Communication-Focused Therapy® (CFT) for OCD
Dr. Christian Jonathan Haverkampf, M.D.
Communication-Focused Therapy® (CFT) is a psychotherapy developed by the author, which can be applied to a number of mental health conditions, including obsessive-compulsive disorder (OCD). The flows of internal and external communication maintain the functioning and the development of the individual in the world. If a communication pattern or channel does not serve its intended purpose anymore, it can lead to a disconnect from oneself and from others. The disconnect internally and externally shows itself in different symptoms. The disconnect also contributes to more uncertainty about the own basic parameters, such as values, needs and aspiration, which can then lead to maladaptive decisions in life. Communication-Focused Therapy® (CFT) works directly with communication about communication to restores the autoregulatory processes that can help to reverse the condition.
Keywords: OCD, obsessive-compulsive disorder, communication-focused therapy, CFT, communication, psychotherapy, treatment
Table of Contents
Communication-Focused Therapy (CFT) was developed by the author to deal directly with the communication processes most forms of psychotherapy work with indirectly. As obsessive-compulsive disorder (OCD) has its cause in unresolved emotional pressures and a malfunctioning in the selection and processing of information, improving internal and external communication pathways usually leads to a remission of the symptoms. However, since there is a significant element of learned thought patterns, the therapy can take a couple of months.
Cognitive Behavioral Therapy (CBT), interpersonal psychotherapy and psychodynamic psychotherapy are often used to treat OCD. They focus on learning and internal conflicts which are also forms of communication patterns. (Haverkampf, 2017a) CFT tries to achieve these results more directly. (Haverkampf, 2017b) CFT uses such techniques as creating awareness, observing, experimentation with the solicitation of feedback and other techniques. (Haverkampf, 2017b) Several case studies have demonstrated the effectiveness of this approach (Haverkampf, 2012b, 2012a, 2012c, 2012d, 2013a, 2013b, 2014, 2015, 2015).
Both therapeutic approaches have shown effectiveness in the treatment of anxiety and panic attacks. Both have theories about the underlying maladaptive mechanisms they address. CBT sees learning processes and certain cognitive thought patterns as central, while psychodynamic considers conflicts and certain dynamics within the psychological structures as central. However, they achieve their results through changes in internal or external communication patterns, even though they see this only as a result of the healing process rather than as the cause of it.
Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. It requires a setting in which it is possible for the patient to freely develop new patterns of communicating, first with the patient, and then internally. The therapist facilitates this process and creates the space in which this is possible. It is then an active process in which the therapist asks questions and together with the patient observes and reflects on communication patterns. This feedback is not so much about a specific content but about how the patient uses communication to search for and receive meaningful messages from the environment and then processes and sends new messages. The internal changes in affective states or obsessive thinking are a consequence of changes in internal communication, while external changes in the world are a consequence of changes in external communication patterns. (Haverkampf, 2010, 2017b)
Communication has rules which are stable over time. This makes a communication-focused approach much more effective than working on content or psychological processes which are subject to change over time. Awareness of communication patterns, whether internal or external, as long as they are relevant in providing and sending meaningful information, lays the foundation for any future work on them. For example, a patient who has difficulties drawing healthy boundaries with his boss, does not have a difficulty with boundaries as a fundamental problem but uses, often subconsciously, internal communication pattern and external communication patterns which are not helpful. Fears underlying an anxiety to say ‘No’ are a product of a deficit of meaningful information, which creates uncertainty, and the timid voice used in the interaction reduces the ability of the boss to receive and understand the message, which means the situation persists.
OCD and anxiety are related to how people communicate with themselves and with others. An obsessive thought or a compulsive behavior is a reaction to an increase in anxiety, which in turn is a reaction to a reduced capability to communicate an emotion or some other meaningful information. The pressure of the anxiety tries to get the system to an adjustment through greater receptivity of information. However, if there are some maladaptive communication patterns which were never corrected, the underlying emotional or cognitive conflicts cannot be resolved because it would require effective communication pathways to do so. If one is stuck in a job which is not fulfilling but at the same prohibits oneself to become aware of it, that is to receive the information that could resolve the conflicts. Conflicts usually exist in places where there is not enough information. With enough meaningful information every conflict can be resolved, emotional or otherwise.
Emotional conflicts, such as sadness about a loss but anger at the person one loves, can be resolved once one has more information. However, when people get stuck in these emotional conflicts they shut down instead of opening up which would allow the information to stream in to resolve the conflict. CFT tries to reverse this by reducing the fear of a free and open communication while exploring patterns which can support this process.
Information needs to be meaningful to be helpful. Taking more charge of the internal communication through awareness, experimentation and internal and external feedback also leads to a greater sense of self, efficacy and agency. This also helps against the anxiety and reduces the OCD. Over the long run the new patterns will offer stability against the OCD. Communication itself is an autoregulatory process which provides the information so that individuals can adapt to their environment and to each other.
Connection is a result of the dynamics of communication processes, but at the same time it also links people over time. A connection is a promise that over time a meaningful communication will continue, which has a benefit to all involved. A connection is a win-win situation. Hate, envy and others occur if there is an information deficit, if the communication between people is somehow compromised. Whether one speaks of nations or on an individual level, obsessions and compulsive behavior are a result of a deficit in meaningful communication. Important is to keep in mind that this is not necessarily a meaningful interaction that can be had in the real world, but the sense that something is missing, a longing for a particular interaction, which does not have to be with a specific person, but can be with the universe as a whole, for example. Loss may be the starting point but does not have to be. Over time, many people would forget some of the triggers that made life less certain and cause the brain to develop rituals to deal with an increase in anxiety. While there are neurobiological variations that can make it more likely that one experiences OCD symptoms, whether one has them or not is to a large degree under individual influence. As will be outlined to a greater extent in the following, having greater influence over information flows inside oneself and with the world can change the dynamics of OCD. The same is the case for anxiety, depression and many other conditions (Haverkampf, 2018b).
OCD is usually triggered by stressful situations. However, often these situations have a strong interpersonal element. The end of a relationship may be such a trigger. Since relationships are promises of future communication, the breakdown causes strong emotions, which in turn can cause anxiety if there is no pressure valve for the emotions, such as sadness, anger, frustration, fear, or a host of others. Anxiety is the result of a disconnect if the individual emotions cannot be identified.
OCD often occurs when a relationship breaks apart or some other interpersonal change or issue occurs. The result is often communicative patterns that are maladaptive to the individual. These changes in communication patterns are what causes then the problems to the individuals because. Cycles of thinking or acting to suppress the anxiety becomes less and less effective as the communication patterns used are maladaptive. As the end of the flow of the information in a rumination or obsessive thinking are no longer any meaningful and relevant outcomes. The content of an intrusive thought may be bizarre and anxiety provoking.
The reason why these patterns keep repeating themselves is because they cannot be dealt with effectively by the communication and information structures that are already in place. The communication patterns an individual uses do not lead to the change that would be needed to effectively counter the maladaptive communication patterns.
Often, there are already maladaptive communication patterns before, that cause the problems in the relationship or interpersonal interactions. The advantage of seeing these issues with oneself and others as maladaptive communication patterns, makes it easier to treat any symptoms that are caused by it because communication patterns can be changed. Various techniques have been described elsewhere. (Haverkampf, 2010, 2017c)
Maladaptive Communication patterns are at the heart of many psychiatric conditions, including depression, psychosis and others. Qualitatively and quantitatively they should be seen as being on a sliding scale of maladaptive communication patterns. What is maladaptive about them is that they do not bring the system to a better-informed state with better regulation, better decisions and a greater sense of self and agency in the environment.
In the case of OCD internal maladaptive communication patterns include the following:
- Observation deficit: The inability to observe own communication, including the maladaptive communication patterns (which it shares with many other conditions)
- Information selection deficit: information is not filtered out adequately. As the anxiety increases the filter is probably becoming even less effective
- Source mix-up: Usually in the case of OCD internal emotions are projected into the environment, but since seeing or making structure in the environment does not reduce them, the OCD continues. For example, hand washing or counting tiles does not take away the feelings of helplessness, abandonment, sadness or anger.
In the case of OCD external maladaptive communication patterns include the following:
- Decoding deficit: less meaning is identified in messages from other people; understanding is reduced
- Encoding deficit: information, whether from emotions, thoughts, memory, perceptions or all four, cannot be packaged in a message to the extent which would be useful
Communication-Focused Therapy (CFT) focuses on a greater awareness for these and other communication problems. Often, awareness in itself is enough to resolve the problem, while in others experimentation and reflection are needed to bring about a change. Overall, it is important to remember that the change has to be in how information is communicated to effect a change, which is more important than the actual content, while the latter can be helpful in identifying the former though.
In anxiety conditions in general, a lack of internal or external connectedness is often present. When the flow of meaningful information is impaired, uncertainties and fears grow. This can also be observed in OCD. Very often the obsessive thoughts and compulsive behaviors become more intense when something in life is misaligned or not working. In this case, there is the information that something is not working, which one may not even be aware of, but the deeper understanding how the situation could be changes is missing. It is not a total disconnect one experiences, because the message still arrives that an area in life is not aligning with the individual needs, values and aspirations one has. This may also explain why anxiety and OCD tend to be higher in patients who can be quite sensitive. It is rather rare to see anxiety and OCD in a true sociopath, for example, but this would be an extreme case. In daily life, there is a choice, whether to make one experience, perceive and feel less, which is impossible, or to go all the way towards identifying own needs, values and aspirations, while working on the communication patterns that make it easier to take in meaningful information and to interact with oneself and others in more helpful ways.
Obsessive thoughts and compulsive behaviors lack meaning in the sense that they do not bring about a benefit for the individual. Instead, they act like a drug which brings a temporary relief but requires ever increasing doses as it builds tolerance. In the same way, an individual suffering from OCD needs to engage in ever increasing obsessions and compulsions to hold the anxiety at bay. At some point, the daily range of activities becomes so limited that a normal life with work and social relationships is no longer possible. The patient becomes so caught up in the obsessive thoughts and compulsive behaviors that the world shrinks to a little box with potentially enormous pain and distress. But worst of all, the focus on the obsessive thoughts and compulsive behaviors deprives other aspects in life of their meaning. The obsessions and compulsions can communicate meaning, such as the one contained in the underlying conflictual emotions or thoughts, but the anxiety which is maintained by the subjective need to suppress the urge to decode and interpret the emotions often blocks this. The therapeutic solution is thus to open up the communication of the signals contained in the emotion to the conscious part of the brain and to interpret them. This may happen not directly but by focusing on how emotions are communicated externally between patient and therapist.
Everybody has intrusive thoughts. However, a patient suffering from OCD focuses more on these thoughts than someone else. While an underlying anxiety can cause this shift in focus, a shift in focus towards more uncertainty and self-doubt can also increase the anxiety. As long as the underlying conflicting emotional and cognitive signals are unresolved, this vicious cycle will continue. The resolution of missing or conflicting information would usually happen through better meaningful information. For example, if uncertainty about a relationship increases the intrusive thoughts that, for example, one has to count in steps of two up to a certain number or that one will drive off a bridge every time one goes across it, resolving the issues one has with the relationship would usually drastically reduce the levels of OCD symptoms.
Intrusive thoughts are attributed a relevance which they otherwise would not have. An important step in therapy thus is to make the person aware of how OCD leads to maladaptive communication patterns, which change the information one primarily sees primarily, and to which one attaches meaning. At the same time, important information in the form of emotions, for example, does not get through to awareness the way it should. The maladaptive communication patterns are thus blocking relevant emotional signals, while amplifying less meaningful information. As discussed above, one may experience a very stressful OCD episode with apparently an overwhelming array of feelings and thoughts, while being in a state of relative disconnect at the same time. One aim of Communication-Focused Therapy® is to end the disconnect and thereby create room for connectedness.
To break through the vicious cycle of OCD, in which emotions like fear and anxiety cause safety thoughts and behaviors, which in turn reinforce feelings of fear, loneliness, sadness, and so forth, it is helpful to focus on identifying what is meaningful and having more of it in life. Communication helps in identifying and finding meaning, either communication with oneself or with others. The exchange of messages is like a learning process in which meaning can be identified, found and accumulated. Through meaningful interactions one accumulates more meaning, more connectedness with oneself and the world and reduces the need for thoughts and behaviors which are triggered by fears, guilt, self-blame and other negative emotions. This also helps against depression and anxiety.
Perceiving more meaning also makes interacting with others and oneself more meaningful. This has a positive effect on one’s interaction patterns, how and in which ways one relates to one’s environment and exchanges messages with it.
Intrusive thoughts and OCD thought patterns in general are communication patterns in their own right. The best way to counter them is with new communication patterns that can bring about a change. Communication-Focused Therapy® focuses on identifying and developing communication patterns, which can bring about a change in existing communication patterns. Many of the communication patterns one can work with in a psychotherapy session or other situations have been described by the author elsewhere (Haverkampf, 2018c). Something as simple as a specific type of question can lead to new information streams, which lessen an OCD communication pattern (Haverkampf, 2017c) “What is the worst thing that can happen?” may be one of the simplest form of a forward directed investigative question, but it can be quite effective.
Thinking about thinking (meta-cognition) is often an important first step. It is the stage in therapy where a patient is helped to reflect on and develop insight into the own communication patterns and communication patterns and structures in general. Meaningful information is what brings about change, and the aim is to help the patient to see more and work better with meaning. As meaning is generated when new information is put in context with existing information, the extent to which one can work with meaning depends on the skill of using good communication patterns that are effective and align with the basic parameters, the individual needs, values and aspirations (Haverkampf, 2018d).
Questions can be very powerful in bringing about changes in communication patterns (Haverkampf, 2017c). As there are many different types and flavors of questions, the latter represent a superfamily of many different communication patterns. But what many types of question have in common is that they request changes in communication patterns and information that is made available by another or by oneself. Questions can as well internal as they are external. Asking ourselves the right questions can make a significant difference. Important is to remember that questions are first a communication pattern, and that they have content which depends on the specific situation. Using the right types of question, it is possible to break through a cycle of obsessive thinking or compulsive behaviors, or both. One would first need to find the right type of question before looking for the content. For example, a sincerely investigative and open yet content specific question like “What is the worst that can happen on my job if I do not find a different way of relating with my boss?” can be a first needed step to look at the interaction patterns with the boss, and to experiment with them playfully. The question can reduce the emotional intensity that underlies the OCD symptoms, such as helplessness, anger, upset, and feeling trapped. It can also help crack and modify the communication patterns that are associated with and maintain helplessness, anger, upset, and feeling trapped.
Trying to find reasons why a particular obsessive thought, or compulsive behavior does not cause any wished changes in the real world is often less effective than looking at what does. Therapy often starts at the point to stop engaging in obsessive thoughts and compulsive behaviors, and finding reasons why they cannot work, rather than exploring, why one has them in the first place and finding ways to get one’s needs met, which then eliminates the dynamic underlying the OCD. This is not to deny biological predispositions for OCD. However, it is important to regard them as just that, namely predispositions. The concrete manifestation of OCD depends on so many other factors, particularly psychological ones, but also environmental stress and social situations, that the more finely tuned treatment will always be the psychological ones. Medication is frequently an important support, but the important long-term treatment is frequently psychological (Haverkampf, 2018a).
OCD thinking and behaving is inherently repetitive and static. If the OCD intensifies, the word of divergent thinking and behaving becomes ever narrower. The OCD patient wants to break free, and there can be considerable pressure to do so, but this is opposed by the fear of more uncertainty and the underlying conflicting emotions rearing their heads. The result is that they remain locked into the endless loop of OCD thoughts and behaviors, while feeling even more helpless, less confident and with a worse self-image from not being able to break free from the obsessive thoughts and compulsive behaviors. A first therapeutic step is here to convey to the patient that OCD like most other things in mental health come on a sliding scale, and that everyone has their thought patterns and rituals in life which provide a sense of safety and stability. Important is also to show the patient how the symptoms can be treated, and that there is no reason to feel helpless or pessimistic.
To break the repetitive patterns of OCD one first has to be able to identify them as such, and then help the patient experience that change can be positive. This can come out of the psychotherapy sessions, in which new communication patterns can be tried out in a safe environment, and the changes the new ways of communicating bring about in everyday life. This reduces fear and opens a window to enjoying novelty and change.
There are many communication patterns that are used in the creative process. They all help in the production of meaning, which has the potential to bring about change. Helping a patient to use more investigatory communication patterns in the world and within themselves can reduce OCD symptoms over the long-term, sometimes after an initial temporary worsening, as long as the aim is the needs, values and aspirations of the patient. Aside from questions, experimenting with new patterns in interactions and with oneself is part of it. The communication patterns themselves may not be as important as the ability and willingness to change them. For example, saying more clearly ‘Yes’ and ‘No’ in increasingly more situations makes it possible to get a better sense of how people really react and think when one is clearer. This added insight can then be helpful in developing new communication patterns that work better for oneself.
Important is also that patients can develop a habit of testing communication patterns. In OCD communication patterns become very rigid. Repetitive thoughts are essentially static communication patterns. Interestingly, when a patient engages in them it keeps anxiety down, while the anxiety becomes greater when the patient stops. An interesting question is why repetitive patterns lower anxiety. To find an answer it helps to look at the other side of the patient’s world. If repetitive patterns are familiar, stable and predictable, they might counterbalance a world which does not have these attributes. One may also see these patterns, at least in the beginning, as a creative product, while the world may seem to the patient a place that does not offer much room for being spontaneous and creative. In other words, the typical OCD internal communication patterns fill a niche the world does not fill.
A helpful strategy is to develop communication patterns that not only patch over where something seems to be missing but that really fill the niche. One sees very often that when people can engage with activities they enjoy and find meaningful the OCD symptoms become less of an issue, which may also be related to the fact that tensions and anxiety tend to be less of an issue when a person is in a good state. Finding what is meaningful and relevant is easiest done through a survey of what was enjoyable and meaningful in the past. As already discussed previously, the basic parameters, the needs, values and aspirations, change little over time.
Testing communication patterns means changing something, and then observing the results. The little something to change in an existing communication pattern or structure can be something very small. Important is that there is a small variation. For example, if one has a relative where one feels one has nothing to say, asking a few questions may be a major game change in the communication dynamics. Another example involving internal communication could involve an intrusive OCD thought. If the communication pattern is to usually push back against it, one may try to just let the thought come, but then question it. So, instead of a communication pattern of forced disengagement one may try one of disengaged engagement. That there is more information available around the intrusive thought is positive rather than a negative. Several schools of psychotherapy, particularly in CBT and exposure-based models, the goal is extinction of the obsessive thought or compulsive behavior through a kind of habituation. The approach in Communication-Focused Therapy® is more insight oriented, but in a way that affects the whole system and not only conscious rational thought. Information flows are ubiquitous in every living system, and when we communicate with ourselves and others, we send and receive messages that contain information from practically everywhere in the organism.
Often, individuals suffering from anxiety or burnout have become uncertain about what is really important to them and the fit between these values and interests and their current life situation. Whether in the professional or romantic realms, getting what one needs and values makes happy in the long run, everything else does not. If I value helping people, it is important that I do that to make me happy, content and satisfied. Since these basic parameters stay relatively constant in the long run, identifying them can also create a greater sense of stability, security and predictability as to one’s own inner world. Reconnecting with oneself and getting a better picture of them not only leads to better decisions, but also to a greater confidence in oneself to chart a long-term course which lowers anxiety considerably. As situations, people and activities can be sought which are more congruent with one’s needs, values and aspirations the potential for emotional conflicts is reduced.
Getting an eye for what is meaningful helps in identifying the own values, needs and aspirations. In this sense, meaningful communication is a learning process in which a sense for relevance can be nurtured. Changes in one’s life begin with the ability to select and filter information, such as that contained in perceptions and thoughts, to make it useful. In OCD, this filter does not work efficiently. However, through interactions with the outside world, the filter with regards to the inner world can be reestablished and maintained.
A change in course towards getting more of one’s values, needs and aspirations fulfilled is better done in gradual shifts because it reduces the anxiety levels that promote OCD symptoms. Gradual shifts also prevent overshooting and make the adjustments easier. Overshooting may occur if one changes one’s job or other aspect in life so radically that the targets are missed and finetuning to adjust is no longer possible. If, for example, a patient who worked in a bank now works for a charity, because he finds this more in tune with his needs, values and aspirations, he may be more valuable and useful to the charity working in finances than auditing farms in remote areas. He may, of course on deeper reflection also find that the bank serves many social and economic functions which are not addressed by the charity. This is one reason why not only connection with one-self but also with others is important to make better decisions in life and have a strong sense of direction.
Communication is the vehicle of change. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings change in both people who take part in this process. The learning curve for the patient may be steeper in certain respects because he or she spends less time in this interaction style than a therapist.
In OCD it is important to help the patient see the communication patterns themselves as something that merits further insight. Patients often focus on the content rather than the pattern of the obsessive thoughts and compulsive behaviors they are experiencing. However, the patterns themselves contain much of the real underlying dynamic, and it is they which provide an important angle for therapy. As mentioned already by the author elsewhere (Haverkampf, 2017c), the use of questions and other analysis inducing communication elements and patterns are helpful in helping the patient opening up and changing malfunctioning communication patterns. The use of emotion affecting communication patterns, such as showing empathy, compassion, and gratitude towards oneself, can help overcome emotions which frequently stand in the way of a change process. Self-criticism, self-blame, and other self-directed negative thoughts are loops of communication patterns which can arise for several reasons. Since they also do not happen without reason, it may often be a pattern that arose to protect an individual from something. It may sound paradoxical but originally, they may have protected from negative emotions combined with the feelings of helplessness to change this experience. Acknowledging these feelings van make the content that is induced by these feelings seem less real and threatening. For example, an experience of hurt, sadness and helplessness may lead to negative thought patterns and OCD patterns. Being able to see what the OCD patterns and negative thought patterns ride on can help to reduce them. Through the use of certain communication patterns, something constructive can happen with the memories of emotional and other information (Haverkampf, 2010, 2019).
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at firstname.lastname@example.org or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
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