What do I do if CBT doesn't work for me?

[Ross Knight]

Hi, my name is Ross and I am new to this forum. I noticed that I had OCD when I was 14 after I started to wash my hands a lot and obsess around the contamination of bodily fluids, I would also change my clothes and wipe my objects a lot as well. About a year later, I began to develop magical thinking and found myself having to repeat and count in multiples of 4. Last year, I went to my doctor and they recommended that I try CBT so I did. When I started I found it quite overwhelming and I struggled to engage in the tasks set and I found it hard to express how I felt and I decided to stop after 8 sessions. In addition to OCD, I also have ASD so this may be why I found CBT difficult. I was wondering what treatments options are left for me if CBT does not work, has anybody else been in a similar situation? It is worth noting I have never tried any other treatments including medication before, I have only ever tried CBT and I am currently 18 years old. Thank you

[Handy]

Intensive psychotherapy has a better success rate it is found. Because CBT treats the symptoms of OCD, not the cause, which is what intense psychotherapy treats. 
 

Of course, one can also go cold turkey if they have the courage. 
 

Ketamine has been proven effective in USA as a medication & it’s very quick, 2 hours, not 8 weeks like for SSRIs.

[Ross Knight]

@HandyThank you for your response, I will give these treatments a look , have you tried these treatments yourself or know anybody who has if you do not mind me asking? 

[L.M.]

Hi @Ross Knight! And welcome to the forum

I wouldn't give up on CBT working for you after that short time with it. Maybe you will need to explore with a CBT therapist the reasons why it didn't work (maybe it was working up too fast, maybe you need to gain more trust with the therapist etc) It isn't an easy therapy to engage with since we are asked to work with so much that we are fearing, but if it's done properly it can ease our way into it in a manageable way. Once we have some small successes with smaller triggers, we start to gain confidence in the way it works and it helps us to keep up with it.

For me it helped a lot to read a good OCD CBT self help book. I ended up doing most of the work on my own using that book, but even if you are to go to a therapist I would recommend at least reading through one to really gain a thorough understanding of the method.

But, yes, if after that you still find it to hard to engage with CBT, there are also medications that can help. I am on an SSRI and do find that helped me to engage with CBT. 

 

[Ross Knight]

Hi @L.M., thank you for your response and help. I have actually considering doing self help CBT and was considering whether that would be better for me and it is definitely an option to try. I found that after my eight sessions I could apply a small percentage of it and shrugg off some thoughts but they seem to have come back in the past week. But self help certainly would be an option I shall look into, I think I found CBT with a therapist very structured and too much for me so think it would better at my own pace and speed. Thank you again for your reply. 

[Ross Knight]

@L.M.How do you find your recovery is going with CBT and your current SSRI?

[Angst]

Hi Ross

I think that you are right in mentioning your ASD -though I am no expert-as a reason why you found therapy difficult. Self help therapy in these circumstances might be a solution. But another therapist with greater knowledge of ASD might be another option. The problem is finding one. Generally, it is a matter of pop luck whether you see therapist who you have rapport with. I have found this with clinical psychologists as well as psychiatrists. So another go at CBT could be helpful. I wonder if anybody on the forum has any recommendations?

[Ross Knight]

Hi @Angst, thank you your comment and help. Both options you have mentioned seem good and is something I will look into. Self help may be the best option for me as it will be easier without the communication difficulties. However, another therapist might an option too, with my CBT therapist I had the eight sessions with it was over the phone as that was the covid guidelines with my local mental health service, my therapist seemed nice but it was just the difficulty of expressing myself really. Thank you again for your advice. 

[Wren]

Hi Ross, you might find this presentation useful...

https://www.ocduk.org/conference/conferences-across-the-uk/2021-virtual/breakout/ocd-autism/

 

 

[Ross Knight]

Hi @Wren, thanks for this, I'll give this a look 

[snowbear]

18 hours ago, Handy said:

Intensive psychotherapy has a better success rate it is found. Because CBT treats the symptoms of OCD, not the cause, which is what intense psychotherapy treats.

I can't allow that to go unchallenged, Handy.

Psychotherapy is about looking back at what caused (past tense) the OCD which is often complex and can't be proved as a direct trigger anyway. Knowing why you've developed OCD won't cure the OCD. Looking back for causes might be interesting from the personal standpoint of reviewing the path your life has taken, but is a waste of time and completely irrelevant when it comes to treatment of OCD.

In America you mostly do ERP, not CBT.

Cognitive behavioural therapy treats the cause of OCD in the present - the faulty thinking processes which drive it and the compulsive behaviours which maintain it.

@Ross Knight  I agree with L.M. that sticking with CBT is the preferred way forward.

Autism alongside OCD may mean you need a few more sessions, or a slower pace, or more structured sessions. Either a therapist trained to adapt CBT for people with autism or just a therapist aware of how autism impacts on OCD therapy would suffice. (They can easily read up on it online if not already aware.)

Self-help books are also an excellent resource. The more familiar you are with how OCD and CBT works before you go to your next round of therapy the more you'll get from the sessions.

And do have a look at the link Wren gave you from the charity's conference last year - very informative and useful.

Lastly, to anybody who says 'CBT hasn't worked for me' I would reply simply... 'Yet!' Give it another chance.

[Ross Knight]

Hey @snowbear, thank you for your comment your encouragement is much appreciated. 

[Angst]

14 hours ago, Ross Knight said:

Hi @Angst, thank you your comment and help. Both options you have mentioned seem good and is something I will look into. Self help may be the best option for me as it will be easier without the communication difficulties. However, another therapist might an option too, with my CBT therapist I had the eight sessions with it was over the phone as that was the covid guidelines with my local mental health service, my therapist seemed nice but it was just the difficulty of expressing myself really. Thank you again for your advice. 

Hi Ross

There is evidence that therapy over the phone is different to face to face therapy. The English system of IAPT - Improving Access to Psychological Therapies - uses phone therapy along side face to face therapy. And of course COVID has increased the number of phone conversations. Incidentally IAPT is the biggest mental health intervention in the world. And managers are committed to continuous improvement.
 

Over the past few years there has been extensive research into phone therapy lead by Paul Drew and Annie Irvine funded by the NHS to improve phone therapy which has resulted in improved training for the welfare practitioners who deliver phone therapy.

I am saying this because there have been communication problems in phone therapy not only for people with ASD but also people without ASD. There are a number of webinars by Paul Drew and Annie Irvine outlining the research and their recommendations from webinars for students of A level English Language to quite technical presentations for NHS managers and researchers and clinicians. There are also new training modules for therapists.
 

 I saying this because I do not think you can generalise from your experience. As Snowbear says a slower pace in face to face therapy could well be the solution. You could direct your therapist to the OCD U.K. webinar. I am sure that there is a solution!
 

 

[Ross Knight]

Hello again @Angst, yes it can be difficult for many with treatment over the phone, there were quite a few things about phone treatment which made it not very engaging for me, thank you again for your advice, it is much appreciated. 

[Angst]

Things  are more difficult in phone therapy such as the co-production of visual models of OCD such as the vicious flower. In my face to face therapy we used a flip chart to build up a representation of how my OCD worked.
 

The research further revealed that more talk needed to be spent on the nature of homework and the importance of it with recommendations on how to do this.

Clients were put off as the therapist typed out responses to the questions. This can happen also in face to face sessions as the therapist writes notes. Notes should be done after sessions.
 

Therapists were over rigorously engaged in following protocols rather than fully listening to the client especially in the opening stages of therapy. And sessions tended to be shorter than face to face sessions.

In my therapy the session were videoed and aurally recorded. This is considered good practice in CBT therapy. Your personal recording would allow you to play back each session and make notes. People without ASD do miss a lot of stuff during sessions and a recording would help.

Edited May 21, 2022 by Angst

[L.M.]

23 hours ago, Ross Knight said:

@L.M.How do you find your recovery is going with CBT and your current SSRI?

Really good! I just posted a longer post in the other contamination thread...but yes my ocd used to be extremely severe and I went through a dreadful time with it. So my ocd went from rituals that took up quite literally my entire day, and feelings of extreme distress about it, to where I am at now--generally pretty happy and with compulsions greatly reduced. I still have ocd and would really like to see myself drop a lot more compulsions and see myself facing things that I am still avoiding (top of my list is trying to get myself to use other people's toilets!) So definitely still working at it, but really the degree of freedom I got from using cbt methods along with medication is just amazing to me and I am so grateful for it.

Yes if you feel motivated enough to work through a cbt self-help book (make sure it's specifically about ocd) then you can really make a lot of good progress like that. I found it much better than any therapists I had actually. Although I did also benefit from an 8 week general cbt series that was done as group therapy...

 

[Handy]

Snowbear, but when CBT & psychotherapy are completed, those that did psychotherapy do better than those that did CBT.

[Ross Knight]

Hello again @L.M., that is good to hear that your recovery is going well, keep up the good work. 

[Angst]

On 20/05/2022 at 23:11, snowbear said:

I can't allow that to go unchallenged, Handy.

Psychotherapy is about looking back at what caused (past tense) the OCD which is often complex and can't be proved as a direct trigger anyway. Knowing why you've developed OCD won't cure the OCD. Looking back for causes might be interesting from the personal standpoint of reviewing the path your life has taken, but is a waste of time and completely irrelevant when it comes to treatment of OCD.

In America you mostly do ERP, not CBT.

Cognitive behavioural therapy treats the cause of OCD in the present - the faulty thinking processes which drive it and the compulsive behaviours which maintain it.

@Ross Knight  I agree with L.M. that sticking with CBT is the preferred way forward.

Autism alongside OCD may mean you need a few more sessions, or a slower pace, or more structured sessions. Either a therapist trained to adapt CBT for people with autism or just a therapist aware of how autism impacts on OCD therapy would suffice. (They can easily read up on it online if not already aware.)

Self-help books are also an excellent resource. The more familiar you are with how OCD and CBT works before you go to your next round of therapy the more you'll get from the sessions.

And do have a look at the link Wren gave you from the charity's conference last year - very informative and useful.

Lastly, to anybody who says 'CBT hasn't worked for me' I would reply simply... 'Yet!' Give it another chance.

Looking back can be part of modern day CBT.  Victoria Bream and others have written in ‘CBT for OCD’ about a ‘developmental formulation’ (p240) which allows the client to ‘reappraise historic events’ They point to the usefulness of this approach when a client has feelings of shame.

[PolarBear]

On 19/05/2022 at 20:27, Handy said:

Intensive psychotherapy has a better success rate it is found. Because CBT treats the symptoms of OCD, not the cause, which is what intense psychotherapy treats. 
 

Of course, one can also go cold turkey if they have the courage. 
 

Ketamine has been proven effective in USA as a medication & it’s very quick, 2 hours, not 8 weeks like for SSRIs.

Absolute garbage. Cognitive Behavioral Therapy is the only scientifically proven treatment for OCD, with or without meds.

Pyschotherapy is great, but is limited in use for OCD. We simply do not know what causes OCD so chasing a cause could take a long time, be pointless and not address how to fix the problem.

[northpaul]

11 hours ago, PolarBear said:

Absolute garbage. Cognitive Behavioral Therapy is the only scientifically proven treatment for OCD, with or without meds.

PolarBear.  Once again you come on a thread with your acerbic put downs.  Who are you?   I see no evidence of you being medically or clinically trained.

[Wren]

Several years ago I joined this forum in a state of extreme distress, I had just finished two courses of CBT with the NHS but my team felt I needed further treatment so they had referred me to psychotherapy. I was terrified of examining my past so didn't want to do it. I was told by this forum to not take up the referral for psychotherapy, so I didn't and carried on with self help CBT for another year. However I got nowhere because my team were right - I needed that psychotherapy. Mental health problems don't come in nice discrete boxes with nice discrete treatments unfortunately, so some people may need multi-pronged treatment. There is a good example of this in the book 'CBT for OCD'. Yes, psychotherapy on its own is probably not going to be great for OCD, especially old school psychoanalysis, but like I say mental health is not simple and we don't know the background and full mental health profiles of the people who post on these forums. So, I'm with northpaul, in saying I wish people would be careful about making blanket statements about things when they are not qualified to do so. 

[snowbear]

On 22/05/2022 at 16:29, Angst said:

Looking back can be part of modern day CBT.  Victoria Bream and others have written in ‘CBT for OCD’ about a ‘developmental formulation’ (p240) which allows the client to ‘reappraise historic events’ They point to the usefulness of this approach when a client has feelings of shame.

I agree, Angst. And as @Wren said, some people need to do a bit of reappraising their past in order to move forward. (Me included.)

Given Handy's later response about CBT and psychotherapy combined (which I agree with) I think I misinterpreted his original post which seemed to suggest psychotherapy was better than CBT at treating OCD. So I apologise @Handy for the misunderstanding. It was just how it came across. I thought you were advocating looking back for the purpose of understanding what caused your OCD. Not a reappraisal of how your life experiences have influenced the default thinking processes you currently use and how you behave in the now as a result of that way of thinking. (Which is what godd psychotherapy combined with CBT does.) 

I also appogise to anyone else thinking it was a blanket put-down of psychotherapy. All I meant was CBT is the gold standard treatment for OCD, and whatever adjunctive therapies an individual might need as well, they will always gain most benefit from CBT.

Hope that makes it clearer!

[bluegas]

7 hours ago, northpaul said:

PolarBear.  Once again you come on a thread with your acerbic put downs.  Who are you?   I see no evidence of you being medically or clinically trained.

Completely agree I get so fed up with people ramming cbt down my throat!! I’ve tried it countless times for ocd and it dose not even touch the sides! I’m not saying it dose not work for any one but there is enough of us cbt has failed ! 

[PolarBear]

3 hours ago, bluegas said:

Completely agree I get so fed up with people ramming cbt down my throat!! I’ve tried it countless times for ocd and it dose not even touch the sides! I’m not saying it dose not work for any one but there is enough of us cbt has failed ! 

There are reasons why you don't improve with CBT. First is that your therapist is not qualified or able to properly teach CBT. That is a big problem according to numerous posters here over the years.

Another is too much emphasis on ERP and little to no work done on the cognitive side. This is what I see as a big problem in America. Sufferers need to see how their cognitive distortions exacerbate their situation. They need to learn to mentally challenge their thoughts. And more.

Likely the biggest reason CBT doesn't work (I suspect I'll get flack over this) is that some sufferers are unable or unwilling to do the actual work involved to get better. A big part of recovery is slowing down and stopping compulsions. Some sufferers can't or won't do that or they go so far then back off. 

It's incredibly difficult for most sufferers to recover. You can know what to do but your own mind gets in the way.