Posted by Dinah on June 8, 2003, at 16:27:27
In reply to Re: Another CBT question. Very specific. » Dinah, posted by mattdds on June 7, 2003, at 21:49:02
>
> I imagine it is tough to deal with ego-dystonic intrusions all the time.
I only wish I was sure they were ego-dystonic. Sure, I know they aren't true. But I am equally sure that they are completely true. Sigh.> 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?
That would be right.
> 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?The emetophobe purists would agree. But the more liberal emetophobes use the term for fear of either vomiting yourself, or having others vomit, or just vomit in general.
>
> 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.
>
Could be....> 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.
>
OK, that I definitely have. If I think I've done something, it *feels* like it's possible that I did it. Reality doesn't seem that well defined from the vividly imagined, or something like that. How do you know *for sure* anything? If I see my keys in my hand, how do I know that I'm not just imagining I see my keys unless I rub my finger along the edge. Otherwise I might just think I picked them up, think I see them, when I really don't. Then I'd be locked out. If I think I wrote something, how can I really be sure I didn't? Even if I check to make sure, how do I know I'm just *not seeing* what I wrote but it's really there? By the way, I'm getting way better at that sort of thing. Way, way better. But it's the way the thoughts work.> 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).
I do have what would be considered scrupulosity, or responsibility OCD. But the thoughts aren't overtly religious in nature. And I don't have thought compulsions, except for occasional undoing rituals if I say something that I think the fates might misinterpret. (And yes, I know how weird that sounds).
>
> 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.I've worked at those techniques. Watching the thoughts float like leaves down a stream. Singing the obsessions. Laughing at them. It helps. But it only goes so deep. Then stops. On a level inaccessible by intellect, there is a certain belief in the thoughts.
>
> 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!"
>
OK, I'm trying to be open minded and flexible about CBT. If you could try to be open minded about what I'm about to say, I'd appreciate it.I really do believe that OCD, in some cases anyway, serves a useful purpose. Mind you, like most dysfunctional coping tools, it also causes problems. And perhaps in some cases it is a simple brain glitch where thoughts repeat. But I really do believe that in some cases it works as a pressure valve, or a better simile might be a controlled burn in a forest fire.
When I first developed it, I was in pretty bad shape emotionally. The only reason I wasn't an early Columbine type shooter is the lack of a gun, and a punitive conscience. And if I had had easy access to a means of suicide, I probably would have acted on it. In the circumstances, having an obsession to divert my attention to may well have saved my life. Constantly thinking about how to avoid vomit, where vomit might occur, planning what to do if someone vomited, directed considerable attention away from my very real life problems. Life problems that were completely beyond the ability of an eleven year old to solve. Even the choice of obsession, vomit, had symbolic overtones that are absolutely obvious in retrospect.
The resurgence of OCD came with my marriage to a terrific man. Such a terrific, disciplined, controlled man that I constantly fell short of his expectations, or (just perhaps) my assessments of his expectations. At the same time, I lost the safety net of being a daughter in my parents home and really entered the adult world. And surprise surprise, my OCD centered around making catastrophic errors. Errors in work, errors in driving, seeing those areas as "bad" because they were potential sources of errors.
And when I got that safety valve largely controlled, by controlling my OCD, other symptoms popped up like Whack the Mole. The OCD somehow protected me from the pressures that an ego held together with spit and scotch tape (or inadequate coping mechanisms in other words) just couldn't handle.
I think any CBT to be truly and completely effective has to reach back beyond the OCD, beyond the obsessions, to the pressures I am unable to handle. And has to be coupled with additional therapy to help me be better able to handle the stresses.
And that doesn't mean I'm anti-CBT. You've given me a lot to think about and a lot to research, and I will do it, and bring the results to my therapist (who really does appreciate CBT). Perhaps I will discover some toolst that will bring me past the behavioral aspects to the pure obsessive aspects.
Thank you, Matt.
poster:Dinah
thread:230572
URL: http://www.dr-bob.org/babble/psycho/20030529/msgs/232445.html