The below is a first draft of some new ideas that are very exciting to me and that I’m eager to share with patients and clinicians. Please note that these ideas are likely to evolve significantly based on feedback from colleagues and patients.
Please also note that the below is geared towards therapists and those very well acquainted with the theory and practice of ERP. I will try to get a more user-friendly version up soon. In the meantime, I hope the below is helpful.
If you have your own feedback about this article, especially criticism or disagreement, please email me so we can work towards the most helpful approach to this issue. If you try the approach below and it works well for you, please let me know that too.
I believe that the issue of compulsive thinking, or compulsive rumination, is a much more significant one in our field than people – from researchers to therapists to patients themselves – realize. There seems to be a sense that only certain patients employ compulsive thinking, and that patients are always able to identify and thus report compulsive thinking. It is my belief that many if not most OCD patients employ compulsive thinking, and that they and their therapists often don’t recognize that this is taking place. Indeed, for some it may happen so quickly or be so pervasive in their lives that it is identified neither by patient nor by therapist. I suspect that many “treatment refractory” patients are simply compulsive thinkers.
An equally significant problem, and a more upsetting one, is that many if not most clinicians aren’t clear in their instructions to patients about how to handle compulsive thinking. Indeed, many clinicians vaguely suggest using mindfulness, and even worse, many tell patients that any attempt to stop their compulsive thinking is futile because of “thought suppression.”
Two current movements in the field, while surely valuable in general, threaten to make this situation even worse. The growing popularity of ACT threatens to encourage (therapists to encourage their) patients to accept their compulsive thinking, by encouraging acceptance of thoughts in general (to my understanding). Less directly, the movement towards conceptualizing ERP in terms of “inhibitory learning” threatens to decrease awareness of the presence of compulsive thinking by deemphasizing the monitoring of distress levels and lessening therapists’ concern regarding a lack of habituation during exposures – something that is often the telltale sign of compulsive thinking.
Indeed, the fact that lectures on dealing with compulsive thinking are consistently among the best attended by patients at the annual IOCDF conference is one indication that many patients continue to struggle with this issue and lack clear guidance as to how to deal with it.
Our field needs to address this problem. I would like to propose a methodology for addressing compulsive thinking that seeks to formalize concepts and strategies that some experts are already employing. I believe that this approach is best understood within the framework of a model of anxiety disorders that is somewhat different from the one we are used to in CBT.
Although it is subject to debate in the world of cognitive psychology, in the world of CBT/ERP, we typically tell patients that a trigger causes a verbal thought (“obsession”), which causes anxiety, which leads to compulsion.
For patients with compulsive thinking, this model is often unbelievably confusing. Usually, before a patient applies a CBT framework to understanding their thoughts, they experience their mind as an overwhelming jungle of thoughts without any discernible pattern. Within a CBT framework, patients and therapists attempt to separate obsessions from compulsions. On paper, this seems pretty simple: Obsessions are the ones that are about the uncertainty and compulsions are the ones about avoiding the uncertainty. This distinction is absolutely not as easy to make about one’s own thoughts. Perhaps compulsive thinking is a string of alternating obsessions and compulsions? Or perhaps the obsession is the first thought and the compulsion is what comes after that? What seems simple on a conceptual level gets very messy in a mind. Few therapists or even researchers confidently take a side on this. Furthermore, as stated above, few are confident about what patients should do once they label something as a compulsion. Push it away? Isn’t that “thought suppression?” Stop doing it? Isn’t that “thought stopping?” If the issue of compulsive thinking is addressed at all, the patient is often given very mixed messages. The clearest and most frequently repeated instruction is: mindfulness. Just lather it on.
Helping patients to sort this out is aided by discarding the idea that there is a verbal thought that precedes a compulsion. Rather, I believe that awareness of uncertainty/threat – without words – immediately elicits fear, and that patients then volitionally (whether this volition is within awareness or not) engage verbal, analytic thought in an effort to address the threat/uncertainty by figuring something out.
Tendency toward intellectualization (using thought to cope with emotion)
Tendency toward moralization (thinking about what one’s behavior in terms of right and wrong)
Learning experiences →
(Mediation by awareness of threat/uncertainty (nonverbal))
Choice to engage verbal/analytic thinking to address the threat/uncertainty by figuring something out (compulsive thinking)
= subjective experience of “anxiety”
→ Lack of habituation and new learning (including lack of developing self-efficacy for refraining from compulsive thinking), per mainstream models
In this model, there is no “obsession.” Rather, a trigger leads directly to fear by generating awareness of threat/uncertainty, and only then does the individual engage verbal, analytic thought in an effort to address the fear by figuring something out. In my personal experience and having suggested this to my patients, this is consistent with individuals’ subjective experience: there’s no initial thought, just immediate fear. The words come on board immediately afterwards, in an effort to figure out a way to address the threat/uncertainty. Any words we use to describe the “automatic thought” or “obsession” are retrospectively applied.
Furthermore, I believe the ongoing analytical process itself constitutes the direct subjective experience of ‘anxiety.’ Walking around figuring out what to do about a threat that’s not immediately present keeps the person anxious.
How to Stop
Crucially, to my knowledge and in my experience, there is no evidence that “thought suppression” applies to purposeful, analytic thinking such as this. You can’t stop yourself from thinking about a white bear, but you can absolutely stop yourself from solving a math problem. (In fact, this is exactly what people are supposed to do during mindfulness meditation! When they notice they’ve drifted off into “Monkey Mind,” they notice that this has happened with non-judgment, and then they make the choice to disengage and refocus their attention.)
Compulsive thinking is an effort to figure something out, whether it’s what to do or what this means or whether there’s really an issue. The person isn’t just repeating the same thoughts over an over. (If the patient says they “just keep thinking about x,” ask them what they are trying to figure out.) Therefore, again, “thought suppression” is irrelevant.
Based on this, the instruction that we should be giving to patients is: “Refrain or disengage from any analytical thought process about the uncertainty.” For patients with OCD, the idea that you don’t have to figure anything out when triggered is completely novel. This is what’s obvious to people without anxiety disorders that never even occurred to people with them. This will probably require psychoeducation about habituation, how compulsion maintains OCD, and the futility of trying to eliminate uncertainty.
Based on my experience, I believe that patients are unable to refrain from compulsive thinking without certain groundwork being laid beforehand, and that making the choice to consistently refrain is difficult at first. I believe the following steps help:
(1A) Psychoeducation about compulsions as efforts to avoid threat/uncertainy that: prevent habituation, prevent new learning, and usually backfire (per ERP as usual)
(1B) Psychoeducation about employing thinking as compulsion in order to figure something out, including that this is volitional though the choice maybe outside awareness at this point
(2) Identification of core fear (per Dr. Elna Yadin) and its connection to triggers
(3A) Cultivation of awareness that threat/uncertainty and fear precede verbal thought, and of transition to verbal, analytic thought
(If compulsive thinking has become a habit that the patient does even absent a specific trigger, help them to become aware of this.)
(3B) Cultivation of awareness of choice to transition to verbal, analytical thought through identification of how verbal, analytical thought relates to core fear:
“What are you trying to figure out? Why is that so important? What risk would you be taking if you didn’t figure that out?”
(4) Using mindfulness, metaphors, and everyday examples to teach the ability to disengage from an analytical, verbal thought process; showing that people do this all the time in everyday life; addressing confusion about “thought suppression.”
(5) Instructing patient to make the decision to refrain or disengage from compulsive thinking every time, explaining importance of consistency/intermittent reinforcement/in or out, no in-between.
(6) Troubleshooting and repeating above steps as necessary, especially by addressing justifications and other sources of ambivalence about the choice to refrain from engaging verbal thought process.
Throughout this process, the goal is to subvert the patient’s moralization such that the right thing to do is no longer “to figure this out” but rather not to do so.
I believe that this conceptualization has transdiagnostic application. I believe it applies not only to worry, but also to self-criticism, and likely to other rumination-based mental health issues. I also believe it has implications for how we do cognitive therapy.
For example, we usually ask people what their anxious thoughts are; instead perhaps we should be asking, “What are you trying to figure out?” (e.g., if there’s a threat, if I’m bad, if I’m in control, if I’m unattractive) and “Why? What risk would you be taking if you stopped trying to figure that out; what are you actually afraid of that’s motivating you try to figure that out?”
We usually ask people (not in OCD but in other issues, such as self-criticism and GAD) to refute their anxious or irrational thoughts; but perhaps that just keeps them engaged in analytical thinking and ‘figuring out,’ as we know it does in OCD. Many people don’t respond to cognitive therapy, and if they do, they still have to constantly refute their negative or catastrophic thoughts.
The goal of the above, would be to build awareness of the choice to analyze, and to build a case, not against the irrational or unhelpful beliefs, but against the choice to analyze, in and of itself.