 We demystify what goes on behind the therapy room door. Join us on this voyage of discovery and co-creative conversations. This is The Therapy Show, behind closed doors podcast, with Bob Cook and Jackie Jones. Welcome back to the next episode of The Therapy Show with myself, Jackie Jones and Bob Cook. What we're going to be looking at and really interested in this is the rising, well no we're going to look at the rising online therapy next time but what we're going to look at this time is how to work with people with intrusive thoughts. What are intrusive thoughts, Bob? Well they're very normal. I mean I don't know how you see intrusive thoughts but I think most people have intrusive thoughts. I mean if you think about from the moment we wake up to the moment we go to sleep or we're just talking to ourselves. So are we talking internal dialogue? Is that intrusive thoughts? When people talk about intrusive thoughts, what they're talking about is thoughts that may appear when they're anytime during the day. So they may appear and it might be things like fantasies or they might have harmful thoughts against themselves or they may think things that they haven't thought before or they may obsess about things or they may think oh well I haven't shut the fridge in my house, I've got to go back. Those are these sort of thoughts which I believe are in the subconsciousness but may raise their head and people don't know why. Okay so yeah they're quite normal, I have those in awful lot. Yeah I think the most important thing to think about is that their thoughts. Now the problem is of course if people then may, if they go the next step in action them then we have got a problem. For lots of people who may think what pops in their head might be oh you know hopefully not but you know as I said I didn't shut the fridge or I didn't shut the gate or didn't shut the house or maybe they have a sexual fantasy or maybe they even think about harming themselves but you know there's a difference between thoughts and actions. Yeah 100% agree with that but I talk with my clients so often about thoughts and the thoughts create our feelings and then we have a choice whether we act on them. And we you know hopefully we don't act on a lot of these compulsive, intrusive thoughts might suddenly pop up and we don't know why we think them and I think then people get worried about why they think about them but actually if you know if you don't action them they might my advice would be just to accept them and let them go. Yeah but for somebody that does have an awful lot of overthinking it's it's quite easy to say just let them go. For me one of the things I talk a lot with people about is that thoughts are neutral until we give them energy. A thought is just a thought whether it's a good thought, a bad thought and a different thought. I want chocolate ice cream thought to anything it's the same makeup but some we give more energy to and kind of build a story around it. And then like you said exactly why am I having that thought? What's it about? Where's it coming from? What if I act on it? What if this happens and then it becomes a bigger thing than what it needs to? Well I agree with you and you know often intrusive thoughts might be linked to OCD and you might start worrying about them, things that pop up in their head about I've left the keys in the car or I keep thinking about whether X is safe or not or I keep thinking about Jo and I don't know why I do. So these sort of thoughts might suddenly pop into people's heads and they are internal and not external unless you carry them to carry them out and put them into actions. There's not really a problem. The problem is when people start worrying and worrying and overthinking and the real problem then is if they act out some of those thoughts. So how would you work with somebody in a therapeutic way if they came to you with overthinking, intrusive thoughts, worrying? Some of the overthinking can be protective. Some of the intrusive thoughts can be protective. Most of them are. Survival, a lot of it. Yeah and keeping self safe and thinking about whether I've, as I've said, whether I've left the phone or not or will I've left the keys in the car or whether. So some of them are protective, intrusive thoughts aren't they? So that's not a problem. Yeah. The problem only becomes when the person's obsessing, overthinking, getting the anxiety with the thoughts or even may worry about acting them out or if they move to actions then it may become a problem. But the first step is to normalise the process. And then if a person, if it gets to a place where they are so worried they might act them out and their functioning gets impaired or they find it hard to concentrate or they confuse themselves or they feel they're going to act out on these thoughts or some thoughts might appear in a way which isn't good for them, then that's another story. So the first step is to normalise the process and then if we are going to go just step further where their functioning is impaired in some way or there's a tremendous lot of anxiety which means that they aren't able to stay an adult or they think they're going to act out on those actual thoughts in ways which might not be useful, then we might take it further and ask them to explore their thoughts and see how much, you know, how much it's actually in reality that they may sort of play out these thoughts or these actions and get to bottom of what these intrusive thoughts actually are. Yeah. So that would be the next step. Yeah. And again in a safe environment in the therapy room. Yeah. Go on. No, I was going to say because sometimes clients are okay kind of having the thoughts but as soon as they start to talk about them, certain clients kind of think well now it's a thing because I've actually said it out loud. It's not just something in my head. It's not just internal talking about it is kind of bringing it to life which can cause stress in itself for some clients. Well, it made. Usually I have the opposite experience by the way. I'm not, you know, in psychotherapies, you know, it's different for everybody. But my experience is usually the opposite with people. And that is once they are start actually talking about the thoughts or what's going on for themselves internally, they usually feel much more reliant, relieved. And instead of repression, you get more relief. Now, but that doesn't mean to say there aren't people who might bring it and bring it alive. And I still not quite sure what you mean by bring it alive. Do you mean that it becomes an entity and they feel compulsive that they're going to act on those posts? What do you mean that it becomes alive for them so they'll get more scared? I mean, yeah, yeah. I think, you know, I'm okay to talk personally. I talk quite a lot about myself, but I suffered from postnatal depression with all three of my children and it got progressively worse. And I can remember having an awful lot of intrusive thoughts after the birth of each one of my children. And I got scared when I spoke about it because suddenly then it be, you know, having my head was one thing. But when I spoke about it, then I got more anxious about, I suppose people knowing about it, am I likely to act on it? All those sorts of things, it then became more real to me, if that makes sense. Well, okay, and this is the therapist's job then to listen to the story and normalise the process. Yeah. That's the therapist's job there. Yeah. I was thinking a step further really, where I see intrusive thoughts can start to be problematic particularly with it. And that's in posttraumatic stress disorder. Yeah. So posttraumatic stress disorder, where somebody's had a traumatic experience in the past that often does come out in flashbacks. It may come out in the present in intrusive thoughts. Yeah. So when I think of intrusive thoughts, I think of that process being linked particularly with posttraumatic stress disorder, maybe with OCD. But certainly, those intrusive thoughts can often be a way of replaying the trauma in a way, in an attempt to get a different outcome. Yeah. Or even an attempt to relieve that trauma from their system. So it's very, very common for people with posttraumatic stress disorder to have intense intrusive thoughts that is linked not to the here and now, but to the time of the trauma. Yes. Yeah. That's extraordinarily common. And actually, so it's got posttraumatic stress disorder, it'd be unusual for them not to have intrusive thoughts. Yeah. And I suppose the thoughts then, you know, the intrusive thoughts can be triggers to take them back somewhere. It usually is. Yeah. Absolutely. It's the same as the function of flashback, flashbacks. Yeah. Which is that both triggers, like you've just said, however, the desire of both of them is to have two parts of it. One, the desire to have a different outcome. And secondly, to get the thoughts and the flashbacks out of their system. The problem is, of course, especially with intrusive thoughts, people keep them in inside rather than outside. So I would always encourage people to talk about their intrusive thoughts. Now, of course, but with PTSD, if they talk about the intrusive thoughts, they usually go back to when the trauma actually began or when the trauma actually occurred. Yeah. That's where healing can happen. So for that bestilling with PTSD and intrusive thoughts, as the person starts talking about the intrusive mind, the trauma. Yeah. Does that make sense? Yeah. Just recap over that again, because my screen actually froze, so I'm not sure whether we got that on the recording. Okay. It didn't freeze my end, but I'll say it again. Yeah. When I think of intrusive thoughts, you're correct. I do think about in terms of, you know, people who come in, they overthink, they worry, they find they may act out their thoughts. I have somebody today in an assessment who actually had intrusive thoughts, they overthought, they were worried that they might act out those thoughts, and then they came to see me. Yeah. Yes, I do see people like that. And the other thing I want to say is, intrusive thoughts are linked to post-traumatic stress disorder. Yeah. And they're often triggers to go back to the original trauma. So a therapist needs to trace the intrusive thoughts back to the traumatic occasion to help get some healing for the client. Yeah. So I would always encourage and facilitate people who have traumatic events who perhaps have intrusive thoughts today to externalize them so we can get back to where the real trauma is. Yeah. It's the same with all intrusive thoughts actually. But it's an interesting thing that you just talked about from a personal experience is that it became more alive for you. Perhaps you can talk about that in a minute. But with most intrusive thoughts, you would not only help them get the intrusive thoughts out and the next step would be normalization because it's very common. Yeah. You would also trace back to where those thoughts actually occurred from. What's the process behind them? What's the function of these thoughts? Now, sometimes they're protective and that's fine, so that's not a problem. But they may and usually do link back to some time of distress or trauma or in fact, where they've been frightened or frightened themselves. That, yeah. See, I think that's very relevant where they were frightened or frightened themselves because I think a lot of the clients that I see, it's around anxiety and it's like they kind of pin their anxiety on something. That's what caused it and then the intrusive thoughts start around that. That what if I do that again? What if that happens again? What if I catch a train and the same thing happens and it's all that overthinking and the what ifs, which is a protective mechanism? That's what I was just wondering. You pointed out what I was going to point out. Yeah. You see the protection in that. Yes. Yeah. Now, usually with clients, when they start seeing these thoughts as protective, then the normalization is much easier to process because they see the function of them. Yeah. And then we can get down to what they're frightened of in the first place. Yeah. I'm frightened of being like my mother. I find of being like my father who hurt people. I'm frightened of so they get so they get intrusive thoughts about being violent. Yeah. Just like that father did, for example. Yeah. Or they get intrusive thoughts about thinking about or sexualized young people or they get intrusive. But if you start, if you start helping the person externalize these processes and trace them back to the point of origin or what the scare was, that is part of the healing. The worst process, Jackie, is when the person keeps them internalized. Because if that happens, it's very hard to get any help. Yeah. And again, just using a few of those examples that you've just spoke about, I would imagine with certain thoughts, there's a lot of shame and guilt around having certain thoughts, which is why a lot of people, I would imagine, don't talk openly about the intrusive thoughts that they're having because of the belief that what is the other person going to think about me if I tell them about these thoughts. Absolutely. So that's what I'm saying. Normalization is the second stage after externalization with intrusive thoughts. And I think most people have intrusive thoughts and usually they're protective ones and the person can accept them and move on. The problem comes, I said, when it's linked to trauma, when it's linked to OCD and it's linked to anxiety, then the person might go to a place where they find every day functioning difficult. Yes. Yeah. And I think that's what I see probably most in the therapy room. Which what? Around anxiety and things like that, overthinking intrusive thoughts around, you know, and it is impacting on their life. As soon as they're doing something that they think is going to trigger their anxiety, you know, the world is getting smaller because of the intrusive thinking that they've got. That's right. So if we look at a stage plan for intrusive thinking then, encouraging them to externalize those thoughts. Number two, normalization. Number three, encouraging them to see the function of the intrusive thoughts. Yeah. Number five, I think, would be to trace back the origin of all the repetitive processes involved in those intrusive thoughts. And usually, you know, however bizarre the intrusive thought is, if you trace the thought back to that origin, it's the opposite of bizarre. It's perfectly normal. Yeah. And that's when healing occurs. Yeah. And I think something I hear a lot of is, you know, before they even talk about the thoughts that they're having, they'll say it's really stupid, but it's ridiculous. But and they kind of, they're minimizing the thoughts that they're having. They're already talking about how ridiculous it is, or it's stupid, or it doesn't make any sense. Yes. And also they're protecting themselves against perceived rejection or ridicule. Yeah. So that's why they say that. Yeah. Which is why I said, you know, earlier on about the guilt around having certain thoughts and what the other person will think of them if they talk about it. Yeah. So this is all very normal. Yeah. And you are right when you say that, you know, that anxiety overthinking and especially the fear of acting out on their overthinking or their intrusive thoughts may bring a certain lack of functioning. And that's when you need to start to help them externalize and talk about their intrusive thoughts and certainly help them seeing that this is normal and protective. Yeah. And also I'll repeat it again. When somebody's had high trauma and they haven't had therapy or haven't dealt with it and they've compartmentalized, then they often have intrusive thoughts. And the intrusive thoughts are number one, they're protective. And secondly, I think they're aimed at a desire for a different outcome. So with trauma will come flashbacks trigger and will often have intrusive thoughts. Yeah. And many intrusive thoughts, by the way, are as I said before, when people are frightened or have been frightened or have fear that they may act out like their perhaps abusive dysfunctional family. Once they've started to separate out that they aren't that, then healing can happen. Yeah. Yeah. I think it, you know, providing a safe space for them to talk about anything is really important. And it's one of the first things in therapy. I've never had anybody come because of intrusive thoughts. It's always been part of something else that's brought them to therapy. Yeah. It's to do with trauma anxiety, OCD particularly, I think, often thinking about, well, as I said earlier, did I leave the cars, the key in the car, or did I close the door, or did I shut the fridge, did I feed the cat, did I take the dog for a walk, did I do this, did I do that? And the more obsessive the process, the more the overthinking, and the more those thoughts rise up from their pre-consciousness. And then they start worrying and overthinking. So they're all linked together. How long have you been seeing clients now, Bob? I stopped two years ago, I mean, still do therapy intensive, but one to one groups finished about two years ago. But when did you start? How long were you? Oh, 1985. Well, so what, 30 years ish? 36 years, 37 years. Would you say that you would towards the end of your, you know, practicing that you were seeing more people with intrusive thinking than what you saw back in kind of 85? I think the language is different. I don't think people use the words intrusive thoughts back then. It's all a common day phenomena. As languages, as mental health has been more accessible and discussed, diagnosis has changed, language changed. But if I look back in 1985, 1986, you know, those 80s and early 90s, I think people talked a lot about intrusive thoughts that probably just didn't use that language. Okay. So only in recent times, I've heard that language where people talk about they have intrusive thoughts because I think it's part of the mental health lexicon now. But yeah, back. I'm just thinking our lives now are a whole lot busier than what they used to be. You know what I mean? Social media, all those sort of things, access to Google, you know, none of that was around kind of in 1985 and 1986 and things like that, that we've got access to so much more information now that I think sometimes our brains can find it difficult to process that information. And whether you've seen a difference in that impacting on clients over a 36 year time frame. Like when you were saying about, you know, checking that you'd left your keys in the door or that you'd turned the cooker off and things like that. I see that an awful lot. But it's because we're not mindful on what we're doing. Our head is so full of other stuff that we're not kind of in the here and now a lot of the time. So we forget whether we've done certain things because we're not focused on it. Yes, true. And that's why I say intrusive thoughts are often linked to OCD. Yeah, certainly linked to trauma. But if we use transaction analysis as a model to look at intrusive thoughts just for a moment, particularly the perhaps the more intensive or intense toxic narrative thoughts, then we can think of using the PAC model among parents and adult child. We need to start working out where those come from. Do they come from the internalized parent? So they actually aren't, you know, they aren't the words from themselves, for example. Do they come from a scared child, which is what I think mostly. Intrusive thoughts come from the child ego state, whether the person's being frightened or fear. And one thing that is really important about this is to help the clients, how can I explain this, be able to soothe themselves under stress. In other words, you know, if somebody's got very little nurturing parents internally, they aren't so able to soothe themselves or understand the process that when they get these sorts of thoughts, they're very common, it's okay, we can accept them and let them go. But often what they start doing is telling themselves off. So there's a toxic narrative, just like you just said earlier on. So I think TA is a good way of thinking about what we need to help the person internalize, which is a nurturing parent, which they've probably never had, and help them understand quite often that these intrusive thoughts come from a child or younger self-position in response to an internalized parent. Yeah. Yeah, I love that, Bob, yeah. That's something that I do talk a lot about with clients, yeah. I'm being compassionate with that side of ourselves, that scared young child that, yeah. Because often we wouldn't do that to an actual child. If a child was scared or needed comforting, we wouldn't tell ourselves, not tell them off. No, we would do the complete opposite, yeah. That's right. So that comes with the territory, how to help people nurture themselves and accept these thoughts as part of a whole process and move on from that and see them as normal. And also at the same time, if those thoughts are so frightening that the person isn't able to function well or regresses or frightens themselves so they get confused or or that process to trace back where those thoughts came from and what's the function of those thoughts and what's the scare about. And I say quite often it's linked to trauma. Yeah. The process is linked to trauma. And also if they've been in a traumatic family situation where they've been part of a dysfunctional system and so haven't been able to internalize a model of positivity, they often get scared that they're going to act out like their mother and father or people they've seen around them which hasn't been positively helpful. Yeah. Yeah, which, you know, what you were saying then it all kind of links together. If they've been part of a you know, a chaotic family and maybe they, you know, there was a time when they were younger where they didn't feel protected or safe, you know, and nobody soothed them, then they don't know as an adult how to soothe themselves at times of high stress and emotion and you know, then it becomes part of who they are. So yeah, it's, it's all linked together. I think self-soothing is something that a lot of us find difficult. We look for something external to make us feel better. Yeah. And if you haven't had in your own history, if you haven't had a model of somebody who is soothing to you or to their partner, then you haven't got that internalized model. You have a high, if you are, I don't know if we've talked about strokes in the podcast, but if you're brought up on a culture of negative strokes, then you haven't had a full meal and therefore you aren't able and distressed to be able to soothe yourself and especially when you're having these intrusive thoughts. Yeah, 100%. Yeah. And I think we have touched on it in the very, very early days. Yeah, positive strokes and negative strokes and yeah, as a unit of recognition from our main caregivers. Yeah. So if we haven't had that or haven't internalized that experience, it's much harder to be able to take care of ourselves in a kind way. Yeah. And the lack of that leads to low self-esteem. Yeah. So, you know, when those clients come to us and say it's stupid and it's daft and, you know, all those sorts of things, it is quite normal for us to have intrusive thoughts, but if they're not dealt with compassionately or maybe in the right way, then the impact of that is like a domino effect with confidence, with self-esteem, with relationships, with trust, with all sorts of stuff. Absolutely. Yeah. Absolutely. You've hit the nail on the head there. Interesting, interesting. So we'll leave it there. No doubt we'll come back to this. It was, I quite like this subject and yeah, I'm interested again to know more about the changes that you've seen over your career, but maybe we'll hold that for the next podcast. The biggest change I think is in accessibility to mental health services, the de-stigmatisation of therapy and counselling and the change in language. That's a long time that you've been doing it, but a long time. A long, long time. Right. We'll leave that there. So the next episode, talking about how things have changed in the time that you've been doing it, we're looking at the impact or the growth of online therapy. Yeah, yeah. Interesting. Okie doke, until the next one, Bob, speak soon. Okay, great. You've been listening to The Therapy Show, behind closed doors podcast. We hope you enjoyed the show. Don't forget to subscribe and leave us a review. We'll be back next week with another episode.