Jump to content

Recommended Posts

I know that with CBT the cognitive work comes first, then the behavioural work.  But just to be slightly controversial (because being controversial is fun :D ) - does anybody disagree with this approach?

I have found in the past that I have been totally unable to get my head around the cognitive side until after doing exposure for a period of time.  For example, I had checking OCD for years and years which I've pretty much beaten now, and with that I blasted myself with ERP first, and once I'd done that and my anxiety had reduced, I was able to look more rationally at my underlying core beliefs and so on.  I know if I hadn't addressed the cognitive side, the obsession would have persisted.  But for me it was much more valuable doing so after I'd tackled the behavioural side.  If I try and address the cognitive side first, it ends up being more like rumination.

The same thing has happened with some other obsessions. I've been unable to grapple with the cognitive side until I've first done some behavioural stuff, even if I don't quite understand it all or believe it's OCD.  "Putting the cart before the horse" I've heard it said.

Any thoughts?

Edited by gingerbreadgirl

Share this post


Link to post

To me it doesn't really matter which comes first, so long as both are part of the therapeutic process. Because both components are self-reinforcing. The sufferer will see the reason why the anxiety is reduced and that in turn dispels doubt, while giving confidence, encouraging the sufferer that they are doing the right thing and OCD is wrong all along. If it is to the benefit of the sufferer that exposure should start first, I don't see the reason why the therapist shouldn't do it that way.

Share this post


Link to post

Hi st Mike,

yeah that makes sense and I see that they should be done in conjunction.  I suppose the reason I raise this is that I think almost too much clout can be given to the cognitive angle in many OCD book I've read, it can make you feel like you need to understand every aspect perfectly before moving on, and to me that seems almost compulsive.  I think it can sometimes be used as procrastination (certainly by me :) ) to avoid the scary work of exposure.  I think personally that - provided a basic understanding of OCD is in place - it's better to strike while the iron is hot, and a more nuanced understanding will come together later.

Share this post


Link to post

Yes i disagree with this approach, although I'm not sure who is saying that it should be that way. 

They come together. You look at, how you think and how that affects behaviour, and also how you behave affecting what you think. Ultimately, stopping compulsions is the aim, seeing how useless they are and how they do the opposite of what you want, is as much cognitive work as it is behavioural. Being cognitive allows you to pick up patterns of thinking and behaviour that is best for preventing relapse which i think is why it is promoted above just the behavioural :)

Share this post


Link to post
5 minutes ago, Gemma7 said:

Yes i disagree with this approach, although I'm not sure who is saying that it should be that way.

Well honestly it's the impression I've got (rightly or wrongly) from almost every CBT-based book I've read on OCD.  In fact the only one which really does a good job of cementing the two is Break Free from OCD.  But even there, there is a lot of talk of doing abundant cognitive work first.  Which I am not disagreeing with, just throwing it out there - the times I've had the most success are when I've done the behavioural work first, and thrown myself into it without a solid understanding at all, and then done cognitive work later.

Edited by gingerbreadgirl

Share this post


Link to post
12 minutes ago, gingerbreadgirl said:

Hi st Mike,

yeah that makes sense and I see that they should be done in conjunction.  I suppose the reason I raise this is that I think almost too much clout can be given to the cognitive angle in many OCD book I've read, it can make you feel like you need to understand every aspect perfectly before moving on, and to me that seems almost compulsive.  I think it can sometimes be used as procrastination (certainly by me :) ) to avoid the scary work of exposure.  I think personally that - provided a basic understanding of OCD is in place - it's better to strike while the iron is hot, and a more nuanced understanding will come together later.

True, GBG, there might be certain situations, where it could seem to be an "information overload" to the tired and confused mind of the sufferer and they might get discouraged because of that. It is like a case of "we scare ourselves silly even before we step out of the door." Maybe in such situations, the therapist might take a different approach such as the one you have mentioned to treat the sufferer.

Share this post


Link to post

I completely agree with you. I made the first small progress (following your recommendation how to challenge my checking compulsion, i.e. your way to put the cart before the horse) when starting with ERP. I was so stuck, I definitely did not have "any access to my brain". Only after confronting the fear (which was terrible at first but a little better by now) and realizing that my fear was not real but in my head only, my brain started to relax a little bit. I think now would be the time for the cognitive part but I simply don't understand it. But back to your question, starting with ERP brought the first small success which I would not have been able to achieve starting with the cognitive side. 

Share this post


Link to post

Part of my checking was so habitual that it was not until I desisted from checking that my fears flooded my consciousness. In my case refusing to check that the front door was locked. Of course, I knew that my checking was unusual but the full extent of the obsessional fear became apparent after the behavioural experiment.

Share this post


Link to post

I suspect everyone is a bit different.

I've written at length how the cognitive side helped me. It was pivotal. I used the analogy of dealing with a bully and finally knowing where to hit him. It's part of a bigger picture that I needed to see.

And this is really why it's important to find the right therapist. What is right for me might not be right for anyone else.

Share this post


Link to post

When I was a child and was carrying out some magical thinking rituals, I stopped doing so. 

Why and how? 

Well I just realised mentally that they were pointless, that there wasn't any real reason for doing them. So I stopped. 

Without that cognitive understanding, would I have stopped?  I don't think so. 

Share this post


Link to post

It's really interesting hearing everyone's take on this - and it goes to show we really are all different.

Just to clarify, I am in no way saying we should do away with the cognitive side - it is crucially important and without it we are heading to relapse.

Share this post


Link to post
1 hour ago, St Mike said:

To me it doesn't really matter which comes first, so long as both are part of the therapeutic process.

Yes I agree with this. Doesn't really matter which approach is first, provided both are part of the therapy.  Usually I would say C > B but sometimes we can try that and it doesn't work so we have to do C > B > C > B again to move forward.

Share this post


Link to post
14 minutes ago, Ashley said:

Yes I agree with this. Doesn't really matter which approach is first, provided both are part of the therapy.  Usually I would say C > B but sometimes we can try that and it doesn't work so we have to do C > B > C > B again to move forward.

I can understand this and St Mike's response. 

Because the important thing is that we work through the therapy. 

What works for some doesn't work for others - one of the particularly maddening things about our illness. 

But I think some people really need that cognitive knowledge without moving forward on the behavioural side. And I still think that exposure and response prevention will be much more successful if we have some understanding, first, of why we think and respond the way we do because of the OCD 

 

Share this post


Link to post

Absolutely! I began my recovery by stopping my compulsions, the behavioural definitely came first, then as my anxiety lessened, so did my obsession and so then I was able to see things more rationally. My sons therapy is all about the behavioural side as he was struggling cognitively because of his black and white thinking due to Aspergers, he has come on really loads later 😀! I guess the order doesn’t really matter, so long as we incorporate them all eventually :) x

Share this post


Link to post
4 hours ago, Ashley said:

Doesn't really matter which approach is first, provided both are part of the therapy.  Usually I would say C > B but sometimes we can try that and it doesn't work so we have to do C > B > C > B again to move forward.

I agree. As long as therapy isn't just behavioural exposure without any cognitive work it's up to the individual and their therapist to decide together how they approach it. 

For me I needed cognitive, cognitive, cognitive before I could accept even the smallest behavioural experiment. Attempts at ERP set me back rather than helping me see what was possible. When the cognitive groundwork had been done, small behavioural changes were introduced, then more cognitive work, then try move behavioural changes etc. So ongoing cognitive work to support the behavioural work (which in my case isn't just ERP.) 

In Ashley-speak that's    C -C- C -b - C-C-C- b - C- C-C -B- B- c - B- C-c -B-B.... you get the gist I'm sure! :D 

 

Share this post


Link to post
14 hours ago, snowbear said:

In Ashley-speak that's    C -C- C -b - C-C-C- b - C- C-C -B- B- c - B- C-c -B-B.... you get the gist I'm sure! :D 

Don't be cheeky!!! ;)

But yes, get the gist, and that's key, for each of us our own therapy process will differ, and there's not really any set way to go about this, but what is clear I think we all agree that we do need both C and B, but in which format is down to the individual. If a person is not sure, I would suggest do some cognitive work first, and then see what takes you. 

Share this post


Link to post

Haha! For me it was a C-C-B ratio I think! And then lots of C and B mixed up along the way. But for sure I needed more C than B at the beginning with a knowledgeable therapist because I could think myself into all kinds of ruts and needed someone to throw me a rope every so often.  I couldn't see the wood for the trees. Again, it's not so simple because I'm still not out of the woods. Too many trees!!! 😬

Share this post


Link to post

You're not doing it right, it's meant to be C > C > B :D 

Share this post


Link to post

I'll pipe in.

Gbg, I am betting you did do cognitive work before doing ERP. In fact, I am sure of it.

Did you educate yourself about OCD first? That's part if the big C to me.

Did you understand that compulsions feed the OCD monster? That's C.

Did you gain the knowledge of why you need to stop compulsions? Big C.

Did you understand how ERP works and what the purpose is? C.

If you did all that, then you did do cognitive work. Maybe you didn't get into cognitive distortions and core beliefs, but you gained knowledge that assisted you to change the way you think.

Share this post


Link to post

For me, it's B, B, B first...... behavioural changes that are critical.  It's horses for courses, and of course everyone is different but once I understood OCD in general, how the fears and distortions manifest, I think it can have a negative impact to explore cognitively every aspect of how it manifests.  For me (and it is only a personal opinion), constant evaluation hinders moving forward.  Understand how ODD distorts reality, understand the general principle, utilise the "If it feels like OCD, it generally is" theory and work towards exposure and facing fears.  Until very recently the feeling was that we didn't need to identify cause, and I still lean towards that theory.  Understand what OCD can make us feel a and fear.  Understand the power of doubt.  Understand OCD as a disorder.  Expose yourselves to the things you avoid and fear in the understanding of what/and why you feel afraid.  I believe cognitive work is importantv (especially in the early/uneducated days)......once you do have a good understanding of OCD I fear it can tie you into an endless cycle of having to understand every facet, every doubt.....rather than doing the necessary work of .facing your fears and dealing with fear.

Disclaimer: Very much a personal opinion based on 42 years of experience.  Everyone's situation will differ slightly.  The bottom line  (to me) is ACCEPT you have ODD, once diagnosed.  Accept doubt is a major symptom.  Proceed with exposure "regardless of doubt and fear".  Don't wait to feel  "safe & certain and cognitively reassured"........it will help somewhat but you could wait forever.....start changing behaviour.  Learn to live despite feelings of anxiety.  Recognise sensations that can trigger anxiety.....a hot flush, feeling unwell, feeling hungry (even), tiredness, real life worries, calendar memories, hormonal triggers, media triggers...,the list is endless.  Recognise and accept (without the safety-net of certainty) that given all you've read, all you've been told, etc etc......that this is OCD, an anxiety disorder that throws up doubt, fear, anxuety.........Face your fears......don't wait for absolute clarity, certainty, clarification of "but why?"

our thoughts and fears may seem real, they are scary but we can change them.  Understand the cause (cognitive) but don't wait for the definitive answer, start acting.

 

Share this post


Link to post

Do we need much cognitive knowledge before we can make the behavioural changes? 

I think we need some essential cognitive knowledge. Like me stopping some mental rituals as a child "because I realised they were pointless". 

But with that essential knowledge, I think we can be up and running and making behavioural changes. 

How much do we need to know?  As that child clearly I didn't need much - just the knowledge that the rituals were pointless. But we may also need to understand the falsehoods and exaggerations of minimum threat, the turning of true core character values on their heads in such themes as harm, relationship, sexual preference, but then yes we may be good to go, learning more cognition on our journey. 

People who are stuck may not have the cognitive knowledge, the belief to apply it. 

Share this post


Link to post

I have been thinking about this some more and I think broadly I agree with Caramoole.

I think that a minimum understanding needs to be in place first of all.  The understanding that OCD can make you feel extreme doubt, fear etc. and that compulsions fuel this cycle.

However beyond that I think for me (and this is very much just my opinion, and even that may change over time) that I have done best when I have done behaviour work first.  I think that trying to make cognitive sense of obsessions when in the middle of them is like trying to come up with a fire prevention strategy while the room is on fire. Right now you just have to put out the fire. For me personally, cognitive work has been much more useful after taking that leap of faith and getting a handle on compulsions.

That said, I do think cognitive work is tremendously important - but for me it has been more useful after my brain has cooled off and I can look at the wreckage.  To take this metaphor to the extreme, if you don't develop a fire prevention strategy, the fire will just come back.  I think core beliefs play an incredibly important role in OCD and they are often overlooked in books etc.  I think once you've put the fire out, then is the time to sit down and look at the underpinning core belifs, cognitive distortions and so on.  I am not trying to minimise the incredible importance of the 'C' in CBT - I am working hard at it right now - but for me it is more like B>C>C>C.

Share this post


Link to post
On 15/06/2018 at 01:30, PolarBear said:

I'll pipe in.

Gbg, I am betting you did do cognitive work before doing ERP. In fact, I am sure of it.

Did you educate yourself about OCD first? That's part if the big C to me.

Did you understand that compulsions feed the OCD monster? That's C.

Did you gain the knowledge of why you need to stop compulsions? Big C.

Did you understand how ERP works and what the purpose is? C.

If you did all that, then you did do cognitive work. Maybe you didn't get into cognitive distortions and core beliefs, but you gained knowledge that assisted you to change the way you think.

I think this post is good because it show us what the C can be.

The thing is that most of us here have some (pretty much) knowledge about OCD, i bet that you already knew those things above Ginger. But we have OCD and the OCD will use it against us, we need to learn a little more before we can start. 

But yes some knowledge is good to have before you cut out compulsions.

 

To me the realisation that i tend to fear being destroyed was a big one, but beside that knowledge haven't done much at all for me. The OCD will just change character if you have knowledge, it is like panicattacks, if you don't fear a heartattack the body will tell you that your toes feels strange and that it could be deadly or something else. It will never just walk away because we know things, not even if we know what we are doing wrong.

Edited by OCDhavenobrain

Share this post


Link to post

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

×