Insight and pathological doubt provides clues about how CBT might work differently for each person 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 is this reinforced?

Well when a client has little insight in their disorder it’s important to note that pathological doubt can stretch as far as the person believing their disorder is some other kind of mental illness – one that is marked by psychosis, not 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, and that feelings and guess-work is not factual evidence.

Is it true that false memory plays a part in OCD?

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 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.

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 means the person goes round in circles, fearing the worst and feeling constantly unsettled. Cognitive restructuring can help a person alter thinking errors linked to faulty beliefs although they often lose sight of their new healthier beliefs because their need for certainty overrides this. Basically doubt drives their behaviours to prove their obsession true or false, and this is the cycle that therapy tries to break.

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

Sometimes. I bring into therapy mindfulness techniques 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. Similarly I 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 dissipating without giving these special meaning. Or listening to a voice on a tape recorder and hearing the echo of the voice fade. 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 more about contradictory echoes?

Yes, intrusive thoughts combine contradictory features or qualities about the person. Basically what the person’s true values are, the obsessions say otherwise. For example, a kind and gentle person who cares deeply for people and animals might suffer from harming obsessions; or a person who loves children and strives to keep them safe might be plagued with paedophile obsessions, and so on.

Finally, how does insight help towards 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 faced with their obsessions (exposure) and resisting compulsions (response prevention) is what eventually weakens the obsessions and aids in their recovery.

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