Category Archives: Exposure and Response Prevention Tips for OCD
Stuart Ralph’s The OCD Stories has just released his second interview with me. We discussed OCD Recovery, treatment resistance and listener questions. To listen, click below:
Click here to watch the Southern California OCD Affiliate’s 2nd annual conference 2 keynote addresses. The first is mine and discusses uncertainty and a number of primary mental obsessions. The second if Ethan Smith, a comedian, actor, spokesperson for the International OCD Foundation and generally a great guy.
This is from a an OCD Awareness Week Event. This is the panel that followed my presentation, “The ABCs of Overcoming OCD.” The speakers, Liz McInvale, Ethan Smith and Jeff Bell humble me with their life stories and their bravery. I hope I could do as well as them if I were in their circumstances. Click here to see their panel.
This is from a livestreamed OCD Awareness Week Event. Click here to watch my presentation of “The ABCs of Overcoming OCD.” My thanks to Liz McInvale, Ethan Smith, Jeff Bell and Barbara Van Oppen for putting this together and for there wonderful presentations. You can check out their presentation which is also shared on this site.
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.
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.
Exposure and response prevention (ERP) is the first line treatment for OCD, but no one should do it! I do believe that any sufferer with OCD who would like to be free of this problem would be well advised to choose ERP for treatment. Many sufferers of OCD find their decisions and actions guided by shoulds, by what is right and wrong. They would say that this is being responsible. Wrong. Responsibility is not a matter of what you should do. Responsibility is taking the steps to accomplish the things you want to do. The responsibility of shoulds involves some authority shaking a finger at you demanding you to be good or to do the right thing or else. This is neither thoughtful nor helpful. When we are working with an individual, we emphasize that we don’t want them following the treatment we are proposing simply because we are experts who are supposed to know, we would like them to follow our treatment if we have convinced them that this is the best way.
The responsibility of taking the steps to accomplish what you want puts the power in your hands. With regard to OCD, this makes the decision to do ERP a matter of thoughtfully looking at what treatments and evidence for them is available. However, it does impose an additional requirement. It makes you responsible for possible outcomes. I often ask someone, can an individual be a responsible criminal and if so how? Many want to say no, because they confuse responsibility with right and wrong. Others will say yes, but if I ask how, they suggest by carefully planning their crimes. This would be part of it; however, in making a choice, I also need to consider the possibilities of what might happen. I used to work with drug addicts on probation and parole and I ran into responsible and irresponsible criminals. The responsible felons were those who had accepted the possibility of landing in jail, since most of the people they knew eventually were caught. They may not have liked prison, some went straight following their incarceration, but they accepted the consequence. The irresponsible felons complained about how unfair it was that they were in prison and why the system should be changed and so on. All of that might be true, but it was true, that regardless of what they feel, the law was the law and they apparently weren’t willing to accept prison as a real possibility. A similar example would be someone who would like to become an actor. It is fine to hope to become a Hollywood star, but if failure isn’t acceptable, then acting makes no sense to try, since this is the most likely outcome. If on the other hand, you want to devote a number of years trying before moving on, or if you are willing to accept not getting further than community theater, then attempting to go into acting is responsible.
Anyone suffering from a problem would wish the problem to be gone quickly. But at this moment in time, ERP is the most researched treatment and the only one that all of the experts and professional organizations (both the American Psychiatric Assoc and the American Psychological Assoc recommend ERP as the first line treatment for OCD as well as the International OCD Foundation). The possible feared consequences that most sufferers face are horrible, but consider a few facts. First, what have you lost to OCD and I don’t mean in general, but in detail, humiliating experiences, being late for important events, lost relationships and so on. Second, how have you hurt your loved ones – forcing them to do rituals, endlessly asking for reassurance, being angry at them for not giving in. If you have children, would you do anything for them? If you say yes, and I don’t mean to be offensive, but you are lying to yourself. You put your OCD fears in front of their welfare. You run the risk of having children who won’t respect you or who will live in fear of the world. There is a 1 in 4 chance your children may have OCD and your behavior teaches them that OCD is something to cope with or not.
And there is a third reason. At this point your OCD steals everything from your life and hurts your loved ones. Even if you were to leave them, they would just be hurt more by your abandonment. And you are willing to have all this happen because of a possibility of something bad happening. Whatever decision you make there is risk. However, the saddest thing about your rituals is that they don’t work. You never get the safety or reassurance you wish for. And if you described your rituals to me, I would be able to find flaws – reasons you are still at risk. So the saddest thing about your rituals is that for all of your pain and efforts, you never get the prize, all of your fears may happen anyway.
I have written elsewhere that the only thing we have is the present. Those you love are only there when you are with them. So when you are alone, there are past good memories and hopes for a future, but that isn’t now. And with your OCD, you don’t even have the present, because you are trapped in OCD land. Responsibility is taking the actions to achieve what you want and accepting the consequences. To give into your rituals is to decide to have a difficult life, hurt the ones you love and have not guarantee that what you want to avoid will be avoided. To fight OCD is to want to learn to live in the moment and enjoy it and to learn to cope with possible risks. Working on your OCD helps you and those you love. Not working on it hurts everyone. Running away hurts everyone. If you really would do anything for those you love, be responsible and take the steps to achieve your goals.
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.
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.