Had several courses of CBT and yet still suffer from anxiety /obsessive compulsions?
Updated: Aug 23
Disclaimer: A course of Cognitive Behavioural Therapy (CBT) should NOT be abandoned part-way through or discarded due to the information in this blog. CBT offers clients many marvellous coping strategies and therapeutic opportunities.
The following information is not to be used as a tool to diagnose or as treatment. When reading symptoms/conditions and behaviours it is a common experience to feel that you or someone you know has these categories. Many people can identify with symptoms/conditions and behaviours and they can be a valued part of their rich character. A 'Disorder' or condition is different to 'character' in that it severely corrodes the quality of life for that person and it is not welcome by the person as part of their continuing life experience. Only a qualified mental health professional can diagnose mental health conditions/disorders. More discoveries in mental health are available for public information that are not covered in this blog. New discoveries may make obsolete some information covered here.
What might be the reason?
There are two contrasting parts to human beings.
1. Our conscious self.
2. Our unconscious and automatic self.
The unconscious automatic part keeps our heart beating and lungs breathing (and more functions) without us having to think about it.
Our unconscious and automatic part also reacts super- fast to keep us safe. Our unconscious automatic part is much faster than our conscious thinking brain.
Have you ever had a situation where a person playing a prank (do not do this!) has sneaked up behind you and shouted “BOO!!” your body jumps – you feel alarmed –you are ready to react? You turn around and realise you are not in danger – it is just a prank.
Why do we have these unconscious automatic reactions?
Imagine for millions of years humans have been hunted by bigger and faster predators. A conscious thinking brain is too slow – evolution gave us a super-fast reaction system- our unconscious automatic nervous system.
At the same time humans being smaller than larger faster predators were able to find safety in family groups- and tribes. In groups we looked out for each other and found greater safety. Our ability to feel safe and connected to others is explored in ‘attachment theory.’
When we feel safe and connected to others with a ‘secure attachment style’ this minimises anxiety.
Insecure/anxious attachment styles can be changed to secure attachments: - This happens in therapy when a compassionate – non -judgemental understanding of self is encouraged. When the client develops reflectiveness and the ability to identify their adaptive insecure attachment behaviours. When the self-esteem of the client is restored, and they are able to change insecure attachment behaviours for secure behaviours.
The changing of insecure attachment behaviours for secure behaviours gives a person suffering anxiety the chance to have good experiences and to make wiser life choices.
Evolution developed our conscious thinking brain. We found safety and connection in our human groups, and we were able to communicate in more intricate ways using our sophisticated conscious thinking brain. As humans we are sociable creatures.
Now consider Cognitive Behavioural Therapy (CBT). As the tile suggests it helps with conscious cognitive thoughts and behaviours that are identifiable. It may not deal with the unconscious automatic part. Feelings can spring on us without warning from our unconscious. Feelings can arrive in split second and be powerful.
Important point- the automatic unconscious brain/ nervous system can override the logical thinking brain in a split second!!!! (Joseph LeDoux neuroscientist & colleagues ‘Two paths to the amygdala’ discovery 1998
CBT has many beneficial psychological tools that clients find very helpful and life enhancing – but it is not always possible to change your life by just changing how you think.
Some CBT therapists do work in a way that connects with parts of the clients unconscious. The question is what did your CBT involve?
As with many therapies new discoveries mean therapy models evolve for example CBT now incorporates mindfulness.
The question for clients of CBT who find they still suffer from anxiety/ obsessive compulsions is – did the CBT they experienced address the unconscious and automatic parts of themselves?
Did the therapy provide_
A good connection between the therapist and client – a feeling of trust?
A feeling of trust (a gut feeling that this person is okay – a feeling from the unconscious part of oneself.) is the language that our unconscious nervous system understands. It enables our nervous system to experience feeling safe and allows the therapy to reach the unconscious parts that need treatment.
There have been many research studies that provide evidence that therapy has been successful when a good alliance is forged between therapist and client.
Were physical exercises introduced at the beginning of therapy to reduce any anxiety build up?
Exercises such as slow breathing techniques, grounding exercises-to help a person destress and become focused on the safety of here and now.
Talking about negative incidents in therapy can cause an increase in anxious feelings. It is important for clients to be able to notice when this happens and to put a subjective stress scale on how they feel. A client needs to be comfortable in the process of therapy to be able to say – for example “my anxiety is rising it feels like 5 out of 10 now”
Did the therapy take into consideration the whole history of the client or only focus on current difficulties?
Sometimes how we felt in our past shapes the way our unconscious nervous system has learned to respond to current difficulties. However, it is not necessary to have specific thoughts- memories of the past- to explore how safe and connected we used to feel in the past.
Consider how vulnerable a human infant is compared to other mammals. Human infants are reliant on their main carer for many years.
Human brains grow slowly over many years and how a baby experiences the world is barely comparable to how a child understands the world and an adult’s experience of life is like another planet compared to a young child’s life.
Panskepp a neuroscientist, Psychobiologist and psychologist in 1998 discovered 7 emotional neural circuits in the brain- preprogramed circuits that protect babies from harm-SEEKING,CARE, PLAY, FEAR,PANIC,RAGE, LUST.
A human baby’s brain looks smooth then as the brain develops the indentations (that give the brain a look like walnut) appears.
A child has no cognitive working memory until around 3 years, the emotional side of a child’s brain is built first and then the rational calming side.
An infant/child needs a loving protective carer (mum/dad) to help regulate their raw emotions. There is insufficient development of the rational brain for a child to manage their emotions alone.
The human brain is finally complete around 27 years old.
When therapy only considers clients recent events – there may be a negative client history that is overlooked. A history that impacts on the client’s feelings and behaviours now.
Was the client able/willing to engage in therapy?
There may be many reasons why a client finds it hard to engage in therapy- such as a hectic life- style and missing appointments. For example, there may not have been enough continuity of appointments- to facilitate the momentum of change.
Therapy is a combination of the therapist and client working together.
Have Unconscious behaviours been identified?
Some clients have unconscious behaviours. Behaviours that they are not aware of. This can create a situation in a persons life where they feel unlucky- like life just repeats bad experiences over and over.
Freud called this Repetitive Compulsion. Having bad experiences repeating can cause anxiety and obsessive compulsive behaviours develop to try to control - to limit the bad things happening.
One example out of hundreds of unconscious behaviours is 'fawning'. A person may be a 'people pleaser' - they fear rejection/ conflict. In childhood they may have had a tricky care giver ( care giver could be parent, teacher, child minder, older sibling etc.) in their life who they were afraid of.
Behaviours may have developed to survive the tricky adult. For example not giving people enough eye contact, over apologising, desperately seeking peoples approval. This adaptive behaviour will have saved the person as a child but in adulthood-the opposite happens the behaviour does not save it creates bad situations.
The unconscious behaviour (in this example) attracts bad behaviours from other people. The fawning unconscious behaviour brings out the bully in others!
Has any fear of the human condition been found?
Sometimes anxiety and obsessive compulsions take the form of obsessive or disturbing thoughts. The brain can generate random thoughts that pop into our minds without our consciously wanting them. The thoughts may be obnoxious - but this does not make us obnoxious.
A kind - conscientious person may get anxious about these thoughts and this could trigger the nervous system into 'flight/fight mode'. In flight fight mode adrenaline and cortisol are dispensed in the body- creating an anxious feeling. This anxious feeling gives the thought too much weight.
When we understand that our brains can create thoughts that are not out choice - that it is a common human condition - we can have compassion for ourselves and understanding. We can observe these thoughts and laugh at our human imperfections. We can let the thought run through our minds without giving them the power of triggering our flight fight nervous response.
( Seek help if these thoughts seem to be coming from outside of yourself - or you feel compelled -not repulsed by them). Clients are often afraid to mention these thoughts to a therapist for fear of being harshly judged. A therapist who understands the unconscious human condition can help with this.
See a CBT -based guide to getting over frightening , obsessive or disturbing thoughts- called 'OVERCOMING UNWANTED INTRUSIVE THOUGHTS ' BY Sally M. Winston, PsyD, Martin N. Seif, PhD
Was the therapy conducted on- line?
Sometimes therapy for anxiety and obsessive compulsions is more successful for a client in a therapy room rather than on-line. Part of anxiety treatments is about helping the nervous system to relax and feel in a safe space. This relaxing and feeling safe may not happen if a client for example must hold their mobile phone for the whole session or feels unsafe in their location.
Did the therapy focus only on you changing – did the therapy explore whether your environment was able to provide your needs?
A person can change a lot but if the environment they inhabit blocks their human needs recognition that it is not their fault is essential. Human needs such as safety & security, need for attention, connection to community, Intimacy, status, purpose, challenge.
Did the therapy consider many small incidents that build up overtime that can increase a person’s likely- hood of feeling anxious/ developing obsessive compulsions?
Often when searching for the reason for our anxiety we look for the big incidents- like being sacked, or death of a relative. It is easy to overlook hundreds/thousands of small negative situations. Such as having a parent who loves us but is consistently negatively critical of us.
Adverse Childhood Experiences ‘ACE’ is a study conducted in a health clinic in California (at the Kaiser Permanente Clinic) from 1995-1997.
Over 17,000 patients receiving health care check-ups completed surveys regarding their childhood experiences and their current health status and behaviours.
The survey found that common negative experiences that one may have as a child, that, when occurring repeatedly or in batches had a harmful impact on a person’s development and long-term health.
One may look at a singular small negative incident as having minor consequence. However, several incidents in sequence or hundreds or thousands of small incidents can later impact on the quality of the adult persons physical/ mental health and particularly on how anxious they feel.
Have basic inquiries about your lifestyle/health been made?
Questions such as are you getting enough quality sleep, how much caffeine do you drink- are you able to get out and enjoy some time in nature, do you eat healthily? What medication (if any are you taking), have you any physical symptoms that started around your anxiety/obsessive compulsions? Is it possible there have been any hormone changes? -could be key to how much anxiety a person is suffering.
If this blog has brought uncomfortable issues to the fore and you need to talk to someone - see 'Helplines' page on this site with useful contacts.
Edelman, Sarah (2018). Change Your Thinking With CBT. London: Vermillion.
Freud, S. (1920) Beyond The Pleasure Principle. Sigmund Freud Collected Works. USA: Pacific Publishing Studio.
Howe, David.(2011). Attachment across the Lifecourse. London: Palgrave.
LeDoux, J.E.(2002). Synaptic self. How Our Brains Become Who We Are. New York: Penguin.
Liessmann, Benjamin (2020) What is Cognitive Behavioral Therapy? Heidelberg Germany: LieBmann
Morrow, Kimberley, J. LCSW & DuPont Spencer, Elizabeth, LCSW-C. (2018). CBT for Anxiety. USA: PESI
Panskepp, J. (1998). Affective Neuroscience: The Foundations of Human and Animal Emotions. New York: Oxford University Press
Winston, Sally, M. PsyD. Seif, Martin N. Phd. (2017). Overcoming Unwanted Intrusive Thoughts. Oakland CA: New Harbinger Publications Inc.