Insight and pathological doubt provides clues about how psychological treatment might work differently for each person on the obsessive-compulsive spectrum and to show whether it is likely to be effective or not.

How can you tell if a client has a lack of insight into their disorder?

This would usually be taken into account during assessment. If not, any signs would normally be revealed during the course of treatment. The same goes with pathological doubt.

How do you tackle these problems in therapy?

I clarify with a client that intrusive thoughts or obsessions are not real thoughts because these are involuntary interruptions that get sandwiched between every day regular thoughts.

How does this help?

It explains that while intrusive thoughts interfere they do not exist outside of their awareness and do not convert to action.

Yet they still desire certainty?

Yes, doubt versus certainty plays a big role in OCD. A person’s search for assurance serves only to strengthen the obsession, and it is this concept that is reinforced in therapy.

Why else is this reinforced?

Well when a client has little insight into their disorder pathological doubt can stretch as far as the person believing their disorder is another type of mental illness – one that is marked by psychosis, instead of neurosis. Other times they will convince themselves their fear has or will come true, even though it is emphasised that their theories are based on emotional reasoning. They find it hard to grasp that feelings and guess-work are not factual evidence and thus miss the threat factor linked with the disorder.

What is the “threat factor”?

This is where a person perceives their problem as one of threat instead of worry. For example, when someone has harm OCD their understanding of the problem is based on an irrational concept. This links to overimportance of thoughts where emotional reasoning further clouds rational thought and has the person questioning their true values, which might be that they care deeply about people but cannot get past the barriers that confuse them. Basically OCD is a paradoxical disorder and there’s the answer, yet a person who has OCD finds this concept difficult to grasp during an episode.

How can you help someone grasp this concept?

One example is known as the Theory A and Theory B experiment (Salkovskis & Bass, 1997). On the subject of harm OCD the person would look at their problem as worrying (theory B) about what bothers them instead of fearing being under threat (theory A).

Can you expand on this?

Yes, worry (theory B) is to feel anxious about something unpleasant that may have happened or may happen in the future; and threat (theory A) comes with “warning signals”. A person agrees in therapy to test out theory B by finding workable solutions to overcome their worry, thus removing the threat element. One suggestion is for the person to observe others using sharp utensils for cooking and noting down the different types of responses that occur in this type of situation.  An example of both theories might be:

Theory A: The problem is that I feel an urge to stab my partner and I’m terrified I will lunge at him with this bread knife and end up alone, and in prison.

Theory B: The problem is that I care very much about my partner and the thought of harming him with the bread knife causes me great distress.

As noted, by working on rational concepts for theory B means the threat element (theory A) starts to weaken.

Is it true that false memory confuses insight?

Well let’s say memory tends to play tricks for a person who has OCD. When this happens they will ruminate at length, searching their minds for abstract recollections. I explain that an existing memory is usually remembered even if bits of that memory cannot be recalled; yet an intangible memory cannot be recalled because it never existed. Sometimes a false memory can be attached to an existing one and it’s a case of working with the client to locate the pieces of information that are true and sieve out the rest. For example, someone who has responsibility OCD might have been in the office at a time when some documents went missing. Later, they might add to the memory a false one in which they fear they might have put the documents in the trash on purpose, which comes back to the threat element.

So would you say that learning to live with risk and uncertainty is one of the mainstays in reaching and maintaining gains in therapy?

Yes, although this is more difficult for a person who lacks insight; and coupled with pathological doubt it means the person goes round in circles, fearing the worst and feeling constantly unsettled.

As a therapist are you able to help a person improve insight?

Sometimes. Cognitive restructuring can help a person alter thinking errors linked to faulty beliefs although some often lose sight of their new healthier beliefs because their need for certainty overrides this. Basically doubt clouds insight and drives their behaviours to prove their obsession true, which makes exposure response prevention (ERP) more of a challenge than those who have fair to good insight.

What else helps?

Mindfulness techniques are helpful because these can help a client see and study a concept with the intention of grasping how and why something happens, yet without passing judgement. For example, I might ask them to visualise blowing bubbles and then seeing them pop. This is done with the idea that when the bubbles pop the liquid dissipates and nothing is there anymore. I then explain that intrusive thoughts and images can be likened to biological bubbles of nonsense. They can then visualise seeing thoughts and images coming in and filtering out and then seeing them dissipate without giving them special meaning. Another technique is listening to a voice on a tape recorder where the voice fades into an echo. Discussing that the echo is heard yet isn’t the original authentic sound can help a person understand the concept that while thoughts are real (in the sense we are aware of them) and we “hear” those thoughts that by contrast intrusive thoughts echo paradoxical information. An echo fades into the distance and as it fades no moral judgement or fearing high probability of a feared outcome is attached to it; likewise I explain that paradoxical echoes can pass and fade without judgement and fearing high probability.

Can you explain a little bit more about paradoxical echoes?

Yes, intrusive thoughts combine contradictory features or qualities about the person, hence OCD being known as a paradoxical disorder. Basically what the person’s true values are, the obsessions say otherwise. For example, a person devoted to their religion might experience intrusive blasphemous thoughts; or a person who loves children and strives to keep them safe might be plagued with paedophile obsessions, and so on. This is why it is demonstrated that a person’s symptoms will diminish when they practice allowing their paradoxical echoes to fade without judgement.

Finally, since ERP is the gold standard treatment for OCD, how can improved insight help a person engage in this treatment and what are the chances of recovery overall?

First, cognitive restructuring helps a person see their illness on a deeper level of understanding. They learn to see that managing uncertainty far outweighs the benefits of living with never-ending doubts and “what-ifs?” Understanding these concepts puts them in better place for working towards the behavioural side of therapy known as exposure response prevention. As a result, they figure out that when they agree to face their obsessions (exposure) and resist compulsions (response prevention) that this is what eventually weakens the obsessions and aids in their recovery.

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