I have OCD. Cognitive behavioral therapy techniques made it worse
‘It’s the original ideas around adapting irrational thoughts – the “cognitive” part of CBT – that seem to have trickled most into the mainstream.’ Illustration: Rita Liu/The Guardian
The first time I learned about cognitive behavioral therapy (CBT), I felt the pleasure of recognition and of superiority. I was in high school, and it would be years before I visited a therapist of any kind, but from what I gathered online, CBT consisted of what I was already doing.
The modality grew from a core belief that irrational thoughts are responsible for emotional suffering, according to Rachael Rosner, a historian writing a biography of Aaron Beck, the father of CBT. It followed that changing these thoughts could alleviate the distress.
Perhaps you’re afraid that your headache is a sign of a brain tumor. The CBT “thought record” technique might advise you to gather the facts for and against this fear. Is there a family history of brain tumors? Could the headache be caused by dehydration? Then, you reframe it into a more realistic, and presumably less panicked, position.
This back-and-forth volley already described my inner monologue. Years later, I chose for my first therapist one who practiced an old-school form of CBT that reinforced these habits.
It was easy to find such a therapist. Though exact statistics are scarce, CBT is a common modality. Many practitioners consider it the gold standard of psychotherapy and use it for conditions including anxiety and depression. By 2002, the Washington Post was claiming: “For better or worse, cognitive therapy is fast becoming what people mean when they say they are ‘getting therapy’.”
Its concepts “are very mainstream now”, says Sahanika Ratnayake, a philosopher of medicine and psychiatry. “You hear people talking about ‘cognitive distortions’ and ‘reframing your thoughts’ and this idea that how you think about something changes how you feel about it.”
Yet despite being fluent in these techniques, I remained trapped in rumination. Knowing all the cognitive distortions – types of negative bias or irrational thinking – didn’t lessen the worry. No matter how much evidence I gathered to prove that a worry was unlikely, I couldn’t forget that improbable things do happen. People were struck by lightning, planes did crash, headaches did turn out to be tumors. Eventually, I switched to psychodynamic therapy (more focused on feelings, more helpful for me) but continued my inner debate tournament.
Then, in my 30s, I was diagnosed with obsessive compulsive disorder (OCD), a condition marked by intrusive thoughts and physical or mental compulsions to get rid of the thoughts. This delay wasn’t uncommon: diagnosing OCD can take up to 14 to 17 years, in part because it can be hard to differentiate from other disorders such as anxiety. During that time, those thought-challenging techniques can backfire. They did for me.
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The story of modern CBT is, in part, the story of being in the right place at the right time: the US in the 1980s. After the Diagnostic and Statistical Manual of Disorders III, the handbook for diagnosing mental disorders, came out in 1980, the National Institute of Mental Health started requiring that researchers conduct randomized controlled trials for therapy if they wanted funding. By then, Rosner says, Beck had already created a manual for CBT so that it could be standardized and studied in this way. This meant CBT therapists could adapt quickly to the new rules, and the techniques took off.
As insurance companies warmed to CBT, therapists developing new modalities liked to associate with CBT too, partly so these forms could also be covered by insurance, according to Ratnayake. Today, CBT is a broad label that can include mindfulness skills and distress tolerance skills, for instance.
When I stopped trying to think rationally, my mind felt freed
Still, it’s the original ideas around adapting irrational thoughts – the “cognitive” part of CBT – that seem to have trickled most into the mainstream. Behavioral and exposure-based CBT techniques are effective, but therapists can be less likely to use these methods, says Dean McKay, a psychology professor at Fordham University. Articles mentioning CBT tend to emphasize the “distorted thinking” aspect, as do most free worksheets – all contributing to the mistaken idea that CBT is primarily about being rational.
Cognitive techniques work for many. But “the typical OCD sufferer already knows the evidence”, adds McKay, who has researched the potential harms of CBT-type interventions. For them, evidence-gathering becomes just “another form of reassurance”. Reassurance (“of course you won’t die after eating food off the ground”) helps people with OCD feel better in the short term but reinforces the fear long term (“what if I’m the freak exception who will die?”), so they end up needing more and more comfort.
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Oddly enough, the first-line treatment for OCD is a form of CBT – just not the type that many would associate with the label. The difference in approach is clear in these practice phrases from a guidebook for people with OCD: There is no way I can guarantee I won’t stab my husband. Despite my best efforts, my neglect might cause a fire at work. I can’t be sure that my spouse will remain faithful to me.
This type of treatment, called exposure and response prevention (ERP), doesn’t try to dispute thoughts. It encourages patients to expose themselves to fears, either in a real or imagined situation, accept that it could happen – and not do anything to relieve the fear. Instead of reaching for the reams of evidence that you won’t stab your husband, live with the possibility that you might.
To me, this approach was more helpful. As someone who would obsess over the 0.0001% chance I could be struck by lightning, acknowledging that chance feels like facing reality.
When I stopped trying to think rationally, my mind felt freed. I no longer needed to constantly remind myself to stop catastrophizing. I had permission to stop sifting through piles of research in a search for certainty. Instead, I started practicing ERP whenever the fears began. I can never be 100% certain that I won’t develop my mother’s disease, I would think, despite “knowing” that her illness was due (almost certainly) to bad luck.
At first, I flinched at the idea and pressure grew in my chest. But with time and repetition, my mind became less prone to these looping thoughts. And I began thinking about how this approach could help beyond OCD.
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O’Dunne, the chaplain, leads online groups for people navigating faith and OCD, but the community has started to include those without the disorder. “A lot of people who have navigated religious trauma or spiritual abuse or really rigid spiritual communities have been told for such a long time that they have to have certainty,” she says. “It’s been such a harmful dynamic.” To her, ERP isn’t just a treatment but rather “a beautiful, healthy lifestyle of uncertainty”.
In fact, “intolerance of uncertainty” is correlated with many conditions, including generalized anxiety, OCD, social anxiety and eating disorders, according to Mark Freeston, a psychologist at Newcastle University who has studied the concept since the 1990s. Instead of focusing on cognitive distortions, Freeston and collaborators help patients accept physical signals of uncertainty.
For example, patients play a children’s game where they pass around a spring-loaded toy. Because people know the outcome – the toy pops up – but not when it’ll happen, they learn to identify “temporal uncertainty” and realize that the feeling doesn’t mean a situation is dangerous. They can experience uncertainty and still be OK. In a study of group treatment that Freeston and his collaborators plan to submit for publication, they found that “making friends with uncertainty” helps decrease anxiety, even if the treatment never addresses a specific worry.
In the end, it’s not that challenging one’s thoughts doesn’t work (it can) or that behavioral strategies work for everyone (they won’t). Some people respond to evidence; they feel its rational force and are comforted. Others may prefer art therapy or internal family systems, a protocol that asks clients to work with different “parts” of their psyche. Approaches that involve analyzing the past can bring insight for some; for others, including people with OCD, focusing on the origin of intrusive thoughts can distract from getting better.
There are many reasons we might suffer, and no approach works for everyone – but for myself and many, with and without OCD, the cognitive form of CBT was the one most often held up to be obviously and generally helpful. For me, this led to simplistic and misguided understandings, both of CBT itself and of what I needed. I loved CBT’s cognitive strategies because the self-questioning came naturally, but for precisely that reason, I needed a treatment that did the opposite. I just wish it hadn’t taken so long.