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