When CBT fails

[Captain Trips]

I want to know people's opinions on the possible failures of CBT. 

I watched a YouTube video that suggested stopping compulsions alone does not lead to an eventual decrease in anxiety, rather the root cause of the anxiety must be addressed.

So how do you go about this and how do I apply it to my problem?

I have suffered with OCD in varying degrees of seriousness and various forms for over 20 years. I am getting ready to engage in a third program of therapy. Previous attempts have failed probably due to past events and behaviours (alcohol and drug addiction, bereavement, relationship issues). Now 5 years sober, I am probably worse than ever. Social life non existent. Not working. Incapacitated.

At present my OCD consumes around 8 hours a day. I am 36 on Yale Brown scale. Over the years I have had multiple forms including checking doors, contamination, toilet routines, checking I did things correctly at work etc. In recent years I have been struggling with the following type of things:

*What was I thinking 5 minutes ago I've forgotten? (Followed by 1-2 hours rumination for each lost thought timed with a stop watch) This is fed by a compulsion of writing down hundreds of my thoughts each day so i dont forget them.

*What was I saying in my conversation to that person earlier? (Followed by asking for reassurance/time ruminating to stop watch).

*Did my family member see me in the toilet earlier even though I closed and locked the door? (Followed by asking them). 

So I've been experimenting with sitting with the anxiety again recently and trying to resist carrying out behaviours in response to thoughts. Whilst I know that if I do nothing, an individual anxiety spike about a thought WILL fade and does, what consistently happens is another takes its place with just as much anxiety. This goes on and on for weeks on end: ignore, repeat, ignore, repeat etc which leads me back to my original question; should you and how do you tackle the anxiety before the behaviour? 

If I'm doing something obviously wrong I'd like to know. Will CBT work for everyone. How long does habituation actually take. I know there are no clear answers even from the professionals...

 

 

Edited April 17, 2020 by Captain Trips

[Handy]

I believe CBT doesn’t do the why of OCD. It’s a bit like pulling leaves off a weed rather then pulling out the weed. So it grows back. Ali Greymond on YouTube does why we have it. 

[snowbear]

4 hours ago, Captain Trips said:

I watched a YouTube video that suggested stopping compulsions alone does not lead to an eventual decrease in anxiety, rather the root cause of the anxiety must be addressed.

Depends what you mean by this whether it's true or completely wrong.

You DON'T need to know the 'why' behind your anxiety. Analytical therapies (like psychoanalysis) are detrimental rather than helpful. 

But the YouTube person is right - stopping compulsions alone is just the 'B' part of CBT. The most common reason for therapy to fail is sole emphasis on behavioural exposure exercises and not enough attention to the cognitive part - the 'C' of CBT. In my opinion the cognitive side is more important and more effective. 

4 hours ago, Captain Trips said:

Will CBT work for everyone.

Correctly done with a good therapist and fully engaged in by the sufferer - YES!  

4 hours ago, Captain Trips said:

How long does habituation actually take.

It's not habituation that you're aiming for. (That's what you get if you just do exposure without cognitive change.) Some people never habituate, no matter how much exposure they do because they haven't addressed the faulty thinking patterns which keep their OCD going. 

Make sure this 3rd round of therapy is Cbt and not just exposure exercises under therapist guidance.

[Captain Trips]

10 hours ago, snowbear said:

It's not habituation that you're aiming for. (That's what you get if you just do exposure without cognitive change.) Some people never habituate, no matter how much exposure they do because they haven't addressed the faulty thinking patterns which keep their OCD going. 

Thanks snowbear. I've been wondering why exposure sometimes doesn't work for a long time. So how does one go about addressing the faulty thinking patterns? 

[malina]

I think that if you focus only on reducing the compulsions, you're just targeting the behavioural part of CBT, but you need to work on the cognitive part as well.

[PolarBear]

The cognitive part of CBT teaches you to change the way you look at your intrusive thoughts. All sufferers take their thoughts seriously, as if they're fact and domething that must be dealt with immediately. That leads to compulsions. You can cut off the vompulsions but if you still take the thoughts seriously, you're going to still have high anxiety.

[snowbear]

On 18/04/2020 at 13:04, Captain Trips said:

how does one go about addressing the faulty thinking patterns? 

Polar Bear nailed it ...

46 minutes ago, PolarBear said:

All sufferers take their thoughts seriously, as if they're fact and domething that must be dealt with immediately. That leads to compulsions. You can cut off the vompulsions but if you still take the thoughts seriously, you're going to still have high anxiety.

The cognitive part of therapy teaches you to think about your thoughts differently so you realise they weren't the 'Truth' you once believed they were. 

It's beyond the scope of the forum to teach you this in detail as we're not qualified therapists, but if you have specific thoughts you're struggling with we'll try to guide you on other ways of interpreting them. 

[Handy]

Brain lock says CBT has a 50% success rate. DBT May be better. But he didn’t mention it. Probably because BL is like 22 years old. 

[dksea]

3 hours ago, Handy said:

Brain lock says CBT has a 50% success rate. DBT May be better. But he didn’t mention it. Probably because BL is like 22 years old.

1. Nowhere in Brainlock does it say CBT has a 50% success rate.
2. The first edition of Brain Lock was written in 1996, but the latest edition was published in 2016 and updated accordingly.

Meanwhile therapy is not medication (though both can be helpful in treating OCD).  With a drug, if you take it, it either works or it doesn't.  We can measure this.  Therapy is different.  You have to be an active participant who is willing and able to take on the necessary work AND you have to be given the correct therapy by someone who is capable.  There are many reasons why therapy might not be working, not because the therapy itself is wrong, but because of other things such as a patient not doing the work, a therapist not delivering it properly, etc.  Yes we can look at studies to determine whether or not one therapy seems to be more effective than another, but on an individual level the details matter. 

Meanwhile throwing out random, incorrect, percentages does not help.

[bookworm30]

I did a 2 year DBT programme when I was diagnosed with borderline personality disorder in my early 20s (long story short, I do not have BPD,  but the label got thrown in my face due to being young, female and engaging in certain behaviours - I don't believe in PD diagnosis, and subsequently because of this diagnosis my OCD was dismissed until 18 months ago).

In terms of DBT, I suppose parts of it might be helpful for managing intrusive thoughts & obsessions and the anxiety that all of this brings, especially since it teaches mindfulness.

DBT a whole won't help OCD because it's aimed at reducing self-harming behaviours, learning to manage suicidal crisis and learning how to regulate emotions & interpersonal skills.

I've just started CBT for OCD, and I'm feeling pretty good about it. I think that mindfulness should be part of OCD treatment as well as exposure and reducing behaviours, though. I've been making sure I practice mindfulness religiously over the last few weeks. The thing with anxious thoughts is you cannot get rid of them, and you need to learn to just let them be. Trying to get rid of them just increases the distress, as does (so I'm learning) the compulsive behaviours.

For years I wanted to know the 'why' for my anxiety, but I tried counselling and it just made me turn to alcohol. The why is not as important as learning to live with it all. 

[Captain Trips]

On 19/04/2020 at 23:46, snowbear said:

Polar Bear nailed it ...

The cognitive part of therapy teaches you to think about your thoughts differently so you realise they weren't the 'Truth' you once believed they were. 

It's beyond the scope of the forum to teach you this in detail as we're not qualified therapists, but if you have specific thoughts you're struggling with we'll try to guide you on other ways of interpreting them. 

Thankyou all for your replies.

Having read these forums extensively, I think some of you could quite easily measure up to be therapists!

So how do I cognitively attack this:

The thoughts that set me off are things like:

"What did person A say to me just a minute ago/yesterday?.. or why did that person say that?" 

Then follows a massive anxiety spike with the doubt and uncertainty associated with not being able to remember. 

Compulsion:

I have to ask that person and then sit and focus all my energy on trying to remember against a timer (usually one or two hours, always ending on the hour as opposed to half past the hour or quarter past etc).

It does not matter whether that person remembers or not when I ask for reassurance, I still have to do the timer thing to reinforce the idea that I've done everything I can do to remember.

Further compulsions:

I have to make endless notes in my phone of thoughts and conversations that I somehow believe to be important to remember for lster in my phone so I do not forget them. Sometimes it gets so bad I get stuck in loops of writing down my thoughts as they pop into my mind. It's all consuming and completely incapacitating.

I however realise that:

A) Recall of memories on cue is rarely if not never possible (total recall)

B) For some reason I attach importance to certain memories and hoard them 

C) It doesn't matter whether I forget things as nothing bad happens other than anxiety

D) The things that really ARE important I am unlikely to forget. 

Up to now I have tried not responding to the thoughts and sitting with the anxiety, I can usually manage one or two days, but as one item fades, another replaces it and so on.....

[snowbear]

5 hours ago, Captain Trips said:

I however realise that:

A) Recall of memories on cue is rarely if not never possible (total recall)

B) For some reason I attach importance to certain memories and hoard them 

C) It doesn't matter whether I forget things as nothing bad happens other than anxiety

D) The things that really ARE important I am unlikely to forget. 

Up to now I have tried not responding to the thoughts and sitting with the anxiety, I can usually manage one or two days, but as one item fades, another replaces it and so on.....

All true. Memories are never recalled exactly as they happened at the time, but are influenced by the mood you're in when you recal them, hindsight changing how you interpret them and more. Not to mention the more times you go over details the more you cement some details while blanking others out - then your brain fills in the blanks at the next recall with whatever seems appropriate at the time and not neceassarily what the original was. Fascinating how memory works, yes?  

I think point B is where you need to focus on: 

Quote

For some reason I attach importance to certain memories and hoard them 

The importance you give to it is why it is remembered, but also why new items from your memory keep cropping up to replace fading worries.

A key part of cognitive therapy is learning how the meaning we give our thoughts influences our mental, physical and emotional response. We can then look at how alternative meanings changes the response we experience and choose a more suitable interpretation (importance) that results in a healthier outcome.

5 hours ago, Captain Trips said:

The thoughts that set me off are things like:

"What did person A say to me just a minute ago/yesterday?.. or why did that person say that?" 

Then follows a massive anxiety spike with the doubt and uncertainty associated with not being able to remember. 

Ask yourself what would happen if you forgot. Whatever importance you're placing on forgetting is what is keeping you in this loop of anxiety and new worries replacing old ones. 

For example 'If I forgot to do something I'd promised to do when we spoke it would mean...'  Chances are the meaning is rooted in catastrophic thinking, black and white thinking, your sense of self worth or how you wish to be seen by others. In reality people won't 'hate you forever' for forgetting something, nor will it make you 'a bad person' or be 'totally unforgivable'. Yet these are typical responses people give when asked what the outcome of the thing they fear would be. 

Some useful mantras are 'Whatever happens, I'll handle it' and 'Nothing is so important I can't sort it out later.'

In other words developing your self-confidence that forgetting or missing some detail isn't the huge disaster you currently seem to think it is. Having accepted that remembering every detail of every conversation doesn't carry the 'life or death' meaning you once gave it, you then resist the compulsions and live with the possibility you might have missed something (knowing 'I'll be ok' and 'It can be sorted'.) 

Doing compulsions tells your brain the original meaning ('It's important don't forget!') has validity. Stopping them tells your brain 'It's ok to let this go and not keep it in my memory'.

 

[Captain Trips]

Hey Snowbear, thanks for your reply.

Can I just say, I think this forum is great. My psychiatrist actually told me to check it out as I can't start CBT again until lockdown is over. I'm also just changing my meds around to a better combination as I don't have work stresses or other stresses at the moment so there's space to deal with that change. I am gearing up for when I can finally go back to therapy, this time as sober person (5 years and counting). 

@snowbearmade a good point saying it's fascinating how the memory works. This is how everything I've read says you should view it. For example, instead of observing the failures and successes of memory with curiousity and fascination as I should be doing, I am catastrophising and despairing at how irritating it's failures are. 

I don't know why I place so much importance on remembering things (or rereading this maybe I do now). I do it with my possessions too. I can't handle it when I have lost something. Like a book I remember I used to have but now I don't know where it is or an item of clothing or a memento of some kind. I can be overly sentimental about inanimate objects. I understand that by definition if I could remember where that something is it wouldn't be 'lost' but clearly the items I care about losing are the ones with an emotional background attached. One of my earliest obsessions going back 20 years ago was around the time I left home, my Dad gave me the coat he was wearing when he met my Mum and I lost it when moving house. I literally spent a year worrying about that and going to ridiculous lengths trying to recover it. I exhausted every avenue of inquiry trying to be certain of its fate which eventually became one of the many things instrumental to me developing OCD. Clearly there were many emotions attached to that object and from that situation going forth, my OCD thrived on any item I attached some emotion to. Fast forward 20 years and it's still ruining my life. I want to say "enough is enough" and "right that's it it's time to beat it" but we all know too well as sufferers how you can get stuck on that square.

54 minutes ago, snowbear said:

For example 'If I forgot to do something I'd promised to do when we spoke it would mean...'  Chances are the meaning is rooted in catastrophic thinking, black and white thinking, your sense of self worth or how you wish to be seen by others. In reality people won't 'hate you forever' for forgetting something, nor will it make you 'a bad person' or be 'totally unforgivable'. Yet these are typical responses people give when asked what the outcome of the thing they fear would be. 

I can see how for some people others opinions of them are a massive issue, but I generally don't care what people think of me these days. If I say something and I forget or if someone says something to me that I forget, selfish as it may be it makes ME emotional, whether that emotion be anxiety, anger, distress  sadness, etc.

Then I end up carrying out the behaviours that my OCD brain tells me will protect me. The same goes for the above description of me losing items. I ruminate, I make notes, I sit and try to remember, I look behind me everywhere I go to check I haven't dropped something or left something behind...

1 hour ago, snowbear said:

Ask yourself what would happen if you forgot.

My last therapist used to repeatedly ask me this and I've listened back to the recordings and I just go silent every time. The answer is nothing. Nothing will happen but anxiety.

1 hour ago, snowbear said:

Some useful mantras are 'Whatever happens, I'll handle it' and 'Nothing is so important I can't sort it out later.'

So so true. The 'I can leave that til later' mantra has worked for me in the past. It's like your tricking your unconscious brain into it thinking you will come back to it later, but in reality you don't and your unconscious forgets and doesn't throw the worry at you again. I find it works better for the minor ones than the major ones though. (I understand that in part of CBT you can grade thoughts into anxiety levels out of 100).

Anyway, long post but feels good to externalise it all for once.

[snowbear]

2 hours ago, Captain Trips said:

I can't handle it when I have lost something.

Somewhere on your journey through life you've picked up 2 false beliefs. 

1) possessions can substitute for the emotional security you normally get from people

2) 'I can't cope with emotional threats'

Attaching a lot of emotional energy to objects is common in people who've learned the second falsehood. It's a form of avoidance - placing value on things (which you can collect, pick up and put down and they stay where you put them) as opposed to people - whose actions and feelings you can't control. 

You've learned to perceive as an emotional threat things that are nothing of the sort. This could be why you struggle to find an answer when asked 'what if you forgot?'

2 hours ago, Captain Trips said:

My last therapist used to repeatedly ask me this and I've listened back to the recordings and I just go silent every time. The answer is nothing. Nothing will happen but anxiety.

That silence is screaming the answer at you loud and clear. What you fear will happen if you forget is you'll feel emotionally insecure, but as you are unaware of this emotional insecurity as you go about your daily life you struggle to name it when asked. 

2 hours ago, Captain Trips said:

If I say something and I forget or if someone says something to me that I forget, selfish as it may be it makes ME emotional, whether that emotion be anxiety, anger, distress  sadness, etc.

It's not selfish to have emotions. It's good to be in touch with your feelings, indeed if you can say 'this makes me angry/sad/anxious' that's useful to know.

Anger is the normal response to things not going how you want them to be, so when something makes you angry you can either get lost in rage, or take your anger response as a sign to step back calmly, accept the situation and look at how to make the best of things.

When something makes you anxious you can tie yourself in knots over it, or treat the emotional response as a signal that you need to look at how you're interpreting things - is xyz really as black and white or catastrophic as you've been telling yourself?

And all the while remember these two great truths of life: 'Whatever happens I'll cope' and 'Nothing is so bad/important that it can't be sorted.'

Whatever caused the emotional insecurity you suffer is long since buried in your past and now unimportant. But as an adult you can learn to generate emotional security for yourself instead of compensating for it's absence with physical objects. That's where I'd concentrate your efforts in cognitive therapy. 

[Captain Trips]

Thanks for another great response snowbear

[Captain Trips]

On 06/05/2020 at 03:06, snowbear said:

Somewhere on your journey through life you've picked up 2 false beliefs. 

1) possessions can substitute for the emotional security you normally get from people

2) 'I can't cope with emotional threats'

Attaching a lot of emotional energy to objects is common in people who've learned the second falsehood. It's a form of avoidance - placing value on things (which you can collect, pick up and put down and they stay where you put them) as opposed to people - whose actions and feelings you can't control. 

You've learned to perceive as an emotional threat things that are nothing of the sort. This could be why you struggle to find an answer when asked 'what if you forgot?'

I was thinking as I was writing my last post that it was the loss of memory of thoughts, conversations or physical items I attach emotional significance to that feeds my OCD, and although it's mainly those things, its also things that have no emotional significance whatsoever. For example, today I woke up and all day ruminated about why I changed two tyres on my car last year. Why didn't I just change the one that was faulty? What happened? Where was I when I got the puncture? 

It gets even more meaningless. Thoughts like: Which bin did I throw that empty box in? What did I do with the receipt for the newspaper I bought? 

I don't attach any emotional importance to those items (well maybe the tyres because they were expensive), but still I have an uncontrollable urge to find out and reconfirm my actions and a huge sense of desire to do so.

I so badly want to be cool about these things and just shrug them off but I can't right now.

Edited May 8, 2020 by Captain Trips

[PolarBear]

You can, with practice. Start realizing that you don't need to know everything. And you need to confirm next to nothing. Stand up to your wayward brain and stop playing its pointless game.