items on your bed for two years. That's not a proper exposure. An exposure should have an end to it and it should last all of a couple of hours. What would have been better would be to touch your bed with a contaminated object for something like 30 seconds or a minute, then stop. Repeat that every day for as long as it takes for your anxiety level to barely get a rise from doing it. Then expand the time period to like 5 minutes and see how that goes. Baby steps. Not big leaps.

[Guest Tricia]

I have also tried the baby steps approach, a year or so prior to contaminating everything.

Dr David Veale says that when contamination fears are severe we really need constant exposure. Edna Foa agrees with this. Even though both suggest beginning with something of a moderate level of fear, they suggest spreading it all around our homes. PB, it sounds as though you disagree with them.

The problem with me now with baby steps, is that even placing an envelope (this is what I left on my bed for two years - one that had arrived in the post) on my bed for a short time would cause me to panic.You said to do it so that I barely get a rise in anxiety, but I can think of no exposure that would be at that low level for me.

There was an excellent documentary on OCD a few years ago on the BBC. A young American lady had a fear of contamination and letters and packages in the mail were a big concern for her. The therapist asked her to drag an envelope across her sofa and you could see the terror in the poor woman's eyes. However, within an hour all her fear had gone. PB, I truly have tried all these kinds of approaches and no matter how long (or short) a time I expose myself, or my things, to a contaminant the fear never reduces.

As I have said previously, when I had a terror of germs I decided it was no way to live and faced everything I feared (also stopped all my compulsions). I was amazed how quickly my obsession faded (I'd been very ill for several years at that time and even struggled to eat). It's not as though I am new to any of this. I just don't know what is different this time around and neither does any specialist I have seen.

Edited February 3, 2015 by Tricia

[Guest Tricia]

Yes, it makes me very frighten to repeat erp. I really would like advices on that. I feel i do progress some now, and really dont want to fall down again. I think i will try as polarbear said, to make a list. But as you write, its difficult to have a hierarchy, cause everything feels unsafe, still i think something might be a litle easier then others..

I really feel for your friend. How painful that must be!! i would be so worried. but i actually think i can understand her. cause i do so much weird and harming things myself. It feels better to be clean and cold without jacket, then to weare a conteminated jacket,

I were at the hospital the other day and i had alot of stuff with me/ in my arms. i couldnt put it down inside the hospital, cause then it would be conteminated. it was so exhausting, and i really felt it in my arm..

I am on the waiting list on erp. But im really not sure what i want to do. i feel pressured to try it again. i dont want people to think i dont want to get better.

but if i can progress some myself now, it would be great.

Im in a new apparment now. i dont have my boyfriend here. Its tough, but i think i can get more focus on working at my ocd. Maybe im no optemistic that i will try and work myself, but im terrified of what happened with erp. atleast i can take it slowly now, and feel im in control.

Ailo, your struggling with a lot of stuff that was heavy, but you still couldn't put it down, reminded me of my one trip abroad. A bag which was very heavy had become contaminated, but I still felt the pavement was more contaminated. I walked two miles with my arm outstretched keeping the bag high above the path but also well away from me. I swapped arms but even so suffered terrible pain in them and they ached for days afterwards!

You've gone through so much recently and obviously all that stress hasn't helped you. I think you're amazing to have coped and I sincerely hope you manage to find some relief soon. It's certainly worth seeing a therapist when you get to the top of the waiting list. Some are obviously much better than others, but you can't (and shouldn't) be forced to face things that overwhelm you.

[ailo]

Thank you Tricia! I feel exhausted now. I try so sleep and eat and relax, but my body really can tell that this is very much to handle both inside and outside.

I identify with carrying things (like once a plastic bag/s with all the thing i had with me on the beach) i couldnt let it touch me, so i held it in a very odd position, and my arm really hurt. so silly!! hehe!

I do not think the people who done my last erp was good. i really strugglewd after that. But im not giving it up, just very critical, and think i should be. im still on waiting list. i just are so frightened to be really ill again. i hope i get time to take it in small steps and not face to much at once. when i get into theraphy, i would like to get some advices from here as well.

I try to work with my ocd now, before getting therapy, as well. I think i had some progress, but i feel exhausted and i dont hope it cracks.. im kind of forced to do alot of things i find difficult now . i just have to do my best, and hope i have more strenght..

[PolarBear]

You said to do it so that I barely get a rise in anxiety, but I can think of no exposure that would be at that low level for me.

No. You expose yourself and it's expected your anxiety will rise significantly. You practice not performing any compulsions during the exposure. Then the exposure ends. Then you do it over and over again until you barely get a rise out of your anxiety. That's the typical ERP exposure.

[Guest Tricia]

Sorry, PB, I misread that sentence.

What I don't seem to make myself clear over, is that touching a contaminated item briefly is as bad as living with it constantly. If I place an envelope on my bed, for example, it wouldn't matter if I removed it within two seconds or left it there two months,. My mind is saying the contamination is there. The 'damage' is done in the first second.

However, every book I have on OCD seems to feel that constant exposure is best.

David Veale says: "Remember, you can never do too much exposure. More complex and severe OCD may require almost constant exposure."

Edna Foa says, "Remember, the longer you stay in uninterrupted contact with the contaminant, the faster your worry will be diminished."

Edna Foa goes on to tell us to spread the contaminant all over our houses, chairs, plates, bed sheets, pillows etc. She also insists we do not touch water for three days and only then to shower briefly - and we are then instructed to reapply the contaminant to ourselves. We are told never to wash after using the toilet, while in therapy.

I can only assume you are saying these two experts are completely wrong and that their programmes are not proper therapy?

Anyway, the point for me is that baby steps don't work either. Which is why I am desperately trying to work out if I am missing something with the cognitive component of therapy.

[Guest Tricia]

I hope you are coping, Ailo.

Please bear in mind that we are all different and even the one individual can react differently to therapy at different times in their lives.

I have a friend who cannot cope with full on therapy for her contamination fear, and she is now an inpatient receiving more help. I have asked her to pass on any tips about cognitive therapy.

[PolarBear]

No, I'm not saying they're completely wrong. The graded exposure system was what I was taught and seemed to work quite well for the people in my ERP group. To tell you the truth, I can see the constant exposure scenario working for some people. The one fly in the ointment is the individual's ability to put up with the anxiety created. I think that is one problem that isn't talked about very much. Some people have a very low tolerance for anxiety.

[Caramoole]

Tricia.....do your compulsions free you from anxiety?

Why doesn't your underwear become contaminated/contaminate?

[PolarBear]

I think it's important to note that exposure therapy is not just about exposing oneself to that which they fear. It's also about practicing not performing compulsions. That's a key piece of the puzzle. Compulsions need to be identified and resisted during exposures.

[ailo]

Could it be that we are doing conpulsions without being aware of it? And could that prevent erp from having full effect? (for example, if we ruminate)