Posted by mattdds on June 7, 2003, at 21:49:02
In reply to Re: Another CBT question. Very specific. » mattdds, posted by Dinah on June 7, 2003, at 19:54:32
Hi Dinah,
I don't have OCD, so I probably can't understand completely what you are going through. I can conceptualize it, but have not experienced it. I imagine it is tough to deal with ego-dystonic intrusions all the time. My intrusive thoughts aren't ego-dystonic, but I do get all kinds of thoughts I don't like.
If I understand right, you have made a lot of progress in the behavioral department, but not so much in the way of intrusive ego-dystonic cognitions. And that you have sort of a split level of understanding; on one hand you realize it is illogical to worry so much about vomiting, but another (more irrational) part of you doesn't believe it. Did I get this right?
I've been doing some research on CBT thought on OCD, and the idea is *not* to settle for just behavioral improvement, but for improvement as far as the obsessions go as well. I would love to discuss this, and have some ideas, but it will take a lengthy exchange, if you are up for it.
My take is that you do *not* have emetophobia. This is just my opintion, but what you describe sounds more like a fear of a contaminated object (vomit). You are not so much afraid of vomiting yourself? Is this accurate?
CBT-ists call this Thought-Object Fusion (TOF). The belief (on some level) that thoughts can make things contaminated. This sounds a lot like what is going on with the fear of vomit, in your case.
You also described that you used to have to check your work to "make sure" you didn't write obscenities on it. This is referred to as thought-action fusion (TAF) by CBT-ists. There is the belief (on some level) that thoughts are fused to actions. Thinking something means that you will do it (or have done it). Another common example is worry about harming someone you love, like "what if I just stabbed my wife for no reason??!!". The corresponding compulsion would be to get rid of all the knives in the house, or something like that. This is thought-action fusion.
Just out of curiousity, are any of your intrusive thoughts religious (sacreligious?) in nature? This is extremely common. A good example would be a person who has thought intrusions that the devil will appear. He holds a belief (on some submerged level) that having this thought will make the devil appear! So the poor indidual will try to crowd out thoughts of the devil by praying or doing Hail Mary's or something like that. This is classic Thought-Event Fusion (TEF).
So these terms help to conceptualize the problem.
How do we solve it?
It appears you have the behavioral aspect pretty well nailed down. So now you work on the cognitive aspect of it. But here is where it gets tricky.
The goal is *NOT* to get rid of the intrusive thoughts! The goal is to change the beliefs about the meaning of the obsessive thoughts. In other words, freely let the thought intrusions enter. You might have heard about thought suppression experiments; they don't work! E.g. try hard for 30 seconds NOT to think of vomit....................................what just passed through your mind? Of course, vomit!
So trying to suppress the thoughts is not the goal, and will likely reinforce the belief that the thoughts are harmful or have some meaning (e.g. you are bad because you had such and such thought). Don't even try to figure out the cognitive distortions in the intrusions; they are self-evident, and already incredibly obvious to you.
Your problem likely is in your *appraisal* of the intrusions, i.e. fallacious beliefs about what "purpose" these intrusions serve. I remember in one of your old posts you wondered what "purpose" your panicky thoughts had when you were younger, and you said "they must have been important!"
Interestingly, this is where metacognition becomes important. The idea is to simply "watch" your intrusions pass through your mind non-judgementally. One method is to get purchase a golf stroke counter. Each time you have an intrusive thought, you simply make a click. "the vomit is EVERYWHERE" - click. "gross drunk teens probably barfed right where I was standing" - click. You get the picture. Keep a log of the number of intrusions. Supposedly, they will go up for a few days, as you become more aware of them. Then after a few weeks, they will go down. Try this with one particular set of thoughts once (e.g. vomiting), then move on to others.
I will do more research on this, but I'm quite sure the idea is NOT to try to control the thoughts; this just makes them come back stronger, as I'm sure you know. The goal is passive, non-judgemental observation of the thoughts, which hopefully will eventually de-fuse the thought intrusion from the action or object.
So CBT for OCD is quite different than for depression. It has certainly moved beyond the simple behavioral techniques. The problem is that most clinicians are too lazy/uninformed/busy/or whatever to keep up on the literature.
I got most of these ideas from Arian Wells books, a pioneer in cutting-edge CBT for OCD and generalized anxiety disorder.
"Cognitive Therapy of Anxiety Disorders : A Practice Manual and Conceptual Guide"
"Emotional Disorders & Metacognition: Innovative Cognitive Therapy"
Perhaps your therapist could take a look at these and formulate a treatment plan customized for you.
I'm only scratching the surface! There are many more techniques, but I'm already getting extremely long-winded. I hope I am not going overboard here!
I wish you the best,
Matt
poster:mattdds
thread:230572
URL: http://www.dr-bob.org/babble/psycho/20030529/msgs/232277.html