CBT
CBT stands for ‘Cognitive Behavioural Therapy. It is in fact a combination of two different therapies.
I will talk about each therapy individually, starting off with cognitive therapy, then moving onto behavioural therapy
Cognitive Therapy
Cognitive therapy was invented in the 1960’s by a psychiatrist called Aaron T Beck. He originally trained as a psychoanalyst (i.e. a therapist that looks for the root cause of mental illness), as that was the prominent form of therapy at the time. However, he had two main criticisms of Psychoanalysis:
(a) it could be a while before patients see improvements in their condition, as therapists needed to look at the entire history of a patient (going back to childhood)
(b) that there is no need to look for a root cause of mental illness, the problem lies entirely in the mind
So, he devised a new form of therapy whose aim was to address those supposed flaws in psychoanalysis, and he called this new therapy ‘cognitive therapy’
The basic model of cognitive therapy is ‘Event – Cognition – Emotion’. This model proposes that events do not cause emotion, instead it’s what the individual thinks about the situation that causes the emotion. Let’s give an example:
The event is you are walking on one side of a street, and on the other side of the street you see your friend. You wave, but your friend seems to ignore you
The cognition (i.e. your thought) could be that your friend no longer likes you
The emotion generated could be sadness, as losing a friend can make a person sad
Cognitive therapy says that the issue in the above scenario is not that your friend ignored you, but your cognition (i.e. your thought) about it. This is because your friend might not have been able to see you from the other side of the street, or that your friend was so engrossed with a problem in his head that he was oblivious to the outside world
In CBT, these types of thoughts are called negative automatic thoughts, because you are not consciously generating them (they just come automatically), and they are always negative (e.g. ‘my friend no longer likes me’)
So, as its thoughts that cause emotions, if you change what you think, then you will be able to change how you feel.
Cognitive therapy teaches how to change what you think. It does this by asking the patient to do thought challenging. Basically, each time the patient gets an irrational thought, they are meant to find arguments against it (e.g. doctors say I don’t need to wash my hands more than once after going to the toilet). The therapy claims that if the habit of replacing irrational thoughts with rational ones is practiced long enough, then the negative thoughts will go away, and the patient will no longer be mentally ill.
I argue that ‘Cognitive Therapy’ isn’t particularly useful for OCD thoughts in the short run (i.e. the next six to twelve months) for three reasons
The first reason is that the part of us that produces the OCD thoughts (i.e. the subconscious mind) doesn’t care whether the thought is rational or not, all it cares about is will the thought generate anxiety. Trying to persuade the subconscious mind that it shouldn’t generate the thought is difficult, as the thought is doing what the subconscious wants i.e. generating anxiety
The second reason why cognitive therapy typically doesn’t work (in the short run), is that if you are in fight or flight mode, our rational side (i.e. the conscious mind) basically gets switched off, and so there is no one around to tell the subconscious that the thought is irrational
The third reason why cognitive therapy typically doesn’t work (in the short run), is that, even if you manage to convince the subconscious to stop generating a particular OCD thought, another OCD thought will replace it, because OCD thoughts are a warning that something else is broken, and won’t stop until that something else has been fixed
For completeness’ sake, I want to mention that, while cognitive therapy is almost useless for OCD in the short run, it can still be helpful for your recovery in the long term. That is, if the underlying cause of your OCD are self-esteem issues, then cognitive therapy can help fix those issues. I will cover the underlying causes of OCD, and how to fix them in the section called psychoanalysis
But to keep things simple, for the next six to twelve months, assume cognitive therapy is useless for OCD
Now let’s move on to the second part of CBT, called ‘Behavioural Therapy’.
Behavioural Therapy
Behaviourism, which is the basis of Behavioural Therapy, was formally invented in 1913 with the publication of John B. Watson’s classic paper, "Psychology as the Behaviourist Views It.”
Behaviourism offers a very different approach to psychology. Its principal aim is not to reduce psychological distress (e.g. anxiety). Its principal aim is to get mentally ill individuals to change their behaviour so that they can function in life. However, changes in behaviour can lead to less anxiety. I will explain how this works later on, when I talk about ERP
The reason why behaviourism focuses on behaviour rather than psychological distress, is that according to behaviourists, things such as thoughts, emotions and moods cannot be objectively measured. For example, it is impossible to know what is going on in the subconscious mind, so how can you attempt to fix it? Related to this, is that at the time behaviourism was invented, psychology was viewed a pseudo-science, precisely because of the inability to measure things like thoughts in an objective manner. So, the behaviourists decided to abandon investigating things such as thoughts, emotions and moods, and instead concentrated on the behaviour of individuals, which could be easily measured
So, essentially, behaviourism ignores the impact of thoughts, emotions and moods on behaviour. If you have OCD, you’re probably thinking ‘what a rubbish theory, the anxiety I get from OCD compels me to behave in a way that stops the anxiety, so it’s clear that emotions can affect our behaviour.’
The behaviourists are indeed wrong about emotions not having an impact on behaviour, but we cannot dismiss their theory completely, as they invented a technique which is very helpful for OCD in the short run. That technique is called ‘Exposure and Response Prevention (ERP)’
Before I explain how ERP works, I feel it would be useful to remind you about which parts of us are involved in OCD. With OCD, essentially the subconscious mind is tricking the brain to generate anxiety (via an irrational/scarry thought). The aim of ERP is to un-trick the brain
ERP is a two-part process. The first part involves a person exposing themselves to the feared thing/situation. For example, if you are scared of the dirt on door handles, you have to deliberately touch a door handle. At this point your brain will start generating anxiety, as the subconscious is telling it that the door handle is ‘dangerous’
The second part involves deliberately not washing your hands. By not washing your hands, the brain gets even more worried, and so generates more anxiety. But, after experiencing this anxiety for a period of time, which could be one minute, or perhaps 15 minutes, the brain will start to learn/realise that the danger is not real, and the anxiety will start to come down. This process is called habituation
Typically, doing ERP once on the feared thing/situation is not enough to completely stop the anxiety from generating. You normally have to do ERP a number of times for the brain to be fully un-tricked.
You are probably wondering ‘how many times? That’s a hard one to answer, as everyone is different.
Instead of thinking about how many times you need to do ERP for the feared thing/situation, I think it is more useful to measure it in terms of how many weeks/months you have continuously done the ERP. That is, if you have done ERP once a day for a month and your anxiety hasn’t come down at least a bit, then that’s not enough ERP. So, you will need to increase it to twice a day, then three times a day etc
As a general rule, if your anxiety from the feared thing/situation hasn’t reduced by at least 25% in a six-month period, chances you are not doing enough ERP. At which point, you either need to step up your efforts, or see a therapist, who can make helpful suggestions
A word of warning. When you do increase the number of times you do ERP, you have got to be careful you don’t increase it by too much. Some people do far too much too soon, at which point they become overwhelmed, and end up stopping ERP completely, and so get worse
Below are some ways/tips on how to do ERP
1. What helps with ERP is doing it in a in a hierarchical manner. That is, if your OCD fears are about three different things (e.g. contamination, symmetry and checking), you would start with the one that is less troubling. Once you have defeated that one, then you would move onto the next feared thing/situation
2. For each feared thing/situation, it could helpful to do the ERP in a graded manner. That is, if you are scared to go outside (because of contamination), then you start by going out for only say 5 seconds, then come back in. The next day, you could try staying outside for 10 seconds, and so on. This is a gentler approach
3. While doing ERP, some people find it useful to combine it with a distraction. If, as in the previous example, you are scared to go outside because of contamination issues, but you are willing to go out for 30 seconds for ERP purposes, in those 30 seconds you could think of something that is going to distract you, such as an important task you need to do soon. The point of the distraction is not to stop the initial anxiety that is generated, you need to experience that anxiety to recover. The point of the distraction is to stop the extra anxiety that might be generated due to catastrophising about how high the anxiety might get
For people who have pure O, that is where the anxiety is not triggered by an object or situation, but is purely in the mind, a good distraction is the watching of a TV program. Pick a programme that occurs weekly, that you like watching. Then each time you watch it, deliberately allow any OCD thoughts and anxieties that occur. On the parts of the programme that are really interesting, you may be more likely to allow any OCD anxiety that comes up. Also, you know that at least once a week you will be doing ERP, and for some people that is good start
4. For some people writing in a diary/notepad how much of ERP you have done is helpful. That is, let’s say on a particular day you got 10 OCD thoughts, and you managed to do ERP for 4 of them. You would write that down in your notepad, so that the next day/week it may encourage you to increase it 5 lots of ERP a day. An additional benefit of writing down the number of ERP’s you do, is that sometimes you have a bad day where you can’t do any ERP, and so it will appear you are failing. But if you look at your notepad over the past six days, you will see you have done lots, so your one day of ‘failure’ won’t seem so bad
5. Some people feel more encouraged to do ERP if they watch a YouTube video about it, just before they start doing it. That is, if you plan to do some ERP in the morning, do your morning routines first (have breakfast etc), then just before you start your ERP, watch a video that encourages you to do it. There are lots of ERP videos on YouTube, search for one that works for you
6. Mindfulness. I will talk about mindfulness in more detail in a later section, but for some people combining ERP and mindfulness helps speed up the recovery process. One of the techniques from mindfulness that helped me massively, is putting my attention on the area of the body that is impacted most by the anxiety. Let me explain
Each time I got anxious, it would hit me in my chest. So, I would stop what I was doing and place my entire attention on my chest
In addition to placing attention on my chest, I would resist the urge to stop the anxiety
Doing the above things has two benefits. The first is that if your attention is on your chest, then you are less likely to think 'what if my anxiety gets worse' (i.e. you are less likely to catastrophise) . And, secondly, if you don't stop the anxiety, your brain will learn that there is no real danger
If you do the above, over time, which could be as little as a few days, you will find that the feelings will bother you less, and they will move on quicker
7. For those of you who are able to go outside, doing exercise in the gym or the park can also help you do more ERP. Exercise has a number of benefits, but the main benefit (for ERP) that is it makes you feel better, and if you feel better, you are more likely to tolerate the anxiety that ERP produces
8. Be wary of therapists that suggest extreme forms of ERP. For example, they may ask a patient who is scared of contamination to lick the bottom of their shoe. Or if the patient is scared they may have run over a person when driving their car (when going over a bump in the road), the therapist may ask the patient to remove their rear-view mirror in the car, so that they can’t check if they have run someone over. I think this is a cruel way to administer ERP, and should be avoided
9. For some people, when they start doing ERP, they can end up experiencing more anxiety in the first two or three weeks than they did before starting ERP. The reason is that before, when you were stopping the anxiety, the subconscious felt its message was not being heard (by the conscious mind), but when you do ERP, the conscious mind is hearing the message, and so the subconscious thinks ‘I’ve now got the attention of the conscious mind, so I will take advantage of this situation by generating more thoughts than usual’. But this doesn’t happen to all sufferers, so hopefully you get lucky
10. ERP is rarely a smooth process. Some weeks you will say ‘It is going really well’, and then some weeks the anxiety will be quite high, and you will say ‘I may be failing’. Always look at the big picture, which is that recovery takes time, and you will get there in the end
Above I have given ten ways/tips for doing ERP. However, everyone is different, so if you they don’t work for you, please search for more ways online, until you find what works for you
At this point you may be thinking 'ERP is too difficult for me to do.' I will mention four things about this
The first is that you will probably spend the next few years searching for an easier way. On the internet there are many websites that promise a quick and easy for recovery for OCD. There is no quick and easy recovery for OCD. These websites are promoting false hope
The second thing is that, the longer you delay ERP, the worse your OCD will get, so when you do eventually get round to doing ERP, it will be more difficult than it would have been had you started sooner
The third thing is that overall, ERP won't be as bad as you think it is going to be. This is because when you are in anxious state, the mind tends to exaggerate the difficulty of challenges (including ERP)
The fourth thing is perhaps you are experiencing secondary gain. This is a psychological term that refers to the benefits people receive from not overcoming a problem. For example, lets say that if you recovered from OCD, it may mean you have to return to work. If your job is a particularly stressful one, then you may sabotage your OCD recovery, so that you don't have to go back to work
So my advice to you is to start doing ERP as soon you can. Read the key parts of this website a number of times, until you have fully absorbed it. Then start doing ERP in a gentle manner.
Behavioural therapy (i.e. ERP) is the best treatment for OCD in the short run. It can massively reduce the amount of anxiety you experience in as little as a few months, if you are willing to put the hard work in
But behavioural therapy doesn’t work in the long run, because as soon as you habituate to one OCD thought (i.e. get rid of it), another OCD thought will pop up in its place. Psychoanalysis is what stops OCD thoughts from being generated in the first place, but that takes lots of time to implement, so its best to do behavioural therapy for a year or so, until your anxiety levels have come down significantly and then you can do psychoanalysis
You now have a good knowledge of CBT, and when you are ready, you can start implementing the ‘B’ part of it (i.e. ERP). While it is possible to do it on your own, it is also helpful to see a therapist, for a number of reasons.
Therapists can provide lots of encouragement to do ERP, which some sufferers need. Therapists can also provide clarification on things that the patient is not sure about, and there are many other reasons why seeing a therapist is beneficial
I acknowledge that it might not be possible to find a therapist quickly. Depending on where you live, waiting times on the NHS range from 3 to 18 months. If you have to wait 18 months its best to start it by yourself, and who knows, by the time you therapist appointment comes, you may not need it!!
If you can afford it, you can also find a private therapist. The best place to start looking for one is on the website of the ‘British Association for Counselling and Psychotherapy’
https://www.bacp.co.uk/search/Therapists
On the webpage, enter what your problem is (i.e. OCD or anxiety), enter your postcode, and it will come up with a list of therapists that are near you, and what they cost.
Be aware that a lot of therapists (whether NHS or private) may not be familiar with model I present in this website (i.e. the subconscious mind generates OCD thoughts to alert the conscious mind that there is an underlying issue that needs to be fixed). Lots of therapists are not taught about this in their education, they are instead taught mainly about CBT, which basically rejects the ideas of an underlying issue, and assumes the problem is purely in the mind
But that doesn’t matter. You know what OCD actually is, and you are just using the therapist to encourage you to do what is needed in the short run (i.e. ERP)
A final thing I wish to mention about CBT is the way it is sold to patients. In particular, most therapists/psychologists say it is the gold standard when it comes to treating mental illness. They base this on the numerous studies that have been done on CBT which apparently show its high effectiveness. But when you look at the details of those studies, you will see that there is a lot of exaggeration or misinterpretation of the data contained within them
The psychoanalyst ‘Jonathan Shedler’ has written a relatively short paper that explains some of these exaggerations or misinterpretations:
If you want a more detailed explanation as to why CBT is not the gold standard, then read a book called ‘CBT: The Cognitive Behavioural Tsunami: The Cognitive Behavioural Tsunami: Managerialism, Politics and the Corruptions of Science’, by Farhad Dalal.
One of the issues raised in this book which I found alarming, was the fact that if a patient saw a therapist on the NHS for two sessions, and the patient chose not to come back for whatever reason, the treatment was deemed as a ‘success’ by the therapist!
To be fair, both of the people I have mentioned above (Jonathan Shedler and Farhad Dalal) come from a rival school of psychology, so they may have a bit of bias against CBT, but I feel their criticisms of CBT are valid
The next section is about psychoanalysis, which is the school of psychology that the above two named people come from - click the below button