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.

Contact Information and Site News

Dr. Grayson can be contacted at:
The Anxiety and OCD Treatment Center of Philadelphia
1616 Walnut Street, Suite 714
Philadelphia, PA 19103
Phone: 215-735-7588

Bi- Weekly blogs and articles by Dr. Jonathan Grayson and his colleages about OCD, including:

Types of OCD and how to cope with them;

Creating scripts for OCD;

Discovering your OCD treatment motivators;

and more…