KEY CONCEPTS
There are more than 100 concepts and techniques which are involved in cognitive drill therapy. I am summarizing many of them. With continued applications and practice, I keep on adding more concepts which I shall update in next revisions. The concepts elaborated here may be repetitive but for the sake of emphasis and clarity I am opting for the repetitions.
1. Triggers: Any object, mental image, stimulus, situation, sensation, thought, feeling, cue and person that elicit body-mind reactions and emotional state are called triggers. For example, a sensation in heart region which activates fear of heart attack, a closed bathroom that activates fear of suffocation.
2. Body-Mind Reactions: The physiological and psychological reactions elicited by an exposure to Triggers or mental representations of triggers. For example, body responds to triggers by increasing heart beat, difficult breathing, sweating, dizziness, nausea, butterflies in stomach, dilated pupil, dry mouth. The mind responds to triggers by going blank, fearfulness, disgust, danger perception, irritability, becoming impatient.
3. Safety Behaviors: Mental or behavioral avoidance of the triggers manifested in repetitive mental acts, keeping oneself away from triggers, exiting triggers as early as possible, changing routes, abstaining from activities which may involve exposure to triggers, seeking reassurance from oneself, practicing positive affirmations to ensure safety.
4. Anticipatory Fear: When a person is exposed to triggers in real life, he/she displays fear reaction. But when an exposure to the triggers is scheduled, the person becomes fearful even before actual exposure just by contemplating and imagining the prospective encounter with triggers. A person with social anxiety becomes anxious upon scheduling of an interview which he would be facing after a few days even months. He/she becomes uncomfortable in advance.
5. Secondary Fear: An exposure to trigger activates fear reaction; and then the fear reaction itself becomes a trigger which further intensifies the fear. A person with social anxiety becomes fearful in the presence of his boss at working place; the awareness of fearfulness and body-mind reactions, scares him/her further that this reaction could escalate and become uncontrollable.
6. Secondary Depression: With persistent phobia/OCD, a person struggles a lot to overcome his painful emotional conditions. His most attempts fail and he/she feels hopeless and helpless. He/she feels ashamed of the phobic and OCD conditions. These reactions to the phobic/OCD conditions can cause low self-esteem, worthlessness and sad mood. The affected person may become pessimistic to the extent of developing ideas of self-harm and destruction.
7. Feelings of Shame: A person affected by phobia/OCD may believe that only he/she is affected by this condition in this world. He/she fails to consider that others too might be having the same situation. They would ask the therapist whether he/she has seen such cases earlier. Because of feeling of shame, these persons may refrain from sharing their anguish with other persons.
8. Resorting to Faith Healing: Many affected person pray to the God to heal them or they can visit faith healers, tantric, shamans for seeking healing. In most cases, these practices are unlikely to provide durable relief.
9. Basis of Substance Abuse: Because of social anxiety and other conditions of fear, a person tends to lose their self-confidence and their self-image becomes distorted. To divert themselves or appear as confident and smart, some person may opt for using substances such as alcohol, cannabis and smoking. But these substances, complicates the fear condition and the person may get entrapped into substances.
10. The Idea of Negative Thinking: Most affected persons are not aware of their psychological conditions and label their suffering as an instance of negative thinking or lack of self- confidence. They think that if they replace their negative thinking by positive thinking they can overcome their problems. They may resort to meditation and self-hypnosis or auto suggestions. These may be partly helpful in some patients.
11. Adoption of Happy Go-Lucky Attitude: Some persons may advise the affected person that he/she should become careless and enjoy one’s life. For some moments, it appears to be working but it does not last longer.
12. Motivational Books: These books are available in thousands. Many affected persons read these books and try to regulate their cognitions and life according to the advices given in these books. Such books do have their role in shaping the optimism and rationale coping. But in many cases, these books are not sufficient enough to eradicate the conditions of phobia and OCD.
13. Non-acceptance of Professional Support: Many affected persons feel it as a disgrace to themselves to consult a professional psychologist for seeking help in remediation of their phobia and OCD. They consider these problems linked to their will power and a prestige issue. This attitude often delays the treatment. They should consider it as a disorder of emotion which can be healed by application of scientific theories by professionally trained psychologists.
14. Stigma: Stigma is widely prevalent in the society. Because of stigma of psychiatric disorders, these persons may refrain from consulting professionals for their problems. They think that they do not have a disorder. The comments like “I am not insane why I should go to a psychologist/psychiatrist” is a barrier in their choice of early treatment.
15. Disguised Identity: Some affected persons approach the professionals by hiding their identity and assuming a fake name or creating a fake ID on social media. They are scared that if someone known to them comes to know about their problem or consultation with a psychologist, it will be a humiliating experience. They want to protect themselves from such happening. Also they remain hyper-vigilant at the consultant’s place and keep on scanning if there is any person known to them.
16. Dependence: Some affected persons tend to become overly dependent upon their psychologist and seek advice even on their mundane routine matters of life. They may seek frequent appointment just to be with their therapist. The therapist’s aim is to enable such persons and make them self-reliant. Whenever, a therapist notices this pattern he/she reduces the frequency of contact to ensure that the affected person learns to face his real life situations independently.
17. Missed Appointments: Some affected persons schedule their appointment with the therapist but do not turn up at the scheduled time, either they come late or do not appear for the scheduled session. This causes loss to the therapist because the time might have been allocated to other patients.
18. Search for Magic Formula: The persons affected by OCD keep on searching for a magical solution to their problems. They think that by extensive and in-depth thinking they could come out with a magical solution which will eradicate their problems instantly. The illusion of magical formula keeps them engaged in thinking and thinking for several years. No such magical formula exists. They should consider this search of magical formula as part of the problem instead of solution.
19. Impact on Life: The problems of OCD/phobia can disrupt life severely. A student may not be able to continue his/her studies; the person in service may find it difficult to perform on duty or can even resign from the job; a business person may see downfall in his/her business. The affected persons think that once they get out of their OCD/phobia they could restore their functioning. They keep on waiting for cure to restore their work. They are advised to restore their work as early as possible at the onset of the treatment. Do not wait for the recovery to happen for restoration of the work. They should consider work as therapy and get into it as early as possible.
20. Medicine Treatment: As an standard practice, I recommend that persons with OCD should continue their psychiatric treatment along with drill therapy. However, for phobia the requirement of medicine treatment depends upon the severity of the condition and its influence on the life of the affected person. Medicines provide good support in OCD for drill therapy as well as maintenance of treatment effects and for prevention of relapse.
21. Over-enthusiasm: When drill is prescribed as homework, some affected persons become enthusiastic about its applications and try to perform drills simultaneously on many objects/feared cognitions. My recommendation is that the drill should be applied in sequence one by one. When the fear reaction subsides to one object/feared cognition, the second should be taken up and so on. However, there may be some circumstances when drill can be performed on more than one item simultaneously but not as a routine matter.
22. Drop Outs: Exposure and response prevention is reported to have high dropout rates. But in drill therapy I am seeing low dropout rates. Sometimes, an improving person can also leave the drill therapy which causes pain to the therapist. The dropouts in Exposure and Response Prevention result from the pain and suffering experienced by the affected person during exposure to the real objects. But in drill therapy this pain and suffering is relatively less.
23. Fear of Aggravation: An affected person when comes to know about the protocol of drill therapy may feel that this therapy is quite scary. It can aggravate the phobia/OCD. Actually, it does not aggravate the condition. I reassure the affected persons that drill is being performed in imagination and at verbal level. There is no point to become scary due to the nature of exposure. Having reassured about aggravation I require the affected person to drill for aggravation. ‘meri problem aggravate ho chuki he’ (My problems have aggravated).
24. Disbelief in Drill Therapy: Some affected persons show their disbelief and skepticism for drill therapy. They may say that how verbalizations could heal their problems of phobia/OCD. I explain to them that the problem lies within their mind. Also verbalization itself activates fear reaction. Since verbalizations activate the fears, the continued verbalizations will remove the fear from feared object/cognition. Also I require them to drill ‘drill therapy is not helpful’.
25. Persistent Reactions: Upon doing the drill, usually the body-mind reactions subside within a few minutes due to drill or intermittent pauses and distractions. However, in some cases the activated reaction may continue longer to the extent of a day or two. The persistent reactions can be converted into therapeutics by adopting an attitude that the reactions are temporary and would subside; and the affected person need to continue more drill to master the persistent reactions.
26. Influence of Suggestions of Friends/Family Members: It may happen that a family member, relation or friend may advise the affected person to discontinue the drill therapy. They may minimize the role of therapy and the problems being faced by the affected person. I recommend the patients to go by their own understanding and the rate of improvement; and not to discontinue the therapy because the person who advised to leave the therapy is not familiar with the nature of the disorder and its treatment.
27. Leaving Drill Therapy after Partial Relief: Some affected persons would leave the therapy in between even if a trend of improvement was visible. After exiting the therapy, they may continue to use the drill by their own.
28. Abreactions: When an affected person commences the drill, he/she may show severe body-mind reactions characterized by crying, breathing difficulties, accelerated heart beat and the like. I allow the person to do so. This I consider as ventilation of pent up feelings and weeping is the natural mechanism to dilute and release the heavy feelings stored in the body and mind.
29. Gradual Reductions in Applications: In the process of learning an affected person will be required to spend about 1-2 hours per day for nullifying the anxiety potentials and this application will effectively switch off anxiety from several triggers. With passage of time, approximately after 10-15 days he/she will feel lesser and lesser need to apply the cognitive drill. The application time will get reduced to a few minutes per day and ultimately forgetting of both the drill and the problems of anxiety.
30. Law of Anxiety: When an affected person is exposed to a Trigger and prevented from getting engaged in safety behaviours, then anxiety follows a defined pattern which is as follows: Activation of anxiety 
rising anxiety to the peak, its maximum heights staying of anxiety at peak level for some time a declining course of anxiety from high to medium reduction of anxiety to low level Zero anxiety. If we plot this pattern of anxiety on a graph it will yield an inverted U shape curve. With continued practice of drill, the peak of anxiety activated by triggers will begin to get lower and lower and finally the triggers would lose the power to activate anxiety.
31. Law of Habituation: If a person is continuously exposed to anxiety provoking triggers without involvement in safety behaviors, the anxiety will tend to decline and the triggers will gradually lose their anxiety potentials. The Triggers will no longer trouble the person.
The mind will become comfortable, at ease and habitual to the Triggers. Think of a situation, when you visit your relations who stay near a railway line. Your sleep gets disturbed because of the noise of passing by trains. But your relations are quite comfortable and they may even not notice the noise of a passing by train. How it happened with them? Initially they were also troubled by the noise, but because of repeated exposure to train noise, their mind got adapted with the situation and lost its power to trouble them. If you stay in such house for a few days, then similar thing will happen to you also because of the Law of Habituation.
32. Inter-relatedness of Sense Modalities: When a trigger troubles an affected person and activates anxiety, it means that he/she is likely to experience anxiety in following manner of exposure to that Trigger – (a) by looking at the Trigger (b) by speaking about the Trigger (c) by thinking about the Trigger (d) by touching the Trigger (e) by writing about the trigger (f) in anticipation of the exposure to Trigger. If there is an involvement of multiple- modalities in anxiety response, then reduction of anxiety in one modality will tend to reduced anxiety in all other modalities too. For example, if an affected person is merely looking at a Trigger for extended period of time and it reduces anxiety, then the reduction in anxiety through visual inspection will have similar positive effects on anxiety reduction in other modalities of touching, thinking, speaking, writing and so on.
33. External Trigger vs. Imagination: There is a difference between having a Trigger in the external environment and mental representation of the Trigger. The presence of Trigger in external environment means, that the Trigger is outside of one’s body and mind e.g. door knob, dirty piece of paper, gas cylinder, a car, a person with dirty clothes. These are the instances of actual physical objects which can be touch and photographed. A person also has mental representation of these actual objects. A mental representation means, the object is not physically present before the person; but can be seen in mind’s eyes. A person cannot touch or take a photograph of this mental representation. It is inside mind. Both the actual physical objects and mental representations of the objects can activate body-mind reactions of distress.
34. Power of Mental Representations: The mental representation of a Trigger can have potentials for activating anxiety response. The Trigger lies in the mind as its mental representation and a person can respond anxiously to his/her own mental representation. The cognitive drill utilizes this potential of the mind to disconnect trigger and anxiety. While performing cognitive drill, a person need to remind oneself repeatedly that he/she is dealing with own mental representations; it is in own thinking and own imagination. The Trigger is being processed in one’s imagination. This awareness of imagination puts the person at ease and which helps in continued attacks on the Trigger-Response connection. For example; only in my imagination, I am touching the dirty door knob; only in my imagination, I have touched a diseased person, I am now infected, truly I am infected.
35. Fear is Future: An affected person can quickly review his/her diary and memory bank, how long has he/she been using a future reference, future tense. It may extend back to a few months to several years. Suppose, a person has been using an anxious future reference program for last ten years. Now if he/she is asked to just pause and recall how many times, the actual events happened exactly the way he/she anticipated. He/she is likely to have a zero or very low level of matching with future reference and actual events. It means, he/she is living in two parallel realities. One is of a future reference and the other one is of the present as it happens in real life. If there were an opportunity to enlist all future thoughts on day to day basis since the beginning of the phobia/OCD vis-à-vis the actual happening of apprehensive events, then one could be surprised to realize that there is little correspondence. Despite, this realization that feared consequences do not occur, the mind remain engaged in apprehension almost in autonomous mode.
36. Concept of Spontaneous Recovery: After successful processing of a Trigger through cognitive drill, the anxiety may re-surface after some time gap of a few days. This re- activation of anxiety is usually of low intensity. The repeat application of cognitive drill would quickly detach anxiety associated with spontaneous recovery phenomenon.
37. Difference between spontaneous recovery and exposure to new triggers: After working through several Triggers through cognitive drill, an affected person may become anxious during exposure to a new Trigger which has not yet been drilled and mistakenly conclude that the condition got relapsed. An affected person should make a difference between getting anxious in response to the processed Triggers vis-à-vis getting anxious in response to non-processed Triggers. This distinction will provide confidence and a framework that there may have been some left out Triggers which need be processed through cognitive drill. Once additional Triggers are also processed in this manner; they too would lose their anxiety provoking potentials..
38. Easy to Difficult: Initially, an affected person should grade your Triggers in terms of their anxiety provoking potentials. He/she should apply cognitive drill to low anxiety provoking Triggers and with practice and continued applications he/she can proceed to the Triggers of more and more severe anxiety potentials. Once several Triggers of low anxiety potentials are drilled then the severity of anxiety evoked by more powerful Triggers will also get reduced and the affected person would be able to deal with them with ease.
39. Cognitive Exposure vs. Exposure to Real Object: When a person is asked to imagine the object of fear and perform the drill in the absence of real objects; it is called cognitive exposure. When a person is exposed to real objects and asked to perform drill, then it would constitute exposure to real objects. For example, asking a person to imagine holding a dirty mug and drill that I have become dirty is cognitive exposure. Asking a person to hold a real dirty mug in his/her hands and drill that I have become dirty would be an instance of exposure to real object.
40. Using Own Language for Cognitive Drill: Remember that an affected person’s own specific language and words are associated with activation of brain centers and neurotransmitters. When formulating converted statements or Keywords for cognitive drill, one should choose own words. A change in words or phrases that are not used by the affected person may not activate anxiety reaction and would not lead to reduction in anxiety and discomfort. For example, if typical future statement is “If I touch door knob, I shall get allergy”; then the affected person should use words from this statement only e.g. “I have touched the door knob, I have developed allergy”. The incorrect statement is – “I have touched the door knob and I have developed some disease”.
Similar other reactions may be noticed in the persons affected by phobia/OCD. A therapist as well as the affected person is required to consider those reactions and solve them through proper cognitive perspective and performing the drill. I am able to manage most such reactions using this approach.
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