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.

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.