EMPOWERING PROFESSIONALS
For a few years, I have been contemplating for conducting a workshop on Cognitive Drill Therapy for professionals. I was not getting appropriate conceptualization for the workshop. How it would be delivered? What will be the content and the methodology? The idea of a simple PowerPoint presentation and lecturing was not fitting well into my mental representations. So the idea remained dormant until October 2015. With an open mind, I invited some of my students to join me in the path breaking and historical event where I would be transferring my concepts and skills of doing cognitive drill therapy. We 10 persons assembled. I did not have any formal outline or pre-determined outline for proceeding and without any such formal preparation; I was destined to spend three days and about 15-20 hours with this learned group of psychologists and professionals. I had already asked them to read my write ups on Cognitive Drill Therapy and Somatic Charge Therapy including two published works. Spontaneously a structure of workshop got formed in my mind and proceeded to deliver it.
On Day-1, I opened with a brief detailing of the purposes and objectives of this workshop. I smoothly moved to the sharing of the case of Mr. Chand in detail. In the context of this case, I explained following concepts:
1. Pavlovian Conditioning
2. Stimulus Generalization
3. Extinction
4. Spontaneous Recovery
5. Role of tense in anxiety and cognitive drill
6. Exposure & Response Prevention
7. Thought stopping
8. Role of hypnosis
Outcomes of Cognitive Drill Therapy: Any kind of exposure therapy including cognitive drill, results in (a) habituation/extinction of conditioned response (b) increased self-efficacy; the patients with OCD and Phobia think that they cannot cope with the fearful situations. Hence, they keep on avoiding it. Through this therapy, they develop a sense of self-efficacy where they come to believe that they can face the fearful situations with ease and comfort or little distress. (c) Cognitive reinterpretation; the patients during anxious states have bias of interpreting stimuli in threatening manner. Through this therapy their interpretation of events changes to adaptive ones. A cognitive restructuring happen naturally.
Experiences with Claustrophobia: I also shared experiences of a professional with Claustrophobia. He was having fear of using lifts. An underlying fear structure of suffocation was detected. He was required to practice the drill for a few minutes, may be 15 minutes. The protocol of drill was “imagine yourself in lift and keep on repeating ‘muje suffocation ho chukka he” (I am suffocated). The SUD units indicated the bell shaped anxiety curve and when he was at ease, he was taken to the lift and was required to use the lift by his own. He was able to use the lift within a few minutes. Also, he was required to practice the drill daily for a few minutes and try to use lifts as Homework. He has improved proportionate to his application of drill therapy.
Most Severe Case of Contamination OCD: I emphasized that in OCD, a combination treatment is a rule rather than exception. All cases of OCD should receive psychiatric medications. I had a case who was having OCD with secondary depression. He had a long term history of OCD for more than 08 years. He had received proper treatment and still continued the same. He was well versed with the medications he received so far and their therapeutic effects and role of neurotransmitters. He had acquired this information from internet. He even consulted for gamma knife and made initial preparing for undergoing this treatment. He was having contamination OCD; while moving even on bike, he would think that important business papers have fallen and he would turn and look back while driving causing accident risk and when sitting on floor he would think that he has killed aunts and he would be cursed by them. I implemented cognitive drill therapy on him. He learned it well and consciously applied to many anxiety provoking situations. He had lost his business for three years. He was not touching his family members for fear of contamination. Now he has restored his business, now he is able to be with him family members, he can comfortably touch them. He is continuing his medication. His improvements are maintained even on a follow up of 04 years.
Standalone Medical Treatment: I have seen extra-ordinary improvements in a few cases who were put only on psychiatric medications. They were not responding to Cognitive Drill Therapy. I remember at least two cases; one lady with severe contamination OCD having secondary depression with suicide wish. She responded quite well and within a span of two months most of her symptoms subsided. She is continuing her medication and she should continue to do so. Another case was of Obsessional doubts and checking. He also responded quite well to the medicines. CDT was not working on him too. He improved considerably and established his business.
Treatment Failures: There are some cases who could not improve despite standalone psychiatric treatment or even combination of Cognitive Drill Therapy or any other kind of psychotherapy. These are the cases, who are disturbed to the extent that they fail to conceptualize the psychotherapeutic work and the cognitive drill therapy formulation. I have seen a few such cases whom I could not help through Cognitive Drill Therapy or any other kind of psychotherapies.
Lack of Generalization: I have seen a few such case where I was able to produce significant changes through Cognitive Drill Therapy in my office but there was little or insignificant generalization. I am still trying to find out how I could help such persons and design the homework so that they can take up and execute the homework. Homework is the primary key for promotion of generalization of the effects to real life situations. Some patients are not able to gather the courage to do homework and promote generalization. Their psychology of not doing homework and lack of motivation for generalization of improvement to real life situations needs to be studied.
Fear of Relapse: During the course of Cognitive Drill Therapy most patients will sooner or later come up with fear of relapse. They will say, now they are feeling better but after some time their OCD or fear will bounce back. This fear of relapse is also a fear and need be drilled in the same manner. “relapse ho chukka he’; “relapse ho chukka he’; “relapse ho chukka he’ (My condition has relapsed). Initially, this drill causes a surprise reaction. But it is a quite powerful drill for dealing with fear of relapse. It gives a pleasant ‘ah’ experience.
Fear of Drill: When I introduce the idea of doing drill and the reaction it activates; initially it can frighten not only the patient but also the therapist. They may think that by doing the drill; repeating the fear related words, holding feared images would worsen the condition and the fear or OCD will aggravate. Barring the exception, the drill is an exposure which is bound to produce extinction. It does not aggravate the condition. This fear dissipates rather quickly as after performing a few cognitive drills, the therapist and the patients come to realize the power of drill in reducing the fears. This fear of drill can be prominent when there is activation of severe anxiety response during the application of the drill. Instead of fearing the drill, simply give a gap of few minutes and resume the drill protocol. This way the anxiety and fear will show a declining pattern.
Disbelief in Cognitive Drill Therapy: The learner therapists and the patients initially have serious doubts regarding effectiveness of drill therapy in overcoming OCD and Phobia. ‘mere repetitions of a statement can give relief in extreme fear and anxiety reaction’ just impossible, ridiculous, quackery or just a new method to impress, fraud, placebo. These may be the reactions. So, to the patients, I say that let us not evaluate the outcomes until one week. We shall collectively examine after one week if the application of drill therapy is useful. By the end of one week if there are therapeutic gains, then drill therapy should be continued else it should be switched over to other models of psychotherapies.
Despite my verbal persuasions, the participants continue to have disbelief. They would say ‘me apni aankho se dekhu to manu’ (I shall believe if I see it happen before me). Over the years, I realized that the population of the believers just by listening or reading is less. There is a tendency just to discard or reject such novel ideas because it does not fit into their existing cognitive structure. It is good for them for protection of their cognitive structure. Nothing should be believed blindly. One should have direct exposure and experimentation to the satisfaction of one’s own curious mind. There is only one problem of ‘concluding on the basis of insufficient data’. The success rate is not 100%. If it is not 100%, that means there are failures. If you take up one case for demonstration and it turns up as failure, you should not conclude merely on the basis of a few observations. Just keep on doing it. I recommend that before forming any opinion of the effectiveness or usefulness of Cognitive Drill Therapy, you must apply and monitor at least 30 cases. A sample of 30 cases is quite reasonable to form an opinion of its efficacy.
On Day-1, I mostly shared my experiences, understanding and concepts of Cognitive Drill Therapy. I had never thought that I would be devoting first day to these topics. But it was a smooth flow of sharing.
Day-2 spontaneously got structured. I encouraged the participants to share their cases. One of the participants had already learnt cognitive drill therapy individually from me. She had applied it on a child with stammering. She got objectively verifiable improvement in social anxiety of that child. She also reported that there is little improvement in stammering. He was not interacting with authorities and participating fully in other social activities. But now this child is involving himself in interaction with authorities and social interaction with support of Cognitive Drill Therapy. I responded that for stammering problem the option of speech therapy should also be considered. The drill therapy is unlikely to change the stammering but it can reduce the social embarrassment and anxiety due to stammering.
Other participants also shared some cases of OCD and phobia. In the process, I emphasized how the case history and other relevant information should be gathered. I educated the participants on the components of history taking and psychological assessment.
I demonstrated case history taking on one of the participants. She was having a specific fear of performing on stage from rote memory. She is into music and required to sing from rote memory without any aide. To manage her fear she had developed a strategy to look towards the judge on the dais and holding some cues. She was getting negative feedback from the audience. She was perturbed with this scenario. While demonstrating case history taking I proceeded in following manner:
1. I simply enquired with an open ended question. Give me a detailed history of your problems. She told that she is not having any fear of social situations as such. She can effectively deliver lectures and other presentations on podium. The only specific component of music performance is the point of concern.
2. How did it originate? She accessed one of her sub-conscious experience that in teenage she was performing on the stage. She got blank. The audience laughed and waved their hands to indicate her to come down from the stage. She reported that she is able to remember this instance after so many years. She was not conscious of this experience. It gave her a sort of insight. She was almost surprised by recalling her experience.
3. She also showed her video clip of her avoidance behavior while performing on the stage.
4. I enquired what scares her while doing singing performance on the stage. She reported following feared consequences:
a. I can go blank
b. I will lose trust of other persons
c. I do not want to let down others who have trust in me
d. An imagery that audience is indicating by their hands to come her down from the stage
5. I partitioned the problem into its (a) surface structure and (b) underlying fear structure.
6. The surface structure consists of performing on stage leading to anxiety reaction and an avoidance pattern by holding cues and looking for reassurance.
7. The underlying fear structure consists of fear of letting others down, fear of going blank and an imagery of people indicating her to come down of the stage.
The live demonstration of this assessment and formulation further clarified the process of collection of relevant information. It raised the confidence of the participants. Still disbelief was persisting. This participant wanted to resolve her issue for getting convinced of Cognitive Drill Therapy.
I say that efficacy of any therapy cannot be contingent upon demonstrations of results in a particular case. But my this point is rarely appreciated until the participants apply my concepts into their practice and see the effects.
I also discussed my published case studies. I highlighted the research potentials of Cognitive Drill Therapy.
I demonstrated that initially many patients reject the idea of underlying fear structure despite knowledge of psychology and even cognitive drill therapy. This happens because the underlying fear structure is sub-conscious and not readily accessible to the conscious unless specifically attended too. With persistence of the therapist, the underlying fear structure can be discerned.
The focus of the second day was on sharing, discussion on the cases of the participants. We discussed other cases too and I clarified many concepts and repeated the concepts of Day-1.
The participants were eager to observe practical applications of cognitive drill therapy. I explained to them how to formulate the drill.
Drill Formulation: The formulation of drill statement is a skill.
1. It consists of overt or covert exposure to the anxiety provoking stimulus. In case of stage fear, ‘imagining oneself on the stage’; in case of contamination OCD, putting a contaminated object in the range of sensory field of the patient.
2. Selection of any one specific string of underlying fear structure such as going blank on the stage or fear of rejection or fear of letting down others etc.
3. Changing the tense of the string of underlying fear structure. Such as ‘I have gone blank’ or ‘I have been rejected’ or ‘other people are let down because of me’.
4. In this instance, following drills were formulated:
a. (i) imagine yourself on stage without any aid or avoidance
(ii) repeat to yourself ‘I have gone blank’.
b. (i) imagine yourself on stage without any aid or avoidance
(ii) ‘I have been rejected’
c. (i) imagine yourself on stage without any aid or avoidance
(ii) ‘other people are let down because of me’
Drill Implementation: I made her to do following drill one by one:
a. (i) imagine yourself on stage without any aid or avoidance
(ii) repeat to yourself ‘I have gone blank’.
b. (i) imagine yourself on stage without any aid or avoidance
(ii) ‘I have been rejected’
c. (i) imagine yourself on stage without any aid or avoidance
(ii) ‘other people are let down because of me’
At the onset of the drill implementation, she started showing heightened emotional reactions characterized by weeping and crying spells. I had to give pauses to manage her severe reactions. Crying, crying and crying, tears into her eyes. I had to persuade her not to resort to mental avoidance. At the end of the drill she felt calm, composed, and even started smiling and laughing.
There was an extinction of anxiety reaction to above stimuli. Her self-efficacy got enhanced. She now felt that she could comfortably be on the stage for music performance without any avoidance, reassurance or memory aide.
The participants got real feel of what Cognitive Drill Therapy is? How much powerful it could be? What kind of emotional reactions can be stirred during drill applications? These were the divine moments for me and for participants too.
The other perspective what I highlighted was that of ‘de-hypnotizing’. Due to conditioning, she used to be in a state of trance while performing music on the stage. The drill therapy could possibly de-hypnotize her from that conditioned state.
Contra-indications: I categorically conveyed that Cognitive Drill Therapy should not be used on the patients having cardiac risk. Also this therapy is not useful on schizophrenic patients.
Indications: CDT is a treatment for stimulus bound anxiety. That is, if you can make out a stimulus- response association in the anxiety state then possibly it can be used. The specific instances where Cognitive Drill Therapy can be used are as follows:
a. Fear of public speaking
b. Sexual thoughts towards religious objects
c. Contamination OCD
d. Agoraphobia
e. Claustrophobia
f. Specific phobia
Psycho-education: The patient should be properly educated prior to the commencement of the drill application. Following specific components should be communicated:
a. Diagnosis of the condition
b. Surface structure
c. Underlying fear structure
d. Theory of extinction
e. Anxiety curve
f. Theory of tense conversion
g. Importance of Homework
Controlling Avoidance: For extinction to occur, it is necessary to prevent the avoidance pattern. Avoidance leads to reduction of unpleasant drive state which is a negative reinforcement and maintains avoidance behavior. I clarify it to the patients through an example of ‘darkness phobia’. Suppose a child has phobia of darkness. We want to remove his fear of darkness. The avoidance of darkness gives him a sense of relief but it does not solve the problem. Somehow, he has to expose himself to the darkness. When exposed to the darkness, this child will initially have an avoidance tendency and would display emotional reactions like crying. With continued exposure without avoidance, the phobia of darkness would disappear. Similar approach needs to be adopted.
Multi-sensory Involvement: The patient is encouraged to imagine the anxiety provoking stimulus in as much details as possible. Involve as many sense modality as possible. The multi- sensory involvement would lead to faster results.
Bearing Discomfort: When exposed to anxiety provoking stimulus without avoidance, there would be anxiety and distress in the patient. I tell them to bear some of the pain and suffering of exposure as this discomfort would lead to therapeutic results. There is pain in both suffering and surgery; but the pain of the surgery is temporary and would ultimately lead to greater comfort.
Recordings by the Therapists: I recommend that case history and details of each session including assessment details should be recorded in any manner with the consent of the patient and be kept safe. These recordings would help in generating research papers, case studies, monographs, books, presentations and lectures. Within a few years each therapist will have sufficient data to add to the pool of database of Cognitive Drill Therapy.
Invitation of Criticisms: I encourage the participants to criticize the concepts of Cognitive Drill Therapy so that I can contemplate and formulate my response to such criticisms. This would help me in refining the theoretical and practical aspects of this novel and effective form of psychological treatment.
Expectancy of Results: I say that no form of therapy of any theoretical framework can cure each and every case of OCD and Phobia. The therapies are more or less effective and useful. I am setting up the perspective that Cognitive Drill Therapy cannot heal all patients of OCD and Phobia; also who respond to this therapy would not be cured 100%. Through this therapy I am able to help some of the patients in a manner so that they can help themselves by managing their OCD and Phobia. I also say that upper limit of improvement is about 70%; a moderate goal. If there is more improvement, it should be celebrated as a bonus.
Role of Hypnosis: Hypnosis can be used to promote adherence to homework. It can also be used to reduce avoidance pattern and enhance vividness of imagination of the anxiety provoking stimulus. Hypnosis can also help in accessing early experiences and initial sensitizing event relevant for OCD and Phobia.
Drill-Daring & Distraction: I recommend drill, daring and distraction in OCD and Phobia. Perform the drill, do daring by exposing oneself to anxiety provoking stimuli and do distraction by keeping yourself engaged in some productive work.
Rationale and Coping Statements: A positive and helpful self-talk is also helpful in managing OCD and phobia. The statements such as ‘this is temporary’; ‘I can reasonably handle it’. ‘Give nil importance to OCD thoughts’; ‘OCD is a trap’ etc can be identified and practiced by the patient.
Thought Stopping: If worry occupies the mind and there are several strings of thoughts running into mind, the technique of thought stopping can be used. The patient is taught simply to mentally shout ‘stop it’ as and when he realizes the presence of repetitive or excessive thoughts in the mind.
The workshop was an enriching experience for me as well as the participants. I urged the participants to record their learning from this workshop and share with me so that I could incorporate the feedback in my work. Also, this will be an opportunity for them to revise most concepts of drill therapy.
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