Relapse Prevention Tips: The Right Attitude

When you are in the middle of suffering from OCD, all of your attention is upon overcoming OCD, that future time when everything will be okay forever.  But it won’t be that way.  Life will be wonderful, but  real life is also full of ups and downs.  After a honeymoon period of having freedom, your next task will be living – finding out how to fill all of that time that used to be devoted to OCD, whether that time way eaten by behavioral or mental rituals.   If you have OCD, you have a wonderfully creative mind and if you don’t use it, OCD will.

And then there is slipping.  It turns out that for any behavior a person has to work on changing , slips will occur.  Your OCD was like a garden full of weeds.  You’ve gone through treatment and worked incredibly hard cleaning out the weeds and planting what you want  –  your garden is beautiful, but weeds will grow.   You have to decide how much effort you want to put into keeping it beautiful, because you can let it get overgrown with weeds again.  The good news is that no matter how much you slip, no matter how weedy your garden becomes, you can always come back, but the more you slip the more work you will have.  In future posts I will discuss some of the relapse prevention that is in my book.  The main focus of this post is a friend of mine, Shala Nicely who is an OCD Therapist; that is, she is a wonderful therapist who treats OCD and she has OCD.  She attended the 2014 International OCD Foundation Conference in LA and attended my “virtual camping” trip.  Shala’s OCD is never going to take control of her again, but she will slip.  Slipping is normal and your relapse prevention work is to make slips less frequent and to keep them small. A major part of the work is learning to have the right attitude.  If you expect to have slips and expect to have to battle them, you will be ready.  If you expect to never have a slip, OCD will blindside you and you will fall.  Click on this link for Shala’s 2014 IOCDF experience to see the fighting attitude you want to learn to adopt to maintain treatment gains.  Shala, I can’t thank you enough for sharing your courage and wisdom.

OCD Treatment In LA!

It’s official, I will be relocating to LA on Dec. 1 this year and starting a new anxiety and OCD treatment center there. The new office will be in LA county (I’m open to suggestions for possible locations, but please have reasons other than convenient to where you might live). Go to LAOCDTreatment.com  for:

  1. New center updates or;
  2. if you are interested in becoming a patient or;
  3. joining the free GOAL support group

 

 

OCD and Hope

OCD can be devastating, but there is treatment that works.  When reading comments from other readers that may sound hopeless, please search through the thread – it is likely that earlier on I did discuss some of what can be done for that manifestation of OCD.  I’ve been working with OCD since 1978 (I know, I’m ancient) and I haven’t seen a manifestation/presentation that can’t be treated successfully.  At the same time, I have seen many people suffer needlessly from bad treatment.  If you’re seeing a therapist and that therapist doesn’t mention exposure and response prevention as a part of treatment, you are probably in the wrong office.  The updated edition of my book (Freedom From OCD) covers many different OCD presentations.  If yours isn’t in it, it doesn’t mean you are untreatable, so there is no reason to give up hope.  A good place to find  a therapist is the Find-A-Therapist section of the International OCD Foundation‘s website and you should look for someone who is BTTI faculty or a BTTI graduate.  Take care all and don’t lose hope.

Freedom From OCD 2nd Edition is Now Available!

The second edition of Freedom From OCD is now available.  It includes updated treatment information (e.g. incorporating ACT into ERP), more OCD presentations (e.g. Relationship OCD, Sensory-Focused OCD, Obsessing about Obsessing) and others.
There is also a website for the new edition:  FreedomFromOCD.com.   The website allows users to download all of the forms that appear in the book for free.  In addition, the FreedomFromOCD.com, website makes available other OCD articles and  MP3s (currently just 1) that can be used for scripts.
The materials on the site are for anyone to use, purchase of the book is not necessary.

SITE NEWS — 2nd Edition of Freedom from OCD has a publication date!

For those of you who have been checking this site, I’d like to thank you for your support and apologize for not blogging enough.

Update on the release of the 2nd edition of Freedom from OCD.  I just heard from the publisher that the release date is April 1, 2014.   At worst, the book would be 1 or 2 weeks later.  The 2nd addition will include additional manifestations of OCD, such a relationship OCD, sections on coping with treatment interfering behaviors (TIBs), how to add Acceptance and Commitment Therapy (ACT) to your program of exposure and response prevention and much more.  In addition, because in the electronic editions of the book, the forms aren’t printable, they will be available for free download on a site, that I will announce when we have it up and running.

Again thanks for your patience and remember, OCD is a problem that can be ruled by you rather than the reverse.

Knowing You Have OCD With Certainty

Max in a post to this site asked what about convincing someone, with certainty, that they have OCD, since this would be comforting and reassuring.   There are three problems with this approach.  First, as I’ve noted elsewhere, research has shown us that the only people who have absolute certainty are stupid, which eliminates this as a possibility for most OCD sufferers.  Seriously, we find that attempts to reassure oneself by saying ‘x’ is OCD followed by the comfort that I don’t have to worry about ‘x,’ tends to be a short run solution.  Usually the sufferer at some point will then begin to obsess and try to reassure him/herself that the problem is OCD and the circle goes round and round (this is 2 of the three points).  We are for the sufferer admitting that it is likely that they have OCD, but that this is independent of whether or not there feared consequences are avoidable.  For example, if your OCD issues focus on wanting your loved ones to never die, the fact this is an OCD concern is independent of the fact that your loved ones might die at any time, so treatment has to help you cope with this fact of life.  Now it is true that some OCD concerns may involve lower probability fears, but that isn’t relevant to treatment.  Whatever you fear is what the focus of treatment needs to be on.   The goal is always twofold: I need to cope with the uncertainty that ‘x’ may happen; and no matter how horrific ‘x’ is, I need to try to figure out a positive way to cope with it, if it does happen.

Answer to Patrick’s Obsessing about Obsessing Post

Patrick, I assume you read the post article here about obsessing about obsessing, so I will not repeat what was there.  This form of OCD is a difficult one to help a sufferer understand what to do and I apologize if this doesn’t seem clear.  In your post you ask if you should ruminate and  I would re-word that to say exposure, since ruminating suggests ritualizing to me.  You mention that you have a number of feared consequences (e.g. becoming poor) that you say may happen.  This would not be enough.  How would you attempt to cope with them in a positive way.  How would you get on welfare and make the best of it.  So part of the exposure would be very detailed that if these things happened what would I do.  The reason for this is that if these things actually happened, life would go on and a person would have to continue.  Though being poor would be very difficult, people in dire straits can still have enjoyment, even if it is less in their life.

Second, whenever you are doing something, we would like some attention paid to whatever good is actually going on.  While learning to overcome this form OCD, it is important to learn how to notice whatever level of enjoyment is present, whether it be 80%, 50% or just 10%.  It is learning to accept that this is my current best and so I might as well get something out of it.

The goal is learning to be able to have the thoughts in your head and feel anxious and learning how to cope with this while it is happening.  This is very easy for me to say and it is lots of work to learn how to do.  Obviously if it were easy enough to explain it all in a post, you would have figured it out on your own.  But you can learn how to do this.  Finally, it is true that OCD is both learned and biological.  I have given you some advice for the learned part and an OCD specialist would be useful for you to be seeing.  Medication would quite likely be a very helpful addition to your treatment and it is usually in the form of an SSRI for those who suffer from OCD.  I hope this provides you with some help and hope.

Susan’s mental obsessions and religious concerns.

Susan’s mental obsessions and religious concerns.
We actually have a sizable number of Orthodox Jews in our practice with a variety of religious concerns. You describe a few different problems with your OCD: words and images you have in your head that you don’t like; concerns about your own level of observance and how G-d may judge this; and finally how you will be judged by your peers. Each of these is a different feared consequence for the general concern about your religious practices. With mental obsessions, it is not the content of the thought that makes something an OCD problem — all thoughts, no matter how bizarre they may seem to you are normal. They become an OCD problem when you want to know what they mean or want to stop them. With you the goals would be twofold – helping you live with the thoughts (once you are able to live with them, they become less frequent and when they occur you would care less) and helping you to accept what you can’t know. In this second category, your neighbors say nothing about your level of observance, but it is true that some may be fine with it and some not. We can never please everyone. With regard to G-d, all of us could attempt to become saints and few do. Even the more observant in your neighborhood could always do more. Treatment would help you to accept that you can’t know the mind of G-d and that your goal would to trust in His judgement even if it went against you, because you’d like your faith to be strong enough to accept whatever He decides. Obviously this isn’t easy, but that is why treatment is necessary. It is likely that their are experienced OCD therapists where you live, especially in the major metropolitan areas (NYC, Washington, Chicago, LA). You can check with the International OCD Foundation to see if there are experienced OCD therapists in your area.   Your other posts are thoughtful, but I wonder if they are a little bit compulsive in trying to assure/explain yourself to others.

Answer to Ed and his pursuit of the perfect looking princess girlfriend.

Answer to Ed and his pursuit of the perfect looking princess girlfriend.
What you are describing could be described as reverse BDD (body dysmorphic dysorder). For anyone, if you stare at a face or body long enough, you will find imperfections and if your OCD attaches to this and you don’t do any treatment, then you will find this problem with anyone you date. If you want to overcome this, which would mean ultimately being able to be in a good relationship, be a good parent and have a partner you can love and depend upon for life, you will have to make a few decisions. And once you make these decisions, you will need to go through the difficult, but not impossible, process of learning to implement them. The decisions are deciding that you want to live with a person who will never look as perfect as you want. The two reasons for this are the one above – you will always find imperfections – and because whomever you are with will age. It may seem like you can’t get your mind off of the imperfections, but learning how to live with them is the process of therapy. You can check with the International OCD Foundation (www.ocfoundation.org) to see if there are experienced OCD therapists in your area.

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.