What models of therapy help with intrusive thoughts

models of therapy- image shows therapist with clock
Dr Elaine Ryan
Written by Dr Elaine Ryan Psychologist and Founder of MoodSmith® Elaine obtained her Dr in Psychology from the University of Surrey and has worked in psychology for 20 years. Dr Ryan specialises in Intrusive Thoughts, OCD and anxiety-related conditions.

There are many models of talking therapy at a therapist’s disposal, but only some will help with intrusive thoughts, and others may keep you stuck or worsen your obsessive thoughts. Just because the therapist is trained in a particular model does not mean it is effective for your presenting problem.

This article ensures you get the best treatment should you decide on counselling to help with your thoughts.

Your choice of therapist largely determines the type of therapy you will receive. For example, a CBT therapist is likely to offer cognitive behavioural therapy; a psychoanalyst may offer longer-term treatment using psychoanalytic models.

Many people with intrusive thoughts may work with a therapist based on a recommendation or referral from their GP. Still, most people don’t know that the therapist’s training determines the therapy model offered, which may not be a suitable model to help with intrusive thoughts.

Models of therapy

There are countless models of therapy, some of them well known, such as

  • Cognitive behavioural therapy, and
  • Exposure and response prevention

through to models you may be familiar with but not necessarily understand, such as

  • Psychoanalysis
  • Acceptance and commitment therapy
  • Dialectical behavioural therapy

and many other models of therapy that you might not have heard of, such as

  • Gestalt therapy
  • Eye movement desensitisation and reprocessing; EMDR
  • Cognitive analytical therapy
  • Existential therapy
  • Freudian psychotherapy
  • Humanistic

In addition to the countless therapy models, there are different types of therapists, including well-known ones.

  • Psychologists
  • Psychiatrists
  • CBT therapists

to less well known, including
Integrative counsellors.

 

What works for intrusive thoughts.

The recommended therapy models for intrusive thoughts include CBT and ERP, for a good reason.

Why do these models help and tend to be recommended?

CBT and ERP are widely recommended as they are researched and have been shown to help people with obsessive thoughts. The Priory states that CBT helps you develop new relationships with, and a more effective way of responding to your obsessions and compulsions. 

The Mayo Clinic , NHS and IOCDF  along recommend CBT and/or ERP.

What models do not help intrusive thoughts?

Psychoanalytic therapy.

Psychoanalysis originates from the neurologist Sigmund Freud and allows the patient and analyst to focus on the patient’s inner world. Free association is a technique that can be used as part of treatment, where the person is encouraged to say whatever comes to mind, thoughts, feelings and images.

This technique of free association will not help the person with intrusive thoughts, as it may inadvertently encourage the person to explore in depth their thoughts and not only give more emphasis to the thoughts but also keep compulsions going.

For example, many people with intrusive thoughts seek reassurance that their thoughts will not come true. My clinical experience showed me that clients would use all the time in the session, if allowed, to get reassurance, but as we know, reassurance seeking is a compulsion.

If you want to recover from OCD, the research shows that the person needs to be able to have their thought without ritualising. This removal of compulsions is at the heart of exposure response prevention.

Worked example

While working in England, I had a client who had intrusive thoughts about death. She was obsessed with the idea that her heart would stop at any moment, even though she was in her early 20s and had no underlying health conditions.

If I were working with her using psychoanalysis, I would have facilitated her to talk at length about her fears, with no direction from me as her therapist.

She would have been given time and space to ask repeatedly how do you know that my heart won’t give up, and other types of questions in need of reassurance.

Working psychoanalytically as her therapist, I would act as a container for her uncomfortable feelings and, at some point, offer her an interpretation of her thoughts and fears.

Explainer. Holding and containment are essential aspects of psychanalysis. Holding originates from the work of Winnicott, and containment is from work by Bion, both in the 1960s. For healthy infant development, holding and containing the infant’s difficult emotions is carried out by the mother. The infant’s emotions are held and contained when the mother allows the infant to express their upset safely, without suppressing or chastising them for their experience.

Example, a young child is screaming because their toy is broken; this emotion of distress is projected onto the mother who contains and manages it for the child. The mother soothes the child, calms the feeling, and returns the emotion to the child.

Working analytically, the therapist would hold the client’s intolerable emotions relating to her intrusive thoughts of death and relay them back in a less threatening way.

There is currently no research to say that this style of working will help, but from what we know from the researched models of CBT and ERP, shining such a spotlight onto the obsessions can increase their intensity and keep compulsions going.

It could also create an overreliance on the therapist, as the client would look forward to meeting with their therapist when they could discuss their obsessions at length in a safe environment without any direction.

Whereas with CBT, successful therapy is to make the therapist redundant, i.e. the client can be their own therapist.

Research has shown that to help someone with obsessive thoughts; they need to be able to experience the thoughts without the need for ritualising. In other words, they need to have obsessions without compulsion.

Being allowed to explore their obsessions in depth through psychoanalysis and seek reassurance from their therapist is actively carrying out a compulsion of reassurance seeking without any intervention or psychoeducational material on the importance of extinguishing compulsions.

Working with the client using CBT with ERP.
I worked with the client who had intrusive thoughts about death using CBT with ERP.
This involved several stages including

  • assessment
  • psychoeducation
  • treatment
  • reviews
  • end of therapy

 

Psychoeducation stage
The psychoeducation stage is of utmost importance as it is where I teach the client about their obsessive thoughts and outline how their suffering is maintained through carrying out compulsions.

CBT and ERP are explained at this stage.

During treatment, the client is taught how to manage their thoughts without carrying out compulsions.

This starkly contrasts to psychoanalysis, where they would have been allowed free association.

Between each session, the client is set tasks or homework, where they can practice managing their obsessive thoughts without ritualising.

Most of the work is undertaken by the client outside of sessions through homework and behavioural experiments.

I write this article to highlight that not all talk therapy is suitable for OCD and intrusive thoughts. I am aware that therapy is considered a safe place to talk, but talking at length without some expert guidance is not going to help and may make your intrusive thoughts worse.

Further reading

Beyond OCD Why some individuals do not recover

Online self-help

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