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Is there too much emphasis on the behavioural side of CBT?


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Hi Everyone,

I was just wondering whether any other forum-users have experienced CBT where there has been more of an emphasis on Exposure and Response Prevention (ERP) and less emphasis on managing the underlying cognitive biases that lead to the compulsions?

At the moment I am just having talking therapy sessions with a Counselling Psychologist but in the past my CBT therapists have been focused on ERP and the only thought challenging involved identifying (but not really learning how to manage) patterns of thinking such as 'All or nothing thinking' and 'Catastrophizing'; which I did not find helpful! 

 

Edited by BelAnna
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It should be a mix but a big part of CBT is challenging your mind through ERP.

The root of all problems with OCD are compulsions. Compulsions are a behavior. Thus the emphasis on changing behavior.

Edited by PolarBear
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I am in support of erp as I believe in learning by doing.

I understood at an intellectual level the irrationality of my behaviour. But only by changing my behaviour did I really or deeply learn. So at heart I believed in behaviouralist led therapy. But preparing the groundwork by cognitive insights.

ERP is learning by doing. How do you challenge a thought? By testing it. So if you feel the need to check all the plugs before you leave your property you need not to test them. The cognitive groundwork should prepare you to take this risk.

I catastrophise a lot. I am aware of this cognitive bias. But you need to put the thoughts into context. By putting them in context you defeat OCD. So if you catastrophise about plugs and sockets you do not repeatedly check them. Nothing happens, you learn a lesson. If you catastrophise about a running tap causing a flood. You do not check. Nothing happens, you learn a lesson. Step by step you learn lessons not to catastrophise. Learning is incremental and cumulative. You learn by practical experiments -by cumulative learning - not to catastrophise. This is deep seated learning which lasts.

If CBT does not involve behavioural experiments then it is by definition not CBT.

Edited by Angst
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The CT side of CBT is important in the sense of developing new therapeutic responses to intrusive thoughts. 

It's also important to teach patients in the beginning how the disorder works:

"cognitive therapy for OCD (CT) has two primary applications: 1) to help people understand the guidelines of an anxiety disorder's overall game plan (i.e. mental mechanisms); and 2) to provide specific suggestions in the face of challenge."  

In contrast though, CT when it involves trying to point out the irrational nature of your intrusive thoughts during a spike is detrimental for long term recovery. 

 I believe the  Behavioural Therapy side of CBT is most important in the sense that you need to teach yourself via exposure and feeling discomfort that nothing bad will happen. It's one thing to be taught what to do, but you can only recover unless you put that education into practice. 

 

 

 

Edited by Ashley
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As has been said, both are important, a cognitive foundation is essential in tackling OCD, but ERP is important because you might have a thorough cognitive insight into the disorder - as is often the case -  and still be no less beholden to that pull.  

I see that Carooba has posted a link to Dr Steven Phillipson's site. I have a high regard for him, though perhaps some here share less of the same.

Incidentally, in terms of the cognitive, some might find his essay 'Choice' worth a look.  

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11 hours ago, BelAnna said:

I was just wondering whether any other forum-users have experienced CBT where there has been more of an emphasis on Exposure and Response Prevention (ERP) and less emphasis on managing the underlying cognitive biases that lead to the compulsions? 

At the moment I am just having talking therapy sessions with a Counselling Psychologist but in the past my CBT therapists have been focused on ERP and the only thought challenging involved identifying (but not really learning how to manage) patterns of thinking such as 'All or nothing thinking' and 'Catastrophizing'; which I did not find helpful! 

 

I absolutely do agree with this BelAnna.  I had IAPT therapy at the tail end of last year and despite me telling them I know what I need to do (behavioural challenges) but the feelings and thoughts around the feelings were all getting muddled up and that I 'wanted' to spend a little time focussing on the cognitive aspect, they insisted I needed to get on with the behavioural. Of course when I asked them to help me do the behavioural they had no real answer.  Which was why I wanted to spend some time on the cognitive to see if that helped initiate the behavioural.

I am now waiting to see someone at CADAT who will hopefully help me with both the C and B. :)

 

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9 hours ago, PolarBear said:

The root of all problems with OCD are compulsions. Compulsions are a behavior. Thus the emphasis on changing behavior.

Not sure I agree with that PolarBear. Surely, if that was the case it would be just called compulsive disorder.  Think about it, I don't just jump in the   :lush: Before that point, something, a thought, a fear, a feeling or for some an image is what prompts me to need that bath/shower (or other compulsion).

So whilst you're right that a significant part of treatment should be on changing our behaviours, if it's done by ignoring the thoughts and feelings that drove us to those compulsions then there is a significant chance that the person will relapse later. 

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Guest OCDhavenobrain

Well everyone is free to not cutting off compulsions and instead undergo another form of therapy. 

I just see it as another trick from OCD. 

Edited by OCDhavenobrain
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Guest OCDhavenobrain

She wrote she is having talking therapy. 

Stop the compulsions. 

Edited by OCDhavenobrain
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1 hour ago, Ashley said:

 

I absolutely do agree with this BelAnna.  I had IAPT therapy at the tail end of last year and despite me telling them I know what I need to do (behavioural challenges) but the feelings and thoughts around the feelings were all getting muddled up and that I 'wanted' to spend a little time focussing on the cognitive aspect, they insisted I needed to get on with the behavioural. Of course when I asked them to help me do the behavioural they had no real answer.  Which was why I wanted to spend some time on the cognitive to see if that helped initiate the behavioural.

I am now waiting to see someone at CADAT who will hopefully help me with both the C and B. :)

 

I had wonderful treatment at CADAT with two therapists for OCD and hoarding. My local Clinical Commissioning Group is blocking me from a brief return there because of ageism. About 18 months ago I had top up with a clinical psychologist who worked with the older persons’ team. First of all I was screened for dementia by a nurse and then saw a clinical psychologist for four sessions. She simply asked me to remember what I learnt at CADAT. She lacked basic knowledge of hoarding such as the idea of churning. I was granted a long period at CADAT by a supporting letter from a consultant psychiatrist because hoarding tends to be quite intractable and requires deep cognitive and behavioural work. What I am saying is that the quality of therapy varies. 

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Having had several lots of one to one CBT and group CBT, I have to say that no two lots were the same! Therapists seem to have different interpretations of what OCD is and how it effects the sufferer, and the therapist also appear to set out their own ratio of CBT to ERP.

The best I found at a proper clinic was about 1-7 hourly sessions covering CBT, and sessions 8-12 of actively doing ERP, with a kind of de brief with CBT after each hour of ERP. This was over the course of 12 weeks, and included homework each week.

Edited by felix4
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Just now, felix4 said:

Having had several lots of one to one CBT and group CBT, I have to say that no two lots were the same! Therapists seem to have different interpretations of what OCD is and how it effects the sufferer, and the therapist also appear to set out their own ratio of CBT to ERP.

The best I found at a proper clinic was about 1-7 hourly sessions covering CBT, and 8-12 sessions of actively doing ERP, with a kind of de brief with CBT after each hour of ERP. This was over the course of 12 weeks, and included homework each week.

Was that Clara's Sussex clinic?

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4 minutes ago, Angst said:

What I am saying is that the quality of therapy varies. 

Absolutely, even within some teams (one therapist knows more than another).  A look at the national recovery rates for OCD highlight this too, although I tend to take that data with a pinch of salt.

One of my biggest jobs on the helpline is spending more and more time having to encourage people to give CBT another chance (after multiple failures). 

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2 hours ago, Ashley said:

 

I absolutely do agree with this BelAnna.  I had IAPT therapy at the tail end of last year and despite me telling them I know what I need to do (behavioural challenges) but the feelings and thoughts around the feelings were all getting muddled up and that I 'wanted' to spend a little time focussing on the cognitive aspect, they insisted I needed to get on with the behavioural. Of course when I asked them to help me do the behavioural they had no real answer.  Which was why I wanted to spend some time on the cognitive to see if that helped initiate the behavioural.

I am now waiting to see someone at CADAT who will hopefully help me with both the C and B. :)

 

Hi Ashley, 

Thanks, that's exactly what I've found too and I've had quite a lot of CBT over the years! The therapy at the ADRU seemed somewhat more ERP focused than 'C' focused but then that might have just been my therapist. 

I was just wondering whether you have spoken to Paul Salkovskis about this at all or whether it has come up at the OCDuk conferences? 

:) 

Thank you everyone for the replies; that is true that ERP exercises can impact on the cognitive side of things but I do think that the 'cognitive' side of CBT is very important; Behavioural therapy by itself has been around for decades and has not produced the same results as CBT. 

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1 minute ago, BelAnna said:

I was just wondering whether you have spoken to Paul Salkovskis about this at all or whether it has come up at the OCDuk conferences? 

:) 

Yes and to Adam Radomsky too who both told me they tend to go with CBT over just ERP)... and yes to conference, it's on my draft agenda to discuss more at this years conference actually. :)

 

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7 minutes ago, Ashley said:

Yes and to Adam Radomsky too who both told me they tend to go with CBT over just ERP)... and yes to conference, it's on my draft agenda to discuss more at this years conference actually. :)

 

Ah amazing; thanks Ashley! Hopefully if it's brought up at the conference it might filter down so that CBT therapists realize that it is an important aspect of CBT! 

 

1 hour ago, OCDhavenobrain said:

She wrote she is having talking therapy. 

Stop the compulsions. 

Surely if it was that easy no-one would have OCD? I am having Eye Movement De-sensitization and talking therapy- they've both been quite helpful to be honest- at times more helpful in terms of facilitating my own ERP than has my previous CBT! 

Edited by BelAnna
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I absolutely agree that you need cognitive therapy as well as behavioral. I certainly went through it and it opened my eyes when I saw my cognitive distortions, how I generally perceived the world.

That said, a number of people have raised this issue about too much emphasis on ERP. I think some of that comes from a fear of doing ERP. It is scary. But it has to be done. You can have all the cognitive therapy in the world, but at some point you will have to face your fears. Slowly, building up. 

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17 minutes ago, PolarBear said:

That said, a number of people have raised this issue about too much emphasis on ERP. I think some of that comes from a fear of doing ERP. It is scary. But it has to be done. You can have all the cognitive therapy in the world, but at some point you will have to face your fears. Slowly, building up. 

 

I don't think anybody did suggest OCD treatment was just about cognitive therapy.  I don't want to put words into BelaAnna's mount (or forum typing fingers) but the point was that here in the UK the NHS do NOT recommend behavioural therapy on its own (or ERP) or cognitive for that.  It recommends up to 10 hours of CBT (with ERP). But all too frequently I am seeing people present to therapists (mainly IAPT) who are told that overcoming OCD is about writing a few worry diaries and facing your fears.

Simply stating facing your fears to overcome OCD is not how we treat OCD and should not be the focus of therapy.

As Dr Bream wrote, CBT makes use of two evidence-based behaviour techniques, Cognitive Therapy (C) that looks at how we think, and Behaviour Therapy (B) which looks at how this affects what we do.  In treatment we consider other ways of thinking (C), and how this would affect the way we behave (B)…. 

It's all linked. So it's not unreasonable for a patient to expect to be offered the full recommended treatment of both parts, C and B if that's what they want, in fact they shouldn't even have to push for it.  The NICE guidelines are pretty clear that we recommend CBT.

Doing one without the other is only half the job.  In my opinion, based of years of anecdotal evidence on here and the phone lines by only doing the behavioural we're most likely leaving ourselves open to relapsing or OCD shape shifting.

 

  

 

 

 

 

 

 

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My view is that the cognitive side is very, very important but it can be easy (at least in my experience) to use it as a way of procrastinating on doing exposure. Although I have not recovered, I have beaten several themes and with all of them the cognitive changes came after the behavioural changes, not before. I think it can be easy to fall into the trap of wanting that light bulb moment before moving onto exposure. Sometimes you just need to start even if you're not quite sure. 

Edited by gingerbreadgirl
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12 hours ago, gingerbreadgirl said:

Cbt is not "another form of therapy" - it is the recommended treatment for ocd. 

Absolutely, but with the caveat that it's specifically for OCD.

'Talk' therapy for say, low self esteem, 'think positively' etc. Is very different, and I think if applied to OCD can actually be harmful, since it tends to search for meaning. That said, therapists, with a little, or textbook knowledge ...  reaching immediately for ERP is probably more ubiquitous than it should be. 

Edited by paradoxer
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13 hours ago, OCDhavenobrain said:

Well everyone is free to not cutting off compulsions and instead undergo another form of therapy. 

I just see it as another trick from OCD. 

 

13 hours ago, gingerbreadgirl said:

Cbt is not "another form of therapy" - it is the recommended treatment for ocd. 

 

56 minutes ago, paradoxer said:

Absolutely, but with the caveat that it's specifically for OCD.

'Talk' therapy for say, low self esteem, 'think positively' etc. Is very different, and I think if applied to OCD can actually be harmful, since it tends to search for meaning. That said, therapists, with a little, or textbook knowledge ...  reaching immediately for ERP is probably more ubiquitous than it should be. 

 

Maybe I have misread this, but my interpretation is that OCDhavenobrain was also saying that CBT is the recommended treatment, but people are tricked by OCD into talking therapy, as in counselling instead.

And with regards to CBT being specifically for OCD, I get what your saying, but it is also used on a whole number of other conditions too.

 

In addition to depression or anxiety disorders, CBT can also help people with:

obsessive compulsive disorder (OCD) 

panic disorder

post-traumatic stress disorder (PTSD)

phobias

eating disorders – such as anorexia and bulimia

sleep problems – such as insomnia

problems related to alcohol misuse

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3 hours ago, felix4 said:

 

 

 

Maybe I have misread this, but my interpretation is that OCDhavenobrain was also saying that CBT is the recommended treatment, but people are tricked by OCD into talking therapy, as in counselling instead.

And with regards to CBT being specifically for OCD, I get what your saying, but it is also used on a whole number of other conditions too.

 

In addition to depression or anxiety disorders, CBT can also help people with:

obsessive compulsive disorder (OCD) 

panic disorder

post-traumatic stress disorder (PTSD)

phobias

eating disorders – such as anorexia and bulimia

sleep problems – such as insomnia

problems related to alcohol misuse

No disagreement, CBT is certainly used for many conditions, but the focus of CBT for OCD should be tailored for the disorder.  

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