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Joewest439

CBT or ERP, or both?

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Hi everyone,

I've been doing some research on CBT, and am still a little confused. Is ERP a part of CBT, or a separate approach?

I understand the concept of ERP, and think it would suit my specific situation.

As for the CBT model in general (notably ABC), I'm not sure it'll help me, as it feels a bit like over thinking in itself, and perhaps defies the point of the concept of not responding (ERP).

Are CBT and ERP separate from each other? And more importantly, is it necessary to do both? Can ERP be utilised alone?

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I am not that knowledgeable but I have had some treatment with ERP, but not full CBT. I am better and it has helped me but I am now being referred for CBT because the cognitive stuff is inportant as well. I feel for me, i need to do this to make a full recovery 

i think ERP is used as part of CBT but CBT includes the meaning behind the OCD as well.

i am sure someone with more knowledge will explain this more fully.

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So CBT stands for Cognitive Behavioural Therapy. The cognitive part teaches you to think differently. The behavioral part teaches you to behave differently. The primary behavioral therapy is ERP.

If you do ERP only you are missing out on the cognitive side, which most here feel is crucially important.

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CBT is an umbrella term and ERP is one of the methods used with CBT. ERP would fall under the behavioral part of CBT, where you change you behavior and responses to you obsessions. The C is where you change your thinking.

In short:

Cognitive: Changing your thinking
Behavioral: Changing you behavior/response.(ERP)
 

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Been wondering the same thing myself.  Thanks for the info. 

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In cbt. you challenge the believes. And then you after gradually start with one of the ocd rituals by leaving it for minutes and then hours and days. And then start with other rituals and do the same. Thats what I have learnt to do with cbt.

Edited by Razzio

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Thanks for the responses. The thing is for me, it's the cognitive part I struggle to grasp.

What I mean by this is, to change ones belief about why one is having intrusive thoughts, wouldn't that be ultimately classed as an act of reassurance?? I hear that trying to rationalise thoughts or recognise them as OCD are things to be avoided. But perhaps I'm being too strict.

In a nutshell, I find the cognitive approach to be contradictory to the only approach that sometimes works for me, which is to not react at all to the thought.

What are people's thoughts on this notion? Polar bear?

Edited by Joewest439

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Joe, our resident expert on the cognitive side is snowbear. Perhaps she'll weigh in here.

Basically, the cognitive side is about thinking differently. Yes, you have to stop your compulsions and yes, it's a good idea to do ERP, but why are you doing those things? The cognitive side teaches you that, that OCD lies, that although OCD is telling you something is dangerous, it's really not. The cognitive side includes learning about OCD, having a good understanding of it, knowing what compulsions and obsessions are and how to recognize your own. It's about learning that you don't have to accept what OCD is dishing out and you don't have to react to the thoughts the way you normally do (with compulsions).

It is most definitely not about reassurance.

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Best speaking to somebody with the full knowlege of cbt. and how it will help you like others have said.

 

Edited by Razzio

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I'm laughing at PB saying 'resident expert on the cognitive side'. :laugh:   I have a fascination for people's thinking processes rather than any formal expertise. Just so you know!  

I can't explain it any better than Polar Bear did - the cognitive side is about thinking differently. It's learning that you always have a choice on how to think and that there are many ways to interpret a thought. When we can see only one answer it's because we've got stuck in a rut and developed a habit of thinking in one particular way about everything.

3 hours ago, Joewest439 said:

In a nutshell, I find the cognitive approach to be contradictory to the only approach that sometimes works for me, which is to not react at all to the thought.

What's interesting about your comment, Joe, is your solution of 'not reacting' is a cognitive strategy, even though you may not be aware that's what it is. :) 

Consciously or unconsciously you changed your interpretation of the thought from 'significant and scary' to 'it means nothing'. As a result you're able to ignore it (and the urge to react to it.)

If we interpret a thought as meaning something significant, then it has to be addressed with action. Significant thoughts are significant for a reason and for as long as we believe the reason is valid they're almost impossible to ignore. Which is a good thing - if you think 'my hand is burning' you need to be motivated to take your hand out of the flame that's burning it. So your brain will go on saying 'ouch' until you take action. 

Where the problems start is when we mistakenly believe our reasons are valid, but they aren't. They're just habit. (You convince yourself there's a fire burning your hand without bothering to find out if there is or not and pull away when there's no danger.)

Thinking habits arise when a particular interpretation solved a problem we faced in the past. Rather than work out the 'right' answer from scratch each time we have a new thought we just apply the same logic we used before and immediately - effortlessly - come up with a 'satisfactory' answer which we expect to be correct. We expect it to work to the extent we can convince ourselves we reasoned this new problem out from scratch, applied logic, and came up with the only possible answer.  

The cognitive side of therapy is about shaking yourself out of the thinking rut that convinces you this easy and familiar answer is the only answer possible. If you like it's a reminder of how you used to think as a child - with an open and questioning mind that accepts there are an infinite number of possible answers from which to choose instead of a habit-based, judgemental mind that can imagine only one interpretation.

In cognitive therapy you learn to question the reasons for thinking what you think and examine your criteria for judging things as either significant or unimportant. You challenge beliefs that have developed out of habit rather than true logic or reasoning.

So when you learned that 'not reacting' works, what you actually learned was to change your old habit of treating the thoughts as significant on auto-pilot. You accepted the alternative answer that the thoughts are unimportant.

Compulsions are actions taken to relieve the anxiety which results from deciding a frightening or unpleasant thought is significant. Decide it means nothing and you no longer feel the urge to perform that kind of compulsive action. It becomes easy (or easier) to ignore. :) 

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Love the term "resident expert" PolarBear - I think you are our resident expert re stopping compulsive behaviour. 

But I will add my twopennyworth, as one who has had lots of CBT from skilled private clinical psychologists and been around these forums regularly for 5 years nearly. 

The cognitive side shows us why we think and feel how we do in OCD, and why our intrusions are in fact irrational irrelevant nonsense. How the OCD functions in the same underlying way whatever the theme or way it is expressed. How it targets an irrational core belief using a fear threat or revulsion.

This little piece I wrote a while back gave more clarity to many here - it's a very simple basic overview of the cognitive side of CBT  

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Thank you all for your responses. I think we may all be resident experts by now in some ways lol.

It seems to me that the cognitive side is based being educated on how OCD operates.

It's interesting about Snowbears observation that my not reacting to the thoughts is me regarding it as 'it means nothing'. For me, I'm not sure I feel that way. When I let the thoughts be, at no point do I do so because of any consideration that they are meaningless. I still believe they could well hold merit, signify danger, and so on. But I let them be anyway. 

Whenever I go down the route of rationalising what is happening, doubt creeps in on however I try to do so.

Perhaps it's the mere act of not responding to the thoughts that defines my interpretation of them? Rather than any logical 'answer' I may use when the thoughts arise?

This is how I struggle, I find it difficult to distinguish between permissable healthy cognitive interpretations, and self reassurance. Know what I mean?

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On 01/04/2017 at 14:49, Joewest439 said:

Perhaps it's the mere act of not responding to the thoughts that defines my interpretation of them? 

:yes: 

If you refer to the 'CBT cycle' you'll see that thoughts and feelings influence behaviours which in turn influence feelings and thoughts. You can intervene in the cycle at any point, so having doubts and acting as if they weren't there also gives you a new interpretation on the thoughts.

Harder to go that behavioural route than the cognitive route in my opinion, but everybody is different and what works best for one person may not be the best approach for the next person. Do what works for you.

'Feel the fear and ignore it anyway' is a permissible healthy cognitive interpretation (as you so beautifully phrased it.) :) 

I used the phrase 'it means nothing' because you used it in your original explanation. But it's not what exact interpretation you put on the thoughts (they mean nothing, I feel danger but must learn to ignore it...) it's simply about changing the interpretation to a better one.

For example,  (I don't know your specific OCD worry or theme so I'm picking a common one at random...)

...say the thought was  'I'm a pedophile'. The next step is they process that thought and come up with an interpretation.

If the person is confident in the sort of person they are the thought holds no fear for them. They'll quite likely not even register having thought it and therefore not even go through further processing, but if it does get processed the interpretation is 'Don't be daft, of course I'm not! Silly thought!' :laugh:  And they'll ignore it as if it never happened.

If the person fears being a pedophile, or fears being thought one by others, or fears they may be falsely accused of being one...then the brain latches onto the thought like lightning and won't let go of it. It gets processed rapidly and intensely and the interpretation is 'Danger! Immediate action required!' 

You can learn to simply ignore these false danger flags (the behavioural approach you're doing) or you can take the cognitive approach and retrain the brain to understand there is no actual danger (you won't act our of character, doesn't matter what others think because you know the truth, and pointless fretting over things that haven't happened and aren't likely to happen.) 

Or you can combine the two approaches (cognitive and behavioural) and change the troublesome 'danger' interpretation to a healthier one twice as fast! :a1_cheesygrin: 

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It's an interesting point about OCD latching onto things one fears. I feel it would be useful for me to give a brief explanation of one of my obsessions.

I have suffered with huge problems with core beliefs about my character, mainly due to unacceptable things I did as a child, during a period of great trauma.

This resurfaced a few months ago and I actually started to do those things again, as an adult. I do believe the very reason for this was because I was so anxious that I would do so, as hard that may be to understand. Almost like an obsession I would turn into that person again, resulting in a compulsive violent outburst, as a result. Ie 'I mustn't do that' = Does it.

Shortly after this, in a completely different situation one day, I experienced what I would normally have considered to be just another intrusive thought, but due to the recent self doubt I described above, I just couldn't let it go.

I think this is a prime example of what you explained regarding OCD latching onto fears.

Of course, I cannot be sure that I am blameless, that it's purely OCD, that I don't have another mental health problem.

My point is, how does one go about the cognitive side of things, when their obsessions are based on core beliefs about themselves that apparently could well be true?

What would be the cognitive approach, when the obsession has apparent actual evidence about one's self doubt?

I don't mean to use this site as therapy, but it is the only place where people seem to understand the condition properly.

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You're probably convincing yourself that your core belief is true due to instances from your past but your perception of what is true may have no validity.

We see people here with a core belief of, I am a bad person. They have evidence of such because they did some questionable things when they were younger. Yet there are lots of people out there who did or do questionable things who consider themselves good people. What's the difference? Perception. That is something that can change.

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That is true. I think I got over the instances of the past because I gradually accepted that I was a child who was going through hell. That has always been my excuse for the behaviour.

But regarding the more recent resurgence of the behaviour a few months ago, I can't apply the same excuse for it. It's thrown the core belief of having a nasty nature right back into the mix.

As I mentioned, I believe the resurgence was due to an overwhelming fear that I would become that person again. Overwhelmingly strong fear that I would do something violent, then the influence of this fear would result in me actually becoming violent, even though I didn't want to. Almost felt like a physical version of Tourettes. And the fact that it's not an occurrence that seems to relate to OCD makes it even more alarming.

I'm struggling to get a foothold in the cognitive side of things with this, I'm just not sure how to actually change my perception into a positive one, without delving into the impossibility that is looking for certainty, you know?

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You can't have certainty and the search for it is fraught with danger. 

No doubt you are ruminating over this core belief, going over these supposed negative examples in your head, analyzing them and trying to figure out what they mean. That's a compulsion and it needs to stop.

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6 hours ago, Joewest439 said:

Of course, I cannot be sure that I am blameless, that it's purely OCD, that I don't have another mental health problem.

The cognitive aspect here is you need to accept you don't have to be blameless. You're allowed to have some nasty things in your nature and it doesn't mean you have a mental illness if you do. 

Telling yourself 'under no circumstances must I become a bad person' :ohmy: sets up the requirement of constant, extreme vigilance to ensure your character never, ever slips off the perfect pedestal you imagine it's on. That's the ideal breeding ground for OCD thoughts and loss of self-confidence, constantly feeling inadequate as a human being, always trying to live up to some idealistic (unrealistic) standard.

On the other hand, if you tell yourself 'I'm not blameless, I've made mistakes and I'll make more. That's ok, it's allowed' :) then your OCD sentinel can stand down and stop pestering you with fears of slipping from perfection. 

Of course people with OCD hearing this immediately respond with 'But I don't WANT to be a bad person!' sending them straight back into the loop of intrusive thoughts that they need to be forever blameless.

It's important to realise this is a faulty interpretation of what was said. Accepting 'it's allowed' does NOT mean you will become a bad person, or that you are one, or even that you condone badness. 

'It's allowed' means you realise you aren't perfect and accept you don't have to be (same as everybody else.)

And, very importantly, that you forgive yourself for past mistakes and are willing to forgive yourself if you make another mistake.

A hurdle many people with OCD trip over is believing that any slip from perfection in their character is unforgivable (hence the all-consuming obsessive desire to avoid a slip.) This unwillingness to forgive their own mistakes is surprisingly often seen as by the person as a strength, yet it's actually a huge character flaw!

We correct that flaw by learning to forgive ourselves as easily as we forgive others, to allow for a few personal imperfections. In other words to be normal and not expect yourself to be superhuman, not to judge yourself more harshly than you judge others (which is in effect an egotistical belief you're better than everyone else.)

Another hurdle  - people with OCD often see character flaws as something permanent and therefore unacceptable. (And I've just suggested that holding yourself to a higher standard than you expect of other people is a flaw! :ohmy: )  But this interpretation that anything bad is permanent is an example of 'black and white thinking'. 

Thinking processes, like character flaws, can be changed. When we learn to accept ourselves as we are, faults and all, it frees us to strive to be better, to become in reality the 'good' person we mistakenly believed our OCD precautions made us. Now that's worth changing your thinking for, yes? :) 

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Definitely. This is an avenue of thinking that I have explored many times, that I have these flaws, maybe even scary flaws. But I know I'm above average overall in terms of who I am and in my conduct in life.

I keep feeling: 'Well, if I truly do accept that I may have these questionable attributes, then why do these obsessions about what I've done still cling to me?' It makes me wonder if I really do accept it at all.

I don't know how I can accept these potential shortcomings any more than I already have done, but it doesn't seem to quell the anxiety they cause me.

On the other hand, I'm not even that sure I care (or ever really did care) about potential dark parts of me in the first place. It's confusing.

In summary, I find it difficult to tell wether core beliefs about myself are what still bothers me, or wether it's purely an OCD obsession, which I am just so damn used to hanging over me.

I suppose both scenarios would require the same treatment?

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wow, this topic is a great read, I can't wait to do it :a1_cheesygrin: but some other time, when I'll be able to better understand the concepts (as I know must go to sleep)

I was wondering, what would be a list of fundamental fears.. I would be really interested in that

as for what you ask, Joe, I would say:

accept that you might have this shortcomings. but if you do that in order for your obsessions about what you've done to go away, it won't work

you have to also accept the intrusive thoughts about what you've done, and not engage in them (by ruminating)

also, don't judge your thoughts: you accepted your beliefs and now you wait to see if the obsessions disappear but then again if they disn't you judge that they had to disappear, so you judge your acceptance of the shortcomings and so forth.. it's just not worth the energy, as we have so much control about the thoughts that pop into our head that we have over to clouds in the sky.

 

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