ERP is a type of cognitive behavioral therapy (CBT) and is the gold standard treatment for OCD. So, if a provider says they utilize CBT to treat OCD, that is not specific enough because some cognitive behavioral techniques that are suited for other disorders do not work in the treatment of OCD. In fact, some techniques can hinder or prevent progress and even worsen your OCD symptoms. While many therapists may recommend these techniques with good intentions, the following techniques may further exacerbate your OCD symptoms. Here are some of the most common CBT techniques that can actually keep you stuck.
Thought-Stopping (aka Thought Suppression)
People with OCD experience obsessions, which are unwanted intrusive thoughts, images, sensations, or urges. The obsessions are ego-dystonic, meaning they oppose a person’s beliefs, values, and self-concept. Some examples include sexually intrusive thoughts about kids, violent intrusive thoughts about harming others or oneself, or blasphemous intrusive thoughts that attack a person’s religious beliefs. The person with OCD does not want to be having these obsessions and is deeply disturbed by them when they pop into their brain. As such, people with OCD will often engage in thought-stopping as an attempt to get rid of these unwanted thoughts. Clinicians might see how anxious your intrusive thoughts make you and may prescribe thought-stopping techniques. They may tell you to visualize a big, red stop sign every time you have an unwanted thought enter your brain or even recommend that you shout the word “STOP” when an unwanted thought pops up. Sometimes, a therapist might suggest that you snap a rubber band on your wrist every time you have an unwanted thought as a way to get rid of it and alleviate anxiety. The goal of these techniques, and any other thought-stopping method, is usually to suppress unwanted thoughts or feelings. The problem is that thought suppression does not work.
Why It Doesn’t Work
The more we try not to think about something, the more we think about it. This is evidenced in psychologist Daniel Wegner’s classic research on thought suppression. Wegner identified a rebound effect that occurred when participants in his study were told not to think about something. He found that when someone tries to resist unwanted thoughts, it often leads to an increased surge of the very thoughts that they are trying to suppress. Thought-stopping techniques can also become compulsive rituals that the person with OCD feels compelled to carry out. They might get temporary relief by snapping a rubber band or visualizing a stop sign, which negatively reinforces the behavior. In turn, the person learns and believes that the only way to feel better is to perform a compulsion (like snapping the rubber band), but the relief does not last long—if at all—because compulsions do not work. Compulsions reinforce the obsessive-compulsive cycle. Using a thought-stopping technique compulsively, to suppress or neutralize thoughts and feelings, adds lighter fluid to OCD’s fire. Thought-stopping robs you of the ability to learn that you can be OK while accepting the presence of an uncomfortable thought, feeling, sensation, or urge. It robs you of the ability to learn that compulsions are not necessary.
Providing Reassurance
When we see someone dealing with something difficult, it is human nature to want to help alleviate it. For example, if your therapist sees you in extreme distress, their first instinct might be to tell you that the thoughts are false and will not come true. While reassurance is comforting in most cases, it is harmful for those with OCD.
Why It Doesn’t Work
Beyond initial psychoeducation about OCD, reassurance is a compulsion that leaves the person with OCD wanting more. It may offer temporary relief, which makes the person believe that reassurance is necessary to be OK, but it will never be enough because the OCD brain has difficulty connecting to logic. If someone could tell a person with OCD that the bad thing will not happen and their brain believed it, the person would not need treatment. This is sadly not the case. Even when reassured about the content of their obsession, the doubt creeps back in and the person with OCD craves more reassurance. But, unfortunately, the reassurance does not satiate OCD. Instead, it fuels the person’s urge to seek certainty and leaves them stuck in a never-ending cycle. Along with being ineffective, reassurance gives weight to obsessions and keeps them alive. It pays attention to the content of obsessions when the obsessions are actually unimportant.
Thought Replacement (aka Thought Neutralization)
Another technique that therapists may have clients utilize is replacing “negative” thoughts with “positive" thoughts. The words “negative” and “positive” are in quotations because thoughts, inherently, are neither negative nor positive. They are not good or bad. They are not right or wrong. They simply are thoughts…words that are comprised of letters. While trying to replace your “bad” thought with a “good” one might provide immediate comfort, it’s a comfort that will not last.
Why It Doesn’t Work
Thought replacement is problematic in the treatment of OCD because it is inherently compulsive. It is another attempt by the person with OCD to neutralize or resist unwanted thoughts, which does not work, and/or quell anxiety associated with the thoughts. Thought replacement may also be an attempt by the sufferer to prevent a dreaded outcome from occurring, even though a thought does not have that power. For example, you might have a violent intrusive thought about pushing someone in front of a bus. This thought makes you anxious. To relieve your anxiety, you might feel the urge to replace that “bad” thought with a “good” thought. So, you might respond to the thought by saying “never!” out loud or in your head to counteract the intrusive thought. Thought replacement also falsely legitimizes the importance and power of thoughts, which is the problem in the first place. Like thought suppression, thought replacement makes the thoughts (obsessions) the problem when the problem is how the person responds to the thoughts (compulsions). Replacing a thought with another thought, or suppressing the thought, sends the wrong message to the brain: this thought is dangerous and important. The person is reinforcing to their brain that the false alarms it—the hyperactive fear center of the brain with OCD—is sending off are actually real alarms that should be paid attention to. The brain then sends off more false alarms in an attempt to keep the person safe. Thought replacement can also serve as a form of reassurance, which is a compulsion if the new thoughts ensure the person that the content of the obsessions is false.
Talk Therapy and Analysis of Obsessions
Many people who see a therapist are looking to analyze their emotions and thought processes in order to get a better understanding of themselves and their experiences. Looking for insight or clarity about the content of obsessions is one big compulsion that many people with OCD perform mentally. It is called rumination. The person is focusing their attention on the intrusive thoughts and trying to figure out why they’re having them, what they mean, if they are true, etc. They are doing this to seek certainty that does not exist, which renders rumination useless. Do not pay a talk therapist to perform compulsions in their office! You’ve likely already been down the analysis road time and time again and you do not need to pay a therapist to keep you there.
Why It Doesn’t Work
First, it pays far too much attention to the obsessions when the goal of treatment is to stop over-responding to obsessions that are unimportant. It is the attention paid to obsessions, and over-responding through compulsions, that keeps the OCD brain overestimating risk and danger. Rumination also offers the person with OCD, who has difficulty tolerating uncertainty, a false sense of control. They believe that the more they try and solve something, the more likely they are to find the answer. This sounds a lot like “If I just think about this one more time, I’ll know for certain." It is a trap. Lastly, trying to find meaning within intrusive thoughts implies that they might mean something about the person experiencing them. This is a nightmare for someone with OCD who experiences intrusive thoughts about the last thing they would ever want to think about or carry out. Asking a client with unwanted violent thoughts a question like “Where is this rage and violence coming from within you?” would crush someone with OCD. It would likely intensify the terror they feel and contribute to the false belief that these thoughts are important and bad and that they are bad. Even a mental compulsion is a behavior, as the person is choosing to respond mentally to the obsession. Talking about the content of obsessions is a mental behavior you’ll want to avoid, not one to spend entire therapy sessions engaging in.
The Role of an OCD Therapist
When a therapist works with someone who has OCD, their role is to help the client better tolerate uncertainty, anxiety, and discomfort. It is to better help you accept the presence of uncomfortable thoughts and feelings without resistance and without engaging with them compulsively. If your therapist asks you to stop or replace thoughts, along with meaning-making and offering reassurance about thoughts, it will rob you of the ability to learn that thoughts and feelings will come and go without you doing anything about them. ERP will teach you that thoughts and feelings are not dangerous and that not everything you think and feel needs attention.
