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Cognitive before behavioural


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For some, just one theme continues. 

For others, sadly, the illness is a shape-shifter, switching around from one theme to the other. 

But the cognitive knowledge that it works the same way, whatever the theme, and the same solutions apply, was a real gamechanger for me - and I think would be for others who take this on board. 

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4 hours ago, gingerbreadgirl said:

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. 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 like your fire analogy. :fireman: Very apt.

This is proving a most interesting discussion and it's got me thinking too, GBG. :) 

We all agree (hopefully!) that there is only one type of OCD - the kind that has obsessions and compulsions. Topic/theme  can vary of course, but so can how the 'O' and 'C' manifest. 

Based on how people have described their experiences so far, I'm coming to the conclusion there are 3 main ways OCD manifests which may require different treatment approaches. Which is best for any individual can be decided in partnership with their therapist.

(Note: I'm not saying 'this is how it is'. What follows is only my work-in-progress thoughts on the matter. I welcome all suggestions, additions and opposing opinions. :) ) 

1. The Leap of Faith treatment group: -

People whose OCD manifests mainly as intrusive thoughts, repetitive rumination and covert (mental) compulsions may find the best approach is to 'take the leap of faith' and start with behavioural therapy (to put out the fire as GBG put it.) Then some cognitive therapy to get to the root of the problem (fire control and prevention) and finally some more behavioural experiments to put the newly learned 'fire drill' into practice. (B> C> B)

2. The Feel the Fear and Do it Anyway  treatment group:-

People who have mainly overt compulsions (cleaning, avoidance, checking) may find the best approach is to start with some simple explanations (Polar Bear's definition of what simple cognitive therapy can be is ideal for this.) Then behavioural therapy to 'feel the fear and do it anyway'. If needed this can be followed with more in-depth cognitive therapy (looking at core beliefs and thinking patterns which are obstructing progress) and finally more behavioural therapy. (c> B > C >B) 

3. The Platypus treatment group:-  ( I was going to call it the 'complex dissociated OCD' group, or the 'crazy-mixed-up kids' group, but platypus seemed a more descriptive and likeable alternative. :D ) 

These are people whose original obsession has become hidden over time, or whose compulsions are not obviously (directly) linked to a particular intrusive thought or fear. (eg. mental contamination.) This group needs in-depth cognitive therapy before any kind of behavioural therapy is possible. Attempts at behavioural therapy after only the simple cognitive explanations (Polar Bear's description above) will be counter-productive. So for this group the suggested best approach may be C> b> C> B.

 

There will be exceptions:

-people who don't neatly fit neatly into one category and need an even more individualised treatment plan 

-people who have more than one way their OCD manifests

-people whose treatment plan needs to take into consideration co-existing diagnoses (eg PTSD, primary depression, bipolar disorder)

- people with other conditions which impact their ability to take instruction/process information (eg Autism, BPD) 

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Well done GBG and Snowbear ; that is really interesting. 

And it shows how a therapist just ploughing on with their standard "one size fits all"  approach may not be helping - the illness just doesn't work that way! 

I like Snowbear's grouping idea, with the small and large elements of Cognitive and behavioural. 

And really from the thread we can see that both elements have different degrees of order and importance, according to the grouping. 

There will be other exceptions such as my particular "bete noir" phenomenon, where absolutely continual repeating intrusions inhibit CBT success whilst they remain constant. 

But, wow, what a result we have from the thread - really eye-opening findings :thumbup:

I just love it when, as a collective, we put our thinking caps on and some stunning developments occur :)

 

 

Edited by taurean
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On 21/06/2018 at 23:58, snowbear said:

I like your fire analogy. :fireman: Very apt.

This is proving a most interesting discussion and it's got me thinking too, GBG. :) 

We all agree (hopefully!) that there is only one type of OCD - the kind that has obsessions and compulsions. Topic/theme  can vary of course, but so can how the 'O' and 'C' manifest. 

Based on how people have described their experiences so far, I'm coming to the conclusion there are 3 main ways OCD manifests which may require different treatment approaches. Which is best for any individual can be decided in partnership with their therapist.

(Note: I'm not saying 'this is how it is'. What follows is only my work-in-progress thoughts on the matter. I welcome all suggestions, additions and opposing opinions. :) ) 

1. The Leap of Faith treatment group: -

People whose OCD manifests mainly as intrusive thoughts, repetitive rumination and covert (mental) compulsions may find the best approach is to 'take the leap of faith' and start with behavioural therapy (to put out the fire as GBG put it.) Then some cognitive therapy to get to the root of the problem (fire control and prevention) and finally some more behavioural experiments to put the newly learned 'fire drill' into practice. (B> C> B)

2. The Feel the Fear and Do it Anyway  treatment group:-

People who have mainly overt compulsions (cleaning, avoidance, checking) may find the best approach is to start with some simple explanations (Polar Bear's definition of what simple cognitive therapy can be is ideal for this.) Then behavioural therapy to 'feel the fear and do it anyway'. If needed this can be followed with more in-depth cognitive therapy (looking at core beliefs and thinking patterns which are obstructing progress) and finally more behavioural therapy. (c> B > C >B) 

3. The Platypus treatment group:-  ( I was going to call it the 'complex dissociated OCD' group, or the 'crazy-mixed-up kids' group, but platypus seemed a more descriptive and likeable alternative. :D ) 

These are people whose original obsession has become hidden over time, or whose compulsions are not obviously (directly) linked to a particular intrusive thought or fear. (eg. mental contamination.) This group needs in-depth cognitive therapy before any kind of behavioural therapy is possible. Attempts at behavioural therapy after only the simple cognitive explanations (Polar Bear's description above) will be counter-productive. So for this group the suggested best approach may be C> b> C> B.

 

There will be exceptions:

-people who don't neatly fit neatly into one category and need an even more individualised treatment plan 

-people who have more than one way their OCD manifests

-people whose treatment plan needs to take into consideration co-existing diagnoses (eg PTSD, primary depression, bipolar disorder)

- people with other conditions which impact their ability to take instruction/process information (eg Autism, BPD) 

I have just got round to reading this and I think you've hit so many nails on the head here.  Although OCD is all the same, not every sufferer is the same and different treatment methods work best for different people.  I think it's important for therapists to recognise this, but I suspect many don't - it is human nature to think our way is the best way.  But as this thread shows, people respond better to very different things.  Some need to get stuck in making behavioural changes, and then afterwards make sense of the cognitive side; whereas others need to have a thorough cognitive understanding before addressing behavioural changes.  If something isn't working for you, it might be worth trying the opposite way and seeing if you make any progress that way,

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