Shakespearean Therapy: Exploring the Bard's Use of CBT Techniques for OCD Treatment

Shakespeare. The beloved bard, the master of the English language, and... a secret CBT therapist? As it turns out, behind those poetic verses and dramatic soliloquies, Shakespeare may have been an early adopter of cognitive behavioural therapy. Who knew that the same man who penned "To be or not to be" was also an expert in identifying and challenging cognitive distortions and obsessive thinking traps? It seems that some of his most famous quotes are straight out of the CBT handbook. So, without further ado, let's explore the world of Shakespearean therapy and see what pearls of wisdom the great playwright might have for us today.

The paradox of thought control

Our thoughts possess the power to shape our world, but only if we allow them to. As Shakespeare astutely observed, 'There is nothing either good or bad, but thinking makes it so.' Thoughts are not inherently good or bad, and they do not possess any inherent moral or ethical value. Thoughts are merely mental occurrences, and it is our interpretation of them them that assigns them a moral or ethical value based on our judgments, beliefs, and attitudes towards them.

Cognitive Behavioural Therapy teaches us to identify and challenge negative or distorted thinking patterns, and to develop more balanced and adaptive thinking styles. By learning to evaluate upsetting thoughts more objectively and realistically, we can improve our emotional well-being, and make better decisions and choices in our lives.

Bring an awareness of the paradox of thought control.

Some studies have suggested that the average person has around 6,200 thoughts per day, although this number can range from as few as 2,000 to as many as 70,000 thoughts per day. We effectively manage to cope with such a huge amount of thoughts by our attentional processes. We learn to filter what we pay attention to and what information to ignore.

Some kinds of information take priority, such as information related to threat, and thoughts that have relevance to our main goals and motives. We ignore thoughts that are not relevant and we attend to those that are.

Obsessional thoughts, are thoughts that arrive in our minds that in some way threaten our immediate goals or values and therefore are distressing. As a result a person with OCD gives them attention and priority and if feels extremely difficult to ignore them, and so starts a vicious cycle. They are in fact more like a faulty fire alarm beeping in our ear, thoughts and predictions that make us feel threatened, rather than a real threat.

The paradox of thoughts control is the harder people try to control thoughts, the more difficulty they have with them. Research has shown that when people with our without OCD try to supress a thought, they may have short term success, but after they stop trying, the thought returns with greater frequency.

The process of actively monitoring and controlling our thoughts can backfire and lead to increased anxiety, distress and sometimes more confusion and uncertainty. What a tangle!

This is because the very act of trying to control or find answers our thoughts can often reinforce them or make them more difficult to ignore.

The paradox of trying to control our thoughts control highlights the delicate balance between actively challenging negative thoughts and allowing ourselves to experience our thoughts and emotions without judgment or suppression. 

For example, a person with OCD may have a thought that they will harm someone they love, which is opposite to their values and desires. However, instead of recognising that it is just a mental event and letting the thought pass, they give attention to it, assign a moral value to the thought and believe that they must perform certain rituals or behaviours to prevent harm from occurring.

The key to overcoming obsessional thoughts and intolerance of uncertainty is to abandon the belief that a thought or idea has to be controlled, or certainty meeds to be gained, by:

Deflating their significance - by paying less attention to the thoughts. Treat them an unimportant products, or guess work of the mind.

Exposure - exposure yourself to the thought or feeing of uncertainty.

Reduce stress - you will have more success in overcoming unwanted intrusive thoughts and doubts if you can also work on improving your mood and reducing your overall stress levels.

Continued below…

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For someone with scrupulous OCD, this quote from Hamlet 'There is nothing either good or bad, but thinking makes it so’, can be particularly relevant and helpful.

Scrupulosity OCD is a subtype of OCD where an individual experiences persistent and intrusive thoughts about morality, ethics, and religious or spiritual matters. They may constantly worry about committing a sin or doing something wrong, and they may engage in excessive and ritualistic behaviours in an attempt to alleviate their anxiety.

The quote suggests that our thoughts and interpretations of events are what gives them meaning, rather than any inherent quality of the event itself. For someone with scrupulosity OCD, this can be a useful reminder that their obsessions and compulsions are not necessarily related to any objective reality but rather are products of their thinking patterns.

By challenging the belief that there is a clear and objective line between good and bad, the individual with scrupulosity OCD can begin to loosen the grip of their obsessions and compulsions. Instead of trying to control every thought and action to avoid any possibility of wrongdoing, they can start to recognise that their thoughts are not always accurate reflections of reality.

Overall, the quote highlights the importance of questioning our thoughts and interpretations, particularly when they lead to negative emotions and behaviours. For someone with scrupulosity OCD, this can be a powerful tool in managing their symptoms and improving their quality of life.

Exposure & response prevention (ERP) therapy.

ERP is a type of CBT that involves gradually exposing the individual to situations that trigger their obsessions while preventing them from engaging in their usual compulsive behaviours.

For someone with scrupulosity OCD, this might involve exposing them to situations that challenge their beliefs about morality or ethics, such as engaging in activities that they consider to be "sinful" or "wrong". The goal of ERP is to help the individual learn that they can tolerate the anxiety and discomfort that comes with confronting their fears and that they don't need to rely on compulsive behaviours to feel safe or in control.

In addition to ERP, Professor Veale might also recommend mindfulness-based interventions, such as developing a more Compassionate Focus, mindfulness-based cognitive therapy (MBCT) or acceptance and commitment therapy (ACT). These approaches can help the individual develop greater awareness of their thoughts and feelings, and learn to relate to them in a more accepting and compassionate way.

What should a person struggling with obsessive thoughts do instead?

Notice that the thought is intrusive and that they are normal events in the human mind. It is important to understand that everyone has intrusive thoughts from time to time. These thoughts are a natural part of the human experience, and they do not necessarily reflect our true desires or intentions.

Challenge the thought - This can be done most effectively out of the moment to start with, so the feelings that may come with this thought, has a chance to reduce, and therefore we can challenge and review the thoughts more objectively than emotionally. Try challenging the thought by asking yourself questions such as "Is this thought true?" or "What evidence do I have to support this thought?" By questioning the thought, you can begin to see it as just a mental event rather than a reflection of reality.

Practice compassionate validation - Compassion is defined as the process of showing sensitivity to the suffering of yourself and others, and having a deep commitment to try to relieve it. This is sone by developing empathy, kindness and being non-judgemental. It is learning to tolerate distress and approaching difficulties with courage. Compassionate behaviour consistent of being encouraging of yourself rather than critical in the midst of difficulty. Taking responsibility to choose change, facing your fears with kindness and strength,

Compassionate validation involves meeting your struggle with understanding, seeing the difficulties you face and the emotions you are experiencing. It is able seeing and hearing you, and supporting you to take healthy and helpful steps forwards towards your valued directions in life, steps forwards that are driven by wisdom and courage.

"Courage without wisdom is reckless, wisdom without courage is inefficient." - Rollo May

Practice mindfulness - Mindfulness involves paying attention to the present moment without judgment. When an intrusive thought occurs, try to observe the thought without getting caught up in it. You can try labelling the thought as "just a thought" and then redirect your attention to the present moment.

Practice tolerance of uncertainty 

This quote highlights the role that doubt and fear can play in holding us back from taking action and pursuing our goals.

Intolerance of uncertainty often sits at the centre of OCD. Doubt and fear can be particularly intense and debilitating, preventing a person with OCD from engaging in activities that they enjoy or that are important to them.

Anxiety is triggered by the idea of an unknown possible threat such as ‘I might have run over a pedestrian’, ‘I could have inappropriately touched someone’, I might be contaminated’ - all these thoughts are guess work of the mind, triggering off anxiety of not knowing whether something bad is going to happen or has happened, it can feel worse than anxiety experienced when something does happen. Very often a person with OCD who struggles with uncertainty will respond to these worry thoughts with efforts to seek certainty, by trying review their actions, check their memories, return to check environments they have been or seek reassurance from others.

By trying to avoid uncertainty we actually become less flexible and less receptive of uncertainty, and therefore lead to more discomfort. The less you practice tolerating doubts and not knowing, the harder you find it to tolerate them. Its a vicious circle. The more you check your memory, the less confident in your memory you become, driving up your anxiety and leading to increase likelihood that you will feel the need to check, mentally review or seek reassurance, and so on.

The thespians rather wise quote “Our doubts are traitors, and make us lose the good we oft might win, by fearing to attempt", encourages us to confront our doubts and fears, rather than allow them to hold us back.

To read more about overcoming an intolerance of uncertainty, head to this blog.

In Acceptance and Commitment Therapy (ACT), the focus is on taking action towards our values and goals, even in the face of difficult thoughts and emotions.

For someone with OCD, compulsive behaviours and intrusive thoughts can be a significant barrier to living a fulfilling life. This quote from Richard II encourages us to make the most of our time, rather than allowing ourselves to be held back by anxiety or indecision.

By focusing on what truly matters to us and taking steps towards our goals, we can learn to live a more meaningful and purposeful life, even in the presence of OCD symptoms. Rather than allowing OCD to control our lives, we can choose to take action towards the things that bring us joy and fulfilment.

Exposure and Response Prevention (ERP) is a type of cognitive behavioural therapy that involves gradually exposing individuals with OCD to their fears or triggers while preventing them from engaging in compulsive behaviours. In the case of mental contamination, ERP typically involves exposure to imagined or symbolic contaminating agents (e.g., thoughts, images, or scenarios that trigger feelings of contamination), followed by prevention of the compulsive behaviours that are typically used to cope with these feelings (e.g., excessive washing, avoidance of certain situations, mentally neutralising a thought with another thought or action or objects).

The quote "Out, damned spot! Out, I say!" from Lady Macbeth's sleepwalking scene is a powerful representation of the futile nature of compulsive behaviours, as Lady Macbeth desperately tries to wash away imaginary bloodstains from her hands. This quote highlights the way that OCD symptoms can persist even when we know on a rational level that they are unnecessary or irrational.

In ERP treatment for mental contamination, clients are guided through exposure to their feared thoughts or situations, which may include imagining or visualising a contaminated object or being in a situation that triggers feelings of contamination. The therapist works with the client to prevent them from engaging in compulsive behaviours such as washing or avoidance while helping them to tolerate the anxiety and discomfort that may arise during the exposure.

Through repeated exposure and prevention of compulsive behaviours, the brain gradually learns that the feared consequences (e.g., becoming contaminated or feeling intense guilt) are not as likely or as catastrophic as previously believed. This process is known as habituation, and it can reduce the intensity and frequency of OCD symptoms over time.

Cognitive behavioural therapy (CBT) and Acceptance and Commitment Therapy (ACT) are both effective treatments for OCD. CBT helps individuals identify the connection between their thoughts, emotions, and behaviours and challenges irrational thoughts and beliefs that contribute to OCD. Clients learn to tolerate uncomfortable emotions and sensations and develop more effective coping skills. ACT, on the other hand, emphasizes acceptance of the presence of unwanted thoughts and emotions and encourages individuals to commit to a life based on personal values and goals.

The quote from Romeo and Juliet, "O, she doth teach the torches to burn bright! It seems she hangs upon the cheek of night as a rich jewel in an Ethiope's ear," captures the intensity of OCD symptoms and how they can feel all-consuming and overwhelming. However, through CBT and ACT, individuals with OCD can learn to manage these symptoms and still live fulfilling life based on their values and goals.

By challenging irrational thoughts and beliefs and developing mindfulness skills, individuals can observe their thoughts and emotions without getting caught up in them. By identifying their core values and taking action towards meaningful goals, individuals can live a life based on what is truly important to them. Although OCD symptoms may still be present, CBT and ACT can help individuals learn to manage them effectively and live a more fulfilling life.

So without knowing it, Shakespeare may have been an early adopter of cognitive-behavioural therapy (CBT). Some of his most famous quotes are consistent with the principles of CBT. Here we have explored CBT techniques such as exposure and response prevention (ERP) and mindfulness-based interventions and how they can be used to manage OCD symptoms.

My final reflection and advice are to do as Shakespeare recommends, to focus one's energies on what truly matters to you and take steps towards your goals.

"I wasted time, and now doth time waste me" from Richard II Act 5 Scene 5.

Lisa Johnston

CBT & EMDR Therapist

 Director My Therapist Online