Gail Steketee, Ph.D.
Master Lecturer Gail Steketee Offers Cognitive Techniques for Treating OCD
On April 1, Boston University's Dr. Gail Steketee addressed New Jersey ACT members at the sixth annual Master Lecture. Her workshop, "Cognitive Treatment of OCD," was loaded with cutting-edge information and techniques. Here's a sampling:
Exposure and response prevention (ERP), the mainstay of OCD treatment, is primarily useful for OCD's most disruptive symptoms: compulsions and thought compulsions. But Beck's Cognitive Therapy can be modified to address the more subtle and pervasive cognitive problems associated with OCD. A recent meta-analysis found traditional ERP less effective than Cognitive Therapy without exposure but including behavioral assignments designed to disprove dysfunctional cognitions.
Cognitive Distortions in OCD
Dr. Steketee urged careful assessment of the OCD patients’ cognitions. She explained that their distorted thinking falls into six domains:
1) Over-importance of thoughts and the need to control them - OCD patients experience their thoughts as abnormal. They frequently display "thought-action fusion," the belief that having a thought makes it come true. Since their thoughts are so dangerous, they also believe they must control them.
2) Overestimation of potential harm - OCD sufferers overestimate the possibility of danger and the consequences making mistakes. They experience too many situations as dangerous and assume that terrible outcomes are extremely likely.
3) Excessive responsibility - OCD patients believe that their “abnormal” thoughts cause disaster and that “normal” thoughts prevent it. They also overestimate their responsibility for an event and underestimate or ignore other influences. As a result, they are extremely vulnerable to guilt.
5) Intolerance for emotional discomfort - Beliefs that they will go crazy, lose control, or be humiliated if they experience too much anxiety seem to play a role in the maintenance of OCD rituals.
6) Fear of positive experiences. Some OCD patients believe they do not deserve or cannot sustain positive experiences in life. If they relax and enjoy themselves, they become anxious and symptomatic.
CT for Symptoms
Traditional Thought Records (a la Beck and Ellis) should be used to monitor and modify faulty OCD thinking. In addition to recommending behavioral experiments to disprove irrational beliefs, Dr. Steketee described more than a dozen cognitive techniques. Here's a sampling:
1) Thought Suppression Test - Ask patients to alternate between suppressing an upsetting thought and not suppressing it. (Dr. Steketee recommends using blocks of 3 or 4 days.) Ask patients to keep records of the intensity of their anxiety and the number of intrusive thoughts they experience during each condition. This experiment helps patients recognize that trying to suppress their obsessions actually increases them, and it motivates patients to passively allow distressing thoughts to flow into and out of their minds.
2) Pie Technique - Develop a list of factors that might be responsible for a potential negative event. Draw a large circle and ask the patient to assign a percentage of the pie to each factor, asking about the patient's responsibility last. Patients usually wind up assigning themselves much less responsibility when they look at their fear in this way.
3) Taking Another's Perspective - Ask patients to conduct a survey to determine if significant others see the fear as they do, or ask them to role play being the therapist and responding to their concern, or a judge and jury evaluating the evidence for and against their fear.
4) Betting Money - Ask patients how much money they'd be willing to bet on the likelihood of the outcome they fear.
5) Calculating Danger Probabilities - Ask patients to enumerate all the steps that lead up to their feared outcome. Then ask them to assign a probability to each step. Calculate the probability of the feared event by multiplying the probabilities of each step.
CT for Core Beliefs
Beliefs from the six domains reinforce more entrenched core beliefs, or schemas, that were developed in childhood. Some core beliefs of OCD patients pertain to the patients themselves: "I am a bad person," "I am a dangerous person," "I am a weak and vulnerable person," "I am out of control." Other core beliefs relate to OCD patients' views of the world: "people are not trustworthy," "people will reject me," "the world is a dangerous place," "people are vulnerable and I must protect them."
To help patients recognize their core beliefs, Dr. Steketee recommended the Downward Arrow Technique. Here the therapist repeatedly asks "if that were true, what would it mean?" until the patient arrives at the core belief.
Modification of core beliefs is a collaborative effort. Therapists and patients should agree on the beliefs to be modified and on the adaptive beliefs they want to establish. Since core beliefs change slowly, it is helpful to assess the strength of the old and the new core beliefs periodically during treatment.
Once patients accept the idea of changing their core beliefs, therapists should devise behavioral experiments and cognitive strategies that strengthen the new, adaptive core beliefs. For example, "If you weren't a dangerous person, what would you do, think, and feel when you drove over a bump in the road?” Here are some additional cognitive techniques that are useful for modifying core beliefs:
1) Re-structuring Early Memories. Ask patients to recall a painful early experience that is relevant to a dysfunctional core belief. Try to heighten patients’ emotion so that they re-experience the event. Then, help patients use current, adult knowledge to develop a new understanding of the early experience. Guided imagery, role-playing, and Socratic questioning can be helpful.
2) Making Extreme Contrasts. Ask patients to describe someone who epitomizes the negative core belief. Then ask patients to compare themselves to this individual.
3) Metaphors and Stories. Remind patients of stories and metaphors that disprove their core beliefs. For example, Cinderella illustrates how parents can treat a child as though she were bad when she isn’t.
Dr. Steketee also reminded us that there is little evidence supporting the necessity of medication to supplement ERP or Cognitive Therapy in treating OCD.
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