Tag Archives: ERP Treatment Motivators
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 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.
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.
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.
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 (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.