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.

Exposure and Response Prevention Motivators

Exposure and response prevention (ERP) is hard work and it can be terrifying.  We always say that both ritualizing and treatment are difficult and that the only difference is that treatment leads to an end of rituals and avoiding treatment leads to endless rituals.  Nevertheless, ERP is painful and what can you do when you feel your fear rising and the idea of a OCD free life doesn’t seem as important as your anxiety in the moment.  I think at these times it is useful to remember why you want to get away from OCD.  Below are two sets of questions with suggested sub-questions.  I would urge you to write about these in the most painful way you can remember, so that when OCD threatens to overwhelm your treatment, you will have more to fight back with.

The first set of questions concerns what have you lost to OCD?  Within this set think about 1) Because of OCD, I’ve Missed; 2) Humiliating Experiences; 3) Financial/Employment Losses; 4) Guilt; 5) Lost/Wasted Time; 6) Because of OCD, I’ve Been Late To; 7) Damaged or Lost Relationships; 8)Other OCD Losses:

The second set of questions concerns how have you hurt your loved ones with your OCD? 1) Forcing Them to Ritualize; 2) Making Them Late or Missing Events; 3) Hurt Them with My Other OCD Demands; 4) Hurt Them with My OCD Anger; 5) Hurt Them with My OCD Rigidity; 6) Ignoring Them Because of OCD Thoughts; 7) Ignoring Them by Withdrawing; 8) Other.

So rather than avoiding an exposure think about your reasons to fight OCD and remember that if you get better, not only will your life improve, so will the lives of your loved ones.

Answer to Reassurance Seeking/Self Reassurance/Uncertainty

Canadian with OCD tells us the s/he feels overwhelmed at times and seeks reassurance from others or attempts to reassure her/himself  about self harm.  S/he also notes that listening to the exposure script activates his/her fears.   I know it is really hard to do exposure, but remember, almost all OCD involves trying to attain 100 %certainty.   Most OCD sufferers are unable to do this, because there is no true certainty in the world.  As you know for every answer or reassurance there is a what if.  Thus every attempt at seeking reassurance from anyone is ultimately doomed.

I suspect that part of the problem with the script is that you don’t want to cope with the possibility that it could come true.  I would ask you to think of how you would best cope with it if it did (assuming you survived).  How can any of us know what we will do next.  I don’t expect to slice and dice my wife tonight, but I can’t know that I won’t go crazy and do it — after all, one doesn’t plan on going crazy.  I have to learn how to live in a world where that might happen and I can only hope it doesn’t.  What would I do if it really happened?  If this were my OCD problem, then my exposure would be to plan how to cope with the guilt afterward and to try to continue on.  Yes it would be horrible and I don’t want it, but what choice do I have?

Why would you want to cope with your worst possibility taking place?  Because trying to not have it happen is robbing you of life.  If it does happen, you will have lost the precious little time you have.  If it never happens, you will have lost all.  In life, the past is nothing but memory, the future nothing but hope and all we have is now.  The goal of acceptance is to learn to enjoy the only thing we can have, the moment.

Answer to Medication didn’t work for my OCD

OCD is both a learned and biological disorder. Given this, medications play an important role, but you need to remember that medication affects biology and not the learned parts of OCD. Because of this, medication alone usually results in a 30-50% reduction in symptoms and sometimes the learned parts of the problem are so powerful, that they overshadow the effects of medication. The best plan of attack with OCD is medication and a form of cognitive behavior therapy known as exposure and response prevention. This treatment has been around since 1979 and both the American Psychological Association and the American Psychiatric Assocation recognize this as a core part of OCD treatment. Unfortunately, it is harder to change mental health professionals than it is to help sufferers of OCD, so that there are many mental health practitioners who ignore these recommendations. 

With this in mind, it still may be that besides exposure and response prevention, you needed a higher dose and needed to give medication more time.  As to what is the best one or the ones with least side effects — there are 6 SSRI’s that on the average are all good and tend to not have side effects.  However, individually, there is much variation, so I wouldn’t be able to predict which might have the least side effects or which would work best for you.

Your Questions Answered

Please feel free to ask questions about OCD and OCD treatment here.  The questions should be of general interest to everyone and not personal questions particular to your situation (those are best asked through private e-mail).   Please forgive me in advance if I don’t answer your question timely or if it doesn’t get answered.  For your answers look for my posts in this section rather than a reply to your comment.

“Normal” people don’t know what they are doing

OCD sufferers often wish they could use the standards that the ‘normal” population uses for living.  There are a few problems with this. One major problem is that “normal” people don’t have consistent standards.  For example, I was giving a lecture to college students and began the lecture by pouring a can of Pringles potato chips on the floor and eating them.  I asked if anyone wanted to join me.   The looked at me as if I were crazy.  Later in the lecture, I asked if any of them went to parties.  As you might expect, the college students eagerly raised their hands.  I then asked if they sat on the floor at parties.   Again the hands went up.  This was followed by, “do you wash your hands before you eat at a party?”  Their mouths dropped open, because they knew they didn’t.  After this, some of them did eat the Pringles from the floor.  However, even those who wouldn’t will continue their party behavior and if you know anything about dorm parties, you can be sure the classroom floor was cleaner.  Another behavior many of them admitted to during the lecture waschewing on their pens, despite the fact that they know their pens have dropped on the floor .

The moral of the story: Consistency is the measure of severity, the more consistent you are, the worse your OCD is.  “Normals” may say they won’t eat after touching the floor, but they don’t really know what they are doing.  An OCD sufferer with contamination issues will be consistent about avoiding the floor and their mouths.  Ultimately, inconsistency  is one of the goals of your OCD treatment.   So next time you want to have “normal” standards, remember that you can’t trust what those “normals” say, but you can be sure they don’t ritualize and avoid the way you do.