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Obsessive-Compulsive Spectrum Disorders

Cognitive Therapy Continued

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute

Cognitive therapy rests upon the assumption that problematic behaviors result from the dysfunctional beliefs (either irrational or distorted). These beliefs developed in response to prior life experiences. Therapy participants learn to recognize these beliefs do not necessarily represent "The Truth." As such, they should not be acted upon as though beliefs are synonymous with facts. The goal of treatment is to identify, challenge, and replace these automatic thoughts and dysfunctional thinking patterns with more rational and realistic ones. The ultimate objective is to change the core beliefs at the root of the dysfunctional thoughts.

stressed college studentSome automatic, dysfunctional thinking patterns are called cognitive distortions. Examples of cognitive distortions include:

1. All or nothing thinking: Anxiety can result when things are seen in terms of extremes and absolutes because most things have shades of grey. The thought, "If I am not perfect, then I am worthless," creates anxiety because it is impossible to be perfectly perfect.

2. Fortune telling: Anxiety can result when attempting to predict the future without adequate information by assuming a negative outcome is certain to occur. A rather extreme version of fortune-telling is called "catastrophizing." For example, "I am certain I will contract the AIDS virus unless I bleach everything before touching it."

3. Emotional reasoning: Anxiety may develop when feelings are interpreted as representations of fact. For instance, the thought "My feelings are hurt, therefore you must have done something unkind to me," could easily provoke an argument full of false accusations. Clearly, there are many reasons someone's feelings may get hurt that may have nothing to do with the actions of another person. Afterwards, when logic is applied (feelings do not depict facts), the person may feel guilty and anxious about their unfounded accusations and hostile behavior.

4. Should statements: Anxiety is often created when evaluating and judging oneself based upon what one "should" be doing, or should be feeling. For example, "I should be clean and tidy at all times" can result in a standard that is impossible to achieve.

Cognitive therapy also assists participants to examine and challenge their appraisal of an anxiety-provoking event. This emphasis evolves from cognitive appraisal theory.You will recall this theory posits that our emotions are partially determined by our cognitive appraisal (subjective evaluation) of a particular circumstance. Thus, in any given situation a person must judge whether the situation poses any threat to their well-being. Then, the person evaluates whether their resources for coping with the threat are adequate.

Our cognitive appraisals are strongly influenced by our core beliefs. For instance, suppose Jamal grew up in an environment where his parents did not adequately protect him. He may develop a core belief, "The world is an unsafe place." Such a belief will likely cause Jamal to over-estimate the threat of a particular situation. In addition, if Jamal's parents angrily and impatiently corrected his mistakes, Jamal might develop another core belief, "I am inadequate and incompetent." This core belief might lead Jamal to under-estimate his ability to cope with challenging situations.

For people with OCRDs, cognitive therapy may address thoughts and beliefs regarding: 1) the tendency to overestimate the importance of thoughts, 2) perfectionism, 3) an intolerance of uncertainty, and 4) an intolerance of anxiety/discomfort. People with OCD may also need to challenge thoughts and beliefs related to: 1) the overestimation harm, 2) a powerful desire control thoughts, and 3) an inflated sense of responsibility to protect against harm.

Challenging and restructuring these underlying beliefs and distortions leads to a better treatment outcome than simply challenging a person's belief that public doorknobs are dirty Cognitive therapy begins with the therapy participant learning to identify their internal mental dialogue. These ongoing internal dialogs are simply thoughts that run through our mind nearly every minute of every day. However, by becoming consciously aware of these thoughts, certain patterns emerge. These patterns reveal core beliefs.

Therapy participants learn to identify this internal dialog during therapy sessions. Outside of therapy, participants record their internal dialog on homework sheets designed for this purpose. Many people are unaware that their mind is constantly evaluating and judging their surrounding environment, and themselves.

After thinking patterns and core beliefs are identified, the next step is to replace unhelpful thoughts with more realistic, accurate ones. The therapist guides the participant to challenge their thoughts by evaluating their validity. Therapy participants then form statements that are more accurate. Then, whenever inaccurate thoughts occur again, the therapy participants consciously correct themselves by replacing the inaccurate thought with a more accurate statement or belief. For example, Jamal might learn to replace the belief, "I am a failure" with the thought, "I may have failed in the past, but when I try my best, I often succeed." Alternatively, therapy participants may wish to replace dysfunctional thoughts with more affirming statements. "My parents chose to believe I was a failure but I choose to see myself as a success." Cognitive therapy research has demonstrated that when dysfunctional thoughts are corrected, people feel better and their behavior improves as well.

Cognitive therapy emphasizes the element of choice. This emphasis extends to the therapy itself. You may recall that one of the psychological variables that increase anxiety is the lack of perceived control. Therefore, a therapy participant would be asked to reframe the thought, "I must do these therapy exercises because my therapist says I should" to "I choose to recover from this disorder. Therefore, I choose to do these exercises." This slight shift in perspective is very important as it empowers therapy participants to develop the willingness to participate in some of the more uncomfortable behavioral exercises such as exposure and response prevention

 

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