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“My Life in Pictures” OCD and CAT

Kimber-Rogal, N., 2008. “My Life in Pictures” OCD and CAT. Reformulation, Winter, pp.7-13.

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Introduction

Many patients present with obsessional thinking which, although indicative of Obsessive-Compulsive Disorder (OCD), remains unclassified because the behavioural component of the typical OCD profile is either obscured or attenuated.  This paper shows how if undetected such thinking can prevent positive therapeutic outcome. Conversely, early assessment and diagnosis, together with contingent response- prevention, can aid a time-limited CAT-based therapy. Therapists are alerted to cases where the cognitive component of the presenting problem may be fully or partially indicative of OCD, and where the patient’s cognitive style and content is distinct from a typical cognitive bias.

Obsessive Compulsive Disorder (OCD)

Biased cognitive processes, including self-regulation strategies, meta-cognition, and attention biases (both in performance tests and self-report measures) are seen as a feature of anxiety disorders, of which OCD is one. Typical OCD symptoms include:

• Repetitive thinking (`Cognitive Looping’)
• Intrusive thinking (`Cognitive Hijacking’)
• Obsessive self-doubt
• Indecisiveness
• Obsessive self-blame
• Ideation surrounding harm and responsibility
• ‘If only/what if’ thinking
• Preoccupation with contamination
• Reassurance-seeking
• Reparation: neutralising and balancing
• Desire for certainty
• Over-responsibility

Traditional cognitive-behavioural interventions have considered obsessional thinking and associated compulsive behaviours as indicative of anxiety and attempts at control, respectively, and have focussed on behavioural non-response. For example, “If I do not tap the table five times, my mother will die”.  The patient is asked to refrain from the compulsive behaviour (table-tapping) and challenge the assumption (obsession) that the mother’s life is dependent on their actions. Logic is employed and faulty beliefs challenged. Scales of anticipated catastrophe are calibrated and direction given. Primitive and magical thinking patterns are highlighted and rational conclusions made. Most importantly, the patient learns to tolerate feelings of anxiety that inevitably surface when the controlling behaviours are prevented.

However, fear of an outcome or event happening is not the only measure by which to judge OCD.  For some patients the feared outcome is more thinking itself: repetitive ‘If this-then that’ and ‘What if-if only’ thinking which goes beyond logical, practical, everyday problem-resolution.

But what about a patient who lives a predominantly dissociated life, one who paradoxically fears something not happening, whose fear was more of the same, of  repetitive and involuntary images running her life; pictures which denoted an inescapable and hopeless life forever?  Such was the ideology of Mrs T, a high-functioning professional whose case, initially and superficially, included very few overt behavioural signs and symptoms of OCD . Whilst differential diagnoses may be made, suffice it to say that Mrs T presented with enough symptoms to qualify predominately for obsessive-compulsive syndrome as well as arguably exhibiting symptoms of PTSD.

OCD and PTSD

Symptom overlap may artificially inflate the significance of a co-morbid relationship between OCD and PTSD (Gershuny et al, 2005), but the role of traumatic experience in the genesis of OCD is well-documented (eg de Silva, 1999) . Fontenelle (2007) states that the severity of dissociative symptoms is not significantly different between OCD and PTSD. Interestingly, patients with OCD are less vulnerable to traumatic events because they have already dissociated. Moreover, many chronically traumatised children and adults have complex adaptations to trauma that are not captured by the PTSD diagnosis (Bessel van der Kolk, 2008).  

The relevance of PTSD to Mrs T’s case is that her intrusive thoughts took the form of a `screen’ – a picture of a school timetable onto which she superimposed life-events, past and present. It was as if, every day, from her first waking moment, she put on a pair of glasses with a timetable on it and through which she saw (and lived) the world. As far as she could remember, this was introduced at a time when things felt very unsafe at home. Not one acute traumatic incident, typical of PTSD; rather, these images took form when she began school – a place within which she found safety, away from the explosive, expressed emotion within her family home. The images had initially protected her but later came to compulsively control and dominate her life. She wanted to be rid of them.

OCD and Dissociation

Dissociation is a process of separating one part of the inner self from others. Splintered-off events and experiences become inaccessible to normal thought processes which, in turn, become intrusive.  These deeply embedded and dissociated values, beliefs, and behaviours nonetheless maintain disturbances in living and relating.  Were events to be processed consciously and contingently – acknowledging talking, thinking, and completing acts of defensive protection – they would remain available for further processing until they began to hurt less. Notably, what happens at the time of the trauma is less predictive of PTSD than the persistence of post-traumatic avoidance which is exacerbated by having no protective or reliable other with whom to process the event.  But when a memory is fixed in isolation, dissociation has occurred and psychological symptoms are likely to ensue. The memory was too terrible for the individual to process spontaneously and trauma has caused the body to shut down or freeze.

Dissociation is on a spectrum; it is not always a disorder and some people have an innate ability to dissociate easily. Whilst PTSD is the best example, a loss of memory for early childhood would also indicate some degree of dissociation. Risk factors in dissociation include genetic makeup or heritability, lack of supportive or comforting persons to turn to plus the immediate influence of other relatives who also have dissociative symptoms.

The Self

A discussion of the constituent parts of the self is beyond the scope of this article. Suffice it to say that the psychological self develops in childhood and exists in relation to the other. This process involves language, dialogue, behaviour, cognition and affect, together with the metaphysics of spirituality and cultural transmission. In CAT terms, rehearsed reciprocal roles become habitual and constitute a large part of what the person considers themselves to be . This external to internal process can be seen at any age in life in, for example, learning by rote, which at first requires effort, repetition and visualisation but later can be recited without thought.  CAT aims to name and access the `unconscious’ or automatic self.

Children may be assigned a role for which they were ill-prepared – too much responsibility too young , `a child with a job’ or `parental child.’ This highly stressful way of coping can, in itself, lead to low self-esteem and confidence: the child will never be able to `get it right’. Later on, symptoms such as indecision and lack of commitment may be part of endogenous anxiety and manifest specifically as OCD, or indicate a reciprocal role of `not-good-enough’ in response to the parent. Whatever, the root causes, avoidance of attendant Core Pain ensues: in CAT terms, avoidance of Core Pain drives Reciprocal Role Procedures. 

More generally, the self may be seen as comprising cognitive, affective (emotional), behavioural and metaphysical or spiritual components, with a neurophysiological substrate. Patients can usually apportion their self-view - either partially or wholly - to these categories, and most will be able to give some indication of where & how they see their true or core selves. They may have a picture of themselves occupying one area or another of their being; eg, head or stomach. They may see a (forlorn) young self, or identify with particular self-talk, verbal memory and so on. Alternatively, thinking in images can predominate, such as the timetables cited in Mrs T’s case and - equally unusually - a Monopoly board around which one patient trudged, either keeping in or out of sync with where they felt they `should’ be at any given time.

In summary, Mrs T’s intellectualised dissociation had left her emotionally frozen. She experienced her life in her head, in pictures. Everything – all internal and external life -- went through a retinal filter, such as a microfiche image might make when laid on top of a screen or a pair of special spectacles may superimpose a grid over the visual field. She never considered that these images were “just” thoughts.

The Self-in-relation -  the Therapeutic Alliance and CAT

Notwithstanding difficulties in measurement, meta-analyses comparing models of therapy show that human-relational or non-specific factors are the strongest indicators of therapeutic outcome (Shapiro, 2001). The one consistent and reliable variable affecting the outcome of therapeutic intervention is the relationship itself.

CAT explains the connections between early patterns of relating and present problems and aims to help people to co-exist with aspects of the self and others more peaceably.  The (relational) self is designated through Reciprocal Roles:  internalised aspects of the primary caretaker (internal parent roles) and paired responses to these (internal child roles), such as, ‘rejecting to rejected’ and ‘controlling to controlled’. The extent to which these selves or part-selves are accentuated and integrated determines the psychological well-being of the individual. Fixed and polarised roles (eg bully/victim) predict mental ill-health or dysfunction.

Role-pairs are not only experienced as and within the self but are also located in others.  Once located, others are invited, knowingly or unknowingly, to reciprocate in a habitual and predictable way.  Unfortunately, this often causes the individual problems and poses questions regarding human nature’s apparent desire for pleasure and avoidance of pain: we seem to elicit roles in another with which we are familiar, regardless of the difficulties inherent in these role re-enactments.  Roles involve behavioural, affective, and cognitive components. Therapy aims to identify and positively adjust the maladaptive responses played out with self and others, including those enacted transferentially during sessions.

Mrs T and I reflected on how the self developed, how much of the self could ultimately be known and, on this basis, how much `cure’ could be expected. We talked about three areas of learning and life – firstly, what is learned and forgotten (early life learning, the amygdala and primitive neural pathways); secondly, what is `real’ in terms of agreed objective reality; and thirdly, what remains mysterious (the metaphysical and invisible). On this last point, it is noted that every patient will have a world-view, be it theist or atheist, and ascertaining how doctrine fits with symptoms is important and merits further research.  Although she described herself as a religious person, Mrs T’s sense of hope, in particular, when we first met, was minimal.  Throughout the early part of therapy she remained wary and unconvinced, contrary to increasing evidence, that the `school timetables’ or ‘plans’ would ever fully go.

By no means the least important element is the therapist who must have “being-focussed qualities and skills” in order to help patients clarify their “deeply embedded and dissociated values, beliefs, meanings and behaviours that serve to maintain disturbances in living and relating” (Spinelli, 2007). Patients predisposed to inherit OCD will find that relations with others will inflame or dampen the condition.  The relationship with the therapist is crucial in terms of trusting that person to be a contributor, and not a contaminator, to healing.  Moreover, the patient needs to be able to distinguish, in their everyday life, between those who contaminate (exacerbate or maintain symptoms) and those who contribute (to reduced distress).

Measures of a positive therapeutic relationship or alliance can be found in the degree to which the patient can:

  a)  Form a trusting relationship with the therapist
  b)  Develop the courage to risk changes and experience feelings.

In terms of therapy, establishing trust with an untrusting patient is by definition difficult. It is a given that a secure founding relationship in childhood is paramount and that separation and individuation can only ensue if attachment has occurred. Poor or inconsistent parenting leads to a lack of trust, followed by reduced exploration, risk-taking and healthy trial-and-error. This in turn, leads to a lack of mastery, courage, and confidence for the challenges of life. Furthermore, the establishment of roles such as ‘criticising-criticised’ results in fear, worry, and continued lack of opportunity to rehearse good enough roles with others and the self.  Without courage there is no risk, without risk no growth, and without growth no life. In CAT, the scaffold of the alliance offers a framework in which to safely identify, isolate, and address the roles and procedures which have contributed to patients’ distress.

Summary of Introduction

This paper will describe the case of Mrs T, using an eclectic but cognitive analytic-based therapy where the following steps guided positive outcome:

1. Recognition and acknowledgement: problem statement and diagnosis
2. Reciprocal Roles and Relationship formation
3. Recognition and reformulation: Making sense of the images
4. Revision and Change

Case Study

The following extract represents a summary only of Mrs T’s case. It is not a sessional analysis nor will it detail the use of specific CAT tools. Additional and relevant descriptive material, together with key points in the process of therapy, will be outlined under Hypothesis and Treatment Sections, below.

When we first met, Mrs T launched straight into a discussion about the relative merits of going or not going to a wedding in Scotland.  There was little, insight or self-reflection, no familial narrative nor discursive element to the session.  The obsessive nature of the disorder, and the extent to which she was in the grips of it, was apparent at this initial meeting, and a fear of compulsively acting out the obsession was strong.  I wrote a letter of thanks to the referring psychiatrist for this interesting and intelligent patient who presented with clear symptoms of OCD, attendant generalised anxiety, and depressive bias.

By the second session I had already taken a behavioural and containing approach to the wedding dilemma by not allowing the Scotland visit to dominate the session. I spoke candidly to Mrs T about my understanding of her problems. The presenting problem (“Should I go to the wedding in Scotland?”) was diagnosed as symptomatic of OCD, and the intrusive thinking which it exemplified was reframed within a CAT Target Problem: “I don’t know how to tolerate strong feelings”.

This transparent approach served as a wake-up call for Mrs T: someone had “named the beast” and enabled her to voice her most-feared thoughts. These were as follows: “What if I never get over it?” (What if’s, If this/then that); “I will cause harm” (fear of damage);”How can I make amends?”(attempts at neutralising, reparation); “I’ll never know if it was the right decision.” (reassurance-seeking, desire for certainty) and lastly, but most intriguingly, “I’ll always see it on my plans”.  This ideation not only typified OCD but, as I discovered later, also revealed idiosyncratic learned thoughts and behaviours from Mrs T’s past. 

Mrs T eloquently reported her historical state as one of “the living dead” and “quiet desperation” – neither being able to let go, nor to fully engage in the present.  Her strongest and most persistent complaint was that of not being able to lose “the plans”.  These plans, as it transpired, were not plans in the normal sense at all; rather they were intrusive thoughts in the shape of school timetables, year planners or wall charts that popped up as retinal images, similar to an eye floater, and with which she was totally identified.  She was a walking head.  She was always placed in her mind’s eye somewhere on these charts –like a chess piece or counter on a game board – which were also inextricably linked with right/wrong, good/bad, fearful/safe dimensions. If she had done something `wrong’ on a Tuesday she would unwillingly visualise Tuesday without the `crime’ and lament:  If only she had done it differently.  If she had to do something next Thursday, all the feared days before would pop up – What if…. She would then laboriously and anxiously hold herself, picking her way through until she got there – only to find that she had omitted some crucial detail, not “tied up a loose end” and spiralled back into self-recrimination – if only.

The traumatic experiences in childhood were paired with non-volitional specific images which, in later life, tormented her. On this basis, the images could be seen as indicative of PTSD: they were introduced at a crucial developmental time (hence the age-specific nature of the image) and acted as a last-resort defence for a frightening and unmanageable world. However, the solution had become the problem: images that once acted as a refuge had become another symptom to manage and extinguish.

As we continued to meet, it became apparent that she was often gripped by `dilemmas’, each one tied to images of plans that denoted life as caged, repetitive, and futile. “If I don’t send the thank you card, I’ll never get over it.” “If I don’t make the phone call, go back to the same place and think a different, overriding thought (make reparation), I’ll feel bad forever.”  At the start, she did not realise the extent to which a compulsive, behavioural element was present. In fact, many of her behaviours, such as placation and over-activity, as well as her choice of partners, were avoidant and compulsively controlled by these thoughts.  Eating and drinking patterns, as well as relationships with family members, were similarly driven.  She had become divorced from her natural desires and was therefore living outside her life. Although apparently unpleasant and undesirable,
all strategies gave her a `fix’ in that they fed
obsessions and precluded pain.

The plans had, she told me, been her “life” – a paradox, since they denoted replication, repetition, and changelessness – a denial of life.  Although desperate to be rid of them, she realised that they may have offered secondary gain in the sense that they gave meaning and safety to both her internal and external worlds.  She also realised that, whilst once adaptive, the cost of these images had come to outweigh the benefit because they represented a prison from which she could never escape.  Every week, month and year ahead would be the same, the essence of futility or hopelessness and, arguably, symptomatic of a chronic low level depression. 

Mrs T was the second child in a family of four children and her upbringing was reportedly chaotic, the atmosphere at home being menacing and ambiguous with many veiled threats and double bind messages. “I never had a moment’s peace.”  Father was experienced as frightening and bullying and mother as honourable but weak – a victim. High levels of criticism and emotional expression were reported. Anxiously clinging to mother precluded any moderating effects of sibling kinship; in fact, her other siblings compounded the problem with their criticism and envy. However, school was a safe haven for her.  Although she was often absent, she loved the protection and structure it offered.  The imagery that currently haunted her was a direct replication of the timetable she was given at around eleven years. 

Mrs T had tried many types of therapy before: phenomenological-existential, CAT, humanistic, but never been told that her symptoms were classically OCD.  Although this came as a surprise to her, it also offered great relief, opening up the opportunity of locating, objectifying, isolating and discerning symptoms so as to make changes, initially, at a behavioural level.  I pointed out that coping strategies are put in place to permit survival. The strategy of dissociating, through imagery as well as intellectualisation, placation, and performance, had allowed her to function highly in many areas.  She began to realise that letting go of the images might be a slower process than anticipated. Since she had identified them as “life”, to be without them could well leave her initially feeling vulnerable and her life meaningless.

However, hope of change was instilled after the first response prevention (no trip to Scotland). I stressed to Mrs T the importance of trust and courage in successful therapeutic outcome, and we worked eclectically, sometimes intervening at the cognitive level (thought stopping and changing, meditation, substituting distressing images for calming ones, challenging beliefs, education), and sometimes at the behavioural level (resisting compulsive behaviours).

A number of turning points occurred during the first few months of therapy, and Mrs T responded well to the above interventions. For example, she was very distressed when prevented from compulsively sending a placatory thank you card to a friend. She did not in fact want to send the card but felt compelled to neutralise any (perceived) ill feeling following an argument.  Merely the thought of not sending the card generated considerable anxiety.  We rehearsed behavioural techniques and substituting activities, and at our next meeting I was delighted to hear that the card had not been sent.  In this instance, Mrs T had attended an art class instead and the dreaded impossibility of surviving unmanageable feelings had not occurred. She had not been `hijacked’ by obsessive thoughts. Having resisted the compulsion, she felt dramatically relieved and, for the first time, the images abated. Things suddenly appeared normal and un-driven for her (she was no longer in her head, in her plans). She did not have to manage her being, but could just `be’: “Look, no plans!” This state could not have been contemplated, since she had spent all her life in a state of constant vigilance – both of self and others.

A second and significant period during therapy surrounded a dilemma about changing her father’s housing arrangements. This reached climactic proportions and left me feeling briefly at the time that she may benefit from some medication.  However, after much vacillation and rearranging of her father’s affairs, she emerged - acknowledging the effects of her OCD along the way - much stronger.  She felt it was the “all time low” in therapy, but a necessary crisis and significant time of learning and recovery.

Mrs T improved greatly in the first six months of therapy: her obsessive thinking following an event or when a decision had to be made was reduced by half and any compulsive behaviours significantly attenuated.  She had individuated to a great extent from family and friends and – most importantly – taken a leap of faith in me and my therapeutic skills.  Her insight into the illness and the extent to which it was driving her obsession was admirable.

Treatment Analysis

In CAT terms, treatment was approached as follows:

1. Target Problem and Reframe: re-statement of presenting problems and diagnosis
2. Reciprocal Roles – Relationship Formation
3. Recognition and Reformulation - Making sense of the images
4. Revision and Change: Cognitive and Behavioural challenge.

Mrs T thought that her actions were driven by a fear being of being imprisoned in the `plans’ in her head (dissociated) for ever. However, I told her that these images were merely thoughts. Moreover, that the thoughts themselves, as well as her fear of them, were disguising an underlying fear of unprocessed feelings associated with repeated traumatic events in early life. Thus the challenge of therapy was to:

1. Recognise and acknowledge the status of the pictures (plans) as thoughts
2. Recognise and monitor verbalisations such as If this/then that, What if, and I’ll never get over it/It will always haunt me.
3. Challenge self-talk and beliefs that could be accessed verbally– eg Everything I do is wrong, I’m not good enough, must try harder…
4. Discern OCD from non-OCD actions and thoughts.
5. Allow the thoughts (images) to intrude and to feel anxious, whilst behaving rationally.
6. Tolerate the feelings until desensitisation occurred. This, in turn, would extinguish the obsessive thoughts, called `plans’ and experienced as reality.

Rather than detail each stage, this linear process is categorised into a Tools of Therapy section, below. It is consistent with cognitive, behavioural, and affective/analytic approaches as well as CAT’s notion of therapeutic progress according to the `Three Rs’ of recognition, reformulation and revision. Moments of recognition are included in the cognitive element of therapy.  Revision may include both behavioural and cognitive measures. Moreover, acknowledgement of reciprocal roles and how these are enacted during sessions are seen as inherent to a trusting therapeutic alliance – the `Fourth R’ of relationship-formation. Lastly, the exposure of core pain, via response prevention, is fundamental to outcome: only through (re)experiencing the feared aspects of self can patients gain the necessary mastery, confidence, and hope.

Tools of Therapy
Analytic - The Therapeutic Alliance

This section covers the psychoanalytical notion of transference and focuses on the relationship. CAT elucidates transferential issues via reciprocal role interactions.  For OCD patients, transference is usually manifest in anxious fearfulness of the rejection, humiliation, and exasperation of the service provider.  In turn, countertransference involves a reaction on the part of the therapist to the fragility of the OCD client.  Patients tend to elicit either overprotectiveness or excessive ambition.  Then, when the slow pace of discernible progress becomes frustrating, there may be an inclination for the clinicians to become the rejecting, exasperated and judgemental people that OCD individuals feared they would be.

Mrs T had attended a variety of therapies but OCD had never been diagnosed. She was relieved to find that there was something well-documented, ostensibly tangible, and clinically categorical to replace what had hitherto been an isolated, frightening world.

Cognitive-Didactic

A crucial part of the distress of OCD patients is ego-dystonia, where the patient is aware that the compulsions are irrational and destructive but feels powerless to control them.  It was explained to Mrs T that what cannot be acknowledged cannot be changed that the two crucial ingredients to successful therapy would be trust and courage. The ultimate goal would be to face feared feelings and to learn to `let go.’

Early labelling of the problem was crucial but tolerable, and Mrs T was at first amazed to think that her symptoms indicated OCD.  Rational approaches were used to enhance recognition, reduce confusion and despair, and bring home the obsessive nature of her illness and looping thoughts. For example, I asked Mrs T to compare two statements:  “If I don’t touch the table, my mother will die.” and “If I don’t apologise to my boss, I will never get over it.”   I put it to her that both statements are indicators of OCD, only the former involves a contingent action or behaviour, table-tapping, that typifies obsessive behaviour to the layman. I also pressed the fact that, rationally, the opposite is true: If she kept up the same `neutralising’ behaviours, the images would continue to intrude and she would be unable to live fully and engage in the reactive present.  Putting it this way was compelling since she could clearly test a hypothesis behaviourally: `If I continue with the same behaviours, things will stay the same; if I stop any neutralising behaviours, this will help the images to extinguish.’

Apart from didactic input, cognitive challenging, rating and reframing, philosophical discussion was used. We discussed the notion that thoughts can be monitored, caught and amended. All this gave hope to Mrs T, as did the idea of the images being thoughts.  In fact, the realisation that the images were just thoughts and not the totality of life was a major breakthrough in cognitive awareness. The what if’s began to lose their charge. She introduced the image of free-wheeling on a bike “Look – no hands!” In other words, she no longer had to exert inordinate control and felt confident that she could cope. There was hope.  In keeping with CAT’s notion of the Observing Eye, objectivity and discernment were crucial parts of the process, and Mrs T became increasingly skilled at identifying which of her thoughts and actions fell into the OCD category. If in doubt she used the list of axioms and mnemonics we drew up (see Appendix 1).

After an initial sixteen sessions, we reviewed every two months with therapy eventually lasting two years.  The following excerpt from Mrs T’s Reformulation letter at Session 6 sums up the criteria by which we continued our work together and monitored progress:

“We have now had six sessions, as well as two assessment sessions. This letter aims to sum up the themes we have spoken about so far, why you came to therapy in the first place, the key reciprocal roles (in CAT terms) we have identified, the procedures you tend to use and ways these may be attenuated or changed.  We also aim to identify the core pain at the centre of your perceived difficulties and what this means to you in terms of developing or hindering your life.

As we think about our discussions, we should think about the key questions in therapy: Is it helpful? Is it hopeful? Is it meaningful or truthful?  I have also pointed out that without recognition or insight, change for the better seems unlikely and we must bear this in mind when reviewing the sessions to date.  You do not have to agree with what I say; rather, we hope to form, collaboratively, a hypothesis or narrative of your own, recognising your stumbling blocks and then actively trying to change them.”

Behavioural Elements

Thought and behaviour-stopping, substitution, focussed attention, replacement of activities, and generally `walking through the fear’ was employed, and I emphasised to Mrs T that is necessary to feel (bad) in order to change.  In other words, there is a necessary pain to be felt through exposure – an experiential and embodied pain which is part of the healing process and which leads to confidence. It is in contrast to a more detached intellectual rationalisation and, paradoxically, it is through this process of engagement that real detachment from or loss of symptoms can occur . Mrs T had spent much of her life, rushing from one thought or action to the next, both mentally and physically – “Too busy to think or Feel”.

Gradually, changes which Mrs T had never thought possible occurred – without an over-intellectualised force of will.  Up to this point she had been over-thinking herself “into a hole” and could not think herself out of it by the same means.  She felt stuck.  But, as therapy progressed, although she would worry over future events, once a decision had been made and an event followed through, she was no longer hijacked by images of the alternative. Moreover, she was not able to conjure up images that hitherto would have tormented her.  She really could make decisions: the neural pathway had been obliterated - disappeared (see eg Schwartz, 2007) - and this type of thinking was no longer an option.  This led to increased confidence. Mrs T was no longer frightened of thoughts.

Affective

Lastly, an important point must be made in relation to self-expression and use of language regarding feelings and OCD.  Patients may, for example, say they feel `depressed’ when they do not carry out a compulsive act.  They may also feel `depressed’ in relation to obsessive thinking.  However, this is not true or pathological depression but part of the OCD profile.  This point overlaps with the philosophical meaning of words covered under the cognitive part of therapy, above. Patients’ self-labelling must be closely attended to and the correct words used to effectively and intelligently describe and communicate unpleasant, but notably ordinary, feelings.

In Mrs T’s case, she felt empty, futile, and hopeless when she feared that her thoughts would continue to loop. Her symptoms may be construed as constituting a chronic, low-level depression but she was not categorically depressed. Whilst her feelings of despair were always acknowledged, the real dynamic affectivity in therapy came from withstanding the fear which followed behaviour-stopping, together with feelings that evolved from uncovering reciprocal roles within the alliance.

Discussion

This case study has shown, firstly, that obsessionality in anxious and depressed patients can obfuscate or truncate therapeutic work.  Once recognised as part of a syndrome, CAT’s active, participatory approach to obsessional thinking can be used to great advantage. The therapist becomes aware of obsessive symptoms in relation to core pain and underlying pathology rather than becoming caught up in the endless dilemmas which patients prefer to focus on.

Secondly, the fearful, negative narrative which typifies OCD cannot be amended at will. Mrs T’s intractable thoughts (images) could only weaken when she was enabled to muster the courage to change behaviours which allowed the hitherto despised feelings to surface.  The talking cures had not been enough for Mrs T; they had allowed her to avoid and intellectualise, remote from feeling the pain for which there is no substitute in terms of real recovery.

Behavioural and cognitive interventions were a necessary but insufficient part of therapy. An essential precursor is trust in the therapist, on which patient courage can grow.  Generally, and in terms of the genesis of the disorder, a multiplicity of factors may be present – some accessible, others not. Whilst anxiety may be alleviated by certain behaviours, it does not explain why the anxiety took root in the first place .

Forming a working hypothesis, based on hearing and understanding the patient’s narrative, is fundamental and interacts with behavioural and cognitive tools. Mrs T’s theory gathered support the more she tested it: “If I obsess and compulsively `act out’, I will continue to have intrusive thoughts; in contrast, if I learn to tolerate and assimilate feelings of any kind (anger, fear) I will be released from anxiety and overthinking.” 

Thirdly, some patients may have been overwhelmed by the directness of the approach, but, for Mrs T, a visible, confident therapist and clear transparent feedback was necessary.  Patients in general and Mrs T benefited from having someone `tangible’ with whom they can fight or from whom they can flee.  Thus, they cannot continue to stay frozen in their heads. In the same way that a child comes to know he exists through the presence and feedback of the other, so must the therapist come forward into the picture.  Patients generally want, but do not always take, direction and information. They must be encouraged to take risks, or to diminish the potential quality of their lives if they cannot do so.  This process takes time and highlights a need for extended therapy . After an initial sixteen sessions we reviewed therapy every two months for two years. We were always aware of time limitation and, despite its length, never considered it to be open-end. Mrs T’s symptoms were unusual and relatively severe. Other cases of obsessional (over)thinking may well take less time.

Lastly, it is recommended that once the CAT profile is established, that an eclectic approach is adopted. Other paradigms such as neural mapping, EMDR, metaphysical-humanistic outlook, exercise, philosophical and didactic elements should be integrated to maximise outcome.

In summary,

1. Obsessional thinking without typical behavioural symptoms can constitute OCD.
2. Undiagnosed obsessional ideation can prevent positive outcome
3. The aetiology of OCD is relational – as is its amelioration.
4. Without acknowledgement and discernment there can be no change.
5. Behavioural and cognitive measures are of significant input to therapy.
6. Trust and courage are crucial to good outcome, as is tolerance of hitherto unmanageable feelings.

Nicola Kimber-Rogal

References

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Van der Kolk, B.A. (2008).   The complexity of adaptation to trauma: self-regulation, stimulus discrimination and characterological development.  The Trauma Centre at JRI.  www.traumacenter.org
Schwartz, Jeffrey (2007). The Mind and the Brain: A Review online, submitted 20.07.07. 
Shapiro, D. A.  and Shapiro, D. (1983). Comparitive Therapy Outcome Research: Methodological implications of meta-analysis. Journal of Consulting and Clinical Psychology 51, 42-53.
Spinelli, Ernesto (2007). Practising Existential Psychotherapy: The Relational World. Sage Publications. London.

Appendix 1

List of Axioms used as a Tool to aid Therapy between Sessions

• Who am I really? – I am not just my thoughts.
• `Walk the walk’. Change the script, change the behaviours ->
• change of feelings.  Am I still the same person? 
• Hijacking and discernment
• (when am I being hijacked by overthinking)
• No acknowledgement  =  no change
• Frozen children - and adults - daren’t take risks. 
• Without risk there is no growth; without growth there is no life
• Life is a Habit
• Life is Maintenance
• Freedom from roles – change the role play and try different ones – do not catch the ball that is thrown; do not get `hooked in’ to old patterns.
• You are better for others doing your own thing; learn to love yourself (with overthinking)
• “Learn to suffer”:  tolerating feelings and letting go is the basis of recovery from anxiety: I can cope.
• Behavioural changes: Walk the Walk: Fake it `til you Make it.
• Don’t do anything which feeds obsession (and thereby avoids anxiety): this is circular and will only make things worse in the long run
• Make snap decisions and stick to them; Be frivolous.
• I have developed my own name (I can discern overthinking from decisions and actions based on ‘ordinary’, problem-solving thinking)
• Monsters grow in the dark:
• have the courage to face things
• Go through, not round

Full Reference

Kimber-Rogal, N., 2008. “My Life in Pictures” OCD and CAT. Reformulation, Winter, pp.7-13.

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