There is one key mistake I come across from clinicians who try to work with OCD but lack training or experience treating it. Simply put, they “play with” obsessions rather than treating the nature of the problem. This can turn into well-meaning psychotherapy being a “rumination-fest” filled with reassurance from the clinician. Clients don’t usually get better. In some cases, they get worse–much, much worse.

Check out the article in full below from the newsletter.

Obsessive Thoughts Are Not Beliefs To Restructure.

By Justin K. Hughes, MA, LPC

Obsessive thoughts are not beliefs to restructure.

There’s one thing in my specialized practice working with Obsessive Compulsive Disorder (OCD) that Cognitive Behavioral Therapists have a poor reputation around—and it’s sometimes warranted. The crucial mistake lies in how clinicians have treated “beliefs” in OCD.

A Brief History Lesson

Let’s first consider our heritage. Before Cognitive Behavioral Therapy, OCD was untreatable. Sure, Freud claimed to have “cured” a case of obsessional neurosis—yet no successful protocols were developed until the 1980s—or, as my teens will say, “last century.”

Once Aaron Beck, Albert Ellis, and others revolutionized treatment by addressing cognition in therapeutic ways, one of the behaviorists, Victor Meyer, released the first known paper detailing what would develop into ERP (1966). ERP was to become one of the most effective of all mental health treatments.

When OCD was only treated strictly behaviorally, it lacked essential components—particularly cognitive interventions—required to treat Obsessive Compulsive Disorder. Behavioral avoidance maintains fear, as do cognitive processes—beliefs and especially mental rituals in OCD (checking, reassurance-seeking, rumination, neutralization/suppression, avoidance—including distraction—and many others).

Missing a Functional Analysis

Fast forward to the present—the irony is that some clinicians misapply the cognitive interventions part of the gold standard treatment: Exposure and Response Prevention (ERP). Some have all but abandoned the behavioral components. For those utilizing Cognitive Therapy for OCD (evidence-based, but not “gold standard”), behavioral experiments are essential to this model. The type of Cognitive Restructuring (CR) to be applied is very specific to the illness.

Case Vignettes

Mary is a patient with OCD and depression, whose obsessive thoughts center on contamination and a fear of getting sick. Her depression increased the more she compulsed, and she was nearly homebound. She was highly critical of herself and grew up in a high-performing family that spoke about “lazy fat asses” who laid in bed all day. She did have both core beliefs and regular automatic thoughts around this, even when she was high-performing prior to her disability. Cognitive Restructuring was essential for her to build her motivation and improve her mood (referencing Beck’s Negative Triad).

Mary, before CR: I’ll never get better.

Mary, after CR: I feel sad and discouraged; I have gotten better before, and it’s possible I can improve again. I have never done this treatment, which statistically works for most people. 

Pradeep, a patient with OCD and Panic Disorder, experienced obsessions around harming others, and whenever he felt a bump on the road in his car, he obsessed over hitting someone. Frequent violent and bloody images occurred in his thoughts around loved ones; in such cases, he would panic and immediately leave. The panic became so bad he preemptively avoided environments linked to past panic.

The clinician assessed the function of his thoughts and discovered quickly he often asked “what if?” This was identified as an egodystonic recurrent doubt—an obsession. Given the working diagnosis of OCD, the clinician and Pradeep identified the phrase as something he ruminated on, looking for proof it might not be true. Cognitive Restructuring was contraindicated because there was an obsessive fear of this being true, not a patterned distortion needing restructuring. Other clinicians previously spent many sessions attempting to “get him to be more realistic.”  He significantly improved through ERP, including exposure scripting, practicing acceptance, and mindfully observing his internal experiences.

Pradeep before ERP: What if I never get better?

Pradeep after ERP: Maybe I won’t, maybe I will. I notice I’m having the thought that I won’t get better. [Followed by proceeding to the next thing he was doing.]

Don’t Make It Worse:

Here are just a few common responses of therapists that play into the OCD Cycle:

• Is that realistic? Let’s look at the evidence.

• What is the alternative? 

• What is the likelihood of that occurrence?

• Look at these outcomes; a vast majority improve significantly with treatment.

• Your prior history would indicate a cognitive error.

Here are some sample responses supporting recovery with an obsessive thought:

• Maybe, maybe not.

• How are you responding to this thought? What sort of reactions or mental rituals might you be doing?

• Observe your ABC in short form (no more than a few sentences).

• Have you done your exposure practices?

It is essential to say that the content of obsessive thoughts can bring up core beliefs to restructure, but not inherently—they must be carefully assessed.

Effective Treatment

Effective treatment for OCD was one of the latest to the game. Let me encourage you today to stand on the shoulders of those who have contributed so much to highly effective treatment, and, in the meanwhile, don’t perpetuate misinformed approaches that have already been tried and found wanting. Obsessive thoughts are not beliefs to restructure.