CBT and the NHS

I started this intending to write about the exposure work I’ve just done, but it turned out I have a lot of thoughts about exposure therapy for OCD, and the NHS provisions for OCD, so I’ll put them here and write a different blog about today’s exposure.

Cognitive behavioural therapy for OCD

The recommended treatment for OCD is cognitive behavioural therapy (CBT) combined with medication (usually antidepressants). One component of CBT is exposure therapy, which involves repeatedly approaching the thing that makes you anxious (yes, it is a brutal form of therapy). Usually you’ll rate your symptoms in a hierarchy of the least difficult to the most difficult, then you’ll start with exposure to the least difficult, and move up the chart. The theory behind it is that when you first encounter the frightening object/situation, your anxiety will spike, but if you stay with that anxiety then it will gradually come down. With practice, the initial spike of anxiety should be lowered.

This technique works pretty well for things like contamination OCD. For example, touching a toilet seat and not washing your hands – this would initially cause a lot of anxiety, but over time the idea is that this anxiety will decrease. In this example it also allows the individual to collect evidence that they have touched the toilet seat and neither they nor people around them have dropped dead from germs. Exposure alone is not so good for religious themes, in my opinion – I could do the things that OCD tells me will send me to hell, but there’s no way for me to see that this won’t send me to hell.

My previous experiences with CBT for OCD

The good

In 2012 I had successful CBT for religious OCD. It did involve exposure, but we spent months working on cognitive reappraisal before I attempted the exposure. This strategy worked, because although exposure was terrifying, I could fall back on my logical arguments that showed me that OCD was lying. In this case the cognitive reappraisal took the place of the “evidence” that I might have had if I was dealing with a different OCD thought (e.g. evidence that no one died following contamination based OCD exposure). It also helped that my therapist had an in-depth understanding of OCD and was a Christian, which allowed her to easily differentiate between what was OCD and what was typical for other Christians (e.g. praying for forgiveness is typical, but compulsively doing so can be OCD). This was before the NHS “reforms” really started to bite, so I was able to have quite a long period of CBT before it had to end because they were prioritising people with “more severe” conditions such as psychosis, and I wasn’t suicidal. Thankfully we’d done enough work that I was able to continue improving over the following months even though I wasn’t having therapy.

The bad (sort of)

In 2016/17 I had unsuccessful CBT for religious OCD (I had stayed well for about two years after the 2012 CBT, but had got ill again). This was with an IAPT therapist who, as far as I know, wasn’t specialised in treating OCD or religious OCD. She was very focused on exposure and not keen on me using cognitive reappraisal. I told her that beginning with reappraisal had worked for me before, and that I had had many years’ experience with CBT and knew what had and hadn’t worked (I had had a lot of less successful attempts at CBT prior to the successful 2012 attempt I described in the previous paragraph). Unfortunately she was worried that if I focused on reappraisal it would end up being rumination (which is a symptom of OCD). This is a valid concern in general, but it wasn’t appropriate in my case as I had 2 decades of experience with the way my OCD operates and 10 years’ on-and-off experience with CBT for my OCD.

I did have some success with the exposure therapy with her, but I had lost confidence in her because she wasn’t willing to adapt according to my experience, so I think that limited the success I could have had. Having said that, I remember feeling that I was working harder than I had done in 2012 when I’d actually got better, so it wasn’t simply to do with my level of effort. Eventually I had to say something along the lines of: I’m not willing to go further with exposure unless we work on cognitive reappraisal. She accepted, but by this point I had nearly come to the end of the 20 sessions that the NHS allows. I was a bit better at the end of that course of CBT than I had been before it. However, that lasted about 2 weeks(!) Shortly after I finished CBT one of my heroes died by suicide – my OCD reacted by getting the worst it had been in years, and it’s pretty much been stuck there ever since. In order to get higher-level help the waiting list would have been 12 to 14 months. Due to my work I didn’t know where I would be living in 12 months’ time. In addition, in order to access that help I was led to believe that I’d need to go via the person who had given the CBT, and I felt awkward about that. I gave up on trying to get NHS help at that time. However, I’ve approached the NHS for an assessment in the place I live in now, so we’ll see what happens. (As it turned out I did end up moving about 250 miles away for work around the time I would have reached the top of the waiting list in that area).

The ugly

Just to make the titles match up nicely, here’s a brief description of a psychiatrist providing “ugly” CBT, from around 2009 before all of the above happened. At the time one of the things my OCD was focusing on was HIV (either that I had it and would give it to others, or that I would catch it from others – it tended to switch between these two, even though logically that makes no sense). I had a cut on my finger and the psychiatrist wanted me to touch the cut to the arm of the chair I was sitting in. I told her I’d had CBT before and was aware of what level of anxiety-increase is therapeutic, and this was too far, but she insisted. I ended up doing it and then rushing in a panic to Tesco after the therapy appointment to buy plasters to cover up my cut. This undid the good work I’d achieved in leaving the cut uncovered. At one point that psychiatrist even said something to the effect of “I can do it so why can’t you?” Not a good experience of CBT.

Back to the good again!

To end the blog on a more cheerful note, I am currently having a small amount of success using CBT techniques with an OCD specialist – we’ve recently started working on exposure. My next post will talk about the CBT I’m doing right now with this new therapist.

I’m privileged that my parents can help me to pay for this private therapist who has expertise in OCD, though I feel a bit ashamed that I am accessing private mental health care when many people can’t. I partly justify it to myself by considering that my job involves improving other people’s lives, and if I can get well then I can devote more energy to my job, though this justification feels a little hollow. I hope that in the future I can pay for high quality, easily accessible mental healthcare through my taxes instead.

The time I got better

I was 10 or 11 when I became unwell with OCD. From then on, OCD stayed with me in various guises, unrelenting. I first sought medical treatment when I was 17 (before that I’d resisted attempts to get medical help). I basically went to my GP and told her I had OCD. By that point I already knew all about OCD and how it affected me.

A quick overview of some of the times I didn’t get better…

I started antidepressants when I was 17, and although I’ve tried various kinds I haven’t seen much of an improvement from any of them. I remember when I was first prescribed medicine I was so hopeful that I would get some relief, but I didn’t. Having said that, more than a decade later I’m still on a high dose of antidepressants – when I tried to come off them a few years ago my OCD got even worse.

In terms of psychotherapy I’ve seen lots of different practitioners over the years. With most therapists my OCD remained mostly unchanged, with one therapist (a psychiatrist) it got worse, and in two cases it improved. The first time it improved was when I had regular sessions with a clinical psychologist who applied cognitive behavioural therapy (CBT) techniques in a dynamic way which took account of my individual symptoms. I made some great progress, genuinely beginning to get on top of my OCD for the first time. The sessions took place over the summer, in between academic years at university. I had been in a sort-of relationship with someone from university, who didn’t like to be seen in public with me, for about 10 months. When I went back to university, and back to the stress and uncertainty of that situation, all the progress I had made over the summer just dissipated. It felt like trying to hold back water. Weeks/months of consistent hard work disappeared within 2 weeks of being back at university.

One of the most cruel things about OCD is that to get better you have to be consistent in your fight against it, which takes a lot of energy and is very frightening, but to get worse all you need to do is have a brief ‘off’ period. But don’t despair, you can get better! Which leads me on to…

The time I got better

The second time I got better my progress did stick. There were a number of factors which I think contributed to me getting well at that time.

  • My life circumstances were more settled and stable than they had been for a long time (e.g. I was now in a stable, beneficial relationship).
  • My therapist had a thorough understanding of OCD, the techniques that could be used to treat it and how to apply these techniques in an appropriate manner.
  • My therapist happened to be a Christian, which meant she could easily tell the difference between my religious OCD thoughts (which were focused on Christianity) and what was actually part of the religion itself.
  • The first ‘half’ of the treatment was focused on cognitive reappraisal (with exposure coming later on). I believe this was fundamental to my success – some people’s OCD responds well to exposure on its own, but the reason I was able to capitalise on the exposure exercises this time is that I had spent a long time strengthening my ability to reappraise the OCD thoughts. This helped me to see them for what they were, at least to some extent, and exposure then helped me to consolidate this.
  • (I changed back onto Sertraline after being on Venlafaxine. This point is in brackets as I didn’t feel an improvement from this in itself (other than the removal of Venlafaxine’s more intense side effects). But it’s possible it supported the CBT I was working on – Sertraline is a recommended medicine for OCD).

I was able to become clinically well (below the clinical threshold for OCD), and to remain well for about 1 to 2 years. I’d guess it took me about 6 – 9 months of weekly or fortnightly CBT to get there. Everyone who knew me well, including me, was amazed. I had been very ill since I was a child, and one of the things you may hear about OCD is that it has to be managed, not cured. Perhaps I just have a different concept of what ‘managed’ and ‘cured’ are, but for me, having the occasional slightly intrusive thought which I was able to bat away, a few times per day, felt like being cured.

How the world felt when I got better.

Being well felt like the world was colourful. I realised just how much I had been dealing with; I remember thinking “if this is what life is like for other people it’s no wonder I’ve been struggling so much with life.” The first Christmas I was well I joined in much more with family activities than I had previously – I had more mental space to engage with others as I wasn’t also dealing with OCD’s constant ramblings. My anxiety level was lower as I didn’t have my worst fears in my thoughts all the time. That helped me to engage more as well.

As you will have realised from the rest of this blog I became ill again. However it took a couple of years and a lot of intense interpersonal and work stress to bring it back. A few months after I had finished CBT my grandma passed away – I thought OCD would use this time of difficult emotions to stage its comeback, but it failed to do that – I kept it at bay. I wish I hadn’t got ill again, but I am optimistic that I can get well again, and stay well for longer this time. After all, this time I know it is possible, because I’ve done it before.