Author Archives: Dr. Jonathan Grayson

The Cruelest Obsession: Obsessing about Obsessing

From: OCD Newsletter.  2004, 18, Issue 4.
by Jonathan Grayson, Ph.D.

From: OCD Newsletter, 2004, 18, Issue 4 – by Jonathan Grayson

If you have OCD, you know the torture of constantly trying to avoid a potential disaster or feared consequence, whether it be harm to you or your family, going crazy, being evil, forgetting something – the list is as infinite as human imagination.  Most of the time, the feared consequences don’t occur  – your family doesn’t contract AIDS, you don’t turn into a serial killer, you don’t molest your children.  For obsessing about obsessing the fear is the obsessions will never end and as a result life will be horrible because.  And it’s true, the obsessing is constant and life is horrible.

Now many of you without this obsession may feel this describes you – you fear you are doomed to a life of endless obsessing and misery.  What you are recognizing is that this fear is a part of almost all obsessions.  However, in most cases it is a secondary fear; that is, you have primary obsession like contamination issues with a primary feared consequence of contracting AIDS.  Treatment of the primary fear usually makes attention to the fear of endless obsessing unnecessary.

So what does obsessing about obsessing look like.  In its most common form, the sufferer is having neutral obsessions, in which something feels “stuck” in your mind such as: noticing your breathing, a song, or a picture.  These are called neutral, because there is nothing about the stimuli that is dangerous, upsetting or even unlucky.  The entire problem is simply feeling you cannot get them out of your mind.  Related to this is pure obsessing about obsessing: constantly thinking and obsessing about how your life will be ruined by your obsessing with little other content.  Some of you may have rituals or avoidances, but the main ritual, the wishing ritual, is usually ignored in treatment.  I’ll come back to this.

A particularly insidious form of obsessing about obsessing occurs when another form of OCD changes into this.  Take the case of Bill who was discussed in my book.  Bill had numerous checking rituals with seemingly obvious disasters.  For example, whenever he used the microwave oven, he would be plagued by images of fire that wouldn’t about without checking rituals.  At bedtime to avoid thoughts of intruders breaking into his house he went through extensive door locking and checking rituals.  His concerns and treatment appear to be obvious: exposures focusing upon the risk of fire for microwave and risk of his house being broken into for the front door.  Exposures like this were done by his therapist, but Bill’s anxiety continued relentlessly.

The problem was focus of the exposures.  Although there had been a point in time when the focus of these exposures had been Bill’s feared consequences, this was no longer true.  His main feared consequence was that the obsessions would continue forever.  So while his therapist was trying to treat his fear of disaster, Bill kept trying to make the obsessions stop.  For Bill, treatment became another one of his rituals to try to stop obsessing.  The purpose of his old rituals was no longer to prevent disaster, but to stop obsessing.  Thus whenever he was confronted by an obsession, he would obsess about what method he should use to stop obsessing: his old rituals or exposure.

But isn’t the purpose of treatment to stop obsessions?  No!  Then does that mean you are doomed to live with constant painful obsessions?  Thankfully, the answer is also no.  In the remainder of this paper, I’d like to discuss: 1) the common mistakes therapists make in treating obsessing about obsessing; 2) the wishing ritual; and finally, 3) what you can do about it.

The first mistake therapists and sufferers make is illustrated by the case of Bill, not recognizing the feared consequence, which results on a treatment that focuses on the wrong symptoms.

The second mistake is seen in the case of neutral obsessions.  The therapist will use downward arrow, a cognitive technique, to discover what your core fear is.  They are trying to find out how life will be horrible if you keep obsessing.  Downward arrow can be very useful, but the problem is they go to far, because the fail to recognize that the emotional pain of obsessing is the worst consequence.  The therapist’s attempts to focus upon his/her perception of the “real” consequences are misguided.  Treatment won’t be effective because it fails to address both the wishing ritual and your worst fears.

The wishing ritual is not a straightforward ritual; its core is denial, so to understand the wishing ritual I need to explain denial.  Undoubtedly, you’ve heard psychologists talk about denial, but have you ever wondered exactly what it is.  For example, what does it mean to say someone is in denial after the death of a loved one.  Simply defined, denial is comparing reality to fantasy.   In the case of death, denial is not a delusional fantasy of believing that the dead are alive; it is comparing the present with how much better life would be if the deceased were still alive.  Life might be better if your loved one were still alive.  On the other hand, perhaps something more terrible might have happened in the future.  Of course, something more terrible in the future isn’t part of the fantasy comparison.  In comparisons between real life and fantasy, fantasy always wins, because you don’t include problems in fantasies.

When we compare reality with fantasy, we destroy and demean the moment.  For example, imagine yourself with your lover at a beach by a small lake at sunset.  And suppose you think to yourself: if we were rich, we could be at a fabulous Caribbean resort by the ocean, watching a brilliant sunset with waiters bringing tropical drinks at the snap of our fingers.  It’s a nice thought, but if you allow yourself to be consumed by such fantasy wishes, the beauty of your very real lakeside sunset is now tarnished.

We see other instances of denial in life.  A woman in a bad relationship may know all her lover’s faults, but will say she can’t leave him because she loves him.  She’ll describe how wonderful he can be at times, and wishes he were that way all of the time.  What she is really saying is that she loves this man 20% of the time and wishes the other 80% would change.  If he changed though, he would be someone else.  Does she, in fact, love him?  I would suggest she doesn’t.  Or to be more accurate, she does love 20% of him and what she needs to do is find someone with more of the qualities she loves and less she wants to change.  Perhaps no one will be perfect, but she could do better than 20%.

But why would any of us engage in denial?  Rituals are supposed to provide some kind of relief, even if it only for a few seconds.  The relief provided by denial and the wishing ritual help us to avoid the loss that acceptance brings.

For the woman in a bad relationship acceptance of her true feelings for her lover would involve loss.  Her friends will tell her it is great she finally left him. But what about her fantasy relationship, the one in which she clung to 20% wishing it was more?  With her fantasy lover gone, she has nothing but emptiness.

Imagine a gambler who has stopped gambling.  Everyone around him congratulates him.  Finally, he will get out of debt.  His family life will come back together.  He won’t lose his house.  It is a time of triumph. But he is sad.  Why?  Because he will never be rich.  He’ll spend the rest of his life being just like everyone else.  Again, this is his fantasy, because in reality he probably never was going to be rich.

Even in mourning, denial can feel better in the short run than acceptance.  You can feel this difference in the words of denial versus acceptance.  In denial, a person says, “Life would be better if my wife were still here.”  In acceptance this becomes, “My wife is gone.”  The sadness of the denial statement doesn’t come close to the stark reality of moving towards acceptance.  Mourning is the process of moving from fantasy to acceptance.  You may always miss your loved one, but you can also relearn to enjoy life in the present.  Mourning is not easy to go through, but to avoid the pain of mourning is to be trapped in a fantasy you can never have.  Just like the gambler.  Just like the lover.  And, perhaps, just like you with your OCD.

For obsessing about obsessing the wishing ritual involves you imagining how much better life would be if you didn’t obsess – your marriage and your work performance would improve, you wouldn’t be so easy to upset, you would enjoy life more and so on.  These may have some truth to them, but they may not.  You may have unrecognized relationship difficulties that need attention above and beyond your obsessing.  Maybe your boss is difficult and you wouldn’t be any more tolerant if your OCD was under control.  Life would be better if your OCD was under control, but probably not as good as your fantasy.

Having your OCD under control does not mean that the thought is gone.  The reason for this is that for any thought will become an obsession if you want to know something about that thought (e.g., does this make me evil?) or if you want to be sure it won’t stay forever.  After all, who wants to have an upsetting thought stuck in their mind forever?  No one, but the goal of treatment is learning have the thought in your mind without caring about it.  Note I said learning, if it were as simple as a decision, you would be cured after reading this article.  Learning is a process that takes time.

Imagine that you have lost a loved one and that it is three weeks later.  You are back at work.  Will thoughts of your loss pop into your mind?  Yes.  Will these thoughts be upsetting and interfere with your concentration?  Yes.  If this happened in a movie theater, would this interfere with enjoying the movie?  Yes, but your enjoyment wouldn’t necessarily be zero.  Would the thought stay for the entire movie?  Maybe.  Would you call thinking about this death only three weeks later an obsession?  No.  The difference isn’t that the death is real, but that you don’t say to yourself I must not think about my loss.

Imagine having a headache.  It hurts and it interferes with functioning and enjoying life.  However, most of you can function with a headache.  While you are suffering from one, you enjoyment of life is interfered with, but it isn’t zero.  Sometimes while you are suffering from the headache, you may even have some time in which you don’t notice it.

Treating obsessing about obsessing or neutral obsession is not a matter of getting rid of the thoughts or images.  It is getting to the point where you don’t care whether or not they are present.  You might recognize that this is the goal of treatment for all primary obsessions.  Exposure and response prevention is the path you will take to achieve your goal.  As with any treatment, it will need to be tailored to you.

The exposure part is simple, you want to make sure that there is no way to get the thought/image out of your mind.  In your environment put as many visual cue reminders that you can.  At any office supply store, you can find ¼ inch red dots, that you can paste in places you are sure to see them, (e.g., the corner of your computer screen, the center of your watch, the bathroom mirror).  If someone sees one on your watch, you can simply say its to help you remember something.  In addition, you can make a cassette tape or burn a CD, that says a single word every one to three minutes.  You should listen to this tape as much as possible.  I mean this literally.  Wear headphones anyplace where it isn’t inappropriate.  You may not be able to listen at work, but you can while shopping, watching TV or a movie, spending time with your family or going to sleep.  You can make the volume low enough so it won’t interfere with these activities.  The more inescapable you can make this the better.

You may feel this isn’t necessary, because your obsession is always there, but this isn’t true.  Sometimes it leaves, even if only for a few minutes.  Then when it reappears, your immediate thought is: “Oh no, there it is again, I can’t believe it…”  Without meaning to, you are off and running into your wishing it was gone.  And just like it is hard for an alcoholic to stop once s/he has started, so too is it hard for you to stop once started.  With the one word script constantly playing, the wishing is partially relieved, because as long as it is playing you don’t wish the thought away, because you know it is impossible while the script is playing.  In addition, you will also be unable to forget why it is playing: that you want to get better by learning to tolerate the thought.

The response prevention is a more complicated, because your rituals ares mental and automatic.  However, the initial goal is to try to have these thoughts in the back of your mind rather than the center.  The first thought to work on is how much better you would feel right now if you weren’t obsessing.  Again, as a result of the wishing ritual, you are taking whatever enjoyment you might be having and making it worse.  Consider the following two examples.

First, example imagine you are in a movie theater and you can hear the soundtrack from the movie in the theater next to you.  You have two choices.  You can accept (the opposite of denial) that you will only get 50 to 70% of the pleasure that you were expecting or you can spend the entire movie focusing on the other sound track and wishing you couldn’t hear it – your pleasure will be reduced to 20 to 30%.  Or perhaps you will leave the movie and get 0%.  By accepting reality, I will not have a perfect time, but I will have a better time than wishing would allow.

Now imagine you’ve lost your arm.  Obviously life would be better with two arms and it wouldn’t be possible to never miss your arm.  However, which life goal makes the most sense: 1) learning to have the best one-armed life possible or 2) comparing every moment and activity to how much better it would be if I had two arms – something that is never going to happen?

Acceptance does involve loss, but it allows us to live in and appreciate the present.  At this moment, with this form of OCD, enjoying things the way you feel you should is not a possibility.  If it were, your OCD problem would be insignificant.  So part of response prevention involves focusing on whatever little enjoyment is present and learning to enjoy the 20 to 40% that can still get through despite your obsessing.  This means not avoiding any activities, because your obsessing will interfere with them.  In addition, you need to schedule and spend time reminding yourself that you are trying to accept whatever you can get in the present.  You can change your one word script recording, so that the one word it repeats every 1 to 3 minutes is “enjoy.”  This way it simultaneously reminds you of your problem and your goal.

This highlights something else you will have to accept.  Treatment will take time.  The amount of pleasure I’m asking you to appreciate is not the endpoint of treatment.  It is the beginning, but if you are unwilling to take the first step, then don’t expect to reach your goal.

As I earlier stated, overcoming obsessing about obsessing will make life better, but it will not make all other problems vanish.  Examine your other problems to see in what ways they may be upsetting above and beyond your obsessions.  Anything you can discover probably needs attention and you shouldn’t assume that overcoming your obsessing means that these other problems will disappear or won’t need attention.  In treatment our assumption is only what is treated gets better.  If I only work on your OCD, then that is all that improve.

Obviously, there is more to working on obsessing about obsessing than can be covered in a short paper.  It is impossible to work on any problem if you don’t understand the problem or the goals of treatment.  Hopefully I’ve helped you to understand this problem and what the goals of treatment are.   Ultimately, overcoming the wishing ritual means moving from denial to acceptance, from fantasy to reality.  Reality may not be as pretty as fantasy, but it is far better than the misery of wishing.  The ultimate goal of treatment is to be able to enjoy the present for what it is.  After all, the only time I can enjoy my family is when I’m with them.  When I’m at work, they are a memory of times past and a hope they’ll be there for the future.  By working on your OCD, you too will find that you can live in and enjoy your world as it is.

No one should do exposure and response prevention!

Exposure and response prevention (ERP) is the first line treatment for OCD, but no one should do it!  I do believe that any sufferer with OCD who would like to be free of this problem would be well advised to choose ERP for treatment.  Many sufferers of OCD find their decisions and actions guided by shoulds, by what is right and wrong.  They would say that this is being responsible.  Wrong. Responsibility is not a matter of what you should do.  Responsibility is taking the steps to accomplish the things you want to do.  The responsibility of shoulds involves some authority shaking a finger at you demanding you to be good or to do the right thing or else.  This is neither thoughtful nor helpful.  When we are working with an individual, we emphasize that we don’t want them following the treatment we are proposing simply because we are experts who are supposed to know, we would like them to follow our treatment if we have convinced them that this is the best way.

The responsibility of taking the steps to accomplish what you want puts the power in your hands.  With regard to OCD, this makes the decision to do ERP a matter of thoughtfully looking at what treatments and evidence for them is available.  However, it does impose an additional requirement.  It makes you responsible for possible outcomes.  I often ask someone, can an individual be a responsible criminal and if so how?  Many want to say no, because they confuse responsibility with right and wrong.  Others will say yes, but if I ask how, they suggest by carefully planning their crimes.  This would be part of it; however, in making a choice, I also need to consider the possibilities of what might happen.  I used to work with drug addicts on probation and parole and I ran into responsible and irresponsible criminals.  The responsible felons were those who had accepted the possibility of landing in jail, since most of the people they knew eventually were caught.  They may not have liked prison, some went straight following their incarceration, but they accepted the consequence.  The irresponsible felons complained about how unfair it was that they were in prison and why the system should be changed and so on.  All of that might be true, but it was true, that regardless of what they feel, the law was the law and they apparently weren’t willing to accept prison as a real possibility.   A similar example would be someone who would like to become an actor.  It is fine to hope to become a Hollywood star, but if failure isn’t acceptable, then acting makes no sense to try, since this is the most likely outcome.  If on the other hand, you want to devote a number of years trying before moving on, or if you are willing to accept not getting further than community theater, then attempting to go into acting is responsible.

Anyone suffering from a problem would wish the problem to be gone quickly.  But at this moment in time, ERP is the most researched treatment and the only one that all of the experts and professional organizations (both the American Psychiatric Assoc and the American Psychological Assoc recommend ERP as the first line treatment for OCD as well as the International OCD Foundation).  The possible feared consequences that most sufferers face are horrible, but consider a few facts.  First, what have you lost to OCD and I don’t mean in general, but in detail, humiliating experiences, being late for important events, lost relationships and so on.  Second, how have you hurt your loved ones – forcing them to do rituals, endlessly asking for reassurance, being angry at them for not giving in.  If you have children, would you do anything for them?  If you say yes, and I don’t mean to be offensive, but you are lying to yourself.  You put your OCD fears in front of their welfare.  You run the risk of having children who won’t respect you or who will live in fear of the world.  There is a 1 in 4 chance your children may have OCD and your behavior teaches them that OCD is something to cope with or not.

And there is a third reason.  At this point your OCD steals everything from your life and hurts your loved ones.  Even if you were to leave them, they would just be hurt more by your abandonment.  And you are willing to have all this happen because of a possibility of something bad happening.  Whatever decision you make there is risk. However, the saddest thing about your rituals is that they don’t work.  You never get the safety or reassurance you wish for.  And if you described your rituals to me, I would be able to find flaws – reasons you are still at risk.  So the saddest thing about your rituals is that for all of your pain and efforts, you never get the prize, all of your fears may happen anyway.

I have written elsewhere that the only thing we have is the present.  Those you love are only there when you are with them.  So when you are alone, there are past good memories and hopes for a future, but that isn’t now.  And with your OCD, you don’t even have the present, because you are trapped in OCD land.  Responsibility is taking the actions to achieve what you want and accepting the consequences.  To give into your rituals is to decide to have a difficult life, hurt the ones you love and have not guarantee that what you want to avoid will be avoided.  To fight OCD is to want to learn to live in the moment and enjoy it and to learn to cope with possible risks.  Working on your OCD helps you and those you love.  Not working on it hurts everyone.  Running away hurts everyone.  If you really would do anything for those you love, be responsible and take the steps to achieve your goals.

Coping With Uncertainty – Your Don’t Ritualize Enough

Recently I answered a question on a list-serv.  The author noted that ERP wouldn’t work for her, because she wasn’t worried about immediate consequences, but disasters that might result in the future.  I let her know that the point of ERP is NEVER to prove anything is safe, but to assist in learning to live with uncertainty.  Her issue was chemicals, so I thought it would helpful to explain why her rituals weren’t complete enough.  My answer to her is below.   Even if you don’t have contamination, think about how you would apply these same ideas as to why your own rituals are inadequate.

My Answer: The goal of ERP is NEVER to prove that anything is safe. The goal of treatment is deciding the you need to learn to live with uncertainty. The world is full of low and high probability dangers. You are at greater risk to be in a car accident than you are to suffer from your fears and yet you might risk death to see a movie – why would you do that?  Do you check your car tire pressure daily to insure proper inflation to maximize control and braking ability of your car?  Do you talk on a cell phone when you drive?  Do you every drink coffee/soda or eat when you drive? Do you talk to others which can be distracting or listen to the radio. Do you ever drive with a single drink in you which is legal, but still should change the odds.

Since you admit to having OCD, what do you want your relationship to your son to be? Do you want to be the mother whom he makes fun of to his friends when he is in HS? Or since he has a 1 in 4 chance of having OCD, do you want him to learn that it is something he can learn to cope with or do you want him to follow your example? If you choose the latter, the sad part is that his health won’t be significantly protected from your actions, but OCD will rule his life. After all, I don’t know what chemicals/germs you are concerned about, but if he isn’t wearing a mask in school, then he risks illness, because the germs aren’t going to wait until he gets home. Is he to have no contact with other children? Canhe never go to a friend’s house, because you don’t know what lawns they may play on and if they have been treated. Do you live in a pollution free arean(eg the middle of Montana with no industry or farming that uses chemical fertilizers)?  How are you with food additives?  Is he ever going to learn to drive?

If you are going to guard against low probability events, then you need to work much harder at isolating your family and teaching your children to live
in fear of the world? They won’t be normal, they actually won’t be safer, but you’ll feel better for having given into fear.

You actually have 2 problems. The obvious one is OCD and the other is an avoidance of a fear that every parent has – we can’t protect our children.
There are a million ways for them to die, diseases that don’t have obvious external causes, falling down, others and the only thing that saves them is
luck. Because although it is true it is safer to walk on the sidewalk than the middle of the street, walking on the sidewalk is not a guarantee that a
car won’t hit them.

The truth is that OCD is about wanting absolute certainty and there is a reason you can’t have it. Research has shown that the only people who are
certain are stupid people.  OCD sufferers are usually above average intelligence and we don’t know how to make you stupid, so you will have to settle for second best: coping with uncertainty.

The truth about your loved ones is that when they aren’t in your presence, they are a memory of good times past and a hope you will see them again.
The only time you have them is when you are with them. But if you have OCD, you don’t even  have that. So if your son dies in 3 yrs you will have
missed those precious years. And if outlives you, you will miss his lifetime. Can you learn to live with uncertainty? We know you can, because in the above paragraphs , I hopefully mentioned concerns that you don’t have; even though, they carry horrible risks. You can be sure that there is another OCD sufferer
whose fears were touched in the above paragraphs. The goal of treatment is to learn how to experience OCD fears the way you experience the uncertainties
you cope with. It is true there are some therapists who wrongly suggest that ERP proves something?  Yes and your observation that ERP couldn’t establish that anything is safe was reasonable.   Luckily certainty isn’t the  goal of treatment.  Again, think about the car accidents that aren’t a part of your fears.  You don’t demand absolute safety upon getting into the car; and your plan for handling a disastrous accident is to wait for it to happen.  With  your OCD fears you attempt to know now.  That is what you can learn to change.

These same ideas about all of the things that you don’t check for can be applied to any OCD problem you have, whether it be scrupulosity, violent thoughts, checking and so on.  The conclusion is always the same, it isn’t possible to ritualize enough to be safe, so you need to decide to be more miserable with no benefit or learning to live with uncertainty and finding freedom.

Scrupulosity – Answer to Faye’s Question

Faye  – I do remember you from last year’s Virtual Camping and it was nice to see it on Nightline — they did a decent job in showing what we did; although, more time and more explanation would have been nice (Click to see Nightline segment).  In answer to your question, can scrupulosity be treated with exposure and response prevention?  The short answer is yes.  Like all OCD, the focus of treatment is learning to live with uncertainty.  There are many kinds of scrupulosity, so depending upon the type there will be variations in treatment.  In a sense, treatment will be taking a risk of offending God, but treatment will also be an act of faith.  For everyone who believes in God, there is the question as to what is his nature – merciful and forgiving or angry and punishing?  The religious texts can provide evidence for either.  In the end, we are stuck guessing and if you think about it, either guess is possibly offending the other version.  If He is forgiving, then isn’t it an insult to treat Him as cruel.  And when you say a prayer over again, aren’t you offending both versions — after all, God always knows what is in your heart even if you don’t, so to repeat a prayer is to suggest he is stupid and can be fooled by words.  So what is to be done?  Like all questions, we have to guess and it doesn’t matter that we all would like to make the right guess, because we all don’t get to find out until we die, unless you get a personal communication and that would be a nice miracle.  On the other hand, suppose God opens your ceiling, looks down and just says, “Hi Faye.”  In the morning your hair is white, you’ve had this wonderful miracle; you know there is God.  On the other hand, you are still uncertain.  His appearance was a blessing, but was it a warning?  What are you supposed to do?  You are back to guessing.

So in treatment, we assume that you are guessing. As long as you are doing this, we suggest picking the God you would like to believe in.  Because the one that leads you to ritualize isn’t comforting and really your prayers aren’t to him, but to the OCDemon.  Your act of faith one that is scary – you commit yourself to the merciful forgiving God.  And what if you are wrong.  I would suggest that you love God so much, that you will accept punishment if you guessed wrong.  I’m suggesting putting your faith on the line.  Because you don’t really have a choice.  Like all OCD treatment, this is hard, but not as hard as your life is when you devote it to the OCDemon.  And the devil is the right analogy, because in listening to your OCD, your life loses meaning, you have trouble helping yourself or others.  You lose everything listening to the false promises of the OCDemon.  It is simple decision, but it is not an easy one.  Obviously treatment and preparation are more complicated than I’ve written her, but I hope this gives you a good start.  Just as you have begun to overcome contamination, you can overcome this.

Reverse BDD – Troy’s obsession about his girlfriend’s appearance

Troy, in your comment, you discussed your concerns about your constant questioning about whether or not you find his girlfriend sexually attractive and if not does this mean you needs to break up with her.  You also compare her to other women to figure out if you find her more attractive.  Medication helped for a bit, but the problem seems to have returned.  You also wanted to know if this is OCD.

The simple answer to your last question, is this OCD, is yes.  I’m sure you are a unique person, but your OCD symptoms are not.   Remember, OCD is NOT having thoughts you don’t like or having doubts.  OCD is wanting definite answers, no uncertainty, and often wanting to control the uncontrollable.   Although it isn’t a formal category, I usually call these kind of symptoms, reverse BDD; that is, your concern isn’t over your looks but over the looks of another, usually a significant other.  Sometimes it is general, sometimes it focuses on some small feature that the sufferer “can’t” get out of his/her mind.

So what is the truth about how you feel about her looks?  The problem is that anyone we look at can be experienced as more or less attractive.   Our perception not only depends upon how the person looks, but upon our mood, their personality and where our attention wanders.  Just as it is possible to repeat a word over and over and the meaning no longer sounds right, if you keep looking at someone and try to have the feelings you want, you often won’t.  If one doesn’t have OCD, this isn’t a problem.  The individual pays no attention to it and on another occasion, likes the way their partner looks.  But if your OCD focuses on this, then you try to figure out what this means:  Do I have to leave her?  Do I really not like her?   How can I be with her, when all that I keep noticing is this flaw that drives me crazy?  What do I really feel about her looks?  If this is OCD, am I really attracted to her, even though I’m not?  The questions are endless.

Like all OCD, conquering this is not getting an answer to your question, but learning to live with uncertainty and to make guesses.  Let’s face it, anyone you marry is not going to look as good in 30 yrs.  Presumably, you won’t get divorced.  Can you still have a full loving relationship?  Yes, because although we all may fantasize about beautiful people, love and sexual intimacy are made up of more than physical attraction.  Are others more beautiful than your lover?   It is normal to notice that others are beautiful and maybe more beautiful than the person you are with.  It is poor taste and not too smart to mention it.

With regard to how this is treated, I can give you some ideas, but obviously a brief blog isn’t a complete treatment road map, which isn’t possible with asking a zillion questions about you and your symptoms.

  1. The goal of living with uncertainty at this point translates to staying with her at this point, because it sounds like you aren’t ready to leave her.  It sounds as if you are saying, “if I’m not attracted to her I should leave, but I don’t want to today.”   So unless you are more sure you want to leave her for more reasons than her looks, I would suggest staying.
  2. You keep trying to measure her attractiveness by her looks and your physical response.  While you do this, you won’t respond.  Because you have ‘reverse BDD,’ the short term goal is to allow yourself to say, I’m currently planning on staying with a woman who doesn’t look as good as I wish.  If you need to fantasize during intimacy, do so.  This isn’t special for you — in any long term relationship, people will fantasize at times and the amount they fantasize is an individual variable.  Your longer term goal is to become less focused or caring about looks.  You and others who don’t suffer from this may say that this isn’t normal, but the fact is that even if you are with the most beautiful person in the world, you actually don’t notice it all the time.  And because of your OCD, you would not notice it at all.  It is odd, but the less focused you become, the better she will look — unless this refocuses you.
  3. In the ideal, when you compare her to other, you allow others to look better and you remind yourself that responding to others tells you nothing about your relationship.

Again, this isn’t a complete program, as is obvious, it is very difficult to do on your own.  You may have some additional interfering thoughts that you deserve someone better looking or that this is in some way unfair.  These thoughts are symptoms not truths.  This treatment can and does work for other sufferers, so don’t give up hope.  It is useful if you can find an OCD specialist in your area and the International OCFoundation (www.ocfoundation.org) may be able to help you with this.

Sarah’s writing problem

Sarah, your comments about your writing problems cover a very common area of OCD for many sufferers.  As you can imagine, many people have dropped out of school as the result of these issues.  Some of the approaches you have tried, we would not expect to work.  For example, timers.  The problem with simply limiting time is that you try to still do the work perfectly, but faster.  You’ve already discovered this is impossible.  If we are going to use a timer, it also has to be coupled with exposure.  For example, if an individual takes long showers, we would also have them take a wrong shower on purpose, that is, they would know that they weren’t perfectly clean. 

There are a number of steps you can take along these lines.  First of all, it is critical to purposely write rough drafts with mistakes and poor wording.   Almost everyone with the writing problem hates doing this and gets caught up in writing very good first drafts.  This may be difficult, but this, because it isn’t the final draft, you could give yourself permission to do this.  If you won’t start doing this for school work, then give yourself a writing assignment; e.g., writing a short story with a horrible first draft for practice.  Second, a step you can do now, is before handing in a paper, make sure to put in mistakes.  Have a mispelled word on every page and one piece of poor punctuation.  Even if this lowered your grade, it would be worth it to start to overcome your OCD.  Part of the decision you are making is to give up on perfect papers.  Some famous writer once said that you never finish writing a novel, you just stop writing.  Obvously, there is more that you can do along these lines.  I would still have many questions about what it means to you to have imperfect writing.  Within your answers are other exposures and possibilities that you need to face.  For instance, some sufferers with this problem would be concerned with how this would make them look to others or that if they aren’t good in this area, they have nothing.  I hope this gives you a bit of a start.

Answer to Amanda’s “Gay OCD” Question and the Importance of Acceptance

Amanda’s suffers from fears of being gay and says that she has read my book and understands that she needs to accept the possibility of being gay to get better (see book for why this is so).  However, she then goes on to say that she thinks she may have arousal feelings and this might make it true and that she doesn’t want to accept.

Amanda, you are raising the most important issue about acceptance.  To work on accepting the possibility is exactly what you are not doing.  And notice how I’m writing this — I’m not saying accept the possibility, because if it were that easy, your problems would be solved in minutes. Acceptance of something we don’t want is an effort and is painful, but it is usually necessary, because the alternative is living in fantasy.  Specifically, for you to work on accepting the possibility of being gay means that you would need to consider how you would make your life worthwhile if you suddenly decide you are gay, as opposed to saying it’s possible, but I know that I’m not.  You may ask why, so allow me to give you a few examples not involving your particular fear.

  1. To not accept means the individual is in denial, which translates to trying to compare real life to a fantasy.  When someone loses a loved one, the statement of denial is: life would be better if they were still here.  This may be true, but it is a fantasy, since the lost person will never be back.  In this case, acceptance doesn’t mean you don’t care about the loss, but it does mean that you stop comparing your real life to the one where the loved one is still here.  You may miss them at times.  You may cry for them.  But when you are doing something, you would enjoy it rather than wishing for your loved one.
  2. This brings up an important point, mourning – the process of moving from denial to acceptance takes time.  No matter how self-aware someone is, when they lose a loved one, they start in denial.  To move and work towards acceptance takes time.  What you can decide is that you want to do this.  Without this decision, the process won’t begin.
  3. The problem with acceptance is that there is always a loss — and it doesn’t matter if you intellectually know the truth, denial is in the wishing.  Again, anyone who has lost a loved one knows they are dead, it is the comparing their current life to the one where their loved one hasn’t died that is denial.  Mourning is giving up this wishing.
  4. Amanda, for your OCD, you fear you may be gay.  So one loss is accepting this as a real possibility.  To accept uncertainty means accepting that you really may be.  So the second loss is that certainty over this issue will never be had, but learning to not care about it is possible.   What would this look like?  At present, you seem to know that you don’t want to live a gay lifestyle, so you don’t have to.  Even if you decide that you are 100% gay, you could still choose to live as a straight person.  So your exposure isn’t saying your gay, but it is saying that if a time comes that I want to live as a gay person, then I will have to figure out how to do it.  Until then, I’ll keep living this way and will work on trying to not figure it out, because I also have OCD and I also have to work on accepting that I can’t know anything with certainty and part of the reason for this is that research has shown that the only people who have any certainty are stupid people.
  5. It is true you don’t like this and would like to figure it out, but that won’t happen.  Again, the best you get is not right now.  It’s true you wish this change won’t occur, but there are a million things you don’t want to happen that you live with — you don’t want to be a mother whose child dies of a horrible disease or gets kidnapped, you don’t want to be maimed and paralyzed in a car crash, you don’t want to get a fatal cancer and on and on.  The goal isn’t to know whether or not you are gay, but to work on deciding that if it happens, then you will work on making the best of it.  Why would you do this?  Because what choice would you have?  Will this be your future?  Will you live long enough to find out?  Maybe.
  6. All we have is the present.  The past is pleasant memories, the future is hope.  When you have OCD, you don’t even get the present, so the purpose of choosing to do exposure and to work on acceptance is to have a life where you get to enjoy whatever you have.  The failure is never in falling down, it’s in not trying to get up.

The Right Treatment for OCD

OCD is both a learned and biological disorder.  Medication may help with biology, but it doesn’t change learning. This is why meds alone usually result only in a 30-50% reduction in symptoms.  For some people, even if meds are working biologically, the learned part of OCD can mask the effects of medication.  The treatment for the learned part of OCD is a cognitive behavioral technique called Exposure and Response Prevention (ERP).  I’ll briefly describe what this entails, but first I wanted to emphasize why this is the first line treatment for OCD:

  1. The research data supporting ERP have been available since 1984 (really research began appearing as early as 1976, but by 1984, ERP has been established as the main treatment for OCD).
  2. The American Psychological Association has a short list of treatments designated as empirically supported treatments, that is, treatment for which there is good evidence they work.  It is unfortunately a short list.  ERP for OCD is on that list.
  3. In 1997, The Journal of Clinical Psychiatry printed, “The Expert Consensus Guidelines for the Treatment of OCD.”  This journal tends to specialize in medication studies.  The guidelines conclude that ERP is the first line treatment for OCD and that SSRI medications are also important.
  4. The 2007 Practice Guidelines printed by the American Psychiatric Association conclude that ERP is the main psychological treatment for OCD.  They report some evidence for other CBT techniques, but emphasize that ERP is the main psychotherapy treatment.  They also say that SSRI’s are important.
  5. Almost all OCD experts, whether behavioral or medical in their backgrounds, agree that ERP is critical for treating OCD.  Such agreement is very unusual in the mental health field.
  6. This is the consistent message that the national OC Foundation tries to spread (their website: www.ocfoundation.org )

So it is tragic to admit that it is easier to help OCD sufferers than it is to change the behavior of mental health professionals.  A treatment that works, is expounded by experts and professional organizations and has been around for over a quarter of a century, should be easy to find.  But it isn’t.

If you are looking for treatment, your therapist should say that ERP is a part of treatment.  Saying CBT isn’t enough, since there are many CBT techniques, and you want the right one.  There are a number of good books about OCD and treatment, obviously including my favorite (my book).  The one popular one most experts disagree with is Brainlock, so pick one of the others.

So what is ERP.  It is simple; however, simple is not easy.  You can try the self-help approach, but this is very hard.  If there are no OCD specialists in your area (the OC Foundation may be helpful in helping you locate one), you may be able to find a therapist who would be willing to be supervised by an experienced OCD clinician.  Many of my colleagues and I do this.  I’m going to over-simplify treatment for now, since the alternative is to write another book.  Treatment has basically 3 parts:

  1. Helping you accept the goal of treatment.  At the core of most OCD symptoms is the desire to be 100% certain about your issue — that you are absolutely clean, that you won’t hurt someone, that you did or didn’t see ‘x.’  This isn’t reasonable as there is no way to be certain about anything.  So the goal of treatment is deciding that you want to live with uncertainty.  Note that I said learn to live with.  If it was a simple decision, you would be better now.  Once you’ve decided this, EPR is a major part of the path.  However, I am not saying ERP instead of meds.  Most of my patients do both.
  2. Exposure, helping you to directly confront your fears.  It is scary, but so is your life at this moment.  Again, because it isn’t easy, you may find a self-help program too hard.
  3. Response prevention.  Helping you to stop the rituals.  Exposure without this is pointless.  If you think about it, many of your worst occasions were marked by the endless ritualizing.  For those with primarily mental obsessions, you also have rituals, mental ones in the form of trying to figure something out or trying to convince yourself that everything is okay.

I know this is short, but ERP and usually and SSRI medication are the treatments for OCD.  If your therapist doesn’t know the above, then you need to educate them or move on.

Answer to Nina about “Compulsive Staring” at Privates

Nina’s OCD behavior, feeling compelled to stare at the private parts of others is not unusual and is an OCD behavior that we have seen before.  Nina, you mention your fear that you will be caught by others and be humiliated.  I am guessing you also have fears/concerns about what this may mean about you and are concerned is this really OCD or is there some other problem you have.  This is OCD.  The targets of OCD are often focused on what might be most threatening to us.  With the trauma you suffered, your mind creatively has figured out what would be terrible for you — further humiliation and, again, what does this mean about you.  Again, I am guessing that you spend an equal amount of time obsessing about being caught, how to control yourself and what does this mean about you.  Because I don’t know you, I can only discuss in general terms what exposure and response prevention would look like.  Because it is impossible to have the concentration to control where you are staring 24/7, initial treatment would have you staring at private parts on purpose, but trying to do so in a sneaky way so as to not get caught.  This gets you out of the control bind.  Scripts to accompany the exposure depend upon whether my guesses about your feared consequences are correct or not and your personal history.  In general, they would focus on how you would try to cope with being caught in a positive way and not having definite answers to questions about yourself.  You’ve mentioned a traumatic experience, this also requires treatment combined with the OCD treatment.  I don’t know if you have seen an OCD specialist.  You can check with the OC Foundation (www.ocfoundation.org) and their find a therapist part of the website.  If you find names that are close to you, you can call the Foundation to find out if they can tell you more about the therapist.  I’m sorry I can’t be more specific, but you should know this is a treatable form of OCD.  If you have a therapist who is willing , I would provide them with some supervision.

Answer to Aaron’s Fears about Exposure to Violent Thoughts

Jonathan Grayson

It is true that many who don’t understand OCD have some difficulty with the idea of treatment. Part of the answer is to check out my blog about normal people don’t know what they are doing. The standards of what they actually think and do are not the same as the standards they claim to have.
The literature on violence/sex in the media as a cause of violence is a broad literature with pros, cons and qualifiers as to when this may or may not happen. There isn’t anything in that literature that alters our treatment.
In reading my book, your statement that exposure will reduce anxiety is not the entire story. The primary goal of exposure in the treatment of OCD is to learn to live with uncertainty. Thus, you are accidentally undermining your treatment, because you want to be sure that you will not engage in any violent or improper sexual behavior. That is, you want to be reassured. Treatment and life are a risk. How do I know that I won’t slice and dice my wife tonight? I don’t have a plan to do so, but one doesn’t plan on going crazy. There is no way I can be sure she is safe. I could stay away from her, but then what is the point of human contact? Or I can do what everyone does without realizing it. I can go to bed, hope it won’t happen and if it does, I will be stuck coping with it. My life will be ruined, I will feel guilty, book sales will go down and even with this I will have to find a way to go on. No one has any other choice, but for most people, they are willing to take the risk. You are trying to avoid the risk and have correctly assumed that even treatment could make you worse. It isn’t where I would bet my money, but it is possible. The reason to do treatment is because of all the options you have to make life better this one is the best bet. No guarantees other than it is wiser to bet on the higher probabilities.