What is OCD (obsessive compulsive disorder)?

Obsessive compulsive disorder (OCD) is a highly distressing anxiety condition experienced by approximately 1.2% of the UK population. All types of OCD include obsessions and compulsions. Obsessions can include intrusive and distressing thoughts, images and feelings (urges). Compulsions are the actions which are carried out in an attempt to ‘get rid’ of the intrusive thoughts, obsessions and feelings, which are highly distressing to the person with OCD. OCD can eat into a person’s time, taking them away from living the kind of life that they would value. In terms of treatment, CBT for OCD is your best option for managing the condition because it helps you to tackle the thoughts and the behaviours which keep the problem going. Cognitive Behavioural Therapy has been widely researched as the most effective method for overcoming OCD.

Why have I used a ladder to illustrate? This is to draw attention to the fact that as human beings we all have the propensity to think in superstitious ways. eg. Don’t walk under a ladder or you will have bad luck. Superstitious and magical thinking has at its heart a very similar theme to OCD, that of preventing harm and bad things from happening. Magical thinking can play a part in OCD when you may come to believe that by thinking certain things, and not carrying out certain rituals that harm can be caused or prevented.

While superstitious thoughts can be normalised as part of the human experience, OCD is an anxiety problem where you may become stuck in a loop of intrusive thoughts and actions while trying to reduce the potential distress caused by believing that you may be responsible for capable of causing harm to the self or others.

In this short introduction to OCD and CBT for OCD, I am aiming to give a broad overview of what OCD is and what you may expect from CBT for OCD, but there are limitations to such a short piece. Towards the end of the article I’ll recommend a couple of excellent books for you to turn to, should you want to know more.

What is obsessive compulsive disorder?

OCD begins with a trigger situation which is closely followed by an intrusive thought or obsession. To the sufferer this is not merely a passing obsession, but one which is highly distressing or anxiety-provoking. There are certain themes which these thoughts might fall under (contamination fears, obsessions related to perfectionism, religious obsessions, unwanted sexual thoughts, fear of causing harm, or fear of losing control to give a general overview). OCD is not limited to feeling anxious, the emotions experienced as part of the problem can be many: including anxiety, shame, guilt and depression.

OCD compulsions fall into two main camps - visible (overt) and invisible (covert). When most people out there think of OCD, they think of visible actions (such as hand-washing, checking candles are out or electrical plugs off, doors and windows being locked, seeking reassurance) but just as common are invisible compulsions which are carried out in the mind of the person who has OCD. Examples might include counting, memory hoarding, reviewing events to see whether or not something happened, self-reassurance, rationalising intrusive thoughts, neutralising words, or trying to prove the thoughts untrue beyond doubt.

Each person’s OCD takes on its own unique ‘flavour’, but whichever form you have, you can be assured that in all cases, the compulsions keep the OCD going. Yes, temporarily you may feel less emotional distress when you carry out a compulsion, but in the long term these are unhelpful actions. Over time these actions can increase your distress, as they keep you locked into a battle with the OCD, limit the activities you would otherwise choose, and negatively impact close relationships.

The problem with OCD compulsions

Compulsions are behaviours which give your brain the message that the intrusive thought (or urge) you have experienced has something of note to offer you. Responding to the intrusion or the obsession with an activity (covert or overt) gives your brain the message that the thought is important. Correspondingly, your brain, will offer more intrusive thoughts as long as you continue to respond with a compulsion. The brain is so generous like that! You can kindly thank your mind for this, it really does want the best for you, it’s just being an overhelpful friend.

Everyone’s OCD is unique to them so it’s important to be clear what you are doing which might keep the problem fired up. This will be useful material in the treatment of your OCD. Treatment of OCD involves a multi-pronged approach. Understanding what OCD is and how it is maintained, learning about the nature of thoughts, relating differently to the intrusive thoughts, and (most important) learning to tolerate the uncertainty and discomfort which comes when you begin to refrain from responding to your obsession through ERP (Exposure and response prevention) are some of the ways forward.

ERP involves gradual exposure to your intrusive thoughts, so that you can begin to habituate to the discomfort you experience as you learn to refrain from the compulsions. This exposure will be through imaginary exposure and real life exposure; your plan for treatment will be quite specific to your own symptoms and behaviours. To overcome the obsessions you will need to repeatedly expose yourself to situations you fear by whilst not carrying out your compulsions. This is done in a gradual way at a pace you can handle! Over time and with repeated new actions, your obsessions and your fear should start to trouble you less.

Thoughts are just thoughts

Learning not to respond to your intrusive thoughts will be a valuable goal. In studies, we know that 90% of people have odd, strange, unwanted thoughts. (And who really knows for sure whether the remaining 10% had thoughts they didn’t want to admit.) Any thought is possible in any person, and for the most part, these intrusive thoughts don’t cause people problems, but if you have OCD and you have begun to attach layers of meaning to those thoughts, you’ll have begun to get hooked by them. What keeps you getting reeled in is acting to try to alleviate the anxiety, guilt or shame which might accompany those intrusive thoughts or urges.

Cognitive behavioural therapy means working on thoughts and behaviours. With OCD, this means that not only are we tackling the behaviours which maintain obsessive compulsive disorder, but we may also be looking at your beliefs about your thoughts and your feelings, your drive to obtain absolute certainty where you may experience a persistent sense of doubt, and a sense of overdeveloped responsibility for preventing harm. With consistent effort and practice, you can learn to manage OCD and break free of its vicious cycle. You can stop yourself getting reeled in, hook, line and sinker. You can stay on the shore and you don’t need to get into the swirling water with it.

You might also be interested in Courtroom Drama analogy for relating to your OCD in a different way.

As I finish this short intro to CBT for OCD, I’m aware this only scratches the surface of what it means to have obsessive compulsive disorder, but I hope it serves as a brief primer on what keeps this problem going and how you can begin to unravel the problem.

If you want to read more, I highly recommend the following:

Break Free From OCD by Fiona Challacombe, Victoria Bream Oldfield and Paul Salkovskis

Managing OCD with CBT (For Dummies series) by Katie d’Ath and Rob Willson

Overcoming Unwanted Intrusive Thoughts by Sally Winston and Martin Self

Ali Binns is a CBT therapist based in Bath. She helps clients to manage their anxiety and mood using evidence-based cognitive behavioural strategies. Please use the contact form if you would like to get in touch.

5 ways to make the most of your CBT therapy sessions

Now that you have taken the brave step of reaching out for help and since you are investing time and effort in coming to sessions, I’d like to offer you some tips on making the most of your CBT therapy sessions. Here's how best to navigate the process and  work towards the life you want.

First task. Let's clear up any misconceptions about therapy. Of course CBT is a talking therapy, but it might be more truthful if we called it a talking and doing therapy. Emotional change only comes from thinking and doing things differently. It will never be as effective to only talk about your problems. Talking may help you to understand why you feel the way you feel or think the way you think; of course, this can be helpful. But, if you think of therapy as like playing a musical instrument, such as the guitar, you will never succeed at playing by just talking, thinking or reading about guitars. Progress comes from practice, perseverance and commitment. Making changes are the way to experience the progress you are looking for, and CBT is most effective when approached as an active therapy.

The more you can do between sessions influences the amount of time you may spend in therapy. If at one far end of the scale, you only turn up to sessions to talk with your therapist, then it goes without saying progress will be slower.

Here are 5 tips to make the most of your therapy sessions.

1 Get yourself a therapy notebook
Even though we all carry phones around, and these can be helpful for on-the-fly notes, slowing down and putting pen to paper really does help to clarify the kinds of thoughts we are having, and can even help us to see our thoughts for what they are. We can better identify patterns of thinking which may be contributing to our problems.

To get the most out of therapy it is beneficial to make notes before, during and after sessions.

Before sessions Make a note of anything which would be helpful for you to discuss in your therapy session. However, since CBT is a goal-oriented therapy, if it is on a different topic entirely, you may have to weigh up whether this is something you would like to spend time discussing. 

Perhaps something might occur to you during the week which you wish you had told your therapist and which you think may be relevant to your treatment. If so, make a note, so you don’t forget.

During sessions Keep your pen handy during sessions and be ready to write down anything you find helpful or that you will want to remember. You never know when you might have a lightbulb moment. And it’s a good discipline to get into so that you remember any tasks you might have planned for between sessions… Therapists don’t like to nag, they really don’t.

After sessions Reflecting on a session is a good way to make the most of your latest session. Find some time, ideally while the session is still relatively fresh in your mind, and ask yourself a couple of simple questions. What stood out for you in the session today? How are you feeling now? What did you find helpful today? Did you (even in any small way) experience different feelings or think differently about yourself, others or the world in general? What friendly, compassionate and kind thing could you say to yourself now, which would support you to go about the rest of your day?

2 Learn to journal
During CBT we will cover different ways of journaling your thoughts, feelings, behaviours and physical sensations / symptoms. Practising noticing your own particular patterns is going to be important, because if we would like to change how we think and act, then we first need to notice our own tendencies which may be unhelpful and maintaining any difficulties we might be experiencing.

I’ll often supply different thought records and templates so you can practise noticing, then working towards reframing or managing your thinking in a new and helpful way.

3 Be clear about your goals
Even if your initial therapy goal is quite general, such as learning to manage your anxiety, or to cope better with life’s challenges, as therapy continues, it will be helpful to spend time reflecting on what specifically you want to be doing differently. As the weeks go by, it will help you enormously to have a picture of what you would like to aim for, the more specific the better. As with all goals, it’s important for your goals to be specific, measurable, achievable and to have an idea of when you would like to do this by. Goals help therapy to remain on track, although it is fine to step off the pathway from time to time. Life is like that and we can accept that sometimes life throws curveballs during your time in therapy and these may be more pressing to talk about at times.

4 Be honest
This is important on different levels. I really encourage my clients to understand that they are the expert on themselves and to be as honest as they can about how they think and feel. This will help your therapist to devise the best plan for you. If ever you don’t understand a concept or the rationale for an exercise, point it out, so your therapist can be more helpful. If you have struggled with an exercise, let your therapist know. 

5 Do your homework
Homework, or as some might call it, an action plan, consists of between sessions tasks. You might be working towards managing your thinking in a different way, practising mindfulness or relaxation techniques, or journaling. You might be changing what you do and approaching rather than avoiding difficult situations, places, conversations or people. You might be learning to relate to yourself in a kinder, more compassionate way.

In CBT we focus on using evidence based techniques, but it is only in the practice of these where you will learn what works best for you. Even if you think it might not work for you, can you be willing just to see that as an unhelpful thought which may be standing between you and feeling better.

Many tasks in CBT need to be repeated in order to experience a benefit, so be prepared to practice and repeat a task for at least a week or two to see what benefits you experience. Once you know what works for you, you’ll feel encouraged to keep doing it.

So these were the five things I’d like you to know. If that all sounds like a lot of hard work, you probably already knew that nobody ever said therapy was easy. It isn't, but it can be the most rewarding and valuable experience. It can be emotional and it can (clients say) even be fascinating. I wish you well in your therapy and much courage to try new and helpful ways of thinking and acting.

Ali Binns is a CBT therapist based in Bath, UK. To find out more click on the links at the top of the page.

A tale of self acceptance: The Two Waves

Ever summed yourself up as a failure, not good enough, worthless or other sweeping negative description? You’re not alone. This tendency to downgrade ourselves if things aren’t going the way we want in life is common place. Self esteem can come crashing down when we do this. In CBT, we call this a global negative evaluation of ourself, and it’s helpful if we can learn to notice when we are doing this and work towards an understanding of the self as far too complex to rate and sum ourselves up with unhelpful all-encompassing evaluations. All too commonly, people suffering from depression, anxiety or stress can sum themselves up as ‘a failure,’ ‘not good enough’, ‘useless’ and so on, when the truth is that none of these can be proved to be 100% true.

Ever noticed yourself doing this? Some of us label ourselves down when things have gone badly in a particular area of our life, but then proceed to sum our whole self up as a result of one mistake or failing. Each person on the planet has a unique and interesting combination of strengths, weaknesses, traits, roles, history, attributes, thoughts, beliefs, emotional responses, so when we explore a ‘global negative rating’, it’s just never true. Each person is so much more than the sum of their parts.

I recently heard this story of the two waves, which I think explains in a vivid way how we are much more than we imagine we are.

There are two waves racing towards the shore, one large and one small. The larger wave is frightened and he says to the little wave, “Oh no, this is it, it’s all over for us. I can see the shore and the cliffs and we are doomed.” The little wave looks back at him and says, “No, we’re fine. I can’t see what the problem is.” The big wave replies, “Look, I am bigger than you, I can see over the top of you and I can see the foam and the shore – I can see that our journey is over.” The little wave looks back and replies, and says, “The end? Not at all you’re not just a wave, you’re the ocean.” The big wave has given himself a self-limiting label, just as we often do, and that has increased his distress as he chases in to shore. Consider for a moment how you might limit your own progress with your own negative labels.

Perhaps you can work on this idea for yourself? Grab a pencil and note down everything you can think of that makes up you. For example, make a note of all your strengths, weaknesses, neutral points, roles in life, beliefs, ideas, attributes, thoughts, likes, dislikes, and feelings.  If it’s hard, you can ask a close friend or family member to get you started. When you’re done, take a look. Now does it make sense to ever sum yourself up in global terms? Can it also be true that you are so much more than any label you give yourself?

Can you begin to learn to accept yourself for who you are – this wonderful one-off and complex human being. There will never be another like you! Sure, you make mistakes, from which you are welcome to learn, or you have weaknesses you'd rather you didn't, but that’s where you’re not alone. Welcome to being human!

I work as an accredited CBT therapist in Bath (MNCS Accred, National Counselling Society) and see self acceptance as one of the keys to improved mental health. If I can help you, please feel free to get in touch via my Contact page or email info@alibinns.co.uk