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PROFESSIONAL MANUAL

COGNITIVE DRILL THERAPY

Fast OCD-Panic-Phobia Relief

Dr. Rakesh Jain, Ph.D.


Clinical Psychologist

2015 Dr. Rakesh Jain, Agra


All rights reserved. However, this document can freely be copied and circulated without making any
changes in the content.
Email: jain.imhh@gmail.com
Facebook Group: http://facebook.com/groups/drjain

Cognitive Drill Therapy (CDT) is developed by Dr. Rakesh Jain, Ph.D. Clinical
Psychologist, specifically for the management of phobia and obsessivecompulsive disorder (OCD). It is a structured, directive and collaborative form of
psychological treatment based on theories of conditioning, cognitive appraisal
and linguistics.

PREFACE
This manual is meant for professional psychologists/ the practitioners who have received
training in Cognitive Drill Therapy (CDT). The training of Cognitive Drill Therapy can
comfortably be accomplished through a three days in person workshops.
I have been developing CDT since 2005 and could get initial success in 2007. Since then I
am successfully applying it in cases of OCD and Phobia. The results of this innovative
therapeutic approach are quite encouraging. Hence, I feel that can be an extremely useful
skill which empowers not only the therapists but also the patients.
I wish that this manual should reach to as many psychologists as possible across the globe.
I am grateful to each and every being that supported me in this passion of mine.
Rakesh Jain
Agra

THE OPENING UP:


I conduct workshops on hypnosis and past life regression in Universities, Institutions and
Colleges across the country. I conducted one such workshop at RGPG College, Meerut in
December, 2007. The workshop was chaired by the then Honble Vice-Chancellor of
Chowdhary Charan Singh University, Meerut. A demonstration on group hypnosis was done
including introductory presentation on past life regression. The workshop was covered by
print media in Meerut.
After about one month of the workshop, two persons arrived at my residence on Sunday
afternoon. They introduced themselves as belonging to a village nearby Meerut District.
They told me that one of their relative is having a problem of Obsessive-Compulsive
Disorder (OCD). He came to know that you were an expert in hypnosis through newspaper
coverage of hypnotism workshop in RG College, Meerut. He wanted your help in
overcoming his OCD through hypnotism and requested my contact phone.
After a few days I received a call from that person named Chand. He requested an
appointment from me for hypnosis. He was 35 years old male and presented with more
than 15 years anxiety disorder characterized by obsessional fears of some words like
nash, Guldiva, Punja Chhipna and the situations, objects and places which were
associated with these terms. He would either not wear or throw his even new clothes if he
listened to those words upon wearing those clothes. Some of these terms are very common
in his culture. He would avoid going near to those people who use these terms. He also
developed secondary depression. He was trying to deal with his problems by avoiding the
places, situations and objects associated with these words and kept attempting thought
suppression or conscious elimination of these thoughts from the awareness. Sometimes, he
was successful and got temporary relief from his distress. Since he was getting
impermanent relief from his severe distress due to avoidance and thought suppression, he
formed an opinion that if there were any method through which he could suppress these
thoughts forever, then he could attain permanent relief from his condition. He had read
Osho literature and some motivational books. He knew about hypnotism and he had a view

that hypnotism can remove or burry his thoughts from conscious awareness. He was in
search of a hypnotherapist for a long time. In this background he finally reached to me.
He had already been to psychiatrists and clinical psychologists over the years. He also had
been to my affectionate mentor Dr Baquar Mujtaba, Hospital for Mental Disease (now
Institute of Human Behaviour and Allied Sciences), Delhi, long back. He reported that he
had improved with his psychotherapies. But gradually his condition relapsed over the
period of time.
I knew that I would not be able to treat this person through hypnosis. But I had to accept
him for the treatment for the prestige issue. I took up the case and listened to his story and
the distress. I noticed an excessive use of future orientation as reflected in the usage of
future tense. He reported that he was fearful and used following statements to depict the
breadth and depth of his distress:
1. His family will be ruined
2. He will face devastation
3. His mother will be ruined
4. His brothers will be ruined
5. He will be held responsible for the devastation
My attention was particularly focused on the verb will which indicates a future
orientation. I had some vague ideas of Neuro-linguistic Programming (NLP) which is said to
be based on Ericksonian Hypnosis. I had some pre-existing concepts that if I can change the
language pattern than there may be corresponding changes in manifest behavior of the
patients. Particularly, I was considering different neural correlates of three tenses past,
present and future.
Tense Correlates: In my view (open to testing), each tense has its locus somewhere in the
brain. The three tenses are not localized to the same site in the brain. This can be easily
understood by using notations. For example, the brain site for the past tense can be labeled
as A; for present tense as B; and for future tense as C. Since the anxiety patients have
over use of future tense, their C centre in the brain is more active during the anxious states.
If we could cool down this centre C then there would be corresponding changes in the
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anxious state. The site C in the brain is correlated with future tense. If we can change the
future tense in the anxiety related sub-vocal speech of the patients, then the centre C in
the brain can cool down resulting in changes in anxious behavior. So I decided to give it a
try by identifying future tenses in his anxiety related language and convert them either into
past tense or the present tense. The sub-vocal speech now would be like this:
1. His family has ruined
2. He has faced devastation
3. His mother is ruined
4. His brothers are ruined
5. He is being held responsible for the devastation
Challenging Magical Thinking: The persons with OCD think that the thoughts have
power to cause physical effects in the external world. Mere repetition of certain thoughts
can have corresponding outcomes in the environment. For example, if an individual have
intruding thoughts of family devastation then he may think that such thoughts by
themselves can cause devastation in the family. Such thoughts have mantra like powers.
Mr. Chand was having magical thinking and thought that his thoughts can actually ruin his
family. Because of this fear of ruining family, he was having severe anxiety response as and
when such thoughts popped up in his mind. For changing the linguistic pattern of future
tense, I considered it an absolute necessity to modify his concepts that thoughts have
mantra like powers; because he would be required to repeat his thoughts by converting
their tenses. So I disputed his magical thinking by citing that if thoughts have mantra like
powers and they can cause devastation in the external world then, can anyone move any
light object such as a pencil from one place to other place merely by thinking or can we
cause a change in criminals just by thinking. When he agreed that nothing can be changed
merely by having thoughts in ones mind a ground for repetition was prepared.
Cognitive Drill: Then I asked him to repeat above statements of past tense. He was having
severe anxiety and difficulties in repeating the statements. He was required to repeat
mera nash ho chukka he; mera nash ho chukka he, mera nash ho chukka he repeat,
repeat and repeat. Since he was having severe anxiety while repeating, I asked him that he
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should just listen to me. I will repeat for him. Then I began to repeat for him, tumhara nash
ho chukka he, tumhara nash ho chukka he, tumhara nash ho chukka he. Initially, he had
an avoidance response both at cognitive level and behavioural level which was reflected in
turning the face to other sides while I was repeating. When he was comfortable in listening
to my repetitions, I advised him to join me in repetitions. After sometime, he commenced to
recite mera nash ho chukka he, mera nash ho chukka he, mera nash ho chukka he. When
he began to repeat, there was an anxiety response which was increasing. I educated him
that this anxiety response follows a pattern of initial increase then decrease in a bell shape
form. He should continue to recite. He kept on repeating and midway I withdrew my
repetitions and he continued to repeat. Later on, I labeled these continuous repetitions of
tense converted statements as Cognitive Drill. He kept on performing the drill and within
a few minutes, there was a significant reduction in the anxiety response to the drill mera
nash ho chukka he.
Anxiety Curve: When exposed to an anxiety provoking stimulus, the anxiety follows a
pattern of rise and fall which is similar to the bell shaped curve. That is, initially the anxiety
increases, reaches its peak, stays for some time and then gradually declines. I explained the
concept of anxiety curve to Mr. Chand so that he could restructure his rising anxiety
experience and bear with it according to the revised conceptualization. To map the
progression of anxiety during drill, I kept on asking the level of anxiety every 30-60
seconds. He was required to say the level of anxiety if it was very low-low-medium-highvery high. This report of subjective experience helped me to conceptualize the moment to
moment changes in his anxiety during cognitive drill; also it provided a framework and
structure to Mr. Chand on the nature and progression of anxiety during cognitive drill. I
noticed that the anxiety curve takes about 5-10 minutes for its commencement, rise,
reaching peak and decline. It gives an effective feedback to the patient as well as therapist.
Measurement of Anxiety during Cognitive Drill: To map the progression of anxiety
during cognitive drill, I follow the established system of measuring Subjective Unit of
Distress (SUD) on a scale of 0-100%; Visual Analogue Scale (VAS) rating on a continuum of
0-10 or a common approach How much in a rupee or a rating such as Zero-very low-

low-medium-high-very high (simply low-medium-high; let the patient add others). I keep
on procuring the rating every 30-60 seconds during the cognitive drill.
Pauses in the Drill: I noticed that sometimes Mr. Chand was extremely distressed while
performing drill. When very high anxiety was stirred during drill, I began to give a pause of
about 1-2 minutes. I would ask him to stop the drill and let the mind wander anywhere. I
may engage him in some other neutral or pleasant talk. After about 1-2 minutes, I will
enquire the SUD unit/rating of the residual distress. If it was minimal, I would ask Mr.
Chand to resume the drill. It was discovered that with one or two pauses in drill, he was
able to complete the drill which resulted in declining patterns of the heightened anxiety.
Giving a pause of 1-2 minutes was a good strategy to enable him to deal with very high
anxiety.
Importance of Homework: After drill of about a couple of days, Mr. Chand, came up with a
wonderful suggestion by his own. He expressed that he wants to purchase a register and
write drill statements on the register as many times as he could. I was instantly illuminated
and attested to his plan. He bought a register and filled it with drill statements. I already
knew the importance of homework in Cognitive-Behaviour Therapy. I say that the inperson sessions are akin to tuitions/coaching. The client is required to learn the skills
during personal sessions and apply during the periods between sessions. He should learn
the formulae of solving anxiety and apply in day to day life. This application of drill as
homework is extremely useful to consolidate the therapeutic gains, generalization of the
gains, and maintenance of the acquired gains. The homework can be done sub-vocally, by
writing or in any form convenient to the client. The insight into the process demonstrated
by Mr. Chand was extra-ordinary as he himself came up with the idea of performing the
drill on the register. He kept on writing the drill statements such as mera nash ho chukka
he on the register.
Behavioral Test: During the course of treatment, Mr. Chand shared with me that he had
brought the new pair of clothe with which the key word nash was attached. He did not
wear these clothes since their purchase. After the drill of 2-3 days, he reported that he
could successfully wear that pair of clothe. He also presented himself before me in that pair
of clothe. I did not recommend him to wear those clothes. He himself reported that it was a
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sort of test that if he could wear this pair of clothe without any distress during treatment, it
would be a positive indication of improvement in his obsessional fears. Also he reported
that on the entrance, he could hear the word nash from a person. Having heard this term,
instead of avoiding, he went closer to the person. He did not feel any distress. In fact, he
himself designed his own behavioural tests. In behavioural tests, a client is required to
expose oneself to the anxiety provoking situations to test if still those situations or objects
do evoke an anxiety response. If anxiety reaction is evoked, it means more drill is required
and if no distress, then it may be considered as an indication of dissolution of anxiety from
those specific situations and objects.
Pass Criteria for Drill Statements: He had multiple items which needed to be processed
through drill. Hence, a decision was required to be made when to switch to next drill
statement and when to consider that the specific drill statement has reasonably be
processed. I arbitrarily opted for a criterion of three consecutive drills without activation of
prominent anxiety response. When he was able to perform the drill three times
consecutively without getting distressed I moved to other drill statement. When he passed
mera nash ho chukka he, he was required to perform drill of mere bhai ka nash ho chukka
he and other drill statements were also processed in the similar manner.
Session Frequency and Duration: I was seeing him daily except on Sundays. I later on
recognized the importance of daily sessions during active phase of the treatment. Cognitive
drill sessions on daily basis were quite useful. Each session took about 60-90 minutes.
Gaps between Drill: One act of drill, that is, commencement of drill statement and its
termination upon reduction in anxiety; takes a few minutes. Usually, 5-10 minutes; may
also be more or less. I was asking him to do the acts of drill repeatedly without any
intervening gaps. But after 2-3 drill acts, I felt need for giving gaps of about 2-5 minutes
between drill acts. During this gap, I would chat with him on diverse topics. During these
gaps he shared with me many of his experiences with OCD, treatment, spiritual procedures
he adopted to overcome his fears. This period was also utilized to identify and formulate
additional drill statements.

Myth Removal: He had come to me specifically for doing hypnotism to suppress his nash
related thoughts. Since, I knew it cannot be accomplished through hypnotism, I told him
that, let me apply some other but powerful procedure for his problems. If there is any
residue or no improvement, then we could consider hypnotism too. I did not disagree or
rejected his idea of doing hypnotism for obvious reason that he could drift away from
treatment. During the course of treatment, I brought this topic back and explained him that
thought suppression is not the solution to this problem; also thought suppression cannot
be done. The fear related situations would continue to exist in the world. The avoidance of
those situations or suppressing the nash related thoughts associated with those situations
would continue to pop up in the mind. Instead of suppressing the thoughts, I am working
on towards breaking the functional connection between situations and fear response. At
the end of the treatment, those situations would fail to elicit the anxiety and distress.
Hence, the focus of treatment is not the thought suppression, instead breaking functional
connections between situations and reactions. So hypnotism is not the choice of treatment,
firstly because thought suppression of this kind cannot be achieved through hypnotism and
secondly, hypnotism is not the treatment of choice for this problem. He seemed to
comprehend the rationale and continued to perform drill with more determination.
Reflections in Voice Quality: While in distress and fear, his voice quality showed
hesitation, low volume and a tremor like quality. But upon performing drill, his voice
quality for fear related terms showed improvement. No hesitation, smooth pronunciation
and confidence.
Fear of Relapse: In the course of treatment, he showed anxiety that he may have all the
fears upon going back to his home. For handling this fear of relapse, I asked him to perform
cognitive drill for fear of relapse too. So he performed cognitive drill for ghar pe fears
active ho chuke hn. Within a few minutes he showed significant reduction in fear of
relapse.
Completion of Treatment: During the course of treatment, following additional drill
themes were identified and all of them were tied with the primary theme of NASH.
1. Punja chhip chukka he
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2. Guldiva ho chukka he
3. Satyanash ho chukka he
On 9th day, he himself declared as free of those fears and requested for termination. Before,
agreeing to his request, I asked him to perform cognitive drill of all the major drill
statements. He confidently performed cognitive drill of all the themes. I also asked him to
imagine himself at his home and village to explore if there is any situation or object that
could potentially activate his fears. He was not able to identify any situation or objects that
could now be associated with fear reaction. I had to agree with his termination request
because no further drill task was apparent. He reported an extra-ordinary improvement in
his condition. His secondary depression had also lifted away. He had never expected a
change to this level and also not experienced the joy of being free of these fears in last 15
years. The therapy was terminated and he returned back to his home.
Follow ups: He lives about 300 km away from Agra. I remained in touch with him through
mobile for a few weeks. He was maintaining well. He resumed his occupational functioning.
His interaction with friends and relatives improved. He was back to his social life. I was also
happy to see him changed. Authentic therapeutic gains must remain stable even on follow
ups. A period of follow up for six months is considered adequate for commenting upon the
maintenance of acquired gains. He maintained well for six months and even more. I was too
satisfied with the six monthly follow up on phone.
After one and half year, he called me that he is experiencing relapse. I asked him about his
psychiatric medication. He told me that he took the medicines for about one month after
therapy and since then he is not taking any medications for his psychiatric problems. He
was feeling too depressed characterized by low mood, hopelessness and even suicide wish.
I advised him to come back and get treatment once again. As advised he came for the
treatment.
Compliance Therapy: I explained him the role of medications and recommended that he
should continue his medications for a long term even if there is no apparent disturbance in
his mental status. He agreed to continue his medicines, henceforward.

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Combination Treatment: I explained him that there are some psychological conditions
where only psychotherapy can be sufficient treatment and minimal or no medication may
be required. In phobias the primary treatment can be psychological. But there are other
conditions including OCD where a combination treatment can be more effective. However,
in part of the OCD population, medicine alone can be sufficient treatment for OCD. I also
explained that in his condition, a combination treatment should be superior. He understood
it and expressed that he would continue the combination treatment. I advised him to
continue periodic follow ups of both Cognitive Drill Therapy and psychiatric medications.
Cognitive Drill in Relapse: For handling his relapse, I recommended him to restore the
cognitive drill. The drill statements were identified and processed through cognitive drill.
After three days, of cognitive drill he declared himself as free of relapse and requested
termination. I enquired from my psychiatrist friend about his current status. He also opined
that he was fit enough now for therapy termination. I also agreed after asking him to
perform all the drill at least once. There was no activation of anxiety during the drill, hence,
I cleared him for discharge from my side. Ideally, he should have practiced the drill on his
own as and when there were activations of anxiety. He had abandoned both the application
of drill and medications. Seeing his response, I realized that relapse can also be handled
through cognitive drill. Again in 2014, he presented with relapse. He was using alcohol and
used to give up medications and cognitive drill. Based upon my conceptualization of
relapse handling, I re-applied the cognitive drill and within a span of three days he was free
from relapse and still maintaining well.
Theoretical Conceptualizations: This was my first ever application with Mr. Chand. I
contemplated on the theories which could be invoked to explain the application of
cognitive drill. I landed upon following major theoretical frameworks. Apart from these, my
thinking was influenced by Eye Movement Desensitization and Reprocessing (EMDR),
Neuro-Linguistic Programming (NLP) and other concepts which are not conscious to me
right now.
1. Pavlovian Conditioning: I conceptualized that the stimuli such as nash, guldiva,
punja etc are conditioned stimulus which elicit the emotional reaction of anxiety.

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This could be an instance of aversive conditioning which can be explained through


following experimental paradigm.
A dog is tied to the cage. The arrangements in the laboratory are made in such a way
that an electrode is attached one of the legs of the dog through which an electric
current of bearable intensity could be delivered and which gets terminated upon
withdrawal reflex. There are signal systems like electric bulb, a bell and the like.
Before commencement of the experiment, the sound of the bell or the light is a
neutral stimulus which does not elicit any withdrawal reflex in the leg. Passing of
the electric current leads to withdrawal reflex in the leg. Now the experiment
commenced. The experimenter pressed the bell (called as Conditioned Stimulus or
CS); delivered the electric shock (called as Unconditioned Stimulus or UCS), which
resulted in withdrawal reflex (called as Unconditioned Response or UCR). This
sequence can be represented as follows:
CS (Conditioned Stimulus - Sound) +UCS (Unconditioned Stimulus - Electric
Current) UCR (Unconditioned Response - Withdrawal Reflex)
If the dog is exposed repeatedly to this sequence, then sound (CS) alone would lead
to withdrawal reflex. When the reflex is elicited by only conditioned stimulus it is
called as Conditioned Response (CR). So the dog which is exposed to above
sequence would respond with withdrawal reflex as and when he is exposed to the
sound. Harm and pain avoidance is the primary motivation. The withdrawal reflex is
the reflection of this primary painful condition. It leads to removal of pain. But this
reduction of pain gives temporary relief. Again when the dog is exposed to the same
sound, it will show the withdrawal reflex. This happens most of the time. So the
problem is not solved by withdrawal reflex and the temporary relief. However, it
leads to a mistaken cognitive framework that avoidance is the only solution.
Mr. Chand was having conditioned anxiety reaction to many conditioned stimulus
which were nash related words, situations and objects. The avoidance of these
objects and situations gave him temporary relief but he developed a mistaken
cognitive framework that if he could find something like hypnotism through which
he could avoid the nash related words; he would achieve a permanent relief.
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There is a process called extinction. When the trained dog is continuously exposed
to the sound in the absence of electric current, the withdrawal reflex will disappear.
For extinction to occur the conditioned stimulus should be exposed in sufficient
frequency and quantity for extinction to occur. The principle seems to be very
simple and effective.
Mr. Chand was periodically exposed to the conditioned stimuli. Why extinction was
not occurring in him? The reason was that the frequency and duration of exposure
was not sufficient enough for extinction to occur.
The conditioned stimuli consist of objects, situations, words, thoughts, images,
sensations, people and the like. The conditioned stimuli can be classified into (a)
external objects such as clothes, people, places and so on. (b) Internal mental
representations like thoughts, images and words of external objects. (c) Internal
somatic representations like sensation, vibrations, pain and so on.
Harm Avoidance/ Pain Avoidance: A propensity to avoid harm and pain is innate.
In case of withdrawal reflex this avoidance is swift, spontaneous and almost instant
without any conscious efforts. When electric shock is delivered to the leg of the dog
in Pavlovian conditioning paradigm, the withdrawal reflex is elicited automatically
without any prior conditioning. However, when potentials for harm or pain are
persistent, the individual will engage himself in conscious avoidance behavior
proportionate to his perceived intensity of harm/pain and the choices available for
avoidance behavior. The avoidance be it a reflex or a conscious act, reduces the pain
and gives a sense of relief. When Mr. Chand encountered nash related words, he
was experiencing anxiety reaction.
Anxiety is an unpleasant and painful emotion. However, it cannot be avoided in
reflex like manner. A person has to engage in some voluntary and conscious acts in
order to reduce the anxiety response. This leads to a conscious behavioral
avoidance, i.e. removal of oneself from the anxiety provoking situation. Mr Chand
was engaged in conscious behavioral avoidance by removing oneself from the
situations and people where nash related words were being used. This reduction in
discomfort due to avoidance creates an illusion in the mind of the patient that
avoidance is the solution to the problem. The repeated avoidance and subsequent
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reduction in pain/discomfort reinforces this idea that avoidance is the solution to


the problem. But the avoidance gives temporary relief and the patient learns to
chase this temporary relief for converting it to permanent relief. He searches a
method through which he can permanently avoid the situations. In the process of
finding a way for permanent behavioral avoidance, the patient becomes almost
housebound. But being confined to the house is not a solution instead it causes more
problems leading to impairment in social, personal and occupational functioning.
The avoidance of painful or noxious stimulus is labeled as negative reinforcement
which increases avoidance behavior (Operant Conditioning).
In case of predominantly obsessions, the patient has obsessions consisting of
thoughts, images and impulses. The patient may have abusive or sexual thoughts
towards deities, religious places, family members and so on. The intrusion of these
thoughts elicits severe anxiety in the patient. To reduce the discomfort and pain
associated with such obsessions, the patient tries to suppress or consciously
eliminate these thoughts and images from the mind. Sometimes, he gets success in
suppression or elimination of thoughts from conscious awareness leading to
temporary relief and pain reduction. In the process of repeated attempts to
suppress or elimination from consciousness, the patient learns that the suppression
or elimination of pain producing thoughts is the solution. Since this solution is
temporary, the patient strives for devising or searching a permanent strategy for
thought suppression or elimination of these thoughts from conscious awareness.
Hypnosis has many myths attached to it. One such myth is overpowering the mind
and potential of hypnosis for removal of thoughts from the mind. This myth propels
some OCD patients to seek the hypnotism services from an expert. They think that
the hypnotherapist will hypnotize him and give such commands through which
painful obsessive thoughts would either be suppressed and buried into deeper
layers of the mind or would be eliminated from the consciousness. Exactly, this
thinking of Mr. Chand brought him to me. He explicitly requested me hypnotism for
removal of nash related words from his conscious awareness. But I know that this
goal of suppression or elimination of thoughts from conscious awareness cannot be
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achieved through hypnotic suggestions. Instead there are tested methods to achieve
relief in OCD.
Search for Magic Formula: The patients with OCD dwell repeatedly and for
extended period of time to find some magic formula which would solve their
problems instantly and permanently. They keep on postponing their social,
occupations, academic and other responsibilities in favor of the mental search for
the magic formula. They keep on trying, trying and trying. I call it manas manthan.
But this manas manthan even for years does not result in finding any magic
formula for OCD. The patient learns to think that once he finds a magic formula, he
would get himself involved in all the pending activities and responsibilities. But he
gets more and more preoccupied in OCD thoughts. This manas manthan
continuously fuel the OCD train of thoughts. So I make a clear recommendation to
the patient that he should not make any work contingent upon the solution of the
OCD. Instead, he should resume his work and duties and complete all pending
assignments despite OCD.
Obstacles in Extinction: Having trained a dog to withdraw leg in response to sound
of the bell, the experimenter now wants to retrain the dog and achieve an extinction.
That is, restore the pre-training condition when the dog was not responding to
withdrawal of the leg in response to the sound. How this can be achieved. Simply
present conditioned stimulus (sound of the bell) without electric current. A
repeated presentation of sound of the bell (CS) without electric current (UCS) will
never lead to extinction unless the behavioral avoidance (withdrawal of the leg) is
prevented. Because if the dog continues to withdraw leg in response to CS (bell
sound) alone, then it will not have an opportunity to learn that electric current
(UCS) is no longer coming. In order to impress the nervous system of the dog, the
experiment now will have to be designed in such a way that CS (bell sound) will be
presented in the absence of UCS (electric current) and the dogs leg will be
momentarily tied or held in some way in order to prevent the withdrawal reflex. In
this framework, the repeated delivery of CS (bell sound) will lead to extinction. The
extinction will occur when the dog would learn that the CS (bell sound) is no longer
a reliable predictor for of upcoming UCS (electric shock). But when the extinction
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protocol is implemented in above manner, the dog will have covert responses of
discomfort which would be reflected in muscle tone and autonomic responses.
Experimental Worsening of the Conditioning: For experimental demonstration of
worsening of established conditioning, the experiment can be tweaked in several
fashion. This worsening would lead to resistance to extinction. The worsening can
be achieved by intermittent pairing of CS (bell sound) with UCS (electric shock)
while leg of the dog is held momentarily so that it intermittently experiences the
electric current and not able to emit overt withdrawal reflex. When dog is exposed
to this partial presentation of UCS (electric current); it will have difficulties in
estimating on which presentation of CS (bell sound), the UCS (electric current) will
follow. This failure in estimation will lead to more and more worsening.
When leg of the dog is held momentarily in order to prevent the withdrawal reflex,
the dog will demonstrate both covert reactions such as stiffness in muscles,
accelerated cardiac activity and overt reactions such as barking, moving other limbs
and so on.
Achieving Extinction: When CS (bell sound) is presented without UCS (electric
current) on repeated trials and the leg of the dog is withheld from executing
withdrawal reflex, the dog will experience covert and other covert reactions. If CS is
continued to be delivered repeatedly all covert and other reactions including the
withdrawal reflex will cease to occur. Exactly this was happening with Mr. Chand. At
the onset of the treatment, I required him to repeat nash ho chukka he. But he
could not gather courage to verbalize this drill statement. Then I began to verbalize
this drill statement nash ho chukka he; nash ho chukka he; nash ho chukka he.
Even upon listening from me he showed withdrawal response by turning his face
away and felt anxious. I continued to speak nash ho chukka he; nash ho chukka
he; nash ho chukka he. Within a few minutes of my repetition, his withdrawal and
cover reaction reduced substantially. Then he gathered courage to verbalize nash
ho chukka he; nash ho chukka he; nash ho chukka he; and continued to do so
which ultimately led to the extinction of discomfort.

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Extension of Application: I introduced the concepts of Cognitive Drill Therapy to Mr.


Ahmed Sameer, a student of MA in Clinical Psychology, Barkatullah University, Bhopal. He
quickly acquired the concepts and skills within 2-3 days. He was required to work for an
MA dissertation for examination. He opted to pursue his dissertation on Cognitive Drill
Therapy. He worked with five patients having OCD. He applied Cognitive Drill Therapy by
using Y-BOCS as pre-post test measure. Four of his patients showed significant
improvement. The fifth one was having a primary diagnosis of Schizophrenia along with
OCD. Through this mini research dissertation I conceptualized that:
1. The persons having comorbid psychotic illness are not suitable for Cognitive Drill
Therapy.
2. The concepts and skills can conveniently be transferred even to postgraduate
students of clinical psychology. This has far reaching implications. If Cognitive Drill
Therapy is really useful in such conditions then we can quickly train many
professionals who in turn would get equipped to apply this form of treatment on a
number of patients, conduct research work and train others. This way we can reach
large number of needy persons in the society.
3. I also recognized that this is a relatively short term treatment which acts quite fast
in some cases.
4. Cognitive Drill Therapy can empirically be put to test.
Based upon the observations in this dissertation, the case studies were published in Official
Journal of Indian Association of Clinical Psychologists. The full reference of the paper is:
Kumar, R., Sameer, A. and Singh, B. (2012) Preliminary test of cognitive drill as an
intervention. Indian Journal of Clinical Psychology. 39 (1) 67-74.. This I consider as a
landmark publication for me. I introduced Cognitive Drill Therapy to the academic and
scientific world. I introduced some of the key concepts in this paper. The paper is attached
for academic and scientific purposes only.
Agoraphobia: Prof. Yashveer Singh served St. Johns College, Agra for his entire service
career. He contributed immensely in the promotion of Clinical Psychology in Agra. He
linked some psychiatric cases to me. Through him I got linked with a middle aged lady. She
came to my residence in one evening and reported her problems of leaving home and
18

getting panic attacks. I quickly arrived at a diagnosis of Agoraphobia with Panic Disorder.
She was not leaving her home alone. She needed a phobic companion while going outside.
When away from home, she would keep a vigil on the nearby hospitals in case she gets
heart attack she would receive emergency medical help. She was not going far away from
the home. She was using scooty earlier for her mobility. She stopped driving three years
back. She was in a teaching job. She left her job due to her psychiatric problems. She would
keep bathroom door open while taking bath. She was terrified with the idea of travelling in
Metro and Airplanes. She have gone to emergency many times with panic symptoms. Her
cardiac examinations are normal. She also had secondary depression. She was having this
problem for about eight years. She was irregular in her psychiatric treatment. I conveyed
her my diagnosis and advised that she should consult a psychiatrist immediately continue
her medication for about 15 days and come back to me for psychological treatment. After
15 days she did not turn up. I also forgot but intermittently I was getting flashes that why
she did not come for psychotherapy. She showed herself to me after three months. She
reported nil improvement with three months of medication. I enquired from her why she
was so late. She told me that she was impressed with my first contact and instant diagnosis
which she verified from internet. She was not aware of her diagnosis. That was the first
time when she came to know about the diagnosis from me. She was continuing medication
and waiting for results. Since there were negligible overt effects of medications, she came
to me for psychotherapy.
I listened to her detailed story and conducted psycho-education. Specifically
1. I told her that Agoraphobia with panic disorder is a recognized psychiatric problem.
2. She should continue combined medications and psychological treatment.
3. Also I educated that there is a difference between actually being away from home
and creating an imagination of being away from home. In the former instance you
are physically present at some place away from home. In the latter instance, you are
physically present before me but in your minds eyes you can imagine yourself away
from home at any place. map is not the territory.
4. I told her that her mind also respond to imagination as if it was real.

19

5. I made her to realize that when she is away form home or she anticipates away from
home, she gets dominated by future oriented thinking such as there can be a heart
attack, help may not be available in case of heart attack, she or anybody else may
not be able to manage the episodes of heart attack.
6. Having grounded in above aspects, I told her that I will require her to repeat some
phrases by converting their tense. The statements of future tense are associated
with the problem. When we convert these statements into past or present, then the
problem mitigates.
7. Also with continuous repetition of those statements would initially elicit anxiety
response which will follow a bell shaped curve and within a few minutes it would
settle down.
Then I commenced application of Cognitive Drill. The primary statements were heart
attack ho chukka he; heart attack ho chukka he; heart attack ho chukka he. She
responded with a great distress, crying and overt reactions in response to the drill. I gave
gaps in between, reassured her and persuaded for the drill. She would weep, cry and feel
like fainting. Lots of reassurance and persuasion was required. Her husband was also
sitting with her. He would also support and reassure her. Despite all these reactions, she
remained engaged in the treatment. I would repeat for her many times the drill statements.
I required her husband also to repeat the drill statements for her. Within a few sessions she
showed tremendous improvement in all of her psychopathology. He agoraphobia, panic
and secondary depression calmed down. I prescribed her daring that she should expose
herself to the places which she has been avoiding due to her problems. She resumed her
domestic activities, began to use her scooter, travelled away from home and other cities.

20

I involved Mr. Satyadhar Dwivedi, Assistant Professor of Clinical Psychology in this case. He
took keen interest, observed the case thoroughly and conducted pre-post and follow up
evaluations. He prepared a thorough case study of the case and got published. The citation
for this study is Dwivedi, S. and Kumar, R. (2015) Efficacy of cognitive drill therapy in
agoraphobia with panic disorder: A case study. SIS Journal of Projective Psychology and
Mental Health. 22 (2) 150-157. This paper is attached for academic and scientific purposes.
He also presented this case study in 41st National Conference of Indian Association of
Clinical Psychology, 2015 at Ahmadabad. He also independently applied Cognitive Drill
Therapy in many cases. He may come up with more empirical data supporting the efficacy
of this novel form of treatment.
Conceptualization of Two Layers Structure: Recently, I have been conceptualizing two
layers structure of OCD and Phobia (a) a surface structure also called as conscious
structure, superficial structure consists of stimulus and reactions (b) underlying fear
structure also called as sub-conscious structure. The surface structure is based on some
underlying fear structure. The underlying fear structure contains imagined feared
consequences. This underlying fear structure is subconscious. That means, the patient can
access these fears when directed specifically to do so. Unless directed he is fleetingly or
21

dimly aware of this underlying fear structure. Most of the time the patients attention
remains focused on surface structure.
The basic premise of this conceptualization is that underlying fear structure is the
maintaining factor of the surface structure. The underlying fear structure can be the focus
of psychological intervention in order to modify the explicit conscious structure. The
examples of two layers structure in some of the conditions is as follows:
i.

Structure of Social Anxiety: In social anxiety the person is distressed and wants to
avoid exposure to social situations such as speaking in public, interview, group
discussion, debate, giving lectures and presentations, performing before an
audience, interacting with superiors and authorities. This is a surface structure
consist of social situations as stimuli and anxiety as reaction. The underlying fear
structure consists of following fears:
a. Fear of humiliation
b. Fear of embarrassment
c. Fear of devaluation
d. Fear of negative evaluation
e. Fear of non-specific outcomes
f. Fear of negative impression on others
g. Fear of ridicule
h. Fear of losing trust of others
i.

Fear of letting others down

j.

Fear of rejection

k. Fear of loss of self-esteem


l.

Fear of being ashamed

m. Fear of going blank


n. Fear of somatic symptoms such as trembling, stammering
Illustration of Two Layers Conceptualization in Social Anxiety:
An adult male presented with significant distress in social situations involving boss,
persons in authority, group of people or girls. The distress is somatically represented
22

primarily on face and feelings of discomfort. He tries to deal with the distress by avoiding
the situations both at Cognitive level or if possible at behavioral level. When he is not able
to avoid, he becomes absorbed in anxiety reaction and mentally get focused over the
sensations and feelings on face. This entire pattern exemplifies the top layer (also called as
surface structure or conscious structure).
A brief interview quickly led to the identification of following underlying fear structure
(also called as bottom layer, sub-conscious structure).
i.

fear of humiliation,

ii.

fear of ridicule,

iii.

fear of devaluation,

iv.

fear of negative view by others,

v.

fear of nonspecific outcomes,

vi.

fear of negative impression on others,

vii.

fear of embarrassment,

viii.

fear of increased distress with passage of time

He is engaged in behavioral and cognitive avoidance of social situations. His strategies of


cognitive or behavioral avoidance would not change the underlying fear structure.
Cognitive Drill Therapy acts directly on the underlying fear structure to modify the top
layer structure.
Two Layers Structure in Contamination OCD:
Layer-1: Surface Structure: Acquired associations between Exogenous/Covert Conditioned
Stimuli and anxiety response, for examples, seeing dirty objects, touching dirty objects,
thoughts of getting dirty leads to severe anxiety response.
The patients are struck in this surface structure in the form of avoidance of dirty objects
and repeated cleaning of self or objects. This focus on avoidance and cleaning is negatively
reinforced by temporary reliefs obtained through cleaning and avoidance. The patient
remains struck in this elusive state for years.
Layer-2: The underlying fear structure: This is the foundation of the surface structure. We
can dig deeper into the psyche of the patients and can discern the underlying fear
23

structure. This underlying imagined fear structure gets reflected in following future
orientations such as
i.

Fear of spreading contamination to other household objects,

ii.

Fear of inhaling germs,

iii.

Fear of contamination of religious objects,

iv.

Fear of being blamed in case something happens due to contamination,

v.

Fear of punishment by god if religious objects get contaminated,

vi.

Fear of jeopardizing safety and security of family members due to contamination.

This underlying fear structure can be destroyed through Cognitive Drill Therapy or any
other methods. The patients' surface structure will get collapsed proportionate to the
destruction of underlying fear structure and there will be rapid significant improvement in
the contamination OCD.
Specific Phobia of Snakes: A senior faculty member met me in a conference in November
2015. He reported that he was having a fear of snake for a long time. He had participated in
one of my lectures on Cognitive Drill Therapy about two years back. He applied the
concepts to this problem. His fear disappeared within a few days which is still maintained.
Two Layers Conceptualization of such phobias (1) the surface structure consists of
exposure to snake or thoughts, images of snake leading to anxiety reaction (stimulusresponse association). (2) Underlying fear structure such as fear of snake bite, fear of death
due to snake bite etc. This underlying fear structure can conveniently be destroyed through
Cognitive Drill therapy leading to fast or even instant relief in such irrational fears.
Fear structure in examination phobia: The underlying fears in examination phobia
include - fear of going blank, fear of forgetting, fear of failure, fear of embarrassment, fear of
humiliation, fear of loss of self-esteem, fear of humiliation of parents, fear of career loss,
fear of not able to manage things after failure, fear of ridicule by the rival etc. This fear
structure can be processed through Cognitive Drill Therapy
The unique aspects of Cognitive Drill Therapy:
1. Verbal Exposure
2. A change in Time Reference at Cognitive Level
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3. Cognitive Drill
4. Directly working on underlying Fear Structure
5. Specific psycho-education
6. Concurrent Psycho-physiological Monitoring
7. Immense Research Potentials
8. Easy to train others
9. Easy to integrate in a protocol of psychotherapy
10. Easy for the patient to learn
Perspective of Anxiety: Anxiety is a normal emotion. However, if it persists most of the
time or attached to ordinary objects or situations such as darkness, closed places,
cockroach; or quantitatively very high in normally anxious situation, then it can constitute
a problem requiring attention. Severe anxiety in interviews or on stage/podium is
instances of social anxiety. We are focusing Cognitive Drill Therapy for this specific
problem. Severe anxiety in interviews, on stage/podium are instances of social anxiety. We are
focusing Cognitive Drill Therapy for this problem.

Anxiety means imagined feared consequences. The imagined feared consequences could be
free floating as seen in Generalized Anxiety Disorder, tied with specific class of objects as in
specific phobia, tied with social situations as in social phobia, tied with intrusive thoughts,
images or impulses as in Obsessions. All forms of psychotherapies like CBT, existential
therapy, behavior therapy, supportive psychotherapy, and mindfulness based meditation,
or any other forms teach us to effectively deal with those imagined feared consequences. In
Cognitive Drill Therapy, also we teach how to master imagined feared consequences
directly and rapidly. The added advantage is that relapse prevention is in-built in it, it is a
self empowerment program, it leads to cognitive reinterpretation of events, strengthen
coping skills.

25

26

First Media Coverage: I participated in a National Seminar on Crime Against Women:


Issues, Challenges and Intervention organized at my alma mater Digamber Jain College,
Baraut (Baghpat) on 1-2 November 2015. I happened to meet my well wisher Dr. Anurag at
Baraut. He has been supporting my passion of hypnosis and past life regression for a long
time. He is aware of my recent interest in Cognitive Drill Therapy through social media.
When we met, I introduced the concepts of Cognitive Drill Therapy to him. He could
immediately conceptualize it and even encouraged me to work on Claustrophobia too. He
related an instance where he had to accompany one of his acquaintance to MRI scan
because of claustrophobia. He impressed me with the limitations imposed on
claustrophobic person while undergoing such examinations. He in turn introduced me and
my work to the Correspondent of Dainik Jagaran, Meerut Issue. With a cool mind, we three
persons discussed and clarified various concepts, theoretical framework and extensive
scope of cognitive drill therapy. A featured coverage appeared on 7th November 2015; the
first media coverage on Cognitive Drill Therapy.

Two layers structure of fear of closed places:


Fear of closed places is called claustrophobia. It is a type of specific phobia. A person with
this phobia feels severe anxiety in closed places like closed room, lifts, surrounded by the
crowd and tries to reduce anxiety by avoiding such places. Feeling anxious in closed places
27

and a repetitive tendency to avoid such places constitute the surface structure (a series of
conditioned stimulus and conditioned anxiety response. Beneath this surface structure lies
the underlying fear structure characterized by fears like fear of suffocation; fear of death.
The underlying fear structure can be rapidly be processed by Cognitive Drill Therapy.
Claustrophobia may have underlying fear structure such as fear of suffocation,
fear of not having sufficient oxygen in closed places
I am quoting an interaction with a person on facebook timeline on 17th November 2015
C: I am a claustrophobic
Me: are you able to identify the underlying fear structure, i.e. of what you are scared of in
closed places?
C: I need fresh air all the time, so I feel when I am at closed places like a lift for instance I get
cut off from oxygen, so I refrain from using lifts. I feel I get suffocated and that makes me
restless
Me: Exactly these were the issues in other person who was having claustrophobia and used to
avoid lifts
C: I feel very uneasy. I start to sweat at times; at times I feel my heart starts to sink. I rush out
for fresh air. I can't be at any place which does not have proper ventilation
Me: Since when you are having this problem?
C: It's been quite long now. I think 10 years or so, but never had too much problem, so never
consulted anyone.
Me: do you have any past traumatic experience related to this problem?
C: I don't think so. I think I developed this only after once my BP was quite low, so I had to
take medication for that. I don't remember any traumatic incident related to it as such
Me: What closed places you are avoiding?
C: Lifts for sure. Or any room which has no doors or windows or if doors and windows are
closed.
C: Or any place which I think I will not be able to rush out for air easily. Even at movie theatre
I take corner seat, because no one will be on one of my sides.
Me: Do you get anxious simply by imagining yourself in a lift?
C: Depends on what floor I have to go. One or two floors doesn't matter much, but if more
than that, then probably I get anxious at the very idea of getting into a lift. I then use stairs, no
matter how much I will have to climb. I simply can't be surrounded by people I get suffocated
in a crowd as well.
Me: Have you tried any method to overcome it?
C: Not as such. I just avoid all this.
Me: Do you want to overcome it now?
C: Yes of course sir!

28

Me: Have you become familiar with cognitive drill therapy


C: Honestly sir I have not been able to read all your posts
Me: alright, we have two layers conceptualization for claustrophobia. Fear of closed places
like lifts, crowd etc is the surface structure. The fear of suffocation and decreased oxygen level
constitute the underlying fear structure. We need to correct this underlying fear structure
through Cognitive Drill Therapy. When this underlying structure will get resolved the surface
structure will also disappear.
C: OK sir. What will I have to for this ?
Me: So you need to work directly on fear of suffocation
C: How sir?
Me: Also you must realize that actual use of lift and an imagination of using lift are not the
same thing. Imagination of using lift is just within your mind. If you understand this
imagination aspect, then let me know
C: Yes sir I understand this
Me: Good. You already know that when a conditioned stimulus is presented repeatedly in the
absence of UCS, the extinction will occur. Also you must realize that your fear of suffocation is
related to imagined feared consequences of being in the closed places. It has a futuristic
orientation.
C: Ohkk. Sir could you please elaborate on your UCS and CS comment please.
Me: You will get it when you read the manual by downloading from http://mindpowerlab.net.
Me: My approach is also based on Pavlovian conditioning and neural correlates of time
reference
C: OK sir. I'll read it and get back to you. Thank you so much. Until today, I had never paid so
much attention to all this..
Me: I will recommend you very simple cognitive exercises within the framework of Cognitive
Drill Therapy. I want to do it right now
C: Yes sir please tell me
Me: for about 10-15 minutes for a few days do the followings: imagine yourself in a life on
floor no. 4 and above, sub-vocally repeat the following - "me lift me hu, suffocation ho chuka
he, oxygen kum ho chuki he".
Me: I am using past tense 'kum ho chuki he"
C: OK
Me: give me feedback after practicing it for 2-3 days
C: OK sir . I will
Me: thanks and for today it is done
C: Ji sir. Thank u so much
This communication illustrates following aspects in claustrophobia:

29

1. Conditioned Stimuli in surface structure consists of using lift for 3rd or above floors;
surrounded by crowd; rooms not having doors or windows; rooms with closed doors and
windows; places not having proper ventilation.
2. The conditioned reaction is distress, restlessness, uneasy, feeling of sinking heart and fear
while exposed to conditioned stimuli.
3. Getting temporary relief through avoidance is the typical strategy.
4. The underlying fear structure consists of (a) fear of suffocation (b) fear of lack of oxygen

Thoughts on Religious OCD:


1. Religious objects such as temples, idols, deities and religious pics (conditioned
stimuli) elicit anxiety response (conditioned response). This is a surface structure.
2. Sexual and aggressive thoughts towards god/godess (covert conditioned stimuli)
also elicit anxiety response (conditioned response). This is also a surface structure.
3. The imagined feared consequences (having future orientation) constitute the
underlying fear structure.
4. As a therapist, we need to address this underlying fear structure through Cognitive
Drill Therapy or any other procedures.
5. Upon modification of underlying fear structure, the surface structure will get
collapsed.
6. The patients keep struggling with avoidance of external objects or suppression of
covert thoughts or images for years. The patients; these strategies strengthen and
consolidate the problems.
7. Through psycho-education, the patient need be oriented to address the underlying
fear structure.
Initial Formulation of Theoretical Basis of Cognitive Drill Therapy:
1.

Cognitive Drill Therapy (CDT) is primarily based on Classical Conditioning and uses
the concepts of linguistics, cognitive approaches too.

2.

According to Pavlovian conditioning, a CS (Conditioned Stimulus) elicits a CR


(Conditioned Response).

3.

Through the process of stimulus generalization, multiple similar stimuli elicit the
same CR.

4.

Theoretically, we can identify and enlist all relevant CS and can assign them
numerals like CS1, CS2,CS3......CSn. The response elicited by all these stimuli is the
same which we can label as CR1.

30

5.

To exemplify, let us take an example of dog phobia. Phobic reaction to exposure to


dog is CR1. This CR1 can be elicited by a number of dog related stimuli like picture
of dog (CS1), actual dog (CS2), toy dog (CS3) and so on.

6.

Let me now go one step ahead. Actual Dog (CS) elicits a phobic reaction (CR). A
phobic stimulus at covert level (that is, mental representation of dog) also elicts
anxiety response (CR). If you ask a phobic individual to form a mental image of dog,
he/she will experience the anxiety reaction (CR). This way, the mental
representations of phobic stimulus can also be conceptualized as covert conditioned
stimulus.

7.

Words are already considered as higher order conditioned stimulus. If you ask the
phobic individual just to repeat the word dog; he/she will experience anxiety
reaction merely by repeating the word dog;

8.

The manifest symptoms of anxiety reaction like racing heart, trembling, sweating
are overt reactions which we are labeling as CR.

9.

BUT, a CS whether it be an overt stimulus or a covert stimulus, produces multiple


responses at covert level such as neural firing, increased activity in amygdala and
other centers in the brain. All these chemical, electrical and motor activities of the
brain can also be conceptualized as Covert CR.

10. So, we have CS-CR at both overt and covert levels.


11. Classical conditioning also teaches us that, if a CS is presented repeatedly in the
absence of UCS, there will be extinction.
12. But, in cases of phobic reactions, a person gets intermittently exposed to CS alone. If
it is so, then why extinction is not happening? This question is answered through
the principles of operant conditioning.
13. The phobic individual keeps on avoiding the phobic CS both at Overt and Covert
level. He does not allow the phobic stimulus to be there for sufficient duration and
frequency necessary for extinction. The covert and overt avoidance of phobic
stimulus terminates the noxious and painful anxiety reaction stirred by exposure to
CS. This acts as negative reinforcement which maintains the anxiety response.

31

14. If a person is exposed to phobic CS for sufficient duration and frequency without
avoiding it (withholding negative reinforcement) the extinction is bound to occur
because, CS is no longer paired with UCS.
15. But, why phobic individual is not able to adhere to this simple strategy of continued
exposure to CS. The answer to this question is provided by cognitive approaches.
16. The cognitive approach teaches us, that a person is perturbed by the meaning
he/she ascribes to an event or situation. The phobic individual when comes across
with a phobic stimulus makes catastrophic interpretations of CS. He/she cognitively
dwells in feared consequences and underestimates ones capacity for pain tolerance
and solution.
17. The feared consequences of CS are centered in some future time. Anxiety looks into
future. There is a future orientation in anxiety response. If we analyze the sub-vocal
speech of phobic individual while exposed to CS, we will find over use of Future
Tense as opposed to past or present.
18. If an anxious person dwells into future and have excessive use of future tense, we
can conceptualize that the brain centers linked with future tense remain overactive
during anxiety response. If it is so, can we do something to calm down the overactivity of future tense related brain centers?
19. The answer lies in linguistic theories. The researches in neural correlates of past,
present and future tense, would reveal that the three verbs are not localized in the
same site of the brain. If tense is changed in the sub-vocal speech of the person, the
neural activity will be different from anxiety state.
20. Keeping with the idea of tense correlates, a person can be trained to identify future
tense in his anxious thoughts and do a drill by converting them into past or present
tense.
Meaning of Drill: This approach although following the principles of cognitive and
behavioral approaches, cannot be fitted completely into the labels of therapies or
techniques already elaborated in the existing literature. Hence, I had to label it for
communication purposes. My mind generated following label for this approach Cognitive
Drill Therapy. I would like to make it explicit that I have not developed any new theories.
32

This approach simply uses the existing theories and knowledge although in a bit novel
manner. It is like a new recipe with already available ingredients.
While using the term drill I meant repetitive nature of exercise. Dictionary definition of
DRILL. 1. a : to fix something in the mind or habit pattern of by repetitive instruction; drill
pupils in spelling; b : to impart or communicate by repetition.
Contamination OCD: A young adult was having contamination OCD for several years. He
was being receiving regular treatment. But his contamination OCD was still persisting. He
would feel severe distress when exposed to dirty objects. It was noticed that he was
having more discomfort particularly in wet contaminated objects and the places where
white ants were present. Beneath this surface structure he was having fear of inhalation
of germs. For processing of his fear of germs; I asked him to do drill in imagination and
at verbal level for the germs. He was required to imagine wet contaminated objects and
verbalize germs inhale kar chukka hun; germs inhale kar chukka hun; germs inhale
kar chukka hun. When he felt comfortable with imaginary drill, I exposed him to wet
contaminated objects and places of white ant in real. He demonstrated severe discomfort
to this exposure characterized by itching sensations in the body and perceptible body
tremors. I told him that he need not touch these wet contaminated objects. He need to
just keep his palm over it and keep on verbalizing germs inhale kar chukka hun; germs
inhale kar chukka hun; germs inhale kar chukka hun. Because of severe discomfort, I
had to give extended pauses in between. I also prescribed the same exposure to him as
homework. He performed this drill at his home also. Within a few days of this exposure
and drill; he is now having negligible discomfort to wet contaminated objects and places
of white ants.
His application of drill was combined with (a) Exposure & Response Prevention (b)
Verbal Exposure (c) Homework of exposure. This demonstrates that Cognitive Drill can
conveniently be integrated into the framework of Exposure and Response Prevention
Therapy. Also it underlines the importance of doing exposure and cognitive drill as
homework.

33

Somatic Representations of Anxiety: Anxiety has three components cognitive,


somatic and affective. (a) Cognitive component represents the feared cognition such as I
may fail in examination; other persons may ridicule me; (b) affective component is the
feeling part (c) somatic component includes body manifestations such as sensations,
stiffness, sweating, trembling, racing heart and so on.
I am trying to conceptualize these three components as (a) cognitive charge (b) affective
charge and (c) somatic charge. The meaning of charge is any departure from normal
which is considered as abnormal. For example, a cognitive charge that if I touch a
contaminated object I will cause to spread the infection in the family is a charge because
it creates state of disequilibrium. A emotional state which is beyond normal level would
be considered as charge because it need be restored to the normal level. The
representations in the body such as pain in cardiac reason, stiff neck, racing heart without
any corresponding patho-physiological basis would constitute the somatic charge.
Cognitive Drill Assessment:
The Cognitive Drill Assessment can conveniently be grouped as follows:
1. Case History: The case history will include (a) identifying information of the
client such as name, age, education, address etc. (b) A comprehensive spontaneous
narrative by the patient regarding his problems, causes, treatments, problems
faced due to the issues. A specific enquiry need be done for early experiences
related to the problem and any other experiences and events that the client
remembers. (c) Salient aspects of family, medical and personal history. If you like
you can follow any standard format for psychiatric case history taking.
2. Formal Assessment: The assessment tools such as followings should be used on
priority basis to estimate the severity and nature of the problem. (a) Y-BOCS (b)
BDI (c) BAS (d) Dimensions of OCD Scale (e) Fear Inventory (f) Dysfunction
Attitude Scale (g) Panic Disorder Inventory (h) Agoraphobia Questionnaire; and
other similar scales should be used. These scales can be procured through Google
Search.

34

3. Essential Assessment: Following assessment should essentially be done in every


case. This will facilitate the determination of surface and underlying structures.
a. List stimuli, objects, situations, places, people that are associated with
anxiety response. Be comprehensive in listing as many triggers as possible.
b. Emotional Reactions: such as fear
c. Avoidance Pattern: How the person avoids the anxiety provoking stimuli.
Record both behavioral avoidance and covert (mental) avoidance patterns.
d. Components of Anxiety/Fear:
i. List cognitive charges
ii. List affective charges
iii. List somatic charges
4. Delineation of Two Layers Structure: Clearly mention (a) surface structure (b)
listing of specific fears in underlying fear structure.
The above assessment would be sufficient to commence the therapeutic work. All
assessments are dynamic means, they can be updated any time as new information is
added to the case history or observation of the patient.
Empowering Professionals:
For about two years I have been contemplating for conducting a workshop on Cognitive
Drill Therapy. 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
power point presentation and lecturing was not fitting well in 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.

35

Day-1: Sharing of my cases and core concepts:


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) 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 claustrophoia. 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. 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. He can now use lifts
36

comfortably. Now he is prescribed to perform the drill for while imagining himself in the
lift, he should keep on repeating, oxygen ki kumi ho chuki he.
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 accidental 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.
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

37

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 need 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. 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
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 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 re-institute 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.
Merely repeating a statement can give relief in extreme fear and anxiety reaction just
38

impossible, ridiculous, quackery or just a new method to impress, fraud, placebo. These
may be the reactions. So, to the patients, I say that do 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. 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 ones own curious
mind. There is only one problems of concluding on the basis of insufficient data. The
success rate is not 100%. If it is not 100%, that means there are failure. 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 and sharing.
Day-2: Sharing of participants cases:
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
39

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 other 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
moved 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 you 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
40

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 also highlighted the research potentials of
Cognitive Drill Therapy.
I also demonstrated that initially many patients reject the idea of underlying fear structure
despite knowledge of psychology and even cognitive drill therapy. This happen 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.
Day-3: Practical Demonstrations of the Application of Cognitive Drill:
The participants were eager to observe practical applications of cognitive drill therapy. I
explained them how to formulate drill.
Drill Formulation: The formulation of drill statement is a skill.

41

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 could be 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.
42

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-hypnotized 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
43

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 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 need 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 say that 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
44

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
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 in 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.

45

Thought Stopping: If worried 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.
Brain Lock: Psychiatrist Jeffrey Schwartz, author of Brain Lock: Free Yourself from
Obsessive-Compulsive Behavior, offers the following four steps for dealing with OCD:
1. RELABEL Recognize that the intrusive obsessive thoughts and urges are the result
of OCD. For example, train yourself to say, I dont think or feel that my hands are
dirty. I am having an obsession that my hands are dirty; Or, I dont feel that I have
the need to wash my hands. I am having a compulsive urge to perform the
compulsion of washing my hands.
2. REATTRIBUTE Realize that the intensity and intrusiveness of the thought or urge
is caused by OCD; it is probably related to a biochemical imbalance in the brain. Tell

46

yourself, It is not meits my OCD; to remind you that OCD thoughts and urges are
not meaningful, but are false messages from the brain.
3. REFOCUS Work around the OCD thoughts by focusing your attention on
something else, at least for a few minutes. Do another behavior. Say to yourself, I am
experiencing a symptom of OCD. I need to do another behavior.
4. REVALUE Do not take the OCD thought at face value. It is not significant in itself.
Tell yourself, That just my stupid obsession. It has no meaning. That is just my brain.
There is no need to pay attention to it.. Remember: You cant make the thought go
away, but neither do you need to pay attention to it. You can learn to go on to the
next behavior. (Source: Westwood Institute for Anxiety Disorders).
Participants Feedback-1:
Cognitive Drill Therapy is a novel therapy specifically designed for patients of OCD and
phobia. Structured over three days, the workshop balanced the theoretical and practical
aspects of cognitive drill.
Day 1 majorly focused on two things. Firstly some cases of OCD and Specific Phobias were
shared which helped us to conceptualize the chief complaints of the patients. We
understood in detail as to how these problems affect the everyday life of such patients and
what all attempts are made by them to cope up with their problems. Secondly, the focus
was on the basic principles of Classical Condition which forms the basis of CDT. It helped us
to understand the application of underlying principles of classical conditioning in
development of OCD and phobia. The distinction between unconditioned and conditioned
stimulus could well be connected to covert and overt structures. The surface structure
needs to be explored for underlying structures. Response generalization takes place
gradually so that each patient develops his own umbrella of causes, meaning that many
stimuli elicit the same response-anxiety. Day 1 gave all of us enough food for thought and
we could appreciate that the suffering of an OCD patient or a phobic might seem very
casual to an outsider but it is very genuine for the patient.

47

Day 2 was power packed as it focused on the implementation. Though individual


differences can exist, but on an average, a patient requires 12-15 sessions of CDT with daily
homework. The important aspects covered on day 2 were as follows:

Case History: The major aims of the case history are detailed background,
discovering conditioned stimuli, underlying fear structures, attempts made by the
patient to cope with the problem and how has the patients life been affected by all
this. The most pertinent question during this enquiry phase probably is what do
you think will happen if . ?

Assessment: it refers to administration of standardized tools to objectively assess


the reported fears and anxiety. Depending upon the requirement one can use YBOCS, Fear inventory and any other relevant scale along with a visual analogue scale
to get a subjective rating of anxiety felt by the patient.

Psycho-education: This is one of the most important stages of CDT. The patient
needs to know the exact diagnosis of the problem followed by the information on
the functional nature of the connection between the conditioned stimuli (triggers)
and reactions (fear, anxiety). The compulsive actions are a form of avoidance which
have been providing a temporary relief to the patient. As a result the problem has
persisted and probably worsened over due course of time. CDT works on two basic
principles. Firstly, anxiety follows the pattern of a bell shaped curve which means
that it rises, attains a peak and declines thereafter. Secondly, sufficient and repeated
exposure to conditioned stimuli tends to reduce its strength. It is desirable to share
the T-R connection with the patient in detail.

Cognitive Drill: The final phase is the cognitive drill. The identified triggers are
converted into past tense and repeated by the patient till a particular triggers stops
eliciting the anxiety response. Each trigger should approximately take about 10-15
minutes. Visual analogue scale is used with each trigger multiple times to assess the
intensity of the response. In one session we move on from one CS to another as per
the comfort of the patient. The drill is effective when it addresses underlying
structures, is multi modality and most important if the patient experiences the
anxiety when presented with the stimulus.
48

Day 2 exposed us to the intricacies of CDT. Detailed case history was demonstrated live and
also through reported cases. Information received in case history was kept safe for the final
day for drill demonstration.
Day 3 began with live demonstrations of the drill on one of the participants who reported
anxiety in a specific performing situation where there was no cue to refer to. The fear of
going blank and being embarrassed in front of the audience and associated fears were
taken up in the drill. The results confirmed the efficacy of the drill. The procedural issues
became very clear on day three.
Over and above the most important take home points that I would like to mention are:

The relevance of Classical Conditioning procedures in learning and unlearning fear


anxiety responses.

The T-R connection

Breaking down of behavior units into surface and underlying structures

The importance of psycho-education

The importance of continuing medicinal support

Multimodality and action in drill

OCD and specific phobias are probably the disorders with the highest rates of prevalence.
The three days workshop was an intense training programme which completely changed
my outlook on these disorders. The highly structured course material and the focused
delivery of that course material worked towards enhancing my knowledge. From the first
day one to the third day it was an upward graph as far as learning and understanding is
concerned. The programme strengthened my understanding of theoretical concepts and
raised my conviction for the practical application of the basic principles of classical
conditioning. Such programmes are an add on to the skill repertoire of any professional
working in the field of psychotherapy.
While writing a memoir for the workshop the very first thing that comes to my mind is that
Dr Rakesh Jain has rightly referred to this programme as empowerment programme. The
three days of intense learning were really empowering. From theoretical to practical, from
other cases to self, I felt more competent in being able to handle the anxiety issues of my
clients. Anxiety is such a natural response that one does not realize when and how it

49

becomes attached to so many stimuli to which it is not a natural response. The abreaction
and the cathartic responses that I saw in the in-person training was a wonderful negation of
my own apprehensions that how can a foolish repetition of a phrase lead to reduced
anxiety. The workshop gave me an opportunity to revisit the theoretical aspects of classical
conditioning theory, and helped me to learn the power of sufficient and continued exposure
of conditioned stimulus in reducing the associated response of anxiety. From interviewing
effectively to explore the underlying issues to prepare the drill for various conditions, the
learning is magnanimous.

Participants Feedback-II:
Workshop on cognitive drill therapy was an amazing learning experience. It was spread
into three days, where on day 1 different cases were told to us of Anxiety, Phobia and OCD.
We were taught of different complaints that patients make in different mental conditions.
How do they react in such a state, how do these anxiety states affect their personal,
professional and social life. We also learned that behind cognitive drill therapy, the theory
that functions is the Pavlovian Classical Conditioning theory. The functioning of classical
conditioning which is mainly about stimulus and response was explained, how anxiety or
phobic responses develop in a person and how such anxious responses get strengthened
and how can we break this connection with the help of cognitive drill therapy. We also
learned that whatever symptoms we are able to see or reported by the patient they are the
overt level and it has a covert connecting cause to it. So its important to identify it.
On day 2, we learnt about the whole process. How should we start the session? So as the
person comes with a problem we should take the case history like what all problems he
has, since when he has this problem, how does it affects him, what are the disadvantages,
what has he done till now to control or treat his problem. Also explore the overt and covert
stimulus or causes that create anxiety. During the history taking session we have to identify
all the stimuli that cause anxiety in the person and make a list of it so that all the stimuli can
be dealt with during the therapy sessions. Then after taking the detailed case history, we
conduct tests for assessment of Anxiety, Fear, OCD and also use the Visual Analogue Scale
to assess the level of anxiety for each conditioned stimulus. After the assessment of the
patient next step is to psychoeducate the person about his illness or disorder where we
have to tell the person the diagnosis of his problem and how has the problem developed
(that can be done by explaining the Stimulus-Response-Avoidance theory).So these three
50

steps case history, assessment and psychoeducation has to be done on the first day when the
patient come. On the second day of the therapy when we have identified all the triggers and
reactions we start up with the Cognitive drill therapy in which the person has to keep
repeating the statement that has been identified as anxiety arousing in past or present
tense. Reason being that anxiety is future oriented and person tends to avoid such stimuli
which he assumes will cause him pain so starts avoiding them or do not confront them.
Avoiding such stimuli which creates anxiety in the person gives the person a temporarily
relief and that becomes a pattern. So in CDT person will repeat the statement in the present
or past tense form which as a result will increase his anxiety gradually, will go higher and
then gradually will go down(forming the bell shaped curve).This bell shaped curve is also a
proof that you are working on the correct stimulus. While doing drill we have to involve lot
of sensory modalities like Patient will himself repeat the statement that is verbal, therapist
repeats the statement and the patient listens to it thats auditory, patient writes the
statement down thats kinesthetic. While doing the drill patient has to visualize the
situation as vividly as possible so that he experiences the same anxiety as if it is real. Along
with the drill, if possible then we have to dare the patient to either touch the object or to
get in close proximity with the feared object. Along with drill and dare we also have to tell
the person to distract himself from these anxious thought by getting engaged into his daily
activities or social activities because by not doing so person is reinforcing his obsessive or
phobic thoughts and giving undue importance to them, So if the person will engage himself
into some work or activity will not give unnecessary importance to them. We also have to
give homework to the patient for practicing these statements at home. These drill dare and
distraction sessions will continue till the time all the stimulus have been practiced and have
lost their anxiety arousing feature and have become neutral.
On day 3 we got a chance to see a live demonstration of CDT, as two of the participants
volunteered for working upon their anxieties. One of them was a case of Social phobia and
another had performance anxiety. So we learned about the practical application of the
Cognitive drill therapy that we had learned in two days in theory form. Watching a
demonstration gave much more clarity to the concepts and brought the realization about
the power of this technique. Along with the therapy we also have to encourage the patient
51

to take medication and not to leave it without doctors consultation. Patients family
members are also to be psychoeducated about the patients illness and therapist can teach
the drill to one of the family members so they can help the patient in practicing at home.
The therapy has to be practiced for 10-15 days, it will start showing its effect within that
period.
My First Manual on Cognitive Drill Therapy:
I drafted following manual of Cognitive Drill Therapy in 2012. I recommend that any
person interested in getting empowered in the process and applications of CDT, should
read this manual thoroughly. It clarifies various concepts and techniques of CDT.

52

A Do-it-Yourself Program:

A Companion to In-Person Training

Cognitive Drill:
A Method of Fast OCD-Phobia Relief

Dr. Rakesh Jain, Ph.D.


Learn innovative methods of dealing with stimulus bound anxiety
Get step by step instructions for doing it yourself
Learn to partition your OCD and anxiety related problems into its ingredients
Manage your OCD bit by bit in divided doses
Design your own creative approach to handle unbearable anxiety
Acquaint yourself with theoretical frameworks of managing OCD
A systematic approach to self-assessment and management
Help other persons in adopting seemingly simple but effective methods

53

Author: Dr. Rakesh Jain, Ph.D.


Title: Cognitive Drill: A Method of Fast OCD Relief
2012, Author
(Email: jain.imhh@gmail.com)
ALL RIGHTS RESERVED. This book contains material protected by Copyright Laws and
Treaties. Any unauthorized modifications, changes or use of this material is prohibited. The
fair usage citations should be done by duly acknowledging the author and title as per
citations standards
Disclaimer: This approach to healing is not an alternative or a substitute to a recognized
and standard medical practice. A person is advised to seek proper medical treatment for
his/her conditions and complement the standard treatment with this approach as add on
with full knowledge and consent of the medical consultant and purely at ones own risk. The
persons with cardiac or life threatening conditions should not use the methods covered in
the book. The author and publishers of this book are exempt from all liabilities or damages
resulting directly, indirectly or in any manner from the use of this book. A user owns
absolute responsibility with the commitment that the authors and publishers exemption of
all kinds of liabilities shall be protected by him/her. If these conditions are not acceptable to
any of the user of this book; the author and publisher strongly recommend that such a
person should not use any part of this book. There is no guarantee or a claim of any kind to
any extent that the procedures mentioned in this book are effective and useful in any human
conditions including OCD; this disclaimer shall have an overriding effect over any language
which is suggestive of any therapeutic claim. No assurance is made for accuracy or
completeness of the information contained in this book.

54

Preface
Obsessive Compulsive Disorder (OCD) is a recognized psychiatric disorder with chronic,
waxing and waning course. The newer psychiatric medicines have made significant
progress in the treatment of this disorder. There are cases that respond to medicine alone
and get substantial relief. Hence, I recommend that on priority a person with OCD should
seek psychiatric consultation and pursue it for a sufficient length of time to get optimum
benefits. If the condition improve sufficiently only with psychiatric medication it would be
an economic and efficient solution for managing ones OCD.
The methods described in this book ideally should be pursued along with proper
psychiatric medications for OCD and other anxiety disorders after a sufficient trial of
medicines. The standalone applications of this program even if may produce positive gains,
should not be pursued. The medicine intake provides a protective covering for application
of the methods described in this book. A person with cardiac and life threatening condition
should not use these methods. Also the persons who develop any side effects or problems
by using these methods should stop further application of the methods covered in this
book.
This book is an attempt to present my understanding and innovations with an objective to
frame it for self-help. However, I recommend that these methods should be learned
through in person training which takes about 02 hours per day for 10 days. I teach lots of
concepts and procedures to make the task quite easy for you to understand and apply in
your day to day life.
I would like to make it explicit that not all kind of OCD and anxiety problems respond to
these methods. I am still in the process of cataloguing indications and contra-indications of
the methods elucidated in this book. It should also be remembered that these methods are
unlikely to produce a cure. There should be an expectation of working improvement in the
cases who do respond favorably to initial application of these methods.
The scientific data need be generated to test its efficacy and the present work is based on
the observations of individual cases. As I continue to pile up the case based data, I may
develop a research project to thoroughly investigate and refine the procedures.
55

I am grateful to my family, teachers, friends, fellow professionals and my students who


have been helping me to develop innovative methods of dealing with a large variety of
psychological problems.
I am also thankful to each and every person with anxiety disorder who relied on my
services and allowed me to experiment on innovative procedures of combating OCD and
other anxiety disorders.
Please take a print out of this document before using it. On screen reading is not
recommended.
I have purposely repeated core concepts at various places to impress your mind with those
ideas so that they get integrated into your system. Your OCD is maintained via repetition
and by the same principle of repetition it will have a roll-back pattern.
If you need to communicate with me, you can do so through my personal email:
jain.imhh@gmail.com. Please note that your communications may be incorporated in
books, journals without mentioning your names in order to help other persons with anxiety
disorders and equip professionals in the application of these methods. If you are not
comfortable with the idea of sharing, then you must explicitly request for total
confidentiality otherwise it would be deemed to have consent by default.
2nd September 2012

Dr. Rakesh Jain

56

Chapter-01: Applicability
======================================================================
Non-applicability:
If you have any of the following conditions, I would like to state that this program is not yet
designed for you. You may continue to seek in person consultation from a psychiatrist and
a psychologist.

Associated life threatening condition or a cardiac problem

Associated psychotic condition, schizophrenia, major depression or significant


paranoid tendencies. Consult your psychiatrist to get confirmation if you have got
any of these conditions.

If you do not consider yourself ill even if others consider you as a person with OCD.

Your consultant psychiatrist recommended you not to opt for psychotherapy

Applicability:
This program may be useful to you in following conditions. The application in all these
conditions would be more or less similar even if I explicitly mention only OCD in the
descriptions.

If you have an OCD and mere talking of the OCD related thoughts make you feel
anxious and produce discomfort

If you have specific phobia like fear of spiders, lizard, cockroach, closed places, open
spaces, height and you feel anxious and fearful merely by talking of those situations.

If you have stammering and you feel anxious merely by thinking and talking about
the situations in which you stammer.

Anticipatory anxiety of examination, public speaking, any performance, asking a


question, responding in public if you feel anxious even when you talk about the
things which make you anxious

If you have an OCD with predominant compulsions; and imagination & talking about
the Triggers of OCD produces little discomfort in you, then this program may not be
of maximum value to you. You would probably get more benefits with Exposure and
57

Response Prevention technique which is a form of behavior therapy and known to


be quite powerful in such situations.

You may need in person training if you have OCD thoughts involving religion, god,
and goddess.
Core Indication:
Try to think, imagine, talk about your OCD related situations and see if you feel
anxious and uncomfortable while thinking, imagining and talking. If yes, you may
get benefits from this program.

Chapter-02: Looking Inside


======================================================================
Cognitive Drill Diary:
At the outset I would advise you to procure a diary or register, a pencil, a sharpener and an
erasure to keep a record of the status of your current problems and other aspects I would
be mentioning at the appropriate places. This would be your diary and you yourself can
maintain its confidentiality as per your convenience. If you are comfortable, you may like to
share your diary with me to gain additional insight into your illness process and the
application of cognitive drill. You may also grant me permission to add it to my database
for analysis and inclusion for further scientific advancements of these methods.
After procuring above material, you should now be prepared for writing into the diary
about your experiences. Name it as Cognitive Drill Diary. As a standard you should record
date and time of each new entry you make in the diary. Now pick up your diary and record
following information in as much detail as possible. Be expressive and write maximum. You
may take 2-3 days to complete this step. If you are not able to cover any of these aspects, it
is OK. I would continue to guide you. Try to work out as per your comfort. There is no
prescribed length, the average could be about 5-10 pages .

A comprehensive narrative account of your problems

Origin of your problems


58

Any associated medical problems

Treatment taken so far and their effects

About your education and occupation

About your achievements and life experiences

Chapter-03: Breaking into Parts


======================================================================
Choose an OCD:
You may have multiple OCD themes and associated anxiety disorders. All the problems
cannot be addressed simultaneously. I would be teaching you a systematic approach which
is more efficient and a time saver. Choose the most problematic OCD theme of your life. I
would guide you for resolution of this major one on priority. Once, you handle it effectively,
the power of other themes may get reduced because of generalization and you may develop
extra-ordinary confidence in handling other OCD themes by yourself with minimal support
from my side. This is an empowerment program which you can extend to other areas
because you tend to learn its various facets and applications. You may spend about 1-2
hours preferably every day for working on this program.
Now mention the priority OCD theme in your diary as Headline and write a comprehensive
narrative of this OCD theme. A write up of about 1-2 pages should be OK.

T-R Partition:
Now quickly review the descriptions recorded in the diary so far and perform a T-R
Partition as per the guidelines given in this section. Make a sub-heading in your diary and
label it as Triggers.
T=Trigger: The synonyms are cue, stimulus, situation, activating event, objects, switch,
signal and the like. A trigger can be any object, idea or person; the exposure of which
activates anxiety in you. The examples of Trigger are a dirty object, a door knob, a lock, a
stranger sitting on your sofa and the like.
Identify as many triggers of your chosen OCD theme as possible and record all of them under the
Trigger label. Write one Trigger per line. This is a flexible listing. You can continue to add more

59

triggers as they strike your mind. Leave at least one page blank in your diary for addition of
more Triggers later on.

R=Reaction: The synonyms are response, behavior and action. This is a cognitive,
emotional and physiological reaction to the exposure of a Trigger. The examples of reaction
are anxiety, fear, a tendency to run away, racing heart beat, feeling of fainting, sweating,
the ideas that if I am dirty, if the house is not locked and the like.
You should now record a label Reaction in your diary and mention your responses when you
are exposed to the listed Triggers. Describe in as much details as possible.

Elaborating T-R: If you have listed the Triggers and Reactions in general, now you
should elaborate upon reactions to some of the specific Triggers.
From the list of Triggers in your diary, underline at least five Triggers.

After making underlines, now you should begin with a new page in your diary and
label it Specific Trigger-Reaction Connections and elaborate in following manner:
Name of Trigger-1:
Reactions to Trigger-1
Name of Trigger-2
Reactions to Trigger-2
In this way continue to complete five underlined Triggers. You will be required to
perform this operation to remaining Triggers after handling these five Triggers. If you
are comfortable with the process, you can even elaborate upon more TriggerReaction Connections.
Examples of Specific Trigger-Reaction Connections:
Trigger-01:Your comes back from the school
Reactions to Trigger-01: He has come into contact with other children who might be
dirty. He will be touching and using objects like sofa, kitchen, clothes and other
things; everything in the house will get dirty. You get anxious, feels extreme
discomfort and to reduce your anxiety level, you force your child to take bath.
60

Trigger-02:Your husband changes his clothes in the evening and puts inside almirah
Reactions to Trigger-02: His clothes are dirty. If he hangs his used clothes in the
wardrobe, these clothes would come into contact with other fresh clothes; these
clothes will get dirty and could possibly spread to all the clothes in the wardrobe. You
feel anxious and extreme discomfort with the idea that you may be required to clean
all the clothes.
Trigger-03: Your handkerchief slips from your hands on the floor.
Reaction to Trigger-03: The floor is dirty. This handkerchief has become dirty. If you
pick it up and keep in your pocket, your trouser will become dirty. This way you
would be spreading the dirt to other objects and clothes. You may be required to
follow detailed rituals to clean your clothes and take bath. You may even feel that you
could spread some kind of unknown and fatal allergy through dirt to your family
members.
I shall be citing many more such instances of Trigger-Reaction in other chapters. At
this point of time these examples should be sufficient to make you understand how to
elaborate upon Trigger-Reaction Connection for the underlined Triggers.
Check Your Understanding: Now carefully review the list of Triggers and Reaction
Narrative and appreciate that most of these Triggers activate this specific characteristic set
of reaction. There are many Triggers of the same reaction. When a range of Triggers
activate the same response, we call it as Stimulus Generalization. This response can be
called as OCD Response. The same OCD response to many varied Triggers. This can also be
represented as follows:
Trigger-I --- Trigger-II --- TriggerIII --- TriggerIV--- Trigger---n -- OCD Response

61

Chapter-03: Explaining Trigger-Reaction Connection


======================================================================
The T-R Partition should have given you enough understanding that many varied Triggers
are connected to a specific OCD response. Please understand that this is a functional
connection instead of a hardwire connection. This is called a functional connection because
there is no wire, neuron or any physical object that connects the Trigger-Reaction. A
simplest example is that while you are on road driving a vehicle, you tend to apply brake in
response to a Red signal and continue to move in response to a Green signal. A response of
putting brake in response to red trigger is a functional connection which was acquired by
you through understanding of rules and repetitions. The signal lies outside your body and
mind; and in response to an external object your mind and body responds according to
some rules and habit.
Similarly, the connection between OCD Triggers and OCD Response is a functional
connection. The clothes, lock, gas, dirty objects, dust, dogs, lizards, cockroach, rats etc. are
external objects and organisms that are there in the external environment. Because of habit
and faulty understanding of rules, the exposures to these Triggers activate OCD response.
With an OCD affected mind you may think that the problem lie with the Triggers and
continue to make untiring efforts to handle Triggers by washing, cleaning, avoiding, reciting
prayers, following rituals. You may keep on cleaning your body, wash hands, clean your
clothes, and clean your house to remove the dirt and contamination to fix the Triggers. With
progression of your illness, many objects, events, persons, organisms tend to get connected
with your OCD response because of the process of Stimulus Generalization. Your life
becomes quite tormenting to the extent that you tend to become house bound and give up
your routine activities, stops engaging in business activities, stops seeing your friends and
relations. There may be an extreme narrowing of your activities and the life may get
centered on your OCD related activities. My latest case says that he remains preoccupied
with OCD 16 hours a day and get relief only for 08 hours that are spent on sleeping. In all
waking hours, he continues to absorb in OCD response. He has stopped is well established

62

business; does not touch his wife and children. Keeps on scanning his body, objects, area
around for contamination and keeps on cleaning.
Message: Triggers are culprit is OCD thinking.
There are several theories that attempt to explain what is happening inside your brain and
mind due to which you got afflicted by OCD. To make you comfortable, I would be
presenting three main theories of OCD (a) Biological (b) Behavioral (c) Cognitive.
Biological Theories:
These theories explain what has gone wrong within the functioning of your brain that is
causing this disorder.

The brain has various chemicals called as neurotransmitters that perform


communication functions in the brain. The people affected with OCD have
insufficient level of one such neurotransmitter known as Serotonin. So you may be
running short of this specific chemical and the deficiency of this chemical might have
been responsible for your OCD response. Some of the psychiatric medicines you take
for OCD are manufactured with a molecule that raises the level of Serotonin in the
relevant parts of your brain. A neurotransmitter balance achieved through
psychiatric medicines by itself may be sufficient to produce major improvement in
your OCD. Hence, make sure to give a sufficient trial of medicine for your OCD.

There are specific interconnected areas in the brain that are responsible for filtering
incoming thoughts for outward transmission, regulation of repetitive and habitual
behaviors, regulation of impulses and control over emotional responses to
obsessions. The prescription medicines help in normalization of these areas of the
brain to effect therapeutic changes in your OCD.

Cognitive Theories:
These theories look into your thinking patterns to explain how your own perception,
perspective, the manner of viewing objects and events, interpreting experiences as
threatening, dangerous, overwhelming, beyond control, potentially harmful and so on
contribute to your OCD response. Your mind finds it extremely difficult to switch off the
63

thoughts which you perceive as potentially dangerous, harmful to you or your family. You
may have a silent or hidden feeling of responsibility that in case something goes wrong you
might be held responsible for not preventing the harm. Because of the alarm raised by OCD
thinking, you tend to keep a vigil on the occurrence of OCD thoughts in your mind, you tend
to become anxious and to prevent the harm as well as to reduce your anxiety level, you get
involved in compulsions and rituals. Cognitive Therapy is a specialized form of
psychotherapy that tries to make you aware of your own thinking program which get
activated during OCD spike and teach you how you can monitor your thought process and
how you can modify your views and perceptions to take a charge over your OCD.
Behavioural Theories:
These theories analyze your overt actions and behaviors to find a consistent pattern and
explain your OCD in terms of conditioning/ habit. The repetitive occurrence of Triggers and
anxious response, such as becoming anxious every time you see a dirty object, the anxiety
response gets functionally connected with the Triggers forming a habit pattern. Since,
anxiety is a painful feeling; your mind tries to find ways and means by which this painful
anxiety can be turned off. This quest for anxiety reduction leads to compulsive behaviors
and rituals. You tend to find certain behaviors like washing hands, taking bath, using
specific soap, detergent powders, cleaning in specific manner, repeated checking, repetitive
ordering of objects, asking for forgiveness, specific prayers and so on. These acts do switch
off your anxiety and reduces your pain and suffering and this reduction of painful emotional
state acts as a reinforcer for your compulsive acts and rituals. But this reduction of painful
feeling is transient. The next time, you get exposed to the Triggers you again get anxious
and again get involved into compulsive acts. This happens because these compulsive acts
and rituals are successful only for a transient relief in anxiety. These compulsive acts do not
act on the Trigger-Response connection. Precisely, this is the reason that you fail to get rid
of your OCD merely by involving yourself in over-elaborate compulsive acts.
A behavior therapist reduces your compulsive behaviors through a powerful behavioral
technique called Exposure and Response Prevention. In this technique, the behavior
therapist would expose you to the Triggers associated with OCD response and prevent you
from getting engaged in compulsive acts. In the process, you shall initially experience,
64

severe anxiety which may persist for minutes to hours and then begin to decline reaching at
zero or near average level. When you continue to adopt exposure and response prevention
regimen, you shall begin to experience sharp reductions not only in your compulsive
behaviors but also in your anxiety and discomfort associated with Triggers. The only thing
is that you tend to experience marked anxiety and discomfort for several minutes and you
may find it quite painful to endure with such an experience of anxiety. But if you can make
up your mind to endure this exposure based anxiety experience, you can certainly make
rapid progress in your OCD response.
Chapter-04: My Formulations:
======================================================================
I am presenting my theoretical speculations of OCD which is also applicable to any stimulus
bound anxiety problem. I will advise you to read this formulation until you have a fair
understanding.
Problem of Future Orientation:

The anxiety associated with a Trigger has future orientation. There is a high usage of
Future Tense in your language when you speak of the problems associated with
anxiety, triggers, OCD. A future tense can be identified by usage of following terms
will, would, shall etc. There may be usage of other tenses as well but when closely
monitored, the anxiety shall reflect itself in a future orientation. The typical
examples of OCD language are my house shall get dirty, my children can get
infected, due to contamination, I am likely to get affected by some kind of allergy, if I
do not ask for forgiveness, the god shall curse me, I should seek forgiveness, else
there can be a devastation of my family.
At this point, turn up to your diary and jump to five elaborations of T-R and examine usage
of future orientation in your write up.

The brain mapping research is likely to show us that all three tenses have
their representation in different areas of your brain. When you are engaged
in future orientation thinking, the activated brain center will be different

65

from the areas which gets activated when you are involved in us of past or
present tense.

For convenience, let me connote the respective brain centers as A, B, & C. Let
us call the brain center associated with future orientation as A; with past
orientation C and for present orientation B. So, when you are using a future
orientation, then your brain Centre labeled as A is more active; and similarly
center B is more active while you are speaking or thinking in terms of
present reference and center C is more active when you are talking, writing,
speaking or thinking in terms of past orientation.

Since, anxiety has a future orientation and you tend to spent several hours a
day in OCD related activities, it means your brain center A is over active and
working on high alert with low rest period. Since, your brain center A has
raised activity, so it compels you to keep on scanning your body, mind and
surroundings for presence of any anxiety/ OCD related Triggers. Because of
this high alert, you tend to notice more Triggers than others and your mind
can go for micro-analysis for detecting OCD Triggers and making sure that
nothing OCD related exist around your body and surroundings. With
progression of your illness, your mind tend to find more and more Triggers
and your Center A continues to get excited repeatedly and for a longer period
of time.

If it is so, can we find any way by which your brain center A can be switched
off. The moment, your brain center A gets switched off you will feel relaxed,
at ease, not compelled by the anxiety for compulsive acts. In this self-help
program I shall teach you how to do that and make you empower for Fast
OCD Relief. This is one of the simplest, powerful and efficient methods of
taking charge of your OCD Triggers.

Role of Trigger-Reaction Connection:

The functional connection between Trigger and Reaction is highly important. You
must have appreciated the relevance and importance of this connection in your
66

OCD. A Trigger acts as a switch to switch on your anxiety response. With every
repetition, the strength of this connection gets strengthened. Your compulsive acts
and rituals only reduce the anxiety response and does not break this connection.
The repeated compulsive acts strengthen the connection between Trigger and
Reaction. Your mind keeps on telling you that by engaging in compulsive acts and
rituals this connection will one day get severed. But it is no so, on the other hand it
becomes stronger.

If there is a method by which you can directly reduce activated anxiety in response
to a trigger then you would tend to loose motivation to get engaged in compulsive
acts. Think of a situation, when a visitor sits on your sofa, and due to OCD
connection, it elicits anxiety in you and you feel compelled to clean your house and
sofa; but if after application of the methods taught in book, it does not activate
anxiety and discomfort, you remain calm and at ease despite the visitor sitting in
front of you then certainly you shall not engage yourself in compulsive acts, why you
should if you are at ease!. So the master key lies in the approach which disconnects
Trigger-Reaction Connection. After disconnection, the Trigger will be right in front
of you, but you will feel calm, compose, quiet and at ease and feel unburdened from
years of anxiety pattern.

Diary Task: Now briefly write in your diary what you understood from above theoretical
perspectives. At the point of time, do not ponder, how it would be possible, can it happen
with you, is it really that simple. Leave all worries and apprehensions, just get into your
diary and communicate your understanding of the theories. This understanding would be
the basis upon which I would teach you master techniques of Fast OCD Relief.
Chapter-05: Core Concepts and Techniques:
======================================================================
1. Check Your Magical Thinking: In magical thinking you tend to believe that your
thoughts have power to cause an effect in external environment. You tend to think
that thinking has power equivalent to Mantra. That is, if you think in certain way,
then there will be corresponding changes in the world. For example, if you are
67

troubled with the word ruin then due to magical thinking you may think that by
having this idea in your mind, there can be actual ruin in your family, your kith and
kin. It is not so. If I give you an assignment of thinking in certain way and ask you to
kill fatal virus of the external environment, then no amount of your thinking can do
so. Think along similar lines to check if your thoughts actually have any such power
to destroy virus, mosquitoes and many other harmful things. No. It cannot be.
2. Your Empowerment: Through in person training of cognitive drill and through this
self-help book you shall get empowered to apply cognitive drill as and when
required and it would take only a few minutes mostly less than 10 minutes. Through
this application you feel confident and at ease and develop an attitude that you can
handle your OCD triggers effectively. This means, you may continue to have OCD
spike but you will learn to take over the charge of such spike within minutes by
applying the methods. You will not need any instrument, gadgets or any object to do
so. It will be a purely mental application which you can do secretly even in public
places and overcome your OCD spikes.
3. In the process of its application, many of your triggers will lose their power as OCD
spike and you will not need to apply these methods.
4. Gradual Reductions in Applications: In the process of learning you 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 you will feel lesser and lesser need
to apply the cognitive drill methods. The application time will get reduced to 10-20
minutes per day.
5. Range of Triggers: A trigger can be anything in the external world, in your body
and even in your mind which has potentials to get associated with anxiety and
discomfort. I am giving some additional examples of Triggers a dirty clothe, fecal
matter, sensations in your body, and thoughts of devastation and so on.
6. Law of Anxiety: If you are exposed to a Trigger and you are prevented from getting
engaged in compulsive acts, 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
68

high to medium reduction of anxiety to low level Zero anxiety. If we plot this
pattern of anxiety on a graph it will yield a bell shaped curve. You should pause
here, re-read it, note this point in your diary and retain this concept in your mind.
This will be used many times in the course of the application of cognitive drill.
7. Law of Habituation: If you are continuously exposed to anxiety provoking Trigger
without your involvement in compulsive act, the anxiety will tend to decline and the
trigger will gradually lose its anxiety potentials. The Trigger will no longer trouble
you. Your mind will become comfortable, at ease and habitual to the Trigger. 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
happens with them? Initially they were also troubled by the noise, but because of
repeated exposure to train noise, their mind 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 with you also because of the Law of Habituation.
8. Multi-modality Involvement: When a trigger troubles you and activates anxiety in
you, it means you are 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. Now try to introspect and
examine if above manners of exposure to the Trigger activates anxiety and
discomfort in you.
9. If there is an involvement of multiple-modalities in anxiety response, then
reduction of anxiety in one modality will tend to reduce anxiety in all other
modalities too. For example, if you are merely looking at a Trigger for extended
period of time and it reduces your anxiety, then the reduction in anxiety through
your visual inspection will have similar positive effects on anxiety reduction in other
modalities of touching, thinking, speaking, writing and so on.
10. Measuring Severity of Anxiety Response: The anxiety can be subjectively
measured in various ways. (1) Giving numbers out of 10 to the severity of anxiety.
Imagine 2-3 Triggers monitor your anxiety and discomfort and rate it on a 10 point
69

scale where zero is no anxiety and 10 is the highest anxiety. This measurement is
quite helpful and would be used to chart your anxiety level at various points. (2)
Simple rating of the anxiety in terms of (a) no anxiety, (b) low anxiety (c) medium
anxiety (d) high anxiety (e) very high anxiety. This measurement scale is more
useful and I would be invoking it several times during your in-person training and
this self-help work up.
11. Law of Tense Conversion: Anxiety and discomfort has a future orientation and
there is a primary usage of Future Tense in ones private internal talk related to OCD
Triggers. This perpetually activates center A in the brain. According to this Law of
Tense Conversion, a person with OCD is required to convert the statements of
Future Tense into Present Tense or Past Tense. For example, if I touch a door knob I
shall get dirty. This is an OCD statement. This statement can be converted into past
tense by saying it as I have touched the door knob and I have become dirty. I am
touching the door knob and now I am dirty. Most future oriented statements can
conveniently be converted into Past or Present statements. I shall be demonstrating
you how to do that.
Now pause for a moment and think along with me. When you speak a future
tense statement, it activates center A in the brain. When you convert such
statements into past or present and repeat the converted statements several times
to yourself, then these converted statements activate alternative brain centers
relevant to past and present. The center A gradually learns to rest in peace and your
internal dialogue is delivered to the centers of Past and Present in the brain. The
two centers B and C responsible for Past and Present are not associated with OCD or
anxiety response. There will be a major shift in the activation pattern of your brain
circuits leading to large improvements in your OCD response. Please remember, I
am not prohibiting the use of future tense in your life and vocabulary. It is only
selective conversion of Trigger related future tense statements. I shall be elucidating
it through several case studies and examples.

70

12. The Concept of Drill: For the purposes of this program, drill is the bulk repetition
of a statement within a short period of time. In drill you would be required to repeat
a statement several times within a period of about 5-10 minutes in your
imagination, writing or speaking. For example, continuous repetition of following
statement for about 5 minutes I have touched the door knob, now I am dirty; I
have touched the door knob, now I am dirty;
I have touched the door knob, now I am dirty; I have touched the door knob, now I
am dirty; I have touched the door knob, now I am dirty; I have touched the door
knob, now I am dirty; I have touched the door knob, now I am dirty; and so on. I
label such repetition of statements either to yourself, speaking before me or writing
on a piece of paper as Cognitive Drill.
13. Keyword Cognitive Drill: After some practicing cognitive drill for some time, I
would introduce to a time saver and more effective advancement of drill which I
label as Keyword Cognitive Drill (KCD). In this KCD, I would give you only the key
words related to the statements associated with OCD Triggers and ask you to repeat
for a few minutes usually less than 10 minutes. For example, door knob, dirty; door
knob, dirty; door knob, dirty; door knob, dirty; door knob, dirty; door knob, dirty;
door knob, dirty; door knob, dirty; door knob, dirty; door knob, dirty. This can be
viewed as a telegraphic language or Google Search Key Words. This KCD is quite
powerful and saves lots of time. The pattern of anxiety rise and fall is the same with
KCD as with full converted statements.
14. Mixed Model of Cognitive Drill: With practice, I will teach you to adopt a mixture
of full cognitive drill and keyword cognitive drill. That means, sometime you will be
using full converted statements as drill and at other time, you will be focusing only
on keywords for drill.
15. The Concept of Physical/ Practical Verification: In Exposure & Response
Prevention (ERP) it is recommended that you come into contact with the Triggers
and then simply wait for reduction in anxiety level. Each successive contact with the
Trigger should progressively reduce the anxiety level. The exposure in such a
manner leads to normalization of anxiety response to the exposed Trigger.
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In contrast to that, in cognitive drill the primary modality is to reduce the anxiety at
psychological level. Once there is a significant reduction in the anxiety at mental
level, actual contact with the Trigger is encouraged to see if actual contact to the
Trigger still activates anxiety response. This is called practical verification. You will
have pleasant surprise that after processing a Trigger through cognitive drill, it no
longer activates anxiety response upon practical verification. So the recommended
approach is to process the Trigger through Cognitive Drill and then do a practical
verification. If any anxiety is left on practical verification; then once again repeat the
cognitive drill for the Trigger. Therefore, actual physical contact with a Trigger is
not required for cognitive drill unless there is a specific form of OCD called as
Predominantly Compulsive Type. The cognitive drill by itself has potentials to
decrease anxiety and discomfort even on practical level.
Chapter-06: A Quick Review of Salient Concepts and Techniques:
======================================================================
1. Cure vs. control: There are some diseases like diabetes, hypertension, and
hypothyroidism which do not have known cures. The medicines, dietary regulations

and exercise help a patient to keep these conditions under control and continue to
function a productive person in the society. An expectation of cure would lead
nowhere. Similarly is the case with OCD. At present your OCD may be overwhelming
and restrictive of your daily routine, occupational tasks, family relationships and
other domains of life. If application of cognitive drill helps you to reduce your OCD
to a significant level and improving your occupational functioning, normalizing your
relationships, restoration of your daily routines, then you should celebrate the
improvement even if your OCD does not reach a zero level.
2. External Trigger vs. Your 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
your 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 you can
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touch and photograph. You also have mental representation of these actual objects.
A mental representation means, the object is not physically present before you; but
you can see it in your minds eyes. You cannot touch or take a photograph of this
mental representation. It is inside you and your mind.
3. Power of Mental Representations: The mental representation of a Trigger can
have potentials for activating anxiety response in you. The Trigger lies in your mind
as its mental representation and you respond anxiously to your own mental
representation. The cognitive drill utilizes this potential of your mind to disconnect
trigger and anxiety. While performing cognitive drill, you need to remind yourself
repeatedly that you are dealing with your own mental representations; it is your
own thinking, your own imagination. You are processing the Trigger only in your
imagination. This awareness of imagination puts you at ease and continues to attack
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.
4. Clear Your Perspective: Quickly review your diary and your memory bank, how
long have you been using a future reference, future tense. It may extend from a few
months to several years. Suppose you have been using an anxious future reference
program for last ten years. Now just pause and recall how many times, the actual
events happened exactly the way you anticipated. You are likely to have a zero or
very low level of matching with your future reference and actual events. It means,
you have two parallel realities. One is of a future reference and the other one as it
happens in real life. On the current date, all your future based thoughts of 10 years
ago have become the past. You have lived your life for 10 years. Dont you think the
data of these years is enough to indicate and confirm you that the events do not
happen in the way you speculate in your future thinking mode? So this anxious
future thinking mode is a culprit in your OCD and I am going to teach you how to
take charge of this future mode and reduce its daily dose in your life.
5. Concept of Spontaneous Recovery: After processing 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 relatively low intensity. The repeat application of cognitive
73

drill quickly detaches anxiety associated with spontaneous recovery phenomenon. It


is seen that spontaneous recovery does not happen for each individual Triggers. It
may be seen only for a few Triggers.
6. Fluctuations: Being a victim of OCD, you may have associated sadness. Your anxiety
and sadness as such may show fluctuations. That is, on some days these emotions
are quite high and on other days, they are under your control and you are at ease.
On the days you are affected with anxiety and sadness spell, you may experience
fluctuations in your anxiety in response to already processed Triggers. You may feel
that there is a relapse. But upon clearance of your anxiety and depression spell, you
will again find that already processed Triggers of Cognitive Drill no longer activates
your OCD response. So in case of stressful situations, anxiety, sadness spells; you
should give yourself allowance that these are temporary feelings and as soon as
these feelings subside, you will feel better and you will not get troubled by the
processed Triggers. You need to ignore temporary fluctuations in your mood, and
OCD response to already processed Triggers.
7. Research Design: Multiple Baselines across OCD Response: This point is intended
for a professional who is reading this book to upgrade his/her skills to help clients
to heal themselves through these methods. If a professional is interested in
conducting robust scientific researches; then this can be done through the subdiscipline of Applied Behavior Analysis and following an established and prestigious
single subject design known as Multiple Baseline Design across Behaviors. A person
with OCD is likely to have more than one OCD theme. Cognitive Drill can
sequentially be applied to each OCD theme coupled with frequent monitoring of 3-4
themes simultaneously. A pattern of improvement in the theme which is processed
with cognitive drill and little improvement in other non-processed themes would
provide evidence that application of cognitive protocol is empirically associated
with improvement in OCD theme.
8. Difference between spontaneous recovery and exposure to new triggers: After
working through several Triggers through cognitive drill, you may become anxious
during exposure to a new Trigger and mistakenly conclude that you have relapsed.
You should make a difference between getting anxious in response to the processed
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Triggers vis--vis getting anxious in response to non-processed Triggers. This


distinction will provide you 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 widening your horizon.
9. Extent of spontaneous generalization: Generalization is a sort of automatic relief
to the Triggers which are not actively processed through cognitive drill. This
automatic relief may get manifested in two ways (a) you get nil anxious in response
to a Trigger which has not been processed through cognitive drill (b) your time
spent on cognitive drill to a non-processed Trigger. That is, if the original processing
through cognitive drill takes about 10 minutes; the generalized effect will dissociate
a Trigger from anxiety within a period of less than 10 minutes may be just 2-3
minutes. This saving of time is the result of generalization effect emanating from
working on other Triggers through cognitive drill. In most instances, the
generalization will manifest itself in time saving. This will enable you to handle most
Triggers quite rapidly.
10. Law of Easy to Difficult: Initially, you should grade your Triggers in terms of their
anxiety provoking potentials. You should apply cognitive drill to low anxiety
provoking Triggers and with practice and continued applications you should
proceed to the Triggers of more and more anxiety potentials. Once you process
several Triggers of low anxiety potentials, and overcome their anxiety, then the
severity of anxiety evoked by more powerful Triggers will also get reduced and you
would be able to deal with them with ease.
11. Law of Coping Statements: You should identify some coping and positive
statements and keep on repeating them to yourself periodically almost every day.
The repetition of coping statements would provide you cognitive strength and you
would be able to continue with the cognitive drill and make faster progress. I am
providing examples of some such statements. You should zero down on only 1-2
statements for yourself. (a) My problem is getting solved (b) I can handle my OCD
Triggers with cognitive drill (c) Every day I am getting empowered with cognitive
drill (d) I can now solve my problems (e) Day by day I am getting confident in
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solving my problems (f) I am now developing a positive life attitude (g) someone is
there to help me out.
12. Law of Sequential Processing of Trigger Series: You should not become a hero in
application of cognitive drill to most of the Triggers in one or two days. You should
have a systematic plan to work through each Trigger one by one. In initial 2-3 days,
you should process only one Trigger each day and thereafter you may take up 2-3
Triggers and not more than 05 Triggers in a day. Also you should solve your
Triggers theme by theme. First take up one OCD theme; clear maximum Triggers
within a period of 7-10 days and then move on to next theme and continue to work
up to one week and so on.
13. Response to Stress: After processing of most Triggers through cognitive drill; you
may encounter an overwhelming stress related to your family, finances, work and
other things. In response to high grade stress you may manifest a tendency to get
anxious in response to OCD Triggers. You should have a firm framework of mind
that this tendency is the result of the temporary stressful situation. Once you
effectively handle the stress and become normalized then your emerged tendency
will again get rolled back to resting and peaceful state. At times, you may find that
cognitive drill does not work in such heightened state of stress. It is OK. You should
be able to apply it effectively after stress reduction. If you find that a cognitive drill
is not working during stress; you should stop applying it and instead resort to
positive and coping statements.
14. Bulk Applications: You should apply cognitive drill in bulk for initial 10-15 days;
then you can space out this application. The bulk application of cognitive drill means
almost daily applications for 1-2 hours for 10-15 days. This app
15. Importance of Home Work: If you are receiving in-person training on cognitive
drill then you can design your own home work. Homework accelerates you progress
to a great extent. The central concept in home work is to process Triggers through
cognitive drill by writing, sub-vocally speaking to yourself, exposing yourself to
Triggers. The other forms of useful homework are using relaxation, maintaining
regular diary and engaging yourself in productive activities. I have seen patients
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coming up with their own creative ideas for executing home work. You also can
develop and design your own home work as per your convenience.
16. Handling Predominantly Compulsive Type of OCD: Cognitive drill is primarily
designed for OCD with predominant obsessions. However, it can conveniently be
extended to OCD with compulsive type. If you have this form of OCD then you are
required to come into contact with OCD Triggers, expose yourself or physically
touch the objects in graded manner from easy to difficult, refrain from compulsive
act, monitor your self-talk, identify future oriented statements and convert such
statements into past or present and repeat to yourself. You may need supervised inperson training for doing so.
17. Use of Your Own Language for Cognitive Drill: Please remember that your own
specific language and words are associated with activation of your brain centers and
neurotransmitters. When formulating converted statements or Keywords for
cognitive drill, you should choose your own words you use. A change in words or
phrases that are not used by you to yourself may not activate your anxiety program
and would not lead to reduction in anxiety and discomfort. For example, your
typical future statement is If I touch door knob, I shall get allergy; then you 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.
18. Repeat Psychiatric Consultations: You should continue to see your psychiatrist as
per follow up schedule. When you are able to handle most Triggers effectively after
processing them through cognitive drill, you may like to visit your psychiatrist for
repeat consultation and seek his/her expert psychiatric opinion regarding your
current status. You must continue your medications as prescribed even if you are
tempted to discontinue. Dont rely on your temptations for discontinuation.
19. Use of Relaxation: Relaxation is an antidote to anxiety. You should incorporate any
form of relaxation in your daily routine. It would take about 5-10 minutes and
would save your lots of energy drained by stress and anxiety. There is no preferred
method of relaxation. You can use any method which suits to your body and mind. It
can be simple visualizations of pleasant relaxing imagery or you could lie down and
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mentally inspect your body parts top to bottom one by one in slow pace and tell
your mind that the body part is getting loose and light. The relaxation can be body to
mind or vice versa.
20. Fixing Responsibility: You should remember that your OCD is not your choice and
you are not responsible for causing OCD to yourself. It is a disorder and your OCD
behaviors are because of this disorder. You should not blame yourself for your OCD.
Most persons have their own vulnerability to one or the other disorder including
physical, psychosomatic and psychiatric. Each disorder and illness is painful. Instead
of blaming you should cultivate a solution focused mindset. You should say to itself,
alright these are my OCD behaviors and gradually I am able to handle the Triggers
associated with these behaviors. You should have an optimism and hope for
handling it effectively through the methods and approaches you are learning from
this program and other methods recommended by professionals.
21. Periodic Compulsive Acts: A few times, you may get involved in compulsive
behaviors even if there is no Trigger. It is a rule that sometime you will get engaged
in OCD related behaviors albeit with lesser frequencies and intensities. You should
not interpret it as relapse. Instead, you should give an allowance to yourself for such
periodic behavior and simply ignore them. Do not ponder over such lapses. Remain
calm, quiet and confident that you are gradually overcoming the Triggers associated
with OCD and you would continue to do so.
22. Change Pattern of Compulsive Acts: In the course of your illness, you tend to
develop specific patterns of compulsive acts and rituals. These patterns get
ingrained in your functioning. As you become confident in reducing your anxiety in
response to Triggers, you can think of simply changing the specific pattern of your
compulsive acts and rituals. You may observe a few healthy people how do they
perform those acts, like washing hands; and re-pattern your acts and rituals in
lighter manner accordingly.
23. Monitor Lessons Learned: While reading this resource and receiving in-person
training you would learn many lessons. With passage of time, you tend to forget
many lessons. To deal with natural memory lapses, I would recommend you to
record key lessons in your diary so that you can quickly revise your diary and keep
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on reminding the important lessons which would equip you to effectively deal with
your OCD.
24. Feeling of Shame and Guilt: A person with OCD may have a feeling of shame and
guilt for his/her OCD. You too may have this feeling. I would like to tell you that OCD
is a recognized psychiatric disorder and all mental health professionals are well
aware of your symptoms and suffering it causes to you. So you can open up yourself
quite freely with a psychiatrist and psychologist. You do not have to be ashamed for
a disorder.
25. Associated Depression: OCD can cause you a secondary depression. If you have
depression because of your OCD then this depression should improve with
medications and improvement in your OCD. If you have a pre-existing depression;
then removal of OCD can surface your depression. This can be handled with antidepressant medications and cognitive restricting.
26. Associated Psychosis: The OCD symptoms may have a link with OCD. This disorder
can protect you from psychosis or have a side by side presence. This program may
not be suitable if your OCD is linked to psychosis. Get it screened from your
psychiatrist and if you have psychotic features, then I do not recommend you to
adopt this program.
27. Follow up: It is seen that persons with OCD after receiving in-person training tend
to discontinue seeing the expert because of major improvement in OCD. I would
however, recommend for periodic follow up and booster sessions of in-person
training.
28. Responding to Your Own Mental Representations: While you process Triggers
through cognitive drill, you should try to conceptualize that you tend to respond to
the mental representations of OCD Triggers. The mental representations as such
have potentials to make you anxious. A reduction in your anxiety and discomfort in
response to your mental representations have potentials to decrease your anxiety
and discomfort in real life too.
29. Review Already Processed Triggers: You should keep a record of already
processed Triggers through cognitive drill. Periodically, you should review the
processed Triggers and derive confidence and strength that you are capable of
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handling even seemingly tough Triggers. Whenever, you feel demoralization; you
should resort to this list of successful Triggers and regain hope and optimism in
your capability in handling Triggers.
30. Work Participation: You should cease to procrastinate your work due to OCD. Do
not defer any work saying to yourself that you would do it after recovery from OCD.
Try to get yourself involved in as much productive and creative work as permissible
by your circumstances and capacities. I am not recommending you to get
overburdened with the work. A balanced work involvement would help you to come
closer to your normal routine.
31. Creative Visualization: Periodically, for about 10 minutes while you are relaxed
you may feed your mind images of restoration of your work and routine. That you
are getting up at the usual time in the morning, quickly finishing your morning
routine, leaving for your work, you are engrossed in your business, office work, you
are feeling confident and comfortable in your office, you are interacting with your
friends and work mates, you are returning to your home with fruits, snacks, and you
are feeling happy inside you and you are now a productive and healthy member of
the society.
32. Medicine Compliance: At times, you may tend to skip your medicines for one or the
other reasons like losing interest in medication, non-availability of medicines,
considering yourself cure and giving up medications, on advice of your family or
friend, not keeping up with medical consultations and the like. The net effect of
giving up medication is re-emergence of your OCD symptoms which may occur
within days to weeks or even months. The best course of action is to restore your
medications after psychiatric consultation. The consumption of the medications as
per prescribed schedule would help you to combat the OCD.
33. Relapse Management: Apart from continuing your medications, you should
develop a habit of continued use of cognitive drill. The discontinuation of the drill
may shift you back to the medication regime alone. The drill along with medication
could empower you to a greater extent for effective handling of your symptoms that
have appeared again.
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34. Action Drill: In the course of your OCD you tend to develop a defined pattern of
actions like washing hands in a particular manner, counting up to specified number,
examining your body in a peculiar way, washing objects in a defined pattern and the
like. These patterns of actions become associated with activation of specific centers
in the brain and release of specific brain chemicals. Mere performing those actions
in the absence of immediate trigger or obsessions, you may tend to feel anxious and
distressed. To break this conditioning you may perform action drill. That is perform
the OCD actions for the sake of drill when you are not obsessed or charged by any
OCD triggers. Initially, you may feel the same anxiety level, as you feel in the face of a
Trigger. Continue to perform the action drill and the anxiety associated with OCD
actions would tend to get dissociated.
35. Relapse vs. Exposure to New Triggers: There would be times and situations when
you will feel that your OCD has returned back. In such a situation, you should try to
identify the triggers of the OCD reaction and pause to evaluate if there is any new
trigger involved in the OCD reaction. If it is a new trigger, instead of considering it as
relapse, you should work out the new triggers. The working through of new triggers
would put you back to the comfortable zone. If there is no new trigger, and you are
re-sensitized only to the already processed triggers, then this would be a case of
relapse.
36. Become an Expert in Your OCD: Since, OCD is a chronic disease, you should try to
learn as much as possible regarding your OCD. This you can do by reading standard
and recommended websites, going through self-help books, participating in
discussions in OCD support groups on Yahoo Groups, Google Groups, Forums. The
knowledge is power. Once you know about various aspects of your OCD, you would
become better equipped to keep your OCD in control.
37. Power of Trigger Detection and Discrimination: Trigger is any object, situation,
people, sensation, thought or image which has potentials to activate your
obsessions, compulsions and anxiety response. I am labeling your OCD response as
ROCD. Various Triggers can be termed as T1, T2, T3, T4, T5, T6. Tn. Suppose you have
cleared T1 to T10. Then, you come across T11 and get your ROCD activated. You may
mistakenly conclude it as an instance of relapse because you are having the same
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ROCD to T11. Instead of looking at your reactions, you should look on the new trigger
and process this trigger through cognitive drill. Once you process it, your OCD
reaction will get calm down and you can resume your regular functioning.
38. Cognitive Exposure vs. Exposure to Real Object: In cognitive drill you perform
most of your work at cognitive and imagery level. With practice you become
efficient in handling many triggers at cognitive level. When encountered with a real
object, you may find yourself temporarily in a fix and say yourself that this is a real
object. How to drill and handle it. If you analyze your inner experiences, thoughts
and feelings, you can easily spot a cognitive elaboration and future reference in your
experience. Actually, you are not troubled by the actual events, instead the main
culprit is the cognitive elaboration associated with the real objects. For example, you
touch a pair of shoes, your hands are actually dirty now. This is a real
contamination. You are not troubled by this contamination instead the way you
assign meaning and importance to this contamination in your mind. You may think
that now your hands are dirty, if you touch your other body parts, then your body
would get dirty. If you go your home with this dirt, then the objects you would be
using in your home would also get dirty, the clothes, utensils, persons in the family;
all would get contaminated and dirty. This would keep on spreading. This cognitive
elaboration is at fault. Through cognitive drill, we address this cognitive elaboration
and cut down the sphere of OCD related thoughts.
39. Non co-operation Movement: A person reported that he used the Non cooperation Movement to combat his OCD. He refused to co-operate with the
persuasions and pressures of OCD to get involved in compulsive acts. Initially, he felt
anxiety which calmed down with repeated application of this policy.
40. Giving Nil Importance to OCD Thoughts: Learn to discard OCD thoughts and the
emergency they create for solving endless problems. Simple give them NIL
IMPORTANCE. Years of thinking and thinking and thinking of OCD thoughts have
only one function of draining your psychic energy. There is no urgency to dwell in
OCD thinking.

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Somatic Charge Therapy


Dr. Rakesh Jain, Ph.D.
There are three major aspects of human personality which are known as (a) Cognitive (b)
Conative and (c) Affective. The cognitive aspects deal with thinking/intelligence. The
affective aspect is related with feelings and emotions. The conative aspect is concerned
with impulse, striving, or directed efforts. When a person suffers from an emotional
disorder like anxiety and depression, one can clearly observe the presence of these three
aspects of the mind. An anxious person has a characteristic thinking pattern, the prominent
emotion of anxiety and bodily manifestations like accelerated heart beat, sweating, dilated
pupil, altered respiration rate, muscle tension and the like. Similarly in depression, a
patient has characteristic thinking pattern, prominent emotion of sadness and bodily
manifestations like fatigue, headache, lethargy and the like.
I would like to rename the expressions three aspects of personality as cognitive charge,
somatic charge (conative) and the affective charge. In a person with psychological
problems, these three charges are present, the magnitude of these three charges may be
different across patients and even in a patient from session to session. In disordered
condition, a patient has problematic and negative charges. The goal of psychotherapy is to
heal these charges to restore the best possible functioning of the patient.
There are many schools of psychotherapy which give importance to one or the other
charges according to the theoretical framework of the school. For example, the
psychotherapy which place an emphasis on cognitive charge, is likely to belong to the
family of Cognitive Therapy. The schools which emphasize role of emotions and focus on
emotional healing directly can be classified as Emotion Focused Therapies. Lastly, the
schools of psychotherapy which gives an emphasis on conative aspects can be grouped
under Body Oriented Psychotherapies or Somatic Psychotherapies. The Somatic Charge
Therapy would belong to the family of Body Oriented Psychotherapies.
In a human personality, the three aspects are inter-related. An intervention and healing of a
specific type of charge is likely to result in the healing of other charges. For example,
healing of cognitive charge through Cognitive Therapy would heal the dysfunctional
emotion and resolve the somatic charges too. Similarly, the Emotion Focused Therapy can
alter the cognitive charge and resolve the somatic manifestations of the emotions. The
direct resolution of Somatic Charge, is also likely to resolve the affective charge and alter
the dysfunctional thinking patterns.
It is the orientation and training of the treating psychotherapist which guide the selection
of any of the charges. A person trained in Cognitive Therapy would obviously focus on
cognitive charge to heal the ailments. Similar would be the case with emotion focused
therapist and the body oriented therapist.
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The therapies of each charge type have their own theories, techniques and rationale. It
would be of interest to run comparative studies of the therapies of each type to explore if
any specific type of therapy consistently produces superior results over other therapies. As
far as I know, the common factors of psychotherapy are also responsible to the changes in a
patients condition.
The traditional psychotherapies were dynamically oriented and considered to dig deeper
into the psyche of the patient and resolve intra-psychic conflicts. They were supposed to
take longer time in producing desired results and the success rate was lower. The behavior
therapies took over the empire of the psychotherapy by critically examining the outcomes
of traditional therapies and empirically demonstrating their effectiveness. The behavior
therapies emerged from learning theories. The covert contents and the cognitive charges
were largely ignored. The Cognitive Therapy became the leader by focusing the ignored
cognitive charges of behavior therapy and by conducting most sophisticated randomized
controlled trials. To date, Cognitive Therapy is the treatment of choice and it prevails
across the world for healing not only the psychiatric disorders but also the negative
cognitive charge in the patients with physical disorders.
The body oriented therapies are existing in the psychotherapy world but they have not
gained any popularity like other therapies. Over the years, I have been conducting my
observations with Somatic Charge Therapy and I am trying to formulate and present
diverse dimensions, theoretical frameworks and the techniques to elucidate my
conceptualization. All of these are open to corrections and updates as I receive feedback
from others and I my make advancement in it.
Psychophysics:
Psychophysics is the scientific study of the relation between stimulus and sensation. A
stimulus can be graded in its intensity along a continuum from almost zero to an arbitrary
point of 100. If a weak stimulus is presented to a human being in laboratory setting, his
senses may not be able to detect the presence of the stimulus. If the experimenter
continues to enhance the intensity of the stimulus, there will be a point when the defined
intensity of the stimulus will affect the senses, it will be detected 50% of the time and go
undetected for 50% of the trials. If the experimenter continues to raise the intensity level of
the stimulus, then there would be more chances for its detection and finally, there would be
a point when the presence of the stimulus will be detected on 100% trials.
In this context, I would like to amplify the importance of the presence of the stimulus in
causing sensations. A stimulus impinges upon the sensory system which produce the
sensation. Sensation is the fundamental unit of study in psychology. Sensation is the basis
of all cognitive, affective and somatic manifestations. Sensation is the basis of perception
and thinking. Without sensation, there would be no perception. The sensation invariably
involves somatic aspects as it relates to the sensory system. If sensation and sensory data is
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the fundamental and the basis of all other psychological phenomena then it legitimately
deserves its due emphasis in healing works too. In Somatic Charge Therapy, I am trying to
anchor myself to the sensations and other charges present in the body.
Sensation precedes the perception and thinking. But when I am developing a framework of
Somatic Charge Therapy (SCT), I would like to make it clear that the somatic charges dealt
in SCT can precede the other psychological processes like perception and thinking or could
also be the outcome of cognitive and affective charges. For example, when a person become
angry, the somatic charges of clenched fist, accelerated respiration, stiffness in muscles
could be the outcome of affective charge. So we can have two kind of somatic charges (a)
Primary Charge: The sensations induced by the exogenous stimulus (b) Secondary
Charge: The sensations and bodily processes which are the result of cognitive or affective
charges or other processes in the body and mind which cannot be directly attributed to be
as the fundamental sensation caused by the exogenous stimulus.
The exogenous stimulus impinges upon the sensory system. This impinging on the sensory
system may produce negative somatic charge of primary type or initiate a chain of
responses finally resulting in a negative somatic charge of secondary type. To illustrate the
point, I would now be using the concepts of Pavlovian conditioning. In a classical
conditioning paradigm, a neutral stimulus (CS) elicits a conditioned response (CR) due to
repeated pairing with an unconditioned stimulus. The pairing of Bell (CS) with Food (UCS)
elicited salivation response (UCR). Upon completion of the conditioning, the presentation
of only CS (Bell) elicited salivation response (CR). The sound of the bell, in fact, elicited a
series of observable and unobservable responses (CRs) apart from salivation (CR). I would
like to enlist some of such responses elicited by the sound of the bell:
1.
2.
3.
4.
5.
6.
7.
8.
9.

The bell (CS) stirred the sensory system in the ears


There is a perception of the sound of the bell
There is an activation of neural network
There is a specific activity at the neural level e.g. nerve conduction, release of
neurotransmitters
There is an integration of past experience with the sound of the bell and the current
sound
The expectancy of food (UCS)
An activation of striated/non-striated muscles activities
An actual salivation
More such response can be added to the list by an expert in anatomy and
physiology.

In my opinion, all these responses can be considered as Conditioned Responses (CR) in


their own right. The final salivation response in the sequence, might have been easy for the
pragmatic reasons and ease of measurement. If we have sophisticated devices, then we can
certainly measure all these activities being initiated by presentation of a stimulus. If this is
85

the case, then a stimulus (CS1) can produce a sequence of inter-connected responses which
can be expressed as CR1, CR2, CR3, CR4, CR5, CRn.
Let us know consider an instance of classical conditioning of noxious stimulus; in which
bell is the CS, the UCS is delivery of electric current to the legs of the dog and conditioned
response is the withdrawal reflex (UCR). In this conditioning process all the above listed
responses would be present and upon conditioning sound of the bell (CS) will result in
withdrawal reflex (CR). In this instance, the withdrawal reflex to CS represents a negative
somatic charge to me. Further, this type of negative somatic charge can be classified as the
somatic charge of primary type.
The Concept of Negative Drive State:
The negative somatic charge can act as a negative drive state which can initiate an operant
response. In such a case, the negative somatic charge would act as a negative reinforcement
which results in acquisition and maintenance of operant response. This can easily be
understood through the experimental paradigm of avoidance conditioning. In avoidance
conditioning, a cue elicits a negative drive state which is terminated by the emission of an
avoidance response. Let us now consider the proper experimental situation. The
experimental apparatus is a box having two compartments labelled as A and B. The floor of
compartment A has an electric grid and the compartment B is safe. There is a cue in
compartment A which could be an electric bulb. A rat is placed in compartment A, the
electric bulb is switched on and then the electric grid of the floor is also switched on. The
rat will learn to jump to compartment B which is safe as and when electric bulb in
compartment A is switched on.
The whole learning scenario in this experiment could be splitted into two levels. Level-I is
analogous to the classical conditioning. The electric bulb is a CS, the electricity in floor grid
is the UCS and the negative drive state caused by the electricity experience is the UCR. With
repeated pairing, the Bulb (CS) alone elicits the negative drive state (CR) in the rat. Harm
avoidance is a primary motive. The resultant negative drive state causes a disequilibrium in
the organism. In order to restore homoeostasis, the organism emits a series of operant
responses until final selection of the response which is successful in terminating the
negative drive state and the restoration of homoeostasis, that is jumping to the safe
compartment (B). In this case, there is a cessation of noxious stimulus upon emission of an
operant response and the negative drive state is the negative reinforcer for the operant
response of jumping. The negative drive state elicited by the bulb (CS) is the negative
somatic charge which resolves upon emission of the operant. This sequence of CS (bulb) a
CR (negative drive state) jumping to safe compartment (operant response) reduction in
drive state (negative reinforcement) may continue indefinitely unless intervened in some
ways.
Examples of Somatic Charges:
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The somatic charge is conceptualized comprehensively and includes both primary and
secondary type. A somatic charge can be a symptom of a mental or physical disease,
sensations, feelings of tightness, strain, heaviness, accelerated heart beat, fullness of
stomach, back pain, teeth grinding etc.
1. Common somatic charges in anxiety includes - pounding heart, sweating,
stomach upset or dizziness, frequent urination or diarrhea, shortness of breath,
tremors and twitches, muscle tension, headaches, fatigue etc.
2. Common somatic charges in depression includes - Headaches, Back pain, Muscle
aches and joint pain, Chest pain, Digestive problems, Exhaustion and fatigue,
Dizziness or lightheadedness etc.
Similar list of somatic charges can be generated for several disorders. It is to be
remembered that the Somatic Charge Therapy is a psychological intervention which
primarily deals with healing psychological issues and disorders instead of physical
disorders. However, there may be exceptions when an application of Somatic Charge
Therapy produces healing effects in physical conditions too. SCT may be useful in the
conditions labeled as psychosomatic disorders.
What Gets Healed in Somatic Charge Therapy?
The applications of SCT can be expected to resolve the affective and cognitive charges
associated with somatic charges. I would like to clarify this position in greater details. A
person has abnormal sensations in heart region and he is anxious and preoccupied with the
possibility of having heart disease despite negative findings on cardiac examinations. The
condition obviously is of psychological nature. The specific charges associated with this
problem can be readily identified. (a) Somatic Charge: abnormal sensations in heart region
(b) Affective Charge: Anxiety/fear (c) Cognitive Charge: I may have a heart disease, I may
get a heart attack, In case I get a heart attack, the help may not be available to me. The
cognitive charge would includes all the cognitive distortions at three level (i) Negative
Automatic Thoughts (ii) Dysfunctional Assumptions and Rules (iii) Core Beliefs/Schema.
Somatic charge is anchored in SCT. That is, the therapist would keep a vigil on the nature,
fluctuations and removal of somatic charges in the therapy.
Inter-connectedness of Somatic-Affective-Cognitive Charges:
The three charges are interconnected. If we strike any of these three charges, then the
other two charges are likely to get activated because of interconnectedness. To clarify it
further, if I ask the person with abnormal sensation in heart region to focus the awareness
on the heart region and notice the abnormal sensations, the affective charge of anxiety/fear
and the corresponding cognitive charges would also get stirred. The other way round, if I
would ask this person to hold in his awareness that he may have a heart attack, then the
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affective charge of anxiety/fear and the abnormal sensations are likely to get stirred. If this
analogy is continued, then resolution of any of these charges would also heal the other nonintervened charges because of the interconnectedness.
Neural Basis of Interconnectedness of three Charges:
Somatic-Affective-Cognitive charges are interconnected. Diverse theories can be invoked to
explain this interconnectedness of the charges. The primary theory would be biological.
The activation of three charges initiates the neural activities in the brain simultaneously
corresponding to the charges. Roughly, the cognitive charge may be localized in the frontal
cortex, somatic charge in the parietal lobe and the affective charge in the limbic system.
There may be an overlapping of the areas. The specific areas can be pinpointed by an
expert in brain anatomy and physiology. An emotionally laden event contains three charges
and activates all these centers at the same time. The activation of the neural centers
corresponding to these charges becomes associated with each other due to simultaneous
activation.
Stimulus-Response Framework:
In a stimulus-response (S-R) framework, a stimulus impinges on the organism and
activates three charges simultaneously. The three charges can be labeled as R1, R2 and R3.
The most likely it would conform to the paradigm of classical conditioning. The three
charges are examples of respondents.
The stimulus which activated the charges could be conspicuous or obscure. It could be
exogenous or internal. In somatic charge therapy, I recommend that a therapist should
keep a vigil on the stimulus of the charges. He should try to detect and pinpoint various
stimulus involved in the charges. In the search strategy for the stimulus, the exogenous
should be given first priority than the internal stimulus. In most instances, a stimulus
would activate all the three charges. But in a given stimulus situation, any of the charges
may be prominent and others may be obscure. For example, when exposed to the stimulus
situation, a person may conveniently report the cognitive charge, the other person may
have convenience in reporting somatic charge. The other charges though present may not
be readily accessible to the patient.
Search Strategies for Charges:
Somatic charge is the anchor in somatic charge therapy. A therapist may begin his
exploration from any of the charges. The possible recommended permutations of the
charges are (1) SomaticAffectiveCognitive (2) AffectiveCognitiveSomatic (3)
CognitiveAffective Somatic. In SCT, somatic charge has an overriding importance over
other charges. It should be remembered that the overriding importance is just for
exploration and anchoring the entire process. The Affective and Cognitive charges have

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their own equal importance and even overriding importance at other levels even within the
framework of somatic charge therapy.
Absence/Difficult of Somatic Charge:
There may be instances when a person with abnormal psychological experiences fails to
report the presence of somatic charge or the charge is present but it is difficult to handle
within the framework of somatic charge therapy. A therapist in such situations have
options to use other psychological methods like behavior therapy, psychoanalytic therapy,
cognitive therapy and any other approaches to heal the individual. An optimistic therapist
may use and develop variants of the techniques of exploration and healing of somatic
charge therapy to handle difficult somatic charges and the absence of somatic charge in a
person with persistent abnormal psychological experiences.
Techniques to Explore Somatic Charges:
It is very easy to locate a somatic charge in a person with psychological difficulties. I am
giving a list of search queries and method which can be expanded upon by the users of this
manual. The entire process must be gentle, compassionate and free of intimidation.
1. Ask the client to gently close his/her eyes and scan body, brain and mind for the
presence of any altered sensations, feelings in the body, pain, heaviness, lightness,
strain, pressure and the like.
2. If a client instead of reporting the somatic charge, come up with cognitive or
affective charge then a note can be taken up for these charges and reverse
exploration can be initiated.
3. If a person reports affective charge like he is anxiety/worried/fearful then ask the
client to monitor his body and report where this anxiety/worried/fearful is felt or
represented in the body. If a client successfully reports its representation in the
body then forward queries need be initiated in the sequence of somatic ->affective>cognitive charge. Ask the client how it feels in the body, procure a descriptive
report of the sensations and experiences in the body. Upon completion of this
narration, the ask what feelings/emotions are associated with this representation of
the body. The client may initially need to understand and discriminate the
feelings/emotions vis--vis thinking. Anxious, fear, joy, disgust, anger, hate are the
emotional terms. Try to get an emotional term associated with the somatic charge.
Upon getting the emotional term then ask the next question, what makes you to feel
like that? This question will yield a cognitive charge associated with the experience.
The client may need help to understand the cognitive charge. Thinking is the
cognitive charge. It is expressed in statements. The statements like I may be a
failure People will laugh at me, I am incompetent, I am not worth living, my

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life is a failure are the instances of cognitive charge which need to be explored and
noted in the diary.
Charge Diary:
A client should be prescribed a diary for recording various charges on daily basis. Ask the
client to record the charges in a narrative form. He should describe the experiences,
timings, situations, peoples involved, thinking, feeling, and body experiences. A client
should preferably record at least one or two such experiences in detail on daily basis. This
diary will add to the understanding of the therapist as well as the client. It will reveal
multiple charges which may otherwise go unnoticed in therapy sessions. The client should
bring this diary in each session.
Session Duration and Frequency:
A session of somatic charge therapy usually takes one hour. However, in some cases it may
extend by one or two more hours. I recommend daily sessions of somatic charge therapy
for about 10 days and then follow up sessions on following points one week, two weeks,
four weeks, eight weeks, 12 weeks, 24 weeks and SOS. The daily sessions produce rapid
and effective reconditioning of various charges.
Baseline/Follow up Assessments:
Prior to initiating the treatment I recommend that a therapist should take comprehensive
case history, conduct clinical interview, conduct relevant cognitive and clinical
assessments. The cognitive assessments include the assessment of dysfunctional
assumptions, core beliefs and other questionnaires/scales which are used in Cognitive
Therapy. The clinical assessment includes the tools which assess the magnitude and
severity of psychopathology like Depression Scale, Anxiety Scale, psychiatric rating scales,
Yale-Brown OCD Scale and the like. These assessments should be periodically repeated
including on follow up. A client may improve rapidly hence do not delay the baseline
assessments. The application of visual analogue scale should be done as frequently as
required and the ratings should be recorded.
Psychophysiological Monitoring:
I recommend the use of psychophysiological monitoring devices like GSR, Respiration,
Temperature and the like while doing somatic charge therapy. These measurements can
provide robust and objective feedback to both the clients and the professional community
regarding effectiveness of somatic charge therapy. This will also help in producing research
documents for peer reviewed journals.
Case Diary of Somatic Charge Therapy:

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I recommend that a therapist should maintain case diary of each individual patient. While
doing SCT, the therapist should record as much narratives as possible and at the same time
audio/video recording of each session should be done with due informed consent of the
patient. These write ups would serve you to contribute research papers, lectures,
workshops and books on Somatic Charge Therapy. Moreover, you will have deeper insight
into various dimensions of this therapy which will stimulate your creativity to develop
concepts, theories and techniques of SCT.
Consider Before You Continue Somatic Charge Therapy:
I have set a criterion of first three sessions of somatic charge therapy to evaluate and take a
decision whether to continue SCT or switch over to other modalities. If a client shows
reasonable progress and reduction in symptoms within three days of the application of
somatic charge therapy, then it should be continued as long as required. If there is minimal
or no gains of SCT in three days application, then I would recommend you to switch over to
other modalities like CBT, behavior therapy etc. If you find that there is minimal or no
improvement in three sessions, but you expect it to happen with continued sessions, then
you can extend the three days rule to five days at the most. If there is no signs of
improvement in the condition of the patient within five days application of SCT, I would
make a recommendation not to continue Somatic Charge Therapy in such clients. You must
switch over to other forms of treatment.
Issue of Negative Side Effects:
Any powerful forms of treatment can have associated negative side-effects. The somatic
charge therapy is not an exception. The expected side effects can be sensitization,
exacerbation of anxiety, disappointment, irritability, sleep disturbances and the like. I
would like to keep on cataloguing the side-effects as and when I notice them in my clients
or I get reports from other therapists.
Positive Side Effects:
Somatic Charge Therapy can produce a number of positive side effects in the clients. It can
boost their self-esteem, produce lasting relaxation, restore their confidence in the
treatment, improve social network, social relations, rekindle lost interests and hobbies,
cause dramatic improvement in occupational functioning, positive changes in life style,
increased optimism and much more.
The Concept of Generalization:
In conditioning theories, generalization is one of the important concept. I would like to
brief as many aspects of generalization as possible.
1. In stimulus generalization, an organism trained with one stimulus say CS1 emits
conditioned response to the stimulus which are similar e.g. CS2, CS3 to the trained
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stimulus. For example, a dog is trained to salivate in response to a red bulb. After
conditioning, if the dog salivates to pink bulb, then it would be considered as an
instance of stimulus generalization. In a classical experiment, an infant developed
phobia when a loud sound was produced in the presence of white rabbit. Because of
the phenomena of stimulus generalization, the infant began to show phobic
symptoms in response to white animals like dog, white clothes, white beard and the
like. The same response gets spreaded over to multiple stimulus situations. This
exactly happens in cases of phobia and OCD.
Non-applicability and Contra-indications:
Somatic Charge Therapy is unlikely to be useful in psychosis, organic disorders, mania,
disabilities, autistic disorders, epilepsy and other similar conditions. Its application need
be closely monitored in paranoid conditions. This list of conditions is open for additions.
1. Response Generalization: In response generalization, the same stimulus (CS1)
elicits more than one response say CR1, CR2,CR3CRn. A single somatic charge may
be associated with multiple affective and cognitive charges. An altered sensation in
heart region, may be associated with two or more affective charges and two or more
cognitive charges. The affective charge associated with abnormal sensations in heart
region may be anxiety and sadness. The associated cognitive charge may be ideas of
having heart disease, loosing grip over life, having pessimistic thoughts and so on.
The Concept of Channels:
While working with the somatic charges in a client, the concept of channels as elucidated
here would be immensely useful and would ensure optimum healing of emotional,
psychological and interpersonal issues of the client.
1. Suppose a client has following somatic charges:
a. Sensations in heart region
b. Back pain
c. Tightness in stomach
d. Burning eyes
e. Persistent headache
Each of these charges can be conceptualized as channels which may be independent
of each other or have interlinks to other charges. Whatever is the condition, a
therapist should have initial working concept that each of these channels is to be
processed sequentially.
2. Each of these channels of somatic charge may be associated with singular affective
and cognitive charge or have plural affective and cognitive charges associated with
them.
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3. The task of the therapist is to process the somatic charges one by one until
dissolution, stagnation, failure or substantial reduction. The primary aim is to
eliminate the somatic charge completely including residual somatic charge of 1-2%.
Because the reminiscent charge can get re-charged and may become prominent
once again. When a somatic charge is dissolved completely, it would be an instance
of cleaned channel and the therapist should switch over to other remaining charges.
The other conditions when a therapist should switch over to other charges are
stagnation i.e. no progress or failure in resolution.
4. As a single charge may have multiple associated affective and cognitive charges, the
therapist would continue to return back to the charge in hand until its clearance.
5. When first somatic charge is healed, then next charge is taken up in therapy and
continued until clearance of most or all channels.
Criteria for Termination of Somatic Charge Therapy:
Somatic Charge Therapy is a focused goal oriented, time limited and active form of
psychotherapy. The first criterion to terminate the therapy is resolution of most or all
somatic charges. The other condition would be of no benefit to the client within 3-5
sessions.
Stand alone or Combination Therapy:
In most cases I would recommend for a combination approach. The somatic charge therapy
should be combined with proper psychiatric treatment. It may also be combined with other
psychotherapeutic approaches. As far as possible, somatic charge therapy should be the
primary and only form of psychotherapy along with psychiatric medicines.
Science or Pseudoscience:
Somatic Charge Therapy should belong the sub-discipline of somatic psychology. Lots of
research data need be generated for SCT to firmly ground it in the science of psychology. I
consider Somatic Charge Therapy as an upcoming science or yet to be a science instead of
rejecting it as pseudoscience. An orthodox scientist may be tempted to discard SCT as noscience and if discarded in this manner, a powerful form of psychological intervention may
be lost in obscurity and causing a loss to the patients who otherwise can get substantial
benefits from SCT quickly.
Need for Training:
To me somatic charge therapy is crystal clear but it may not be a case with most readers of
this document. It may be overwhelming and unconvincing to some of them. I do provide
training in Somatic Charge Therapy. Any professional genuinely interested in rapid healing
of the patients can request for a training. The training would take only a few days, less than
one week in most cases.
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Who should practice somatic charge therapy?


I recommend that somatic charge therapy should ideally be practiced by qualified
psychologists and psychiatrists who have firm grounding in theories of psychoanalysis,
behavior therapy, learning theories, cognitive therapy, biofeedback, psychological
disorders and the field of clinical psychology as a whole.
Techniques of Resolution of Somatic Charge:
I am open to the application of any of the techniques of behavior therapy, cognitive
therapy, hypnotherapy and any other techniques of conventional and unconventional
therapies. The ultimate goal of the therapy is the resolution of somatic and other charges.
SCT provides a framework and an easy to understand and implement model for application
of various techniques. I shall be elaborating a few powerful techniques, some of which are
directly contributed by me to more or less extent. Many of these techniques have already
been tested in my applied clinical work, however, empirical data need be generated to
substantiate these techniques through scientific methods.
How to identify three charges:
1. Level-1: For detection of somatic charges, a therapist would ask the client to gently
close his eyes and be comfortable. Having done this, the therapist would suggest the
client to scan his body, mind and brain with his minds eyes for any heaviness,
strain, altered sensations and pain. If it is there on any of the body parts, then the
client is required to report the form of the somatic charge. The therapist clarifies the
nature and magnitude of the charge in as much details as required.
2. Level-II: Having detecting the somatic charge, a therapist explores the affective
charges associated with the somatic charge. A simple question, What
feelings/emotion is attached with the [name the detected somatic charge]? Many
client will report cognitive charge in response to this question. Help them by
explaining that anxiety, fear, anger, disgust, joy etc are the feelings/emotions. He
needs to identify the feelings/emotional terms for the affective charge associated
with the somatic charge.
3. Level-III: Having detecting the affective charge, a therapist then explores the
cognitive charge associated with the feeling/emotion by asking a simple question.
For example, if a client is anxious, then the therapist would ask, what makes you
anxious? What thoughts are crossing your mind while are you anxious? The client
will come up with a series of statements which will represent the cognitive charge.
Pass Criteria for Charge Resolution:
1. At least three scanning of the somatic charge should be done to ensure that the
charge has actually been resolved. A therapist should always remain open to the
possibility of re-activation and relapse in charges. The re-activation/relapse can be
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conveniently handled with the same techniques and procedures which were used to
resolve the charges originally. However, other techniques and procedures can also
be invoked depending upon the requirements of an individual case.
Cognitive Drill:
Cognitive drill is one of the most powerful procedures for resolution of somatic, affective
and cognitive charge which revolves around anxiety and fear. Cognitive drill should not be
applied in organic and psychotic conditions. For implementation of cognitive drill, a
therapist should first try to identify the somatic charge.

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PUBLISHED CASE STUDIES


Indian Journal of Clinical Psychology-2012

Preliminary Test of Cognitive Drill as an Intervention for


Obsessive Compulsive Disorder
Abstract
Exposure and response prevention (ERP) and cognitive behaviour therapy are the
first line and established treatment for persons with obsessive compulsive disorder
(OCD). While working with an adult with chronic OCD; we came up with a procedure
which we labelled as Cognitive Drill that yielded rapid and durable results which
were later extended to a series of cases for exploring its efficacy and maintenance of
outcomes. The sample consisted of five adult patients, selected according to lCD-10
diagnostic criteria for OCD. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was
used for baseline and post-treatment assessment. The intervention lasted for ten
sessions. At the end of ten sessions four patients showed significant reduction in
YBOCS measures, which were statistically significant indicating initial success of the
procedure.
Keywords: Obsessive compulsive disorder, cognitive drill, cognitive behaviour
therapy

Introduction
Obsession is characterized by recurrent and persistent thoughts, impulses, or images that
are experienced at some time during the disturbance, as intrusive and inappropriate and
that cause marked anxiety or distress. Compulsion is characterised by repetitive
behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting,
repeating words silently) that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly (American Psychiatric
Association, 2000).
Obsessive-Compulsive Disorder (OCD) is a common and chronic disorder with a waxing
and waning course having a lifetime prevalence of 23% in nearly every country for which
epidemiological data are available (Bland, Newman, & Orn, 1988; Horwath & Weissman,
2000; Karno, Golding, Sorenson, & Burnam, 1988; Robins et al., 1984; Sasson et al., 1997;
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Weissman et al., 1994). OCD has been recognized as the fourth most common psychiatric
conditions (Girishchandra & Khanna, 2001). In India it is more common in unmarried
males, persons coming from higher socio-economic class and with high intelligence (Ahuja,
2006).
Treatment of OCD typically involves the use of psycho-education, pharmacotherapy
especially serotonin reuptake inhibitors (SRIs), behaviour therapy and cognitive therapy
(Bandelow, 2008). If a patient partially responds to pharmacotherapy or cognitive behaviour
therapy alone; practice guidelines recommend adding the other one (American Psychiatric
Association, 2006). Patel and Simpson (2010) reported that

most participants chose combination

treatment (43%) or exposure and response prevention (42%) over SRI medication (16%).
The efficacy of exposure and response prevention (ERP); and cognitive behaviour therapy
in OCD has been well established. The patients who are not able to tolerate anxiety
produced by ERP may respond favourably to the cognitive techniques which rely mostly on
cognitive re-structuring with behavioural experiments designed to expose to the anxiety
provoking situations. Cognitive-behaviour therapy (CBT) has emerged as a promising
therapy for pure obsessions. According to March et al. (1997) when properly administered,
CBT/ERP is an efficacious treatment modality and can be considered as a first-line
treatment for some patients.
One of the authors (RK) while working with an adult with chronic OCD, landed up in a little
innovative procedure which we labelled as Cognitive Drill that produced rapid and
durable results. This procedure was then systematically applied to a series of cases of OCD
to generate preliminary data on its efficacy and maintenance of outcomes. The present
paper is an outcome of this attempt which presents comprehensive cognitive drill protocol
and results of its application in a series of five cases.

Method
Sample

The sample consisted of five patients with OCD (4 males, 1 female) in the age group 20 to
45 years (Mean= 30 years). All of them came from middle socio-economic status. They had
no comorbid psychiatric, neurological or medical illness. None of the patients had
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undergone any psychotherapeutic intervention for OCD prior to this study. The sample was
drawn from patients seen at V-care Clinic in Bhopal city in Madhya Pradesh, India. The five
cases had following salient problems: (1) A male obsessed with turning into a gay, (2) A
woman who kept cleaning, (3) A male with Compulsive Cleaning Rituals, (4) A male having
compulsive hand-washing, (5) A male who was scared of making mistakes
Case-1: A Male Obsessed with Turning into a Gay: PK, a 30 years old, postgraduate,
unmarried male, working as Clerk presented with the c/o feeling tensed, blasphemous
thoughts, difficulty in maintaining eye contact, mentally reviews his interactions for any
possible errors. The symptoms appeared about eight years ago when he was approached
by a male for homosexual act in a bus. He developed apprehensions that gradually he too
may turn into a homosexual person and he began to avoid bus journey. He once again saw
that person on a railway station and avoided him by exiting the station. He shared all these
feelings and experiences with one of his friend who did not keep it confidential and made it
public leading to embarrassment. Since then he did not reveal his feelings and turmoil to
any other person. Gradually, his problems got worsened and he kept on avoiding any
person who even slightly resembled to the homosexual person. He also began to avoid his
friends because they may come to know about his problems and think of him as
homosexual. He also began to avoid eye contact with others and felt uncomfortable and
anxious. He also started avoiding females. He had been somehow managing his problems
until two years back, but the intensity increased to the extent that he sought psychiatric
treatment. He is continuing medications since last two years. Y-BOCS was used to rate
baseline intensity and his score was 16. In the course of explorations he came up with
following thought patterns. People will think Im gay, my image will be ruined, many
people will come to know, marriage will become difficult, family will have a bad name, my
chest is becoming like a woman.
Case-2: A Woman who Kept Cleaning: Ms. AN; a 45 years old, postgraduate, married
female presented with compulsive washing of one month duration. In the past, she had
obsessional doubts of checking locks and gas which she had been managing by her own.
Also there is a history of depression characterized by anxiety, depressed mood, decreased
appetite, low confidence of one year duration. She also attempted suicide once. She is on
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regular psychiatric treatment since the onset of depression. The obsessions of dirt,
contamination and compulsive washing got added to the clinical picture about one month
back, which is consuming her lots of time and interferes in other domestic responsibilities.
Y-BOCS rating at baseline was 27. Upon exploration, she came up with following sequence
of thoughts. I cant touch toilet slipper--- Hands will get dirty--- Towel will get dirty--Everyone will use towel and their hands will get dirty--- Daughter will touch matchstick,
ghee and other things for doing pooja and everything related to God will get dirty and God
will punish me for all these contaminations. In the course of treatment, she revealed
another obsession that when she reads about an illness, she gets obsessed about
contracting it. This obsession was also successfully handled during the treatment.
Case-3: A Male with Compulsive Cleaning Rituals: Mr. A.M., a 30 years old male,
postgraduate, unmarried presented with c/o repeated hands washing, excessive time spent
in bathing and teeth brushing. His problems began in 2002 when his father committed
suicide. He secluded himself and would spend several hours on his own. He was found to be
muttering to self and his speech became irrelevant and incoherent. He was diagnosed as a
case of schizophrenia and received treatment from a psychiatrist. He showed significant
improvement with the treatment which continued for about six years. About one year back,
he developed cleaning rituals. His Y-BOCS score was 13.
Case-4: A Male having Compulsive Hand-Washing: Mr. VA, a 20 years old male, studying
in B.Sc. presented with compulsive hand-washing, lack of self-confidence, fear of pigs and
poor memory. A few years back, one of his friends had teasing commented and asked him
to clean thoroughly as a pig has touched him. He was maintaining well until one year back
when he failed in second year examination. He became anxious and apprehensive that he
may fail again and other symptoms like repeated hands washing and fear of pigs developed.
He would continue to wash his hands and get re-assurance from others that his hands are
clean. His baseline Y_BOCS score was 17.
Case-5: A Male who was Scared of Making Mistakes: Mr. MA, a 27 years old male,
studied up to 8th std. working as mechanic presented with c/o fear of doing wrong things
and repeated checking of doors. He was not able to provide a detailed account of onset and
circumstances of his illness. His baseline Y-BOCS score was 29.
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Tools:
Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used for assessment. The Y-BOCS is a
semi-structured interview which was developed by Goodman and colleagues (Goodman et
al., 1989). The scale ratings do not depend on specific types of symptoms (e.g. washing,
checking, counting) instead aspects of the symptoms such as duration, interference, degree
of resistance are rated The scale is divided into two parts having five questions in each part
(a) the Obsessions subscale (b) the Compulsions subscale. On each subscale five aspects of
pathology are rated on a scale ranging from 0 (no symptoms) to 4 (extreme symptoms): (1)
time spent, (2) degree of interference, (3) distress, (4) resistance, and (5) perceived control
over the symptom. Scores obtained from the subscales are summed to yield Y-BOCS Total
scores. The maximum possible score is 40. Higher is the score, greater is the severity of
psychopathology. A score of 0-7 is sub-clinical; 8-15 is mild; 1623 is moderate; 24-31 is
severe; and 32-40 is extreme (Federici et. al 2010). Y-BOCS is used extensively in research
and clinical practice to both determine severity of OCD and to monitor improvement during
treatment. Woody et. al. (1995) presented comprehensive data on reliability and validity of
Y-BOCS.
Procedure: To evaluate effectiveness of the cognitive drill on OCD patients, a Pre and Posttest design was used. Measurements were taken on YBOCS. Following the baseline
assessments each subject attended 10 therapy sessions. The duration of each session
ranged between 40 to 90 minutes. The intervention consisted of following treatment
components.
Cognitive Drill Protocol: The Cognitive Drill primarily consists of following components
which are executed in an average of 10 sessions.
1. Psycho-education: In psycho-education, a patient is educated regarding the nature of
obsessions, compulsions, neutralizing behaviours, the prevalence of OCD in general
population, treatment options, the prevalence of similar cognitions in general
population with an emphasis that merely the obsessive thoughts of an individual cannot
produce the feared outcomes in real life. The psycho-education uses a didactic format
with plenty of examples to dispute magical thinking and re-assure for feared
consequences. A patients initial agreement with the analogies provided by the
therapist is the cornerstone for further work. A patient not ready to agree with the
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explanations provided during this phase, is not expected to make further progress in
the model proposed here. Sufficient time is devoted to educate, clarify the
apprehensions and queries of the patient.
2. Initial Identification of Fear Producing Stimulus Events and Cognitions: The
characteristic anxiety provoking stimulus situations and cognitions that are associated
with obsessions and compulsions are identified and listed in a hierarchical manner.
Usually, a patient comes up with multiple anxiety provoking stimulus events and
cognitions. A detailed list of such objects and situations is prepared. A patient is also
assigned the home work of maintaining a diary of the events that elicit an OCD response
and the characteristic cognitions associated with the stimulus. If a patient finds it
difficult to understand or partition the stimulus, cognitions in homework, then he/she
is asked to simply write a narrative of his/her OCD behaviours.
3. Conversion of Linguistic Pattern: The anxious cognition mostly expresses itself in
future perspective; the crucial component of this protocol is conversion of this future
perspective into a past or a present one. For example, I will become a gay (future tense)
converted into, I have become a gay (past tense) or I am a gay. This cognitive drill
protocol may not be suitable for the patients with maladaptive cognition either in the
present or the past perspective. For example a person who already has a belief that he
is a gay may not respond to this procedure. To be effective, the diary and the clinical
assessment should clearly indicate a future reference in the thinking of the patient.
4. Cognitive Drill: To begin with, a stimulus or a thought is identified for commencing
this component. This item should be of low to moderate anxiety provoking potentials.
High items are not taken in the beginning. In this procedure, an identified anxiety
producing idea is repeated verbally, in writing or covertly in bulk for a short period of
time may be for 5-10 minutes; and again resumed after a gap of a few minutes and
continued in this manner for about one hour session. The drill for an anxiety producing
idea continues until it ceases to evoke anxiety response on three consecutive drill of
about one minute in a session. In cognitive drill, a patient is encouraged to verbally
repeat the converted statement in slow manner continuously for a few minutes guided
by the subjective report of discomforts sought intermittently by the therapist. Initially, a
patient may not be able to verbalise and repeat the converted statements because of
anxiety provoking property of such a statement. In such cases, a therapist needs to
model and speak to the patient for a few times and encourages the patient to verbalise
simultaneously and then enables the patient to take up the lead of repetitions. For
example, a patient who was obsessed with the word ruin came with following
cognition my family may be ruined. This cognition was converted into the following
my family is ruined. Initially, he refused to repeat this converted statement. Then the
therapist (RK) modelled and repeated this idea verbally before the patient with an
instruction that he should just listen to it. After sometime, the patient accepted the drill
101

and commenced to repeat the idea. He was required to keep on repeating my family is
ruined; my family is ruined and the therapist regulated the drill based upon
subjective reports of discomfort (SRD). When there was significant reduction of anxiety
in response to one idea; the next anxiety producing idea was processed through the
cognitive drill in the similar manner. In the course of the drill, a patient comes up with
multiple anxiety producing ideas which need be repeated as per the protocol. The drill
to a beginner may appear to be counter-therapeutic with an apprehension that it itself
may convert an apprehension into a belief system. We too had the same apprehension
which did not hold empirically as demonstrated by its application in several cases.
Cognitive drill does not convert an apprehension into a belief system.
5. Subjective Reports of Discomfort (SRD): This is an essential real time within session
subjective assessment of the anxiety levels of the patient in response to the cognitive
drill; which guides a therapist for continuation or amendment of the cognitive drill
within a session. A client is intermittently asked to report the magnitude of discomforts
in any quantifiable format which could be a visual analogue scale of 0-10 points, a
simple report on a three point scale: Low-> Medium-> High or any other system which
can communicate the gradations of subjective discomfort to the therapist quickly. A
query regarding level of anxiety is raised about every alternate minute when a patient
repeats the anxiety producing idea. He/she is asked what the level of anxiety is. A clear
pattern of initial rise and then decline in anxiety level can be seen within a few minutes.
The anxiety response usually follows this pattern: Low-> Medium-> High -> Plateau of
about 1-2 minutes -> Medium and finally -> Low or resolution. Then a gap of a few
minutes is allowed and then the same idea is processed once again. A therapist
continues the application of the drill until the evoked anxiety falls to the low level or
there is a resolution. Also if there is a prolonged plateau of the anxiety level, a break is
allowed for about five minutes and then resumed either with the same idea or with a
different idea. In case of hanging of anxiety at high levels, a therapist enquires about any
other idea or images in the mind of the patient to which such a response can be
attributed. The application of cognitive drill for an idea with a trend of rise and fall of
anxiety takes about 5-10 minutes.
A pattern of thought stream away from the target converted statement can be observed
during the SRD. This is an indication of positive change. Also if there is an initial rise in
anxiety in response to commencement of cognitive drill, it is considered as an initial
indication that cognitive drill has a potential for arousing emotions associated with the
problems; and the cognitive drill can possibly produce therapeutic gains.
6. Change of Cognitive Drill Statements: Upon dissociation of anxiety from one
statement which is indicated by SRD; another statement is picked up and continued as
per the procedure stated above. Most major cognitions and stimulus events are handled
in this manner.
102

7. Homework: A patient is assigned a home work of continuing to perform the drill by


writing on a piece of paper; sub-vocally repeating the converted statements for one
hour or more per day in between sessions.
8. Other Considerations: We advise the clients to continue to perform the drill even after
termination of therapy sessions, to present for follow up sessions initially weekly, then
fortnightly, monthly, six monthly and so on. We also emphasize the need for continued
medication as this model utilizes the power of combination treatment. At times, a client
may report empowerment and generalization effects over other anxiety related
problems. Relapse prevention through follow up and maintenance medication are
highly recommended.

Results
The YBOCS scores of each case are depicted in Figure 1 which reveals that except Case
No.3, all cases showed substantial reduction in the scores on post-test. Case Nos. 2 and 5
had very high baseline scores and both of them showed greatest decline in the scores on
post-test. For quantitative analysis of the pre-test and post-test scores, Wilcoxon Signed
Ranks Test was conducted. The results are presented in Table 1. The analysis indicated a
statistically significant change in the scores over post-test.
The reports on patients behavioural status were cross checked with the relatives and
informants. Follow up were conducted after three months of the therapy which did not
reveal deterioration in the condition.
Pre-test Scores

35

Post-test Scores

30

YBOCS scores

25
20
15
10
5
0

3
4
5
Cas
Figure1. YBOCS Pre-test and post-test scores of each
Table 1. YBOCS Scores: Mean, SD and Z value and level of significance
Conditions

Mean

SD

Z value

Asymp. Sig.

103

Pre-Test

20.4

7.12

Post-Test

11.0

2.0

-2.023

.05

Discussion
The present study was designed to gather systematic preliminary evidence for the efficacy
of Cognitive Drill in OCD. The results do indicate a substantial positive gain as a result of
about 10 sessions of cognitive drill protocol. The study has methodological flaws. The
sample size is very small and the therapist and evaluator was the same person, there may
have been biases in the ratings on two occasions. Follow assessments were not collected.
The results of this study need be construed in the light of these limitations. No one to one
comparison could be made with existing literature because of novelty of the procedure.
This procedure does not involve any theoretical innovation; instead it is an instance of the
application of existing theoretical frameworks to combat anxiety response in persons with
OCD. Ideally, the procedure should be developed based upon the established theoretical
frameworks, but here the application came first which we are trying to link to the existing
theoretical frameworks; an exercise which is open to further refinements. We are trying to
understand and explore its theoretical links with the existing knowledge in diverse fields.
Cognitive drill can be contrasted with existing procedure which possibly have shared
theoretical basis. In Covert Extinction, a patient is required to imagine a target behaviour
occurring in the absence of a reinforcer. It is a covert procedure as contrasted to the
cognitive drill which is an overt procedure in which a patient is required to repeatedly
express his fear evoking cognitions.
Cognitive drill is more akin to exposure in which a patient is required to repeatedly express
his/her imagined consequences; and refrains from engaging in neutralizing or avoidance
behaviour. Cognitive drill belongs to the family of desensitization procedures. The
dictionary meaning of desensitization is to render insensitive or less sensitive.
Desensitization is the process through which a previously learned response is weakened. In
desensitization, an emotional response is repeatedly evoked, through which an action
tendency that is associated with it proves irrelevant or unnecessary. Many individuals with
OCD are afraid that something terrible may happen, if they fail to perform their ritual or
104

neutralizing act. In exposure and response prevention procedure, a patient is exposed to


his/her obsessions and feared consequences coupled with not engaging in the compulsive
or neutralizing act. Cognitive drill also exposes a patient to his/her feared consequences
albeit in a little different way by making a tweak in the linguistic pattern and expressions in
bulk. This procedure can seamlessly be integrated within an exposure and response
prevention protocol; which can possibly accelerate the progress; at least our anecdotal
observations are indicative of that which can be explored through systematic researches.
The simplest explanation seems to be that of a habituation procedure. As a procedure,
habituation is defined as the repeated presentation of an eliciting stimulus that may result
in the decline of the elicited behaviour (the process of habituation), an increase of the
elicited behaviour (the process of sensitization), or an initial increase followed by a decline
of the elicited behaviour (a sensitization process followed by a habituation process)
(Domjan, 2010).
Since we are making a little linguistic tweaks in the application of this procedure, we
thought that the existing linguistic pattern of future frame of reference and the tweaked
frame of reference past or present frame of reference might have different neural
correlates leading to the activation of different pathways. With this idea, we Googled
relevant key words and came up with some relevant studies. The studies are from different
fields but are being quoted to underline the concept of different neural correlates of verbs.
Damasio and Tranel (1993) suggested the involvement of left frontal convexity in the case
of verbs. A PET study revealed that left hemispheric areas, including the dorsolateral
frontal and lateral temporal cortex, were activated only by verbs (Perani et al. 1999). The
researchers have also hypothesized beyond it and suggested different neural correlates of
different kind of verbs. According to Bushell and Martin (1997) the action verbs are
processed in brain regions involved in motor function, such as the frontal lobe, other verb
categories, such as abstract verbs related to psychological functions, may involve different
neurological substrates. In a similar vain, there could be different neural correlates for past,
present and future frame of reference.

105

Anxiety is "a future-oriented mood state in which one is ready or prepared to attempt to
cope with upcoming negative events" (Barlow, 2002). Hence, a person with anxiety disorders
including OCD is usually troubled by a predominant future perspective. The conversion of
this future perspective into the present or past may modify the neural pathways and land
on different centers not connected to the anxiety response leading to faster habituation.
More methodologically sound studies are required to establish the efficacy of Cognitive
Drill

protocol,

cataloguing

indications

and

contra-indications,

durability

and

generalizability of the acquired therapeutic gains and its theoretical basis. The preliminary
evidence of a simple Cognitive Drill protocol are encouraging in producing rapid
therapeutic benefits in persons with OCD..
Declaration
This work was carried out as a part of dissertation for a postgraduate program in clinical
psychology in Barkatullah University, Bhopal by Ahmed Sameer in 2009 which was
supervised by last two authors.

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..

SIS Journal of Projective Psychology and Mental Health-2015


Efficacy of Cognitive Drill Therapy in Agoraphobia with Panic Disorder: a Case Study
Satyadhar Dwivedi and Rakesh Kumar
This case demonstrates the role of cognitive drill therapy in the treatment of

panic disorder with

agoraphobia. A 52-year-old female patient presented with eight years H/O panic disorder with agoraphobia.
The Body Sensations Questionnaire, Agoraphobic Cognitions Questionnaire, Mobility Inventory, Generalized
Anxiety Disorder scale and Beck Depression Inventory were administered at baseline and follow ups..
Cognitive drill therapy was administered in 10 sessions. She continued pharmacological treatment as usual.
The periodic assessments including follow ups indicated substantial change and clinically significant
improvement in her condition which is being maintained even at six months follow up and thereafter.
Keywords: Panic disorder, agoraphobia, cognitive drill therapy, Psychotherapy

107

Initially called agoraphobia with panic attacks (American Psychiatric Association, 1980),
and later renamed panic disorder with or without agoraphobia (American Psychiatric
Association, 1987, 1994, 2004), is one of the most cited anxiety disorders due to its high
rate of lifetime prevalence (about 5.1% of adults; Bienvenu, 2006). Panic disorder is
characterized by its resistance to spontaneous remission, its co-morbidity with other
disorders (e.g., depression, alcohol or substance disorders), and the decrease in quality of
life. Additionally, panic disorder can have serious social and economic consequences, since
a large number of individuals with panic disorder suffer difficulty in maintaining their
social relationship andmost of them have to leave their work (Klerman et al., 1991; Mitte,
2005; Tsao, et.al, 2005).
In order to be diagnosed with panic disorder a patient must have suffered recurrent and
unexpected panic attacks over a minimum period of a month, followed by persistent
concern about having additional attacks. Panic attacks are commonly accompanied by
uncontrollable fear, worry about the implications of the attacks (e.g., losing control, having
a heart attack), or a significant change in behavior relating to these symptoms.
Furthermore, the attacks are not due to the direct effects of substance abuse or to a medical
condition, and they cannot be explained by the presence of another mental illness. On the
other hand, panic attacks often come together with agoraphobia, that is, an uncontrollable
fear of having a panic attack in a setting from which it may be difficult to escape or receive
help. About one in three people with panic disorder develops agoraphobia, but
agoraphobia without a history of panic attacks is rare, with a lifetime prevalence of about
0.17% (Bienvenu, 2006).
Cognitive Drill Therapy:
This therapeutic technique was originally developed by Kumar, et. al.(2012). Cognitive drill
therapy is very effective to deal with stimulus bond anxiety. The therapist tries to change
patients future orientation to past or present orientation at cognitive level. For example, a
patient has fear of travel in train and gets panic attack. In this situation the therapist
would ask the patient to repeat statements like I am travelling in train; I have got the panic
attack. She is required to repeat such statements continuously until significant reduction
in anxiety level, which usually takes 2-5 minutes. The therapist identifies the situations and
events which elicit the anxiety response and prescribe the drill in similar manner. This
therapy uses the principles of cognitive exposure, Pavlovian conditioning and a change in
linguistic pattern.
The application of cognitive drill has yielded promising results in patients with OCD
(Kumar et al, 2012). The therapy is useful in patients who have stimulus bound anxiety,
specifically when exposure of the anxiety related cues in imagination elicits an anxiety
response. The therapy has yielded promising results in conditions like examination anxiety,
108

specific phobia, social phobia, obsessions, compulsions and health related anxiety. The case
study has illustrated the effectiveness of Cognitive Drill Therapy in a case of chronic panic
disorder with agoraphobia.
Case Summary:
SK a 52 years old female was diagnosed a case of Agoraphobia with Panic Disorder as per
ICD- 10. She was experiencing panic attacks 2-3 times ina week characterized by fainting
spells, difficulty in breathing, palpitations, sweating, tachycardia, choking sensations and
felt as if she would die since last 8 years. This led to multiple emergency hospitalizations
and cardiac investigations, but all the investigations were normal. During panic attack she
used to scold her family members and could not attend routine work. She avoided going to
public places, travelling in trains, and stopped driving scooter because of fear of getting
panic attacks. However, she kept visiting selected places with her husband with confidants.
During such visits, she would keep tracking the location of hospitals so that she can get
hospitalized immediately in the event of panic symptoms. She resigned her teaching job in
a reputed public school and remained mostly at her home.She needed presence of someone
while using bathrooms. She also had secondary depression characterized by sad mood, lost
of interest in pleasurable activities, weeping spells, hopelessness and helplessness. During
the course of illness she lost interest in her hobbies like gardening, going for outing and
entertaining children.
She did not follow psychiatric treatment regularly and never sought psychotherapy for her
psychiatric problems. When she approached for psychological treatment, she was
recommended to consult a psychiatrist prior to administration of psychotherapy. She
returned back for psychotherapy after about three months with little improvement in her
psychiatric condition.
Assessment:
She was administered the following tools initially with multiple repeat assessments.
1. Body Sensations Questionnaire (Chambless, Caputo, Bright & Gallagher, 1984)
2. Agoraphobic Cognitions Questionnaire (Chambless et al., 1984)
3. Mobility Inventory (Chambless, Caputo, Jasin, Gracely and Williams, 1985)
4. Generalized Anxiety Disorder Scale(Spitzer, Kroenke, Williams, Lowe, 2006)
5. Beck Depression Inventory(Beck at al., 1969).
Body Sensation Questionnaire (BSQ) measures various sensations in the body like
palpitation, sweating, breathing difficulties etc seen during panic disorder. She had
elevated levels of body sensations. Agoraphobic Cognition Questionnaire (ACQ) revealed
that she had following prominent cognitions I am going to throw up, I must have a brain
tumour, I will have a heart attack, etc. Mobility Inventory (MI) suggested extreme
restrictions in her mobility outside home. She scored very high on Generalized Anxiety
109

Disorder Scale (GADS). Beck Depression Inventory (BDI) score was 42 suggestive of
marked depression.
Case Formulation:
We formulated the primary problems of the patient according to the concepts and relevant
theories of cognitive drill therapy which is summarized below:
1. Her anxiety was conceptualized as respondent behavior elicited by a range of
external cues like open places, crowded places, travel by train and internal cues like
increased respiration, sensations in cardiac region, words, images and thoughts
related to panic attack.
2. She avoided anxiety provoking situations which resulted in negative reinforcement
and maintained her avoidance of external situations which could potentially activate
panic attack. Besides, avoidance at overt level, she also had avoidance at cognitive
level. She avoided considering encounters with potentially anxiety provoking
situations even at covert level.
3. The external and internal cues elicited anxiety response (classical conditioning) and
avoidance of such anxiety provoking situations at cognitive and behavioral level
resulted in anxiety reduction which served to maintain the anxiety response
(Operant Conditioning).
4. During anxiety, a person holds a future perspective at cognitive level which gets
reflected in the language of the patients which consists of frequent use of future
tense. For instance, I may have heart attack, I am going to die, I will not survive,
what will happen if I get a heart attack, palpitations means I am going to have a
heart attack.
5. It is hypothesized that this future perspective may have its specific neurobiological
correlates. When a person turns towards this future orientation, the related
neurobiological processes get activated which maintain the anxiety response.
6. The depressive condition was hypothesized to be secondary to phobic and anxiety
symptoms.
Application of Cognitive Drill Therapy:
Following components of Cognitive Drill Therapy (CDT) were implemented.
Psycho-education:
Psycho-education regarding illness is the core foundation of the application of CDT. She
was explained that she is having Agoraphobia with Panic Disorder and Secondary
Depression. The symptoms of these conditions were enumerated and explained. These
conditions are recognized as psychiatric disorders of which she was not aware of.The case
formulation was also explained to her in her own language. The process of treatment was
also explained to her. It was told to her that she is trying to manage her anxiety and phobic
110

symptoms by avoiding them. The avoidance results in temporary relief which acts as
reinforcement instead of improvement. Instead of avoidance, she required to expose
herself to anxiety provoking situations. This exposure would initially boost the anxiety
response and in the process would get reduced. She was also explained the concept of
cognitive exposure. It was told that during the initial phase of treatment it is not necessary
to expose her to actual anxiety provoking events and situations. This can be done at
cognitive/imaginative level. The concept of excessive use of future perspective during
anxiety activation was also explained. She was told that she would be trained to expose
herself to anxiety provoking situations at cognitive level and integrated the tweak of future
perspective into past or present perspective. Appropriate examples were used to clarify the
concepts and applications of CDT. She was asked to continue her psychiatric treatment.
Identification of Anxiety Cues:
With the help of the patient a number of internal and external anxiety cues were identified.
The list was updated as and when additional cues became apparent in the course of the
treatment. Some of the cues are listed such as: thoughts related to death by cancer; deaths
of family members, travelling in train/metro; visiting multi-storey buildings; elevators;
market place; thoughts of heart attack; thoughts of being alone in the home; crowded
places etc.
Cognitive Drill:
In cognitive drill, specific thoughts and images were identified, converted into past/present
tense and she was required to verbally repeat the converted statements in bulk until
anxiety reduction which usually takes about 2-5 minutes.The cognitive drill was applied
initially for mild anxiety cues, then to moderate and finally severe anxiety provoking cues.
For example, I have died of heart attack; family members have died; I got stuck in metro
and no help is available and so on.
Behavioural Tests:
Upon significant reduction in anxiety during cognitive drill, she was told to expose herself
to the real life anxiety provoking situations to which drill has been applied to test whether
the real life situations still elicit anxiety response. If it did so, then she was recommended to
repeat the cognitive drill for such cues. Usually, the application of drill reduces/eliminates
anxiety response to many real life situations.
Home-Work:
She was asked to consider our sessions as training sessions. Learn the procedure of
cognitive drill therapy and apply the same concepts when you are out of therapy sessions.
Specifically, she was told to recognize anxiety cues and practice cognitive drill.
Sessions Details:
111

Ten sessions were conducted each lasted from one to two hours. In the sessions, she was
required to perform drill on the identified anxiety cues. Her husband was also allowed to
remain present during the sessions. The active therapy sessions were conducted in three
blocks. Four daily sessions were conducted in second week of July 2014. Again two
sessions were conducted in the last week of July 2014. After a gap of about four months,
three more sessions were conducted in November 2014. Periodic follow ups were done on
telephone and she was asked to submit the filled up scales.
Results:
Total four formal assessments were done on the listed scales. (1) Baseline on 7th July 2014
(2) Second assessment on 23rd July 2014 (3) Third assessment on 21st August 2014 (4) Last
Assessment on 25th December 2014. The results are depicted in following figures.
Figure-1: Agoraphobic Cognition Questionnaire
60
40

20
0
BaselinePost Asessment
Follow up-1Follow up-2

Figure-1 displays the scores on Agoraphobic Cognition Questionnaire on baseline and


follow ups. The questionnaire has 15 items which are rated on five point scale where 1
means thought never occurred and 5 means thought always occurs. The maximum possible
score is 75 and minimum score is 15. On baseline she scored 58 which got reduced to 20 on
last follow up indicating a highly significant improvement in her agoraphobic cognitions.

Figure-2: Body Sensation Questionnaire


60
40
20
0

112

Figure-2 displays scores on body sensations questionnaire on baseline and follow up. It
consists of 18 items rated on five point scale where 1 means not at all, and 5 means
extremely frightened by the sensations. Maximum possible score is 90 and minimum score
is 18. On baseline she scored 60 and on last follow up her score was 22 indicating a
significant improvement in her reactions to body sensations.
Figure-3: Beck Depression Inventory-II
60
40
20
0
Baseline

Post
Follow up- Follow upAsessment
1
2

Figure-3 displays scores on Beck Depression Inventory. It consists of 21 items which are
rated on four point scale ranging from zero to three. On baseline she scored 46 and on last
follow up she scored 11 indicated highly significant improvements in her depression.
Figure-4: GAD Scale
25
20
15
10
5
0

Figure-4 displays scores on GAD Scale on baseline and follow ups. It consists of 7 items
rated on four point scale ranging from zero to three. 0 means not at all sure and 3 means
nearly every day. Maximum possible score is 21 and minimum possible score is zero. On
baseline
she
scored
21
which
got
Figure-5: Mobility Inventory - When Accompanied
reduced to 02 on
last
follow up.
100
50
0
Baseline

Post
Follow up- Follow upAsessment
1
2

113

Figure-5 displays scores on Mobility Inventory - When Accompanied on baseline and follow
up. It consists of 28 items rated on five point scale where 1 indicates never avoid, and 5
indicates always avoid the situation. Maximum possible score is 140 and minimum score is
28. On baseline she scored 90 and on last follow up her score was 31 indicating a
significant improvement in her mobility in different situation.

Figure-6: Mobility Inventory - When Alone


150
100
50
0
Baseline

Post
Follow up- Follow upAsessment
1
2

Figure-6 displays scores on Mobility Inventory - When Alone on baseline and follow up. It
consists of 28 items rated on five point scale where 1 indicates never avoid, and 5 indicates
always avoid the situation. Maximum possible score is 140 and minimum score is 28. On
baseline she scored 122 and on last follow up her score was 44 indicating a significant
improvement in her mobility in different situation.
Discussion:
The application of Cognitive Drill Therapy produced substantial and clinically significant
changes in her anxiety, agoraphobic cognition, body sensations, depression and mobility
which were maintained on follow ups. She also showed meaningful improvement in her
social relations, affect, self-efficacy, engagement in household work, going away from home
even without accompanying person, shopping etc although these aspects were not
measured formally.
Cognitive drill uses principles of exposure therapy (Vincelli, 1999; Vincelli, et. al. 2000).
The repeated exposure at cognitive and verbal level causes extinction and habituation of
acquired anxiety response (Watson & Rayner, 1920; Lovibond, 2004 p. 495). The words
and images of anxiety cues elicited anxiety in her; and when exposed repeatedly to those
words and images at cognitive and verbal level, it had expected effects of extinction and
habituation. The exposure to anxiety cues also results in enhancement of self-efficacy
114

(Bandura et al,1975). The cognitive drill being based on exposure also enhances selfefficacy and other faulty cognitions which are also observed in this patient.
One of the hypotheses invoked in Cognitive Drill Therapy relates to the neurobiological
correlates of linguistic aspects particularly verbs. That, each tense, present, past and future
have their own distinct neurobiological correlates (Ullman, 2008; Pinker & Ullman, 2002;
Bickerton 1990; Lightfoot, 1991; Chomsky, 2005). The anxious state has a predominantly
future perspective. The conversion of this perspective into past or present at cognitive level
somehow modifies the future perspective and calms down anxiety response to conditioned
stimuli. The testing of this hypothesis would require highly sophisticated and advanced
researches involving live scanning of brain during verbs usage. May be future studies at
some point of time may take up and consider the hypothesis. Empirically, in clinical
settings, it is a common observation that a relief in anxiety through any modality shifts the
future perspective of the patient into the present one.
It is observed that when there is an extinction of anxiety response to the anxiety cues at
verbal and imagination level, there is an automatic generalization to the real world cues in
most of the instances. This patient when exposed to anxiety cues at cognitive and verbal
level, showed minimal or no anxiety to the real world situations. If still a cue produces
anxiety after drill, then drill was repeated and this reduced the anxiety. This cross modality
generalization is extremely useful for the purposes of therapy, economic in terms of pain
experienced during live exposure vis--vis cognitive and verbal exposure, quite faster in
resolution of anxiety.
In exposure treatment, many patients drop out because of the pain and suffering
experienced during live exposure sessions (Michele et al, 2008). The cognitive and verbal
exposure is not that much overwhelming and may have a value in decreasing attrition rates
in psychotherapy. The studies need to be conducted to compare the rates of drop outs in
live exposure therapies and cognitive exposure therapies.
Relapse prevention is one of the primary concerns in the treatment of psychiatric disorders
(WHO,2004). Cognitive drill seems to have an inbuilt component of relapse prevention.
Because during the course of treatment, a patient learns to identify anxiety cues, formulate
drill statements and perform cognitive drill on the fly. Through the intensive treatment it
becomes an integral part of coping with the anxiety provoking situations. She also reported
that as and when she finds herself in any anxiety provoking situations, she detects her
sensations and anxious cognitions and immediately performs the drill. The patient is
required to learn only a few concepts and skills which enable him/her to effectively deal
with the anxiety provoking situations.
Conclusion:

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The case study demonstrates how time efficient and intensive cognitive drill therapy can be
applied in such patients. A clinically significant improvement could be achieved in the
relatively short time of two weeks and the gains/improvements of therapy were
maintained at 6-month follow-up.
The Cognitive Drill Therapy seems to have produced clinically significant results in indexed
patient of agoraphobia with panic disorder. To establish a functional relationship between
this modality of treatment and outcomes in patients of anxiety disorder, large scale,
randomized controlled trials would be required.
Controlled studies comparing cognitive drill therapy and cognitive behaviour therapy in
panic disorder with agoraphobia could help to understand the specific procedural and
process-based aspects that help making this kind of treatment so effective.
References:
American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.).
Washington, DC: Author.
American Psychiatric Association.(1987). Diagnostic and Statistical Manual of Mental Disorders (3rd Ed.,
Rev.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th Ed.).
Washington, DC.
Beck, A., Steer, R., & Brown G. (1996). BDI-II: The Beck Depression Inventory. The Psychological
Corporation Second edition.
Bickerton, D. (1990). Language and Species. Chicago, IL: University of Chicago Press.
Chambless, D. L., Caputo, G. C., Bright, P. and Gallagher, R. (1984).Assessment of fear of fear in
agoraphobics.The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire.
Journal of Consulting and Clinical Psychology, 52, 10901097.
Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracely, E. J. and Williams, C. (1985). The Mobility Inventory for
agoraphobia. Behaviour Research and Therapy, 23, 3544.
Chomsky,N. (2005). Three factors in language design. Linguistic Inquiry.Clinical Protocol. 36, 122.
Deacon, B. and Abramowitz, J. (2006). A pilot study of two-day cognitive-behavioural therapy for panic
disorder. Behaviour Research and Therapy, 44, 807817.
Ehlers, A., Margraf, J., Chambless, D. L. (1993). FragebogenzukorperbezogenenAngsten,Kognitionen und
Vermeidung (AKV) mit den Skalen BSQ, ACQ und MI. Weinheim: Beltz.
Foa, E. B., Jameson, J. S., Turner, R. M. and Payne, L. L. (1980).Massed vs. spaced exposure sessions in the
treatment of agoraphobia. Behaviour Research and Therapy, 18, 333338.
Kumar.R.,Sameer.A., Singh.B. (2012). Preliminary Test of Cognitive Drill as an Intervention.Indian J.Clini.
Psych., 39, 67-74.
Lightfoot, D. (1991).Subjacency and sex.Language and Communication 11, 67 69.
Lovibond, P.F. (2004)Cognitive processes in extinction. Learning and Memory. 11:495500.

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Mathews, A.M., Gelder, M. G. and Johnston, D.W. (1981). Agoraphobia: nature and treatment. New York:
Guilford Press.
Michele, A., Schottenbauer, C.R., Glass, D. B., Arnkoff, V.T. and Sheila, H. Gra.(2008) Nonresponse and Dropout
Rates in Outcome Studies on PTSD: Review and Methodological Considerations. Psychiatry 71(2)
134-168.
Pinker, S., Ullman, M. T.( 2002).aThe past-tense debate: The past and future of the past tense. Trends in
Cognitive Sciences 6, 456463.
Ullman, M. T. (2008). Variability and redundancy in the neurocognition of language. Paper presented at the
DGfS workshop on Foundations of Language Comparison: Human Universals as Constraints on
Language Diversity, Bamberg, Germany. Universitat Bamberg, 2729
Vincelli,

F.
(1999).From
imagination
to
virtual
Psychology.CyberPsychology&Behavior 2(3):241 248.

reality.The

future

of

Clinical

Vincelli, F., Molinari, E., Wiederhold, B.K. , Riva, G.(2000) Cyberpsychology&Behavior ,3,
Watson, J.B., Rayner, R.(1920)Conditioned emotional reactions. Journal of Experimental Psychology. 3:134.
World Health Organization.(2004). Prevention of Mental Disorders.Effective interventions and policy
options.Summary report.Jeneva,
..
SatyadharDwivedi, M.Phil (Cl. Psy.) Asst. Professor, Rakesh Kumar, Head, Department of Clinical
Psychology, Institute of Mental Health and Hospital, Agra -282002 (India) Email: jain.imhh@gmail.com
..

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Updates
A session of Cognitive Drill Therapy on 25 November 2015:
1.
2.
3.

4.
5.
6.
7.
8.
9.

10.
11.
12.
13.

Background: Opposed an illegal construction by influential and rich people of a


temple in a public park
Surface Structure: When exposed to that park and construction, it leads to anxiety,
worries and irritability
Underlying fear structure consists of (a) fear of getting dominated by these people
(b) He has support of his father, but he is ill. In case of father's death he will lose
support and those people can dominate.
Somatic charge in head and heart region.
Cognitive Drill "me akela pad chuka hun, wo hawi ho chuke hn"
Anxiety is rising during cognitive drill. Still continuing drill with pauses.
Instructions: Continue drill and allow stream of consciousness to flow naturally
without holding it and no mental avoidance.
Cognitive Drill is continuing. Now feeling relief.
Anxiety and obvious distress reduced to 50% as per subjective report. Objective
observations of facial expressions, diversions and expressions of distress also
showing a declining pattern of anxiety.
Cognitive drill is continuing.
SUD reduced by 70%.
SUD: almost reduced.
Session terminated. Session duration: 60 minutes.

Cognitive Model of OCD:

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CDT for Specific Phobia of Dog:


An older adult presented with 38 years h/o specific phobia developed after dog bite in
early childhood. He even reared a dog to overcome his phobia but the phobic reaction and
avoidance still persisted.
A brief Cognitive Drill Assessment revealed following conditioned stimuli in the surface
structure (1) street dog (2) group of dogs (3) proximity to street dog (4) crossing the roads
where street dogs are present (5) diseased dog etc. The underlying fear structure
(imagined feared consequences) was characterized by (1) fear of dog bite (2) helplessness
if dog bites (3) loneliness (3) not able to defend oneself (4) not able to hit the dog if it bites
etc.
A single session Cognitive Drill Therapy was conducted for one hour in which hr was
required to imagine himself near dogs and repeatedly verbalize as if each of above
consequence has occurred. He performed the drill. During the drill typical bell shaped
anxiety curves were noticed as per SUDs. Within the session, significant reduction in
anxiety was observed. He no longer felt anxiety upon imaginal and verbal exposure of dogs.
He is prescribed drill and daring in real life situations.
Single session of CDT for Contamination OCD:
An adult female presented with more than 20 years h/o contamination OCD characterized
by distress, anxiety, fear and irritability coupled with nausea feelings for contamination in
toilets. She keeps her bathroom spotless which is a cause of concern because of time
consumed in cleaning and issues with husband and children regarding maintenance of
cleanliness. She would ensure clean toilets. Due to the concern over cleanliness, she finds it
extremely difficult to use public toilets or toilets of other houses. She would hold herself
from using others' toilets as far as possible. She uses specs. While using others' toilets she
would either remove specs or would not switch on the lights to avoid noticing any spots,
site of hairs, shit and wet soaps. Also, she would try to distract herself from the mental
images of contamination or try to eliminate those images from awareness.
In her teen age, she had to use extremely dirty public toilet which precipitated her problem.
Also she was in NCC and did a course in mountaineering where she got exposed to dirty
places.
Quick Cognitive Drill Assessment revealed following fear structure (imagined feared
consequences)
1. She would not be able to eat.
2. Hairs could come into food items

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3. The mental images of shit would dominate her mind and she would not get rid of them
4. She would feel nausea.
She was given psychoeducation that she has been avoiding the contaminated objects of
surface structure. She never worked on underlying fear structure. The fear structure is
responsible for continuation of her problems. If she works on the underlying fear structure
then the contaminated objects will cease to elicit the problematic reactions.
Cognitive Drill Therapy was applied on her in which she was asked to form mental images
of shit and repeatedly verbalize feared consequences in past or present time reference.
Initially she felt visibly anxious, defensive, hesitant and tried to avoid mental images of
contamination. The drill continued with pauses for 30-90 seconds as and when the SUDs
were medium to high. After 20 minutes of the application of Cognitive Drill her reactions
significantly subsided to imaginal and verbal exposure. She was then taken to others toilet
as a behavioural test. She did not feel anxious however, because of the fear of anxiety
activation she took 2-3 minutes to come near the gate of the toilet. She was not forced into
this exposure. She felt comfortable to stand near the gate of the toilet.
After one hour of this application she comfortably took her lunch even when the bathroom
door was open within her vision.
Any practicing psychologist can conveniently learn CDT and add it to her skills.
Zero contingency procedure
In this procedure, the CS is paired with the US, but the US also occurs at other times. If this
occurs, it is predicted that the US is likely to happen in the absence of the CS. In other
words, the CS does not "predict" the US. In this case, conditioning fails and the CS does not
come to elicit a CR. This finding that prediction rather than CS-US pairing is the key to
conditioning greatly influenced subsequent conditioning research and theory.
THE TILISIM OF BELLS & CURRENTS
Let me begin with a simple experiment on animals. A dog is tied in a cage. The floor of the
cage is electrified in a manner that a mild electric current could be circulated on one leg of
the dog. As soon as the current is circulated the leg of the dog will show a withdrawal
reflex. It is natural and normal response to show withdrawal because of the pain and
suffering caused by the electric current. Now experimenter took one bell and made
arrangements in following manner ringing of the bell followed by electric current. Again
there will be withdrawal due to electric current. But with repeated pairings and
presentations the dog will learn to withdraw as soon as the bell rings. The ringing of the
bell alone would lead to withdrawal even if it is not followed by the current. This happens
because the bell rings predicts the upcoming current. Bell sound becomes a signal for the
current. The neutral and unrelated object acquired the power to predict that current will be
coming hence there is a withdrawal response.
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Now the experimenter wants to delete the prediction power of bell rings. To achieve this
goal, the experimenter will have to make following two arrangements (1) bell sound is not
followed by electric current (current removal from the scenario) and (2) momentarily
preventing withdrawal response to impress the animal that bell sound no longer predicts
the electric current. If the withdrawal is not prevented the animal will not get chances to
learn that electric current is no longer followed by the bell sounds.
But initially due to established conditioning, the animal will show withdrawal reaction or a
tendency to withdraw in response to bell sounds. This initial reaction of withdrawal will
continue until the animal realizes that bell sound has lost the power of prediction. Once this
power of prediction is lost from the bell sounds, there will not be any discomfort or
withdrawal reaction on the part of the animal. The neutral stimulus will once again become
neutral. This is a kind of normalization or neutralization of the bell sounds. A process called
extinction.
If a bell acquires the power of prediction of electric current, the situation can get worse in a
manner that the stimuli similar to the bell sounds would begin to falsely predict the electric
currents and the animal will begin to show the withdrawal reaction to these false alarms
also. A process called as stimulus generalization. The extinction of generalized stimulus can
also be achieved in the similar manner by repeatedly presenting the false alarm and
preventing the withdrawal reaction.
== = = = = = ==
Cognitive Drill Therapy (CDT) Workshop: A 3D therapy (Drill, Daring, Distraction)
Dr. Jain is known for his unique expertise of offering, professionals as well as patient
friendly therapeutic interventions. He artistically converts complicated therapies into
concise therapeutic models, and effortlessly trains his trainees and transform them into a
skilled professionals. The Four days workshop on hypnotherapy is a glaring example of his
skills, which was introduced in 2003, wherein the complicated therapy based on hypnosis
was simplified and presented to trainees in easy language. It is astonishing to witness that
within four days, the trainees not only learn various techniques of hypnotherapy, but also
gain confidence in single handed patients management. Many professionals who had learnt
hypnotherapy from other institutes joins Dr Jains four days hypnotherapy course to refine
their skills and gain confidence, for which they are reluctant to join other institutes due to
heavy finances involved for attaining advance levels
Continuing with the trend of presenting complicated therapeutic interventions in concise
capsules Dr. Jain has developed a breakthrough therapy Cognitive Drill Therapy (CDT) for
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the patients with OCD, Phobia and panic attacks. OCD is a chronic disorder and is
considered a common psychiatric condition. In India, It is more common in unmarried
males, especially coming from higher socio-economic class with high Intelligence.
Treatment of OCD typically involves the use of Psycho-education, pharmacotherapy
especially serotonin reuptake inhibitors (SRIs), behaviour therapy and cognitive therapy.
Cognitive behaviour therapy (CBT) /Exposure response prevention (ERP) is considered
first line treatment for some OCD patients. As Clinical Psychologist across the world know
very well that treating OCD, Phobia and panic attacks is lengthy treatment irrespective of
the therapeutic model preferred by the professionals, and significant improvement in the
illness is also not perceived by some patients which lead to significant dropouts.
Dr. Jain while working with an adult with chronic OCD, had illuminative thought of
cognitive drill as therapy. The cases of OCD treated with cognitive drill in combination with
pharmacotherapy have been instrumental in establishing CDT as an potentially rapid
therapy for treatment of OCD. He initially prescribes a 10 days course in OCD which can be
repeated as per the requirements of the patients. However, in cases of Phobias it usually
needs less than10 days course of Cognitive Drill Therapy. He is demonstrating success of
Cognitive Drill Therapy in various phobias including social anxiety, agoraphobia and
specific phobias. Also it is observed that a simple listening to his approach of Cognitive Drill
Therapy, a few patients integrated it into their lives and got improved without explicit and
interactive focussed sessions with Dr. Jain.
Dr. Jain started imparting the three day CDT training to the professionals from October
2015 and we, the batch of seven professionals have been blessed to be trainees of the first
batch. On the first day of the training we were sceptical of success of the CDT in OCD and
Phobia patients, Social anxiety and panic attack patients per se. We trainees underwent the
first day training with sceptical thoughts laden with our own fear of failure to treat OCD
originating out of our past experiences with OCD patients. When a larva comes out of its
cocoon and converts into an ugly caterpillar no one can imagine that the same ugly
caterpillar will transform into a beautiful butterfly. This was the experience of each and
every students after completing the three days training. We were transformed into a
confident professionals bubbling with energy and conviction to treat disorders like OCD,
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Social anxiety, panic attacks, phobia in just 1 hour per day for 10 days on an average,
depending on severity of the case. The OCD patients however, may need longer time
depending upon the severity. Dr. Jain is very clear that this therapy cannot treat 100%
patients with equal level of success and no unrealistic claims of absolute recovery from
these disorders is claimed. However, the applications of Cognitive Drill Therapy do produce
significant improvement rapidly in many cases.
Day 1- Understanding theoretical perspective:
On day Dr. Jain oriented us towards new perspective on application of Pavlovian theory of
conditioning for extinction of the fear (conditioned responses) with various stimulus of
obsession (CS). We were also sensitized that thoughts associated with CS in case of
phobia/social anxiety/OCD are originated in brain centres which are responsible for future
tenses. A OCD patients speculates the consequences of his obsessive thought and to avoid
the harm and the pain he develops various anxiety and fear; and by making a patient do
cognitive drill, we symbolically align the patients brain and in turn he is benefited rapidly
through following mechanism1. Neural pathways of brain (centre of future tense) diminishes responsible for OCD/
anxiety disorder
2. The fear / crystallized anxiety (CR) extincts in absence of UCS stimuli.
3. Patient does cognitive reinterpretation of the fear , underlying themes and attains
self efficacy
A few important component of CDT were also elaborated1. Anxiety on stimulus can be elicited by its mere mental representation (Covert
conditioned stimulus). the process is as follows
Covert stimulus = covert response (Neural firing & Release of hormone)
2. Emotionally charged word acts as conditioned stimulus and has potential to elicit
conditioned response (fear/ anxiety) . Mere repeating of the conditioned stimulus
/word will elicit fear and after a period of time when anxiety (CR) will reach to its peak,
it will decline.

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3. Therapist needs to identify all possible spectrum of associated stimulus and response
(umbrella). And make the patient do drill till the time

S3
Word Dog
S2
Dog's
Image

anxiety (CR) extinct. e.g In case of phobia with dog , the


umbrella of CS could be as shown in the picture.
4. There are three systems of anxiety viz cognitive,

S4
Real Dog at
distance
S5
Dog's
barking

S1

Fear

dog's
picture

(CR)

S6
Dog
standing
close

somatic and affective. This therapy is effective when a patient reports all three systems of
anxiety. All systems should be incorporated in CDT.
5. The therapist should prefer all modalities for CDT e.g taking patient to real site, writing,
imagining, auditory.
Day 2- Case studies and experiential learning though CDT session on one of the
trainee suffering with social phobia
The theoretical perspectives we learned on day one were explained by Dr. Jain with
supporting case studies. CDT was demonstrated on one of the participants who was having
stage phobia. Steps were as following1. Taking relevant case history
2. Taking problem statements
3. Identifying underlying themes (umbrella). Make him aware that CDT doesnt eliminate
anxiety, but it disconnects the connection between stimulus (feared stimulus) anxieties
(conditioned response).
4. Identifying three modalities of anxiety viz cognitive, affective and somatic.
5. Psycho-educate the patient about CDT on following aspectsa) Meaning of the illness
b) Three types of anxiety reactions fight, flight, freeze. We react to feared stimulus by
avoidance thereby we avoid.
c) Fear has many underlying themes/ issues which need to be addressed. Identifying
the umbrella is required. The patient avoids object/ stimulus which only give
temporary relief from fear, thus real issues are never addressed. E.g. A student might
be avoiding giving presentation, because he has underlying fear that he may be
ridiculed, looked down upon if he makes mistake
d) Fear has future orientation in brain. By changing the orientation from future to past
during CDT the neural pathway of fear breaks down in brain.
e) Fear has its cycle. after reaching its peak fear /anxiety diminishes

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f) Importance of medicine/pharmacotherapy in treatment of OCD. He encourages


combination treatment in OCD. Medicine recommendations are invariably made
through psychiatric consultations.
g) CDT is three component therapy- Drill, Daring & Distraction.
h) Patients should also be told that all existing OCD themes will extinct after therapy but
new themes may develop over the period of time, same therapy can be used.
i) Patients should be psycho-educated for giving NIL Importance to their OCD thoughts
and study about OCD as much as possible. He may be recommended to read book
brain lock which illustrates OCD is due to thoughts locked in brain.
5. Following test to be taken pre & post CDT
a)
b)
c)
d)

Narration from patient about illness


Visual Analogue Scale
Subjective Reports of Distress
Depending on the case test pre and post CDT to administered on the patient. For
OCD patient YBOC, Generalized anxiety scale, fear inventory, etc can be used

6. CDT Session Practice session may continue for 10 days (1hr /day + Home Work).
Therapist should make patient perform drill for all stimulus in umbrella using as many
modalities as possible (speaking, writing, listening, imagining, seeing in real). When patient
ceases to exhibit anxiety he should be asked to perform a daring act by facing the feared
stimulus in real. If patient doesnt exhibit anxiety; the drill on that stimulus can be
terminated as its the indicator of extinction of anxiety (CR)
a. 1 hr CDT to be done at clinic.
b. Each trigger of anxiety to be given 15 min approx. All modalities of stimulus
presentation viz. visual, auditory, writing and tactile should be used.
c. Report on level of anxiety to be taken after 15 min.
7. Patient should be given Home Work to do CDT at home. He should be advised to keep
himself distracted means engaged professionally / socially.
Day 3- Day for skill refinement on CDT & trainees cognitive reinterpretation of
social phobia:
On day three feedback was taken from the participant, who had been given the CDT for her
stage fear on previous day. It was amazing to witness her cognitive restructuring on her
stage fear; it was surprising to notice that she was laughing at her irrational themes of fear.
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Unbelievably we also noticed her enhanced self efficacy. The same participant who was
shivering while narrating her fear, had reframed her thoughts on stage fear. The same
participant later reported that after three days she gave a live performance before huge
audience without any sign of stage fear
Last day CDT was demonstrated on other participant who was having anxiety for public
speaking. Patient of OCD will have many stimulus of anxiety whereas patient of phobia will
have limited anxiety.
We all felt skilled and empowered. I also applied Cognitive Drill Therapy by my own and
observed extra-ordinary improvement in the condition of the recipients. I am excited to
extend its applications as and when I get cases on which this novel and highly effective
form of psychotherapy is indicated.
Cognitive Drill Therapy:
Phobia: Phobia is an irrational fear of objects and situations such as closed places, height,
insects, crowd, open places, performing on stage, facing an interview and so on.
OCD: In OCD, a person gets intrusive images, thoughts and urges in his mind which he tries
to resist but fails. Also, such persons are driven doing repetitive compulsive acts such as
washing and cleaning, arranging objects in order, checking door knobs. Some OCD persons
are severely troubled by objectionable images and thoughts towards religious figures and
temples.
Conceptualizations: Both OCD and Phobia are caused by an interaction of brain related
and psychological factors. Some chemicals particularly serotonin level gets decreased.
According to psychological perspective, learning plays a key role in the maintenance of
these problems. When exposed to feared objects and situations, the patients keep on
avoiding them and get temporary relief. Since they do not face the feared situations, the
phobia and OCD continues.
Cognitive Drill Therapy: We are developing a novel form of psychological treatment that
is highly useful in cases of Phobia and in cases of OCD along with regular psychiatric
treatment. This treatment is based on psychological theories of conditioning, Cognitive
Appraisal and Psycholingustics. It is a form of verbal exposure which we labelled as
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Cognitive Drill Therapy. It is one step ahead and powerful to the existing form of real time
and imagination based exposure treatments.
This is a light weight treatment for both the psychologists and the patients. In this therapy,
we analyze and partition the problems of the patients into two layers. (1) Layer-I: We
identify the situations and objects that trigger phobic and OCD reactions such as closed
places, height, stage, temples, dirty objects, leaving house, insects and so on.
(2) Layer-2: In this layer, we analyze the underlying imagined fear structure of phobia and
OCD. This is the key structure on which the surface phobic and OCD structure are
maintained. The underlying fear structure includes fears like (1) fear of suffocation; lack of
oxygen in cases of claustrophobia (2) fear of heart attack, death, unavailability of help at
the right time in cases of agoraphobia. (3) fear of humiliation and embarrassment in case of
social phobia (4) fear of germs and disease in cases of washing compulsion (5) fear of going
in hell, committing sin in cases of religious OCD.
Treatment: We provide daily sessions for a few days in phobia lesser than 10 sessions and
in cases of OCD a few more depending upon the severity of the problem. Initially, we
recommend 10 sessions.
The patients are required to imagine the fearful situation and repetitively verbalize the
feared consequences by converting them into past tense. For example, in stage fear the
person will be required to imagine himself performing on the stage and verbally repeat he
is being ridiculed, humiliated, rejected and so on. Initially, repetitions in this manner will
cause phobic reaction but the continued repetitions will rapidly calm down the fear
reaction wihin a few minutes. We prescribe to practice this repetitions (called drill) at
home also for a few minutes daily.
Results: We have treated about 50 patients successfully. Most of them are showing drastic
improvement which are being maintained for months and years.
Rsearch: We are looking forward for a collaboration with neuroscientusts for brain
mapping under conditions of anxiety and cognitive drill to empirically and scientifically
validate the effects of cognitive dill therapy through fMRI or even more sophisticated
researches.
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This therapy is being developed in India, hence we need support from highly skilled
behavioral scientists to establish and reach globally for the wellbeing of the patients,
society and the Nation as well.
Psychophysiology of Desensitization:
There are many desensitization procedures used in anxiety disorders specifically phobias
and OCD.
The goal of desensitization procedure is to neutralize the anxiety provoking potentials of
conditioned stimuli. For example, a person with claustrophobia gets fearful when exposed
to closed places such as lift. The goal of treatment is to make such persons non-anxious in
closed places.
This goal of not getting anxious could be achieved through behavioural approaches of
desensitization and other approaches such as cognitive restructuring.
The typical behavioural approaches includes some kind of exposure to anxiety provoking
stimulus either in real time or in imagination. Also this exposure could be in minor and
divided doses or could be in bulk.
The approach in which anxiety provoking stimulus is presented in minor and divided doses
in imagination under conditions of deep relaxation is called as systematic desensitization
which is based on the theory of reciprocal inhibition.
The approach in which anxiety provoking stimulus is presented in minor and divided doses
in real time is called graded expoure.
The approach in which anxiety provoking stimulus is presented in bulk in imagination is
called as flooding.
The approach in which the anxiety provoking stimulus is presented in bulk in real time is
called as......
There is another kind of exposure which I call as Verbal Exposure in which a person is
primarily exposed to emotionally charged words related to the anxiety condition.
In virtual exoosure, a patient is exposed to phobic situations in 3D virtual computerized
environment.
The system of measurement used in these procedures is called as Subjective Unit of
Distress (SUD Units) or Visual Analogue Scale. Both are subjective rating of perceived
quantity of anxiety response elicited by the anxiety cues.
Usually, subjective ratings are sufficient to achieve desensitization.
But there are instances when one needs objective evidence of implicit changes in arousal
for both the patients and the therapist to keep track of the changes.
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The objective evidence adds to the scientific credibility and provides robust feedback to the
patients which boosts their confidence in the desensitization procedures.
It is the context exactly in which biofeedback devices can be used to meaure arousal level
and to reflect back to the patients.
This is a versatile use of biofeedback devices which are used mainly for
psychophysiological measurement instead of biofeedback.
Fear is an emotion which is primarily involved in anxiety disorders. Like all emotions, fear
has three systems (1) physiological arousal (2) subjective feeling of fear (3) cognitive
component of threat.
Following biofeedback parameters can be used to measure the arousal level of the patient
(1) GSR (2) ECG (3) Respiration (4) EMG
Usually, single parameter is enough for mapping the arousal level. GSR can be a good
option for that.
While implementing any desensitization, attach GSR device and proceed as per the usual
protocol of the chosen desensitization procedure.
When exposed to anxiety provoking stimulus, the arousal follows a pattern of rising and
declining which is conceptualized as a bell shaped curve also called as anxiety curve.
This pattern of arousal should be measurable and the devices should be sophisticated and
sensitive enough to chart variations in arousal.
======================================================
Revision in Theoretical Framework of Cognitive Drill Therapy:
I am contemplating to migrate from the Pavlovian Conditioning to Operant Conditioning as
the theoretical basis of Cognitive Drill Therapy.
For the conditions of anxiety e4scape and avoidance conditioning are more relevant.
In escape learning, the organism learns to emit a response that successfully terminates the
painful state elicited by a stimulus.
Let me clarify it through an experiment. Let us take a two compartment box partitioned by
low height wall. Let us call two compartments as A & B. The A compartment has an
electrified grill floor. The B compartment is safe. Let us place a rat in Compartment A.
Switch on the electric grid. The pain caused by the electric grid will initiate escape oriented
random movements like jumping on the electrified floor. Eventually, the rat will learn to
jump to safe compartment B. On each successive trial the latency of jumping will get lesser
and lesser. A point will come when the rate will jump to the safe compartment as soon as
the grid is switched on.
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Now let us analyze the operations that take place in such type of aversive conditiining: (1)
The electric current ( painful stimulus) (2) The experience of electric current causes a
natural painful drive state in the organism (Emotional response) (3) Escape into safe zone
(Operant behaviour) (4) Termination of electric current upon jumping in safe zone
(Negative Reinforcement) (5) Cooling down of painful drive state (Pain Relief)
Clarifications on Random Behaviours to Escape: The quantum of random movements upon
onset of painful stimulus, and successful jumping to safe zone is mediated by cognitive
maturity of the organisms. The human being will make fewer random movements
compared to the animals; so much so that even a single exposure to painful stimulus may
initiate successful escape into safe zone.
Concept of Antecedent Stimulus: Any planned or non-planned antecedent stimulus which
precedes the onset of actual painful stimulus can become associated and acquire predictive
power for upcoming painful stimulus. In above experiment an array of stimuli like mere
touch with grid in compartment A, the visuals of the Compartment A can become
associated as cues for upcoming electric current. If it is so, as soon as the rat is placed in A
compartment, it will tend to jump to B compartment even if no current is yet circulated in
the grid. If it happens, we can say that there are some cues in A compartment, and the rat is
responding to cues instead of actual current.
To demonstrate this cue triggered phenomena, above experiment can be extended a bit. All
experimental arrangements are the same plus a cue in the form of electric bulb is added to
the experimental scenario. That is, the experimenter is now first switching on the bulb,
then delivering the electric current. The repeated presentation in following manner
bulb+current will lead the rat to respond to bulb. As soon as bulb will be switched on the
rat will jump to safe compartment B. This form of learning is called avoidance learning
becuase the rat successfuly avoids the experience of painful stimulus by responding to the
cue.
The avoidance learning in human being can be complicated and multiplied by their
cognitive faculty of anticipation and brooding over the likelihood of the consequences of an
event. As soon as a human being is exposed to fear provoking stimulus, his/her cognitive
network of fear will get activated. This is an instance of cognitive mediation.
With cognitive mediation the scenario becomes like this: Cue leads to Apprehension and
Feeling of fear which in turn evokes Avoidance response.
Hence, the fear reaction can be explained through combined theories of (a) conditioning
(S-R connections) (b) cognitive appraisal (S-O-R).
Both behavioural and cognitive framework are important to explain and treat fears.
======================================================
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Fear of Spoken English:


Many people are afraid of communicating in English language. They may have following
underlying fear structure:
1. Fear of devaluation
2. Fear of humiliation
3. Fear of ridicule
4. Fear of rejection
Instead of these fears one should always remember that English is a language not a
measure of one's intelligence.
To overcome this fear, i would like to recommend drills in following manner:
1. Imagine yourself speaking in English language before others and think that others have
devalued, rejected, humiliated and so on. Do it for a few minutes daily for a few days. You
will be surprised by realizing that this simple method can actually reduce the fear
significantly.
"Face the Underlying Fears"
For the attention of claustrophobics:
1. Are you really afraid of closed places?
2. OR you are afraid of suffocation or lack of oxygen that may occur in closed places?
3. If Point-2 is correct why don't you treat yourself by visualizing youself in closed places
and thinking that you are experiencing suffocation and lack of oxygen. You may do so for
about 15 min at a time 2-3 times daily. Within a few days you are likely to feel tremendous
relief in your phobia.
4. If you need personal assistance, you can contact me through personal messages.
5. Also share your experiences in this group.
Destroying the Predictability of Fear Provoking Stimuli to Overcome Phobia:
Phobia is said to be an irrational fear which get activated in response to some anxiety
provoking stimuli called as conditioned stimulus. For example, fear of closed places, dog,
examination, cockroach, crowd, height and so on. When exposed to these fear provoking
situations, the affected person show a phobic reaction.
When properly analyzed it can be established that the person is not fearful of these anxiety
provoking situations instead he is plagued by a kind of threatening superstitious thinking.
The fear is activated by the rational and irrational possibilities of painful outcomes.

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The phobic person holds a belief that anxiety provoking situations are likely to result in
potentially harmful outcomes. The phobic individual may hold a belief as if cause effect
relationship exist between feared objects and painful outcomes (magical thinking) or the
thinking may be of a predictor-predicted kind. The anxiety situations may act as cues for
threatening outcomes.
To attain effective resolution of the fear, the phobic individual will have to destroy the
magical thinking and predictability of feared outcomes with false cues. Phobic cues are
false.
The falsity of prediction need be addressed effectively. Once this falsification of feared cues
is realized at experiential level; the fear reaction get detached from such neutral cues. This
falsification can be established by exposure, CBT, mindfulness based meditation and other
approaches.
Cognitive Drill Therapy:
Cognitive Drill Therapy is a form of Exposure Therapy in which OCD and Phobia patients
are exposed to feared consequences at verbal level. The patients are required to repeat the
underlying feared cognition of future orientation by converting it into past or present
framework. The repetitive verbalizations in this manner lead to typical anxiety curve (bell
shaped curve) of rising and declining pattern of anxiety. The drill of feared consequences
leads to faster extinction (dissociation of the functional links between anxiety provoking
stimuli and anxiety response).
This therapy is based on the theories of (1) Conditioning (2) Cognitive Appraisal and (3)
Linguistics.
I have drafted a comprehensive manual of the therapy which is available as free download
I am providing free of cost services to OCD and Phobia patients with this therapy in Agra.
Since, this therapy is being developed in India, I would like to appeal all of us for making
this therapy available to as many patients as possible either through me or through fellow
professionals who could add this highly useful skill in their repertoire.
CDT WORKSHOP REPORT: January 2016
The Cognitive Drill Therapy (CDT) Workshop was a 3 day workshop at Agra. The resource
person was Dr. Jain. This therapy has been successfully developed by him. The CDT is
basically designed for OCD patients, social anxiety and some specific phobias, like:
agoraphobia, claustrophobia, fear of certain animals or reptiles like dog or lizard. The
therapy is not applicable on cardiac patients, psychotic patients, major depression or
paranoid tendencies. It is not a completely new therapy but is taken up from the pre132

existing theories like classical conditioning (Pavlovs) i.e., CS elicits a CR, operant
conditioning, stimulus generalization and extinction. The principles used in these theories
have formed the basis for CDT. This therapy can be given the name as Verbal Exposure.
The concept of Cognitive Drill Therapy can be well explained through the following:

Tense correlates

Magical thinking

Measurement of anxiety

Anxiety curve

I would elaborate on these one by one. The first day of the workshop focused mainly on the
concepts that are the foundation for CDT. It was well explained that anxiety being an
unpleasant emotion causes some amount of discomfort in an individual and he gets
apprehensive about the future. The individual believes that something wrong will happen
in future. The manifestation of anxiety can be seen in three forms, namely:

Cognitive

Affective

Somatic

The cognitive charge is the thinking associated about the thought that produces anxiety.
The affective charge is that component which describes about how an individual feels in
that situation. The somatic charge deals with the various bodily changes like headache,
sweating, dry mouth, choking sensations, chest pain, tremors, etc, This is the Conditioned
Response seen when a stimulus that generates anxiety is present. Therefore, whenever a
stimulus situation is foreseen the response to it is manifested in these three forms.
As discussed on the first day of the workshop, let me define the concepts of the drill
therapy in detail one by one.

Tense correlates
According to the biological perspectives, the brain has various neurotransmitters
that perform the function of communication in the brain. As per the disorder, the
level of insufficiency of these neurotransmitters creates an imbalance and the
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individual suffers. But these imbalances can be worked out with the aid of
psychiatric treatments. If we look carefully the anxiety is always associated with a
future orientation. There are certain pathways in the brain as pointed out by the
brain mapping research each working on the three different tenses like past,
present and future. The kind of thinking activates the respective pathway. If we
name the tenses like past, present and future as A, B and C brain pathways
respectively. The brain site for the past tense can be labeled as A, for the present
tense as B, and for the future tense as C. Since the anxiety patients have a future
oriented thinking, their C centre in the brain is more active during the anxious
states. If we cool down this centre C then there would be corresponding changes in
the anxious state. This can be achieved through changing the future tense in the
anxiety related sub-vocal speech of the patient. For example, a patient of
claustrophobia thinks that on taking up the lift I will be suffocated and I will die.
In CDT the patient is asked to verbalize that Im suffocated and have died. On
continuous drill of this statement the C centre in the brain gradually learns to rest
and the drill statement is delivered to the centers of Past and Present in the brain.
There will be a change in the activation pattern of the brain circuits leading to an
improvement.

Magical Thinking
The patients with OCD think that thoughts have power to cause physical effects in
the external world. Mere repetitions of certain thoughts can have corresponding
outcomes in the environment. The patients think that these thoughts have powers
to change anything and everything. This kind of thinking can be well intervened by
giving out a rationale that by mere thinking one cannot do a particular task.

Measurement of Anxiety
It was emphasized that in order to measure anxiety in the Cognitive Drill Therapy,
the following scales can be considered:
1. Subjective Unit of Distress: It can be measured on a scale of 0-100%.
2. Visual Analog Scale: It has a rating on a continuum of 0-10.

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3. Common Approach: It implies a common principle how much in a rupee,


or we can also use terms as low, medium and high.

Anxiety Curve
When exposed to an anxiety provoking stimulus, the anxiety follows a pattern of
rise and fall which is similar to the bell shaped curve. The anxiety initially increases,
reaches its peak, stays for some time at a stable rate and then gradually declines.
It was further brought in the notice that the drill therapy is a two layer structure:
Surface Structure
Underlying Fear Structure

Surface structure
A surface structure is a superficial structure consisting of stimulus and reactions. It can also
be called as the Top layer or Conscious structure. The patients are stuck at this surface and
only avoid the stimulus or situations, e.g., if an individual has a fear of dog and if he
encounters the dog in his way he would change his path i.e., he is avoiding the situation. We
need to identify such surface structures which would further form a stimulus
generalization in the form of an umbrella. It is a therapists work to identify the
Conditioned Stimulus and make the umbrella lighter with the help of drill therapy.
Underlying Fear Structure
It is this Underlying fear structure which needs to be worked on. This can also be called as
Bottom layer or Future Oriented Thinking. The patient is not affected with the stimulus but
the consequences that are going to occur after the stimulus presentation, e.g. , the dog
immediately pulls up his leg as soon as the bell rings because of the fear of the current.
Similarly the patient of OCD is not worried about the nude images of God or blasphemous
thoughts but the guilt that is associated with it, that makes him feel evil about him.
It is the therapists work in the Cognitive Drill Therapy to identify the surface structure, the
avoidance that the patient makes and the temporary relief obtained. This is a part of the
surface structure. This goes in the following manner
Conditioned Stimulus

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Conditioned Response (Cognitive, Affective & Somatic)

Avoidance

Temporary Relief
After doing the partitioning, the analysis of the Underlying fear structure is done. It is this
structure which needs to be re-interpreted, as it focuses on the future oriented thinking. A
list of all such structures is prepared and taken up one by one in the therapy. As the anxiety
for one stimulus is decreased or when it does not cause much discomfort another stimulus
is taken up. It should be noted that during the drill if much distress is caused then a pause
should be made.
The first day of the workshop dealt with the concepts that form the basis of the Cognitive
Drill Therapy. It made us well acquainted with the terms and the applications used.
The second day of the workshop dealt with the Cognitive Drill Assessment and a
demonstration of one of the candidates who had a stage phobia. The CDT assessment
involves the following:
Case History
The relevant history is taken up which includes identification of the data, the chief
complaints, the duration of the illness, the origin of the illness i.e. how it started, the
patients experiences related to the problem and how do these problems interfere
with the life situations.
Relevant Psychological Assessment
After the history take up, it would be clear what assessments need to be done, i.e. if
it is an OCD patient Y-BOCS can be used. If it is a patient of GAD HAM-A can be
applied; depending upon the nature of the problem the questionnaires or
inventories can be applied in order to record the level of severity of anxiety or
significance of the Obsessive-Compulsive behavior.

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Psycho education
This covers an important aspect of the therapy. It is important on the part of the
patient to understand what the problem is and how can he overcome it. In this
therapy we need to make the patient aware about his/her problem in detail. It is the
responsibility of the therapist to create an insight in the patient. The patient is made
to know about the role of the conditioned stimuli and its connection with the
response. The patient is explained about the surface structures and the underlying
fear structure. There is an urgent need to explain the patient that it is these
underlying fears that are left untreated and the problem persists. The patient is
psycho-educated on the concept that if these underlying fears get treated with the
help of the drill the problem will be solved. Here, it is important to make the patient
aware of the concept of the anxiety curve.
There was a candidate in the workshop that had stage fear, and she thought each
time that her presentation would go bad and she would be insulted. This would
make her feel nervous with tremors in her hands, cold hands, reddish face, and
increased heart beat. A demonstration was done on how to psycho-educate a patient
of social anxiety. The description of the demonstration is as follows:
Therapist: The increase in the heart rate, cold hands, reddish face and
apprehensions, do you know what it is?
Client: Anxiety, Stress
Therapist: It is a case of Stage Phobia (in specific). There are many other phobias
and associated names to it, you have this phobia.
Client: Okay
Therapist: Have you ever examined it on the internet on what it could be?
Client: No
Therapist: In this therapy we will partition your problem in two layers, Top Layer
and the Bottom Layer.
Client: How will that be done?
Therapist: In the top layer, we will keep the stimulus situation i.e. the performance
on stage. Your response to such a situation is that you continue but with fear in your
mind that your presentation will not be good, this in turn produces anxiety with a
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thought that people will not like it, you feel afraid that whether people will
understand it or not, henceforth, you encounter the somatic charge i.e. cold hands,
increased heart rate etc. In your case there is endurance present with distress and
hence you achieve temporary relief after giving the presentation.
Client: Alright
Therapist: We further conceptualize it in the analysis of the Underlying fear
structures. These are basically the imagined fear consequences, the future oriented
thinking.
Client: How?
Therapist: What do you think will happen if your presentation goes bad?
Client: Many things will happen like, beizzati ho jaayegi, juniors mere bare me kya
sochenge ki mai kuch bol nahi paayi, internal me kum marks milenge and papa ki
beizzati ho jaayegi.
Therapist: If you notice carefully the entire thing that you listed has a future tense.
Client: Yes
Therapist: As it was told earlier the underlying fear structure has a future oriented
thinking that makes you apprehensive.
Client: Right
Therapist: So we need to work on the Underlying fear structure be changing the
tense of the situation. Instead of saying beizzati ho jaayegi you need to say
beizzati ho chuki hai, and similarly for the other stimuli.
Client: Why?
Therapist: There are 3 centers in the brain called the brain pathways namely; Past,
Present and Future. Let us denote these pathways as A, B and C. Since the anxiety
patients have a future oriented thinking, their C centre in the brain is more active
during the anxious states. If we cool down this centre C then there would be
corresponding changes in the anxious state. This can be achieved through changing
the future tense in the anxiety related sub-vocal speech of the patient. On
continuous drill of this statement the C centre in the brain gradually learns to rest
and the drill statement is delivered to the centers of Past and Present in the brain.
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There will be a change in the activation pattern of the brain circuits leading to an
improvement.
Client: okay
Therapist: Initially, the anxiety would increase as it follows the pattern of a bell
shaped curve i.e. first it rises, attains a peak and declines thereafter.
Client: This is interesting.
Therapist: You need to practice the drill statements for a particular duration so that
the extinction occurs i.e. you no more feel discomfort or anxious when exposed to
that stimulus.
The psycho-education is the part of treatment and helps in re-conceptualization of
the problem.
Drill Prescription
After the psycho-education the drill is prescribed to the patient. All the stimuli
which produce anxiety are identified; their partitioning is done through the
classification of the surface structure and the underlying fear structures. The drill
statements are converted from the future tense to the past tense. While making the
patient repeat the statements, it should be kept in mind that if the statement creates
a great amount of distress a pause for a few seconds should be given. After every 3060 seconds patients report about the level of anxiety is recorded on SUD or VAS or
through a common approach like low, medium and high. The CDT is a verbal
exposure given to the patient. It can also be used with the presentation of real
object, imagined (mental representation) as well as verbal exposure. It is a
standalone therapy as well as can also be used in combo with the others mentioned
above. The patient is asked to attend the first 3 days without thinking of anything
and just by following the instructions. If the patient is on medication e.g. OCD
patients, it is wise for a therapist to explain the patient to continue with the
medication prescribed and follow the therapy at the same time , because medicines
play their role and therapy helps in its own way. Both work in a combination in
order to have an effective treatment.

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The third day of the workshop was unique and amazing as it dealt with the
demonstration of candidates having stage phobia and fear of pointed objects. All the
queries regarding the therapy were quite clear as the explanation provided was
quite descriptive in itself. There was a candidate who had stage phobia since past 13
years. After the partitioning of the surface structure and the underlying fear
structure the drill statements were formed. It was seen that within an hours time
the candidate fell relief from the thought of performing on the stage. Initially, when
the drill began she was quite anxious and at high discomfort, it could be elicited
from the tremors in her hand, the shaky voice and a reddish face. On continuous
verbalization of the statement, her anxiety decreased as per the principle of the
anxiety curve.
There was another candidate who had fear of pointed objects. She could not even
stand for a second before a pointed finger or pen. She thought that it would go into
her eye and she will die. But it was quite surprising to see that the candidate
overcame her fear within minutes. It was well evident as she not only verbalized the
drill statements but she verbalized it in combination with the presentation of the
real object. It was quite surprising to see that initially she denied even to look at it
but after a continuous repetition of the statement she herself took an initiative and
adjusted the real object i.e. straw at her comfort level, so that she could verbalize
better. It was seen that after a few minutes the distance between her eyes and the
straw was quite less. This was even tested in a real life situation which provided an
aid in understanding its relevance.
My experience for all these 3 days of workshop had been wonderful, as I being a
trainee in M.Phil Clinical Psychology consider it to be bliss. This therapy is easy to
understand for the therapist as well as the patient and of course it works wonders. I
would take the opportunity to thank sir who enlightened us and gave us an
innovative vision for treating patients of Phobias and OCD.
THANK YOU SIR!!!

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SIS J. Proj. Psy. & Ment. Health (2016) 23: 125-126

Cognitive Drill Therapy:


A Potent Application of the Principles of Psychology for OCD and Phobia
Rakesh Kumar and Bankey L. Dubey
Cognitive Drill Therapy (CDT) capitalizes on the principles of classical conditioning, operant conditioning, cognitive appraisal
and linguistics. Combined together in a customized manner, application of these principles have the potentials of efficient
handling of stimulus bound anxiety more specifically phobia and Obsessive-Compulsive Disorder (OCD). In these disorders,
exposures to neutral objects tend to trigger fear reactions amounting to panic in some cases. The patients learn to deal with
these fears by avoiding as far as possible the exposure to such fear provoking stimuli. For example, a person with
claustrophobia exhibit fear reaction in closed places. As and when such patient comes into contact with closed places like
lift, MRI Scanner, metro trains, closed bathroom etc. will experience severe anxiety reaction. To prevent the experiences of
fear reactions, he/she will avoid these situations by opting staircase even in multistory buildings, Open MRI Scan or
scanning under anesthesia; avoid using metros and take bath in open bathrooms. The avoidance in this manner reinforces
the patients strategy and the patients adopt a life style which minimally involves exposure to closed places. Whatever, is
the lifestyle adopted by the patients to avoid closed places or objects of any phobia for that matter imposes limitations on
the optimal functioning of the patients. The life is crippled in many cases.

Cognitive Drill Therapy conceptualizes stimulus bound anxiety as a two layer structure; (a)
Top Layer also called as surface structure/conscious structure. (b) Bottom Layer Structure
also called as underlying fear structure consisting of imagined feared consequences/
subconscious structure because the patients remain dimly aware of the bottom layer.
The top layer structure consists of objects of fear such as closed places, heights, open
places, crowds, animals, insects, pointed objects, examination (as seen in specific phobia);
social situations like asking a question in class, talking to superiors, making a presentation
on stage, giving a speech, talking with authorities (as seen in social anxiety); being away
from home, in a crowded place (as seen in agoraphobia); dirty and contaminated objects;
abusive, sexual and aggressive thoughts in religious places, sexual thoughts and images for
family members; objects kept in disorganized manner, displaced objects, locking of doors
(as seen in OCD).
These apparently neutral objects elicit fear and disgust reactions in the patients. These
reactions are usually associated with psychophysiological arousal characterized by
accelerated/shortness of breath, faster heart beat, tense muscles, sweating, blurred vision,
trembling. The patients subjectively feel discomfort, uneasiness and psychic pain at
cognitive level.
To deal with the arousal or to prevent the arousal, the patients would avoid exposure by
taking alternative routes so that feared objects are not encountered, shy away from the
social situations, would not leave the house alone; keep on cleaning the apparently clean
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objects, would repeatedly check the doors, gas, locks; seek forgiveness from the God for
abusive and sexual thoughts, would go at length to keep the objects organized and in order.
These attempts are successful for a temporary period; and the cycle continues. The Top
Layer can be summarized as follows:
Exposure to objects of fearPsychophysiological arousal/Subjective experience of pain or
discomfortEscape/Avoidance patterns (negative reinforcement) Temporary Relief
The bottom layer consists of a series of underlying fears and imagined feared consequences
such as fear of suffocation and death in closed places; fear of negative evaluation, ridicule,
rejection, loss of self-image in social anxiety; fear of catching a disease like rabies in dog
phobia, fear of failure, going blank, losing face, spoiling career in examination anxiety; fear
of inhaling germs and spreading contamination and disease in OCD; fear of Gods
punishment, causing curse or misfortune to the family in aggressive/sexual thoughts for
God and so on.
In Cognitive Drill Therapy, it is believed that the patients remain struck in top layer and
rarely deal with the underlying fear structure. For efficient handling of these problems we
need to directly address the bottom layer and expose the patients to this underlying fear
structure. Once this underlying fear structure is destroyed, the patients will show
proportionate improvements in OCD and phobia. The drill therapy utilizes the principles of
exposure therapy to attack on the underlying fear structure.
The protocol of the therapy is very specific, clear and straightforward. A patient is given
proper psychoeducation which consists of sharing the diagnostic label of the problem,
communicating the understanding of two layer structure, handling magical thinking that
merely by having thoughts in ones mind actual physical events cannot be caused. An
education regarding anxiety curve and mandatory requirement of homework is also given.
The patients are specifically educated about the future orientation of anxiety. They are
made to realize that anxiety looks into the future. Under conditions of fears, their sub-vocal
speech centers around imagined possibilities of harms in some future time; and our task is
to convert this future orientation into past or present orientation.

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The objects of phobia are implicitly and mistakenly perceived as predictive of harmful
future consequences. One of the important goal of Cognitive Drill Therapy is to destroy the
perceived predictability of the neutral objects leading to harmful consequences. The
neutral objects are neutralized in the process. The patients are also educated regarding the
Concept of Universal Probability, which means that harmful consequences can occur to any
person any time. All of us are having more or less equal probability of such an outcomes.
Having given the psychoeducation, the patients are required to imagine objects of phobia
and repeat covertly or verbalize the imagined feared consequences by converting the tense
to the present or the past. For example, in claustrophobia, imagine yourself in a closed
place and verbalize I am suffocated; I am experiencing suffocation; I have died of
suffocation. Initially it leads to quick spike of fear reaction and with continuous
repetitions, it leads to resolution of fear within minutes. This procedure is repeated for as
many objects of fear as possible both in sessions and in homework. Drill & Daring is the
slogan. Perform drill and dare to expose yourself to objects of phobia. The resolution of
phobia can occur in a single or a few sessions. OCD takes longer time.
The pre-post case studies (Kumar et al. 2012; Dwivedi & Kumar, 2015) documented the
efficacy of this therapy. Many more researches are in pipeline. We are looking forward for
task based fMRI researches for demonstrations of live changes in the brain during drill
therapy and inclusion of projective techniques such as Somatic Inkblot Series-II and Live
Images Version for exploring changes in the perception of objects and inner cry through
this therapy.
References:
Kumar.R., Sameer.A., Singh.B. (2012). Preliminary Test of Cognitive Drill as an Intervention. Indian J.Clini. Psych., 39, 67-74.
Dwivedi, S. and Kumar, R. (2015) Efficacy of Cognitive Drill Therapy in Agoraphobia with Panic Disorder: A Case Study. SIS Journal
of Projective Psychology and Mental Health, 139-146.

=========== = = = = = = = = = = == = = = = = = == = = = = =
Rakesh Kumar, Ph.D. HOD Clinical Psychology, Institute of Mental Health and Hospital, Agra; Bankey L.
Dubey, Ph.D. President, SIS Email: jain.imhh@gmail.com Website: www.Cognitivedrill.com (Free Manual
Download)
Key Words: Cognitive Drill Therapy, Exposure Therapy, OCD, Phobia

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Concepts used in Cognitive Drill Therapy:


1. Objects of Phobia
2. Body and Mind Reactions
3. Safety behaviours
4. Underlying fear structure
5. Concept of ABC
6. Soch & Sachhai
7. Formulation of Drill
8. Reactions During Drill
9. Drill Dilution
10. Magical thinking
11. Drill as bringing subconscious
to Conscious
12. Types of Phobia
13. Types of OCD
14. Pauses during drill
15. Imagine objects of phobia
and convert underlying future
statements
16. Quantification of fear
17. Formal assessment of phobia
and ocd scales
18. History taking and interview
19. Multisensory involvement
20. Contraindications of drill
21. Drill diary
22. Drill daring and distraction
23. Attrubution of ocd behaviour
to icd
24. Anxiety curve
25. Monitoring of severity level
during drill
26. Drill homework
27. Training of family member in
drill
28. Psychoeducation
29. Case studies in drill
30. Exercises in top layer and
bottom layer.

31. Session frequency


32. Medicine plus drill therapy
33. Behavioural tests
34. Fear of relapse
35. Fear of drill
36. Fear of lack of generalization
37. Testing improvement by exposing
to objects in imagination and reality
38. Stress induced relapse
39. Drilled vs. Non-drilled objects of
phobia
40. Layered and connected phobias.
41. Search for magic formula
42. Somatic representations of anxiety
43. Outcome expectancy in CDT
44. Disbelief in CDT
45. Emotional processing
46. Bearing discomfort
47. Audio recording of sessions
48. Spreading awareness of cdt
through lectures and presentation
including social media
49. Nonapplicability of cdt
50. Mental representations of external
objects
51. Research ideas in cdt
52. Research designs in cdt
53. Lack of homework
54. Lack of generalization
55. Using patients language in drill
56. Periodic lapse
57. Refrain from avoidance and safety
behaviours mentally and behaviourally
58. Feelings of shame and gulit
59. Associated depression
60. Associated psychosis

61. Follow ups


62. Whatsapp Feedbacks
63. Drill with real objects
64. Drill with google images and
youtube
65. Giving nil importance to ocd
66. Non cooperation with ocd
67. Predictability of obects of fear
68. Future orientation in fears
69. Use of psychophysiological
measurement devices
70. Add sis paper
71. Theoretical frameworks of cdt
72. Future pacing
73. Drill under hypnosis
74. Restructueing of imagery
75. Microscopic examination
76. How to test improvements
77. Restoration of work, work is a
therapy
78. Pts sochta he ki kewal mujhe hi ye
bimari he
79. Abstinence from safety behaviour
80. OCD Tips
81. Stimulus generalization
82. Extinction
83. Response prevention
84. Negative reinforcement
85. Anxiety fear and phobia
86. Alternative imagery
87. Outcomes of exposure therapy
88. Verbal exposure
89. Emotions in phobia and ocd
90. Universal probability
91. Biological mechanisms
92. Limitations imposed by OCD and
phobia
93. Celebrities who had OCD and
phobia

Objects of Phobia and OCD: Any object, situation, person, body sensation, thought or
mental image can become the objects of phobia and OCD. The list of such objects include
closed places, darkness, water, height, crowd, pointed objects, skin infection, lizard,
cockroach, hairs, body sensations, abusive or aggressive thoughts for religious objects,
sexual thoughts or images for religious objects or family members, asymmetrically placed
objects, blood, speaking before others, performing on stage and so on. Based upon the
nature of objects of phobia, specific names are given to the phobia such as:
1. Acrophobia fear of heights
2. Aichmophobia fear of sharp or pointed objects (such as a needle or knife)
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3. Aquaphobia fear of water.


4. Arachnophobia fear/dislike of spiders
5. Claustrophobia fear of having no escape and being closed in
6. Colorphobia - fear or a strong aversion towards a particular color
7. Cynophobia fear of dogs
8. Dementophobia - fear of becoming insane
9. Enochlophobia fear of crowds
10. Halitophobia fear of bad breath
11. Hemophobia fear of blood
12. Mysophobia fear of germs
13. Trypophobia fear of holes or textures with a pattern of holes
Psychophysiological Reactions: When a person with phobia or OCD comes into contact
with his/her objects of phobia, both body and mind react to such an encounter. The body
reactions include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

sweating
trembling
hot flushes or chills
shortness of breath or difficulty breathing
a choking sensation
pounding or racing heart
pain or tightness in the chest
rapid speech or inability to speak
a sensation of butterflies in the stomach
nausea
headaches and dizziness
feeling faint
dry mouth
a need to go to the toilet
ringing in ears
elevated blood pressure

The symptoms of mind include:


1.
2.
3.
4.
5.
6.

Perception of some danger or a threat to life


Feelings of uneasiness
Feelings of confusion
Disgust
Fearfulness
Difficulty in decision making
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7. Mind going blank


8. Restlessness
9. Feeling entrapped
10. Thoughts of avoiding/escaping the objects of phobia
Safety Behaviors: The exposure to the objects of phobia activates reactions in both body
and mind. The reactions and perception of the possibility of some kind of danger are
painful to the affected person. Because of this painful state of body and mind a person tend
to either engage in safety behaviors or continue to remain in the situation with stress. As
and when there is an opportunity to avoid or escape, the person will preferably opt for
making himself/herself safe by avoiding the situation. Such a phobic person would go at
length to make sure that objects of phobia are not encountered. The phobic person shows
typical avoidance patterns and feels safe and relieved of perceived danger and body
reactions.
1. A person with claustrophobia would avoid lifts and climb the staircase in multistory
buildings, take bathe keeping bathroom doors open, avoid crowds
2. A person having fear of social situations would avoid assignments involving
presentations or speaking in public/audience.
3. The one who is phobic of height will avoid going to the buildings/places of height.
4. A person having phobia of dog would take a route on which there are less
probability of encountering a dog
5. A person having disgust for lizard would avoid the lizard, ask family member or any
other person to remove the lizard if it is there, run away from the place if a lizard is
seen.
The safety behavior in the persons with OCD is a little different from the persons having
phobias:
1. A person who is troubled by dirty objects, would avoid the dirty objects and go at
length to clean the dirty objects especially in his/her home. Such a person would
wash hands repeatedly in a ritualistic manner, take bath for hours and spend lots of
water, ask the family members to maintain cleanliness, will force family members to
clean themselves and objects according to his/her manner, clean floors and the
objects touched/used by guests and so on. These extended and repetitive cleaning
would consume most of his/her time. If a family member tries to restrain cleaning
attempts, then he/she may have to face the anger of the affected person.
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2. A person who is troubled by the possibility of door remaining open, would check the
doors and locks repeatedly
3. A person having sexual/aggressive thoughts towards god/goddess would avoid
visiting temples and religious places. He/she may repeatedly seek forgiveness from
the god/goddess. He/she may try to keep away such thoughts from mind, but the
thoughts pop up in his/her mind against his/her wish. Repeatedly he/she gets
thoughts in his/her mind and in order to keep the thoughts away, he/she may
engage in ensuring safety by seeking forgiveness or counting or replacing the
thoughts and images with other neutral thoughts and images.
Underlying Fear Structure: Most of the objects of phobia are neutral for a healthy human
being. These objects do not activate any painful body or mind reactions. But in persons
with phobia and OCD these objects activate body and mind reactions. When examined
meticulously, even these persons are not afraid of these objects. At psychological level,
these objects represent something else to the affected persons. These persons are terrified
because of the likelihood of some threatening or dangerous outcomes. These perceived
outcomes constitute the feared cognition or imagined feared consequences. Underneath
the phobia of objects, these imagined feared consequences can be readily identified. The
examples of imagined feared consequences include:
1. Fear of suffocation in claustrophobia
2. Fear of heart attack and unavailability of medical help if such an attack occurs in
agoraphobia
3. Fear of having heart attack in panic disorder
4. Fear of ridicule, rejection, negative evaluation, becoming conscious, saying
something foolish, going blank in social anxiety
5. Fear of failing, possibility of getting difficult questions, spoiling career, loosing
prestige of self and parents in examination phobia
6. Fear of catching skin disease by seeing the objects having patterns that remind of
skin disease
7. Fear of spreading germs in the house and catching illness in OCD
8. Fear of touching religious objects with dirty hands, committing sin, fear of Gods
punishment in OCD
9. Fear of Gods punishment, fear of going to hell in OCD persons having
sexual/aggressive thoughts towards god/goddess
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10. Fear rabies, fear of pain, fear of injections, fear of injury in dog phobia
Anxiety vs. Fear: Anxiety is an emotional reaction which is not tied to any specific object.
It is a state of vague apprehension, nothing specific. Fear is a normal emotional reaction to
a real danger event such as when there is a snake inside house, gas cylinder catching fire.
Phobia: Phobia is an abnormal fear reaction to normal or neutral object, person or
situation. Phobia is an irrational fear. A person with phobia reacts with excessive fear to
minor/neutral objects. Such as shouting, crying, running away by seeing a cockroach. Both
body and mind react excessively to non-threatening conditions. Phobia involves
imaginative magnification of potential threats which is unreal. Phobia has a very high
prevalence rate. One or the other phobia can be found in most households.
Classification of Phobia: Based upon the nature of objects/situations; the phobia is
classified into:
1. Specific phobia
2. Agoraphobia & Panic Disorder
3. Social Anxiety
4. Blood Injury Phobia

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