TECHNIQUES OF DRILL THERAPY
In Cognitive Drill Therapy I utilize a number of techniques to make the task simplified and straightforward. With time and experience more and more techniques could be added to the list presented in this chapter. The practitioners and the affected persons may also come up with creative solutions to master distressing emotions.
Psychoeducation: After taking relevant case history and conducting formal assessment of the problems of the affected person and prior to commencement of drill therapy, psychoeducation of the affected person and family members if available should be done. It is an essential component in drill therapy and mandatorily be done with every affected person. No drill therapy be commenced without proper psychoeducation. In general terms, psychoeducation involves educating the affected person on the nature of his problem, its causes, psychological theories, two layer conceptualization, cognitive drill, anxiety curve, homework and the like. I usually cover psychoeducation in following format which is open to adaptation by the therapists:
I. At the outset, I convey the label of the problem to the affected person. A person came to me with 08 years history of extreme fearfulness. After listening the story I communicated that it is a case of Agoraphobia and Panic Disorder. You should actually read about it on the internet and match the symptoms. This was the first time when she came to know about the diagnosis of her problems. She checked it and confirmed. Conveying the label of the disorder itself is a part of healing process; it implicitly implies to the affected person that his/her problems have been understood. For several years, the affected persons keep on worrying what the problem is and what are the solutions? A definite labeling of the problem straighten the task and consolidates the mind of the affected persons to adopt remedial measures accordingly.
II. Then I would explain the causal hypothesis to the affected person. I would say that such problems are caused by a combination of biological, psychological and social factors in more or less quantity. At biological level there may be a sort of chemical disturbances in the brain that may originate from biological or psychological reasons.
III. If I consider the role of biological factors in the continuation of the problem, I would invariably recommend the affected person to go for a psychiatric consultation along with drill therapy I will encourage by saying that for correction of chemical disturbances it is recommended that you see a psychiatrist and if he/she prescribes a medicine based upon his/her evaluation; then continue with the medicines and join me for drill therapy sessions as per my schedule.
The affected person or the family members may express their stigma or concern for side effects. I would try to deal with both. For stigma, physical diseases also range from minor fever to the most fatal categories. Your problems require medicines for effective management. For the concern over side effects and potentials for dependence on medications; discuss this issue with your psychiatrist. He/she would prescribe you medicines accordingly and explain the potential side effects if any.
IV. Regarding psychological theories, I would say that there are many theories of psychology like psychoanalysis, cognitive theories and behavioral theories which can be invoked to explain and manage your problems. Each theory has its own merits and applicability. Each therapist has his/her own preference and choice of therapies. Now-a- days Cognitive Behavior Therapy (CBT) is being used extensively. I am practicing and formulating Cognitive Drill Therapy and finding it useful, hence, I would be considering this therapy for your problems.
V. In Cognitive Drill Therapy, I consider the problem in two layers. A top layer consisting of the objects of fear such as dog, picture of dog, toy dog, dog on TV etc, body-mind reactions such as accelerated heart, breathing difficulties, danger perception and the measures of safety behavior like avoidance of encounter with dogs. The bottom layer consists of imagined feared consequences such as dog can bite etc.
VI. Then I would point out the presence of Future Tense in imagined feared consequences. I will emphasize that under conditions of anxiety and fear, the mind is focused on future orientation which is reflected in sub-vocal speech consisting of future tense. Since the beginning of the problem, the mind is engaged in future oriented thinking.
VII. Then I will explain the concept of ABC as it is used in drill therapy. I would say that there may be specific tense correlates in the brain. When mind is using past tense, the information goes to the centers in the brain dealing with past tense; for which the notation ‘A’ can be used. The information of present tense goes to the brain area related with present tense for which a notation of ‘B’ can be used. For future tense and their brain correlates a notation of ‘C’ can be used.
VIII. Due to the condition of fear your ‘C’ centers in the brain remain overactive. If we could cool down the overactive brain center ‘C’ through psychological methods, the fears would subside. Fears do not belong to ‘A’ and ‘B’ centers.
IX. For cooling down the activity of ‘C’ centers I would ask you to verbally repeat the statements of feared cognition by converting them into past like dog has bitten me.
X. With repetitions, initially there may be an activation of fear reactions. With continued repetition it will get dissolved. It will lead to a bell shape like graph called as anxiety curve. The fear will rise from low to medium to high and then it will begin to decline from high to medium to low to minimal or zero.
XI. The problem lies inside the mind. That is, why mere verbalization of drill statement activate body mind reactions. Verbalizations will escalate the fears and continued verbalizations will dissolve the fear within a few minutes.
XII. Under conditions of fear, you are already experiencing lots of pain and suffering. There will some distress and fear during drill which you need to bear to dissolve it. If there is escalation of fear to very high level during drill, I will be giving you pauses so that your mind gets enabled to process the activated fear.
XIII. I will recommend you to procure a diary and record all your problems, my lessons, your learning and progress in that diary on a day to day basis. The diary will be immensely useful for revising the sessions and monitoring the progress.
XIV. I will also prescribe you some home work of drill and daring. You will learn the drill therapy from me and apply it in your real life situations. Most therapy happens between sessions. You will be required to do daring to expose yourself to real situations to the extent bearable to you. Before daring, perform the drill and continue to do the drill during daring and exposure to real life situations.
XV. The affected person may become scary of repetitions and think that by repeating the problems, it can get deposited in subconscious mind and the feared consequences can certainly happen. A sort of magical thinking, that mere repetition can cause external physical events. I would clarify it by saying that mere repetitions cannot cause a physical event in external world. If I place an object on the table, and keep on repeating it that the object is flying, object is flying; nothing will happen even if I keep on verbalizing it for years.
XVI. I also point out to the concept of Universal Probability. I would say to the affected person that all of us have more or less probability of experiencing accidents/adverse circumstances. It can happen to anyone at any time. This Universal Probability applies to everyone. If I am not a dog phobic, I am passing through a street and a dog can bite me or anyone else if there is such a stray dog. That is, part of the Universal Probability.
XVII. Given the allowance for Universal probability, the repetitions will not increase the chances of dog biting. The idea that mere repetition of dog bite, would increase the probability of dog bite is untenable. Through verbal repetitions, we are not depositing the idea in the subconscious mind, instead we are bringing it to the surface conscious awareness.
XVIII. I will also highlight that over the years he/she is managing his/her problems by avoiding the objects of fear. This avoidance gives temporary relief. The transient relief obtained through avoidance creates an illusion in the mind that avoidance is the only solution. To secure avoidance an affected person may go at length.
XIX. Instead of avoidance, exposure is the solution. The exposure should be done for both the objects of fear and the imagined feared consequences. The exposure to underlying fear structure is most important.
XX. I would also give an example of darkness phobia. If a child is scared of darkness and keeps avoiding the dark place; his problems will continue to exist. Somehow, he must learn to expose himself to the darkness in divided doses to overcome this fear. He would be required to dare and enter the dark places. With repeated daring the fear will subside.
XXI. The imagined feared consequences lie in the mind. They have universal probability of occurrence. But the mind in imagination is multiplying the fear manifold. Most of the persons are operating in this world within the framework of Universal Probability.
XXII. Through drill therapy, we do not remove fear emotion from your system. You will continue to experience the fear as and when there is a real danger. Phobia is an irrational fear whereas fear is emotional reaction to actual danger. For example, if there is a snake in this room, most people will get scared and would try to ensure safety either by removing the snake or removing oneself. Since there is a real danger, it is called fear. But when a person sitting in the room sees a poster of snake in the room and get scared and try to remove either the poster or oneself, it would be irrational fear because actual snake is not there. Drill therapy normalizes the fear. It does not exclude the fear from the personality. Fear is an essential emotion required for survival. But the irrational fear is an obstacle and a problem in the life which needs to be corrected.
XXIII. I will clarify most questions and concerns raised by the affected person and his/her family members and then proceed to the application of drill therapy. I also use guidelines from other therapeutic approaches, my common sense and intuitive understanding to clarify the concerns and questions of the affected person.
XXIV. At the end of the treatment, the objects of fear will remain as such in the environment but those objects would fail to elicit fear reaction or there would be minimal reactions in response to the distress.
XXV. Through drill therapy we do not aim at cure of the condition. Instead, the condition will become manageable and you would be able to face the objects of fear and they would either not disturb you or produce minimal distress.
XXVI. In case of obsessions, those obsessive ideas may come to the mind but would not elicit prominent distress. They would get normalized.
XXVII. Research studies show that all kinds of obscene/filthy thoughts can occur in the mind of healthy persons. They tend to ignore them and do not give any importance.
Formulation of Drill Statement: It is the most important, easy and readily comprehensible technique. From the two layer structure, focus on the feared cognition of future tense in bottom layer and convert the tense of the future oriented cognition. The future tense should be converted to past or present tense preferably past tense. For example,
A. Dog can bite
B. I can catch rabies
C. If dog bites, there will be injury to muscles
D. I shall have to take anti rabies injections
E. Pain shall be inflicted due to injections
F. I may die due to rabies
A. I am bitten by a dog
B. I have caught rabies
C. Dog has bitten me, my muscles are injured
D. I am taking anti rabies injections
E. I am experiencing pain due to injections
F. I am dying due to rabies
Drill Execution: Drill is executed in a sequence. All statements are not processed simultaneously. For application of drill two things are required: (a) Object of fear (2) Tense Converted Feared Cognition. The object of fear can be in imagination or in real time an actual object. The first priority is for holding the mental representation of object of fear. If mental representation fails to elicit the body-mind reactions, then actual object is considered. Having settled upon the nature of feared object and feared cognition; the drill is applied in following manner:
Ask the affected person to hold mental image of the object of fear and verbally repeat the tense converted feared cognition
For example, hold a mental image of scary dog in your mind and repeat I am bitten by a dog.
Repeat, Repeat and Repeat.
Body-Mind Reactions during Drill: When an affected person commences repetitions of drill statements, he/she may experience no reaction, a mild reaction, a moderate reaction, or a very severe reaction. Moment to moment monitoring of body-mind reactions is required. Drill adaptation is required based upon the feedback received during moment to moment monitoring of the distress. This monitoring is done every 30-60 seconds. If the stirred body mind reaction is low or medium the drill is continued. If it escalates to high level; the drill may either be continued or a pause of 1-2 minutes may be given depending upon the distress bearing capacity of the affected person. If the distress escalates to very high level; invariably pause must be given to 1-2 minutes or longer depending upon the resolution from the very high level. When it returns to medium or low level; then only the drill is resumed.
Pauses during Drill: Giving pauses during drill is extremely helpful in processing the overwhelming emotions stirred by the drill. Pauses are given when the distress of body-mind reaction escalate to high or very high level. A pause is a must when distress rises to the level of very high on moment to moment monitoring of subjective distress level. During the pause, a silence may be maintained or any topic other than the fear can be discussed. Usually a pause of 1-2 minute is sufficient, however, a longer pause may be required if distress persists. It is speculated that the brain takes some time to the processing of activated overwhelming emotional response. During the periods of pauses, brain adapts itself and becomes enable to process the emotional data activated by imaginary/verbal exposure to the objects of fear/feared cognition.
Drill Dilution: This is an important technique in drill therapy. When distress shoots up rapidly to very high level upon 2-3 drills, in that case drill dilution must be considered. In drill dilution the drill is broken into low doses so that the activated body-mind reactions remain in manageable limits. There can be a variety of method for drill dilution. I am enumerating the approach to drill dilution adopted by me. Any of the following or creative solution to drill dilution can be adopted.
I. I will tell the affected person that I will be doing the drill for me, just listen. I will continue to perform the drill until resolution of distress due to listening.
II. I will break the drill statement into parts and will ask the affected person to do drill of the part statement. For drill statement ‘dog has bitten me’ I may break it into following parts (a) dog (b) bitten. First I will ask the person to drill the word ‘dog’ and after resolution of the distress, I will ask for drill of ‘bitten’ and upon resolution of distress to this, I will ask the drill for full statement; ‘dog has bitten me’.
III. I will choose any other drill statement from the list which is less anxiety provoking.
Pass Criteria for Drill: When to switch over to other objects/cognition during the application of drill is a decision to be taken by the affected person or therapist. I follow a simple rule. When a drill fails to activate body-mind reactions upon three consecutive repetitions; then I switch over to other object of fear/feared cognition. By following this rule, I continue to pass on to other objects of fear and the feared cognition.
Managing Hanged Distress: At times, the distress due to drill may get hanged at high or medium level. When the distress persists beyond five minutes, I consider it as hanged. To release the hanged distress, I recommend for giving pauses or asking the affected person to introspect and tell me what else is running in his/her mind. I look for feared cognition which get activated in response to drill statements. I will keep a record of such activated feared cognition. To melt the hanged distress, I may switch over to those feared cognitions that run in the mind. For example, when drill is being performed ‘dog has bitten me’ and the distress get hanged. I will ask what else is running in your mind. If the affected person say that ‘help will not be available’ then I will ask him/her to drill ‘help is not available’. The drill of such concurrent feared cognition dissolves the hanged distress. It is speculated that distress gets hanged in response to concurrently active feared cognition. The drill of such cognition dissolves the hanged distress.
Drill Compounding: After a couple of sessions of drill therapy, I may execute processing of multiple feared cognitions in a single drill. I call it as drill compounding. When two or more feared cognitions are combined in a single drill statement, it is labeled as compounded drill. For example, ‘dog has bitten me’ is a single feared cognition. ‘Dog has bitten me, I am having pain’ is a compounded drill containing two feared cognition ‘bitten’ and ‘pain’. ‘Dog has bitten me, I am having pain, I am feeling helpless’ contains three feared cognition; hence compounded drill. Drill compounding is done when the affected person becomes enabled on single statement drills. After a few sessions, brain starts processing the emotional data in bulk.
Imagination vs. Reality (Soch vs. Sachai): The terms soch vs sachai, shared by Dr. Richa appealed to me and I included it in my working. It is a powerful concept to clarify the distinction between objective fears and irrational fears. When a person says that on a street a stray dog may bite him/her and he/she can catch rabies. A simple question is asked is it in your imagination or a reality. The goal of this enquiry is to impress him/her that the fears are being held in imagination (soch) and imaginative fears are to be corrected.
Multi-sensory Involvement: All sense modalities – eyes, ears, nose, skin, mouth, process emotional data and can become associated with objects of fear and feared cognition. Any single or a combination of sense modalities can be used in drill therapy. I recommend to use as many sense modalities as possible for faster procession of emotional experience at brain level. While performing the drill, I may show picture of dog, ask the affected person to attend to the dog barking and then perform drill ‘dog has bitten me’. Multisensory involvement is a better way to process the fears in drill therapy.
Outcome Expectancy: An affected person may harbor an expectation of complete cure of his/her problems. This expectancy of cure should be regulated through psychoeducation. I would say to the affected person and family members, that through drill therapy, the irrational fears will come under control. About 10-20% fear may remain in the system but that would not interfere in the life that much. Also drill therapy cannot heal each and every case of phobia/OCD. There may be some cases who would show minimal response to drill therapy. In those cases, other approaches of psychiatric and psychological treatment may be tried.
Session Duration and Session Frequency: A session of drill therapy may last from 60-90 minutes. The sessions may initially be conducted every day for a couple of days then to alternate days. When most objects of fear/feared cognition get processed, the follow up schedule can be implemented. One or two follow up sessions may be conducted on weekly basis, then every 15 days, one month, three months and at six month. Some booster sessions may also be required to process the objects of fear and feared cognition that may emerge later on.
Use of YouTube and Google Images: All situations and objects of fear cannot be simulated in therapist’s room. Google Images/YouTube can be a good choice to expose the affected person to his/her objects of fear. I expose the affected person to this content and require him/her to perform drill while exposed to this content. I have tried this exposure in fear of skin disease, dog phobia and other conditions.
Enhancing Generalization: For promoting generalization of acquired gains through drill therapy, I promote generalization by recommending the affected person to do drill and daring in as many real life situations as possible. For a dog phobic, I would recommend the person to go to the street, go in proximity of dogs and perform the drill. This real life exposure will enhance self-efficacy of the affected person and he/she would be able to face the situations with confidence. This will boost the sense of mastery over fears.
Ignore, Ignore, Ignore: The persons having obsessions keep on dwelling into the mental content of obsessions and worries for hours in a day. They get involved into it and try to solve by reasoning and finding some solutions. This solution finding quest consumes lots of time. I say to the affected person that this solution finding thinking itself is an OCD. The best way is to ignore, ignore and ignore it. Get out of your mind, involve yourself in some physical activities. The mind will get distracted and feel liberated by engaging in other activities. Give NIL importance to your OCD thoughts. The idea of giving Nil importance can work like magic in some cases.
Non-cooperation Movement: The persons affected by OCD feel compel to get involved in covert or overt activities due to OCD. The best approach to deal with this compelling quality of OCD is to adopt a non-cooperation movement. Do not co-operate with your OCD compulsion. Refuse to comply with the demands of OCD in executing compulsions. Initially, the OCD in mind will shout louder and louder, show imaginary threats but if you can persist in ignoring and not complying with OCD demands, the OCD compulsion will begin to fade away.
Drill, Daring & Distraction: The three components can produce major changes in the life of affected persons. Drill is the repetitions of tense converted statements of feared cognition. Daring means exposing oneself to the objects of fear in real life, and distraction means getting oneself busy in work be it occupational, academic or domestic. Application in this manner will enhance the probability of positive results from this approach.
Attribution to OCD: The persons with OCD attribute obsessive thoughts to their will. They think that thoughts are under their direct control. Which thought should come to the mind and which not can be controlled by exercising will power. Their such thinking is grossly wrong. Obsessive thoughts get hanged in the mind due to the disorder; a disturbance in chemical functioning of the brain. It is taught to the affected person that he/she should dissociate from these thoughts. Every time the thoughts come, they should say in their head that these thoughts are due to OCD. They are not healthy thoughts. With continued treatment, the quantity and the importance of thoughts will fade away.
Co-therapist: To encourage the affected person to carry out home work, practice of drill in real life setting, we need to train any family member who can act like a therapist in real life situations. The co-therapist is educated and demonstrated the procedures of drill therapy. They are also educated not to promote avoidance and compulsive behaviors of the affected person. The induction of co-therapist in the drill therapy program can accelerate the progress and the generalization of therapeutic effects.
Responsibility Appraisal: The persons with OCD have an inflated sense of responsibility for the feared consequences. If a person has abusive thoughts in his mind towards god, he/she may think that god may punish him or his family due to these thoughts by causing accidents, deaths and disability. If any such things happen then he/she would be held responsible because these thoughts originated in his/her mind. To deal with such thinking the concepts of magical thinking and multiple determinants of an event are discussed with the affected person.
Thought-Action Fusion: The persons with sexual OCD think that having such immoral thoughts in the mind is equivalent to the actual act. They equate thoughts with action. To clarify this pattern, the idea of soch vs. sachai can be helpful in explaining that thoughts are thoughts and acts are acts. Both are not the same thing. If I think in my mind that I have killed an ant, that does not mean that I have actually killed an ant.
Stress Induced Relapse: Upon remission of irrational fears/OCD, it may surface in response to stressful life situations. If a person comes with relapse after drill therapy, then presence of stress in his life should be explored. If it is present then a therapist should help in resolving the stress which lead to the relapse. After successful management of stress factors, the relapse condition will get rolled back. Drill may or may not be required in such cases.
Exposure to Unprocessed Trigger: During the course of drill therapy an attempt is made to identify and make a comprehensive list of the objects of fear/feared cognition. All recorded objects/feared cognition are processed in the therapy sessions. Upon termination of therapy, additional objects of fear/feared cognition may become apparent to the affected person. Since no drill was performed to these unprocessed objects/cognition; the body-mind reactions are likely to get activated during exposure to those objects/cognition. For example, a person has 10 objects of fear and 5 feared cognition. All got processed in therapy sessions. None was left. The affected person showed substantial improvement. Therapy terminated. After some time, an 11th object of fear or 6th feared cognition may become apparent to the affected person. This 11th object or 6th feared cognition was not drilled during the treatment. Since it was not drilled, the body-mind reaction is attached to the object/cognition. This newly identified object/cognition should be drilled to detach the body-mind reaction.
Here I make a distinction between relapse and the unprocessed object/cognition. Relapse means activation of body-mind reaction to those objects/cognitions whose body-mind reactions were detached through drill but resurfaced. That is, drilled objects/cognition activate body mind reactions. But when non-drilled objects/cognition activate body-mind reactions, it is not relapse because these objects/cognitions were never processed in drill therapy.
This phenomena of activation of body-mind reactions to non-drilled objects/cognition, favors the position that spontaneous generalization across objects of phobia/cognition does not occur spontaneously. Hence, train and hope approach to generalization does not work here.
Each identified object/cognition has to be drilled. There are few cases where generalization across objects/cognition can occur spontaneously.